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Surgical Options

Weight-loss surgery helps the patient help themselves.

If you are severely obese, and suffer from obesity-related health conditions, weight-loss surgery can help you lose weight. But surgery should only be considered after all other options have been exhausted. Such procedures are highly invasive, and the road to recovery is long, usually 12 weeks or more.

After surgery, you have to make lifelong changes in your eating habits that some find excruciatingly difficult. Women who have weight-loss surgery should avoid pregnancy until their post-surgical weight stabilizes. Pregnancy too soon after this type of procedure carries a high risk of injury to the fetus or miscarriage because of nutritional deficiencies.

There are two ways doctors can surgically aid weight loss: restrictive and malabsorption procedures (see "What's available?" below). Liposuction, a very popular spot-reducing surgery, has been mislabeled a weight-loss surgery. Liposuction does not help you lose weight. It does help reduce fat in certain areas, like your stomach and hips, but it will not result in dramatic weight loss.

Because weight-loss surgery is risky — roughly one in every 200 people who have weight-loss surgery will die as a direct result of their operations — surgeons have very stringent qualifications for people who undergo these procedures. An obvious qualification is being severely obese, and having been unsuccessful with other weight-loss therapies.

More specifically, someone who might benefit greatly from weight-loss surgery has a BMI (body mass index) of 40 or more, (for men, that's usually 100 pounds over their ideal weight, for women, 80 pounds), or has a BMI of 35 or more with weight-related complications (such as diabetes or heart disease).

Surgeons also consider how long someone has been overweight, and typically won't consider someone who has not been severely overweight for at least five years. They also consider psychiatric history, making sure you are ready mentally for the changes in your lifestyle as a result of surgery. And surgeons won't operate on anyone who is under 18 or over 65 years old.

What's available?

Surgeons perform two types of weight-loss surgeries: restrictive and malabsorption. A restrictive procedure actually closes off the majority of the stomach with a band, leaving a pouch that's about the size of a walnut. Imagine tying off a small portion of a balloon with a rubber band. Because restrictive surgeries make your stomach smaller, you eat less and lose weight.

The two most common restrictive surgeries are vertical-banded gastroplasty and gastric banding. They sound very technical, but are relatively simple procedures.

  • Vertical banded gastroplasty. The most common restrictive surgery, this procedure combines a stomach band with stapling to create a small stomach pouch. The stapling and banding tend to make the pouch less likely to expand.
  • Gastric banding. Surgeons place a band made of special material, such as silicone, around the upper end of the stomach. It creates a narrow passage into a little pouch of stomach that holds a very small amount of food.
Malabsorption procedures also have very technical medical names like Roux-en-Y gastric bypass and extensive gastric bypass (biliopancreatic diversion). The best way to envision this type of procedure is to think about taking a road trip. You are moving smoothly down the interstate around rush hour and decide to avoid the traffic by taking a bypass around the most congested part of the roadway.

In gastric bypass surgery, the surgeon attaches the stomach to a lower section of the small intestine, so that food never goes through the upper sections of the small intestine. Because the upper sections of the small intestine (the duodenum and part of the jejunum) are where you absorb calories and some essential nutrients, skipping those parts of the small intestine causes food to be poorly absorbed. This leads to weight loss, but may also result in nutritional deficiencies.

  • Roux-en-Y gastric bypass. This procedure combines two methods of surgery — first, small vertical bands or staples are used to create a small stomach pouch (gastroplasty), then a section of the lower part of the small intestine (a section that looks like a "y") is attached to the new, smaller stomach pouch. When you eat something, it passes through the lower parts of the small intestine only, reducing the amount of calories and nutrients absorbed by the body.
  • Extensive gastric bypass. Also called biliopancreatic diversion (because it bypasses the pancreatic juices that normally help break down food in the small intestine), this procedure isn't done very often, mainly because it can cause substantial nutritional deficiencies. The surgery works like this: Part of the stomach is permanently removed, leaving only a small pouch, which is attached to the last segment of the small intestine. This helps people eat less and reduces calorie absorption.
Be on the lookout for the word laparoscopic in connection with weight loss. Laparoscopic surgery makes five or six small hole-like incisions in a patient's abdomen and uses a tiny camera and tiny instruments to perform surgeries like gastric banding, and even gastric bypass. Using laparoscopic procedures is much less invasive than traditional methods, and recovery time could be quicker.

What are the risks?

As with any surgery, you run the risk of infections, complications, a long recovery period (about three months or more), and even death.

Something not often considered by people having weight-loss surgery is the extreme lifestyle change you face when you opt for one of these procedures. You must be on a low-calorie diet for the rest of your life to maintain weight loss. Eating foods high in fat, especially sweets, can cause significant problems because your body isn't able to digest food the way it once did. And resuming a high-fat diet can cause the weight to pile back on, defeating the purpose of the surgery.

Making that change is often difficult psychologically, which is why experienced doctors only choose to offer this surgery to patients who are very motivated to lose weight. If you choose to go back to former eating habits, you risk physical problems as well as psychological ones like guilt or major disappointment in yourself.

"Weight-loss surgery is not a free ride," says Dr. Harvey Sugerman, surgeon. "Weight-loss surgery helps the patient help themselves."

There are physical risks unique to gastric surgery. Having a smaller stomach means you can only eat very small amounts of food, which must be chewed well because they have a much smaller opening to pass through. Not chewing well can cause problems for two reasons — 1) banding makes the hole where your stomach empties much smaller, 2) bypassing most of the stomach means you only have a small amount of gastric juices to break down your food.

And eating larger amounts than your new stomach can handle can make you sick because you fill up more quickly and the food backs up into the esophagus, just like when you feel nauseous after eating too much Thanksgiving dinner.

Gastric-bypass operations also can cause a problem called "dumping syndrome" where contents of the stomach move through the small intestine too quickly. The rush of undigested food can lead to nausea, bloating, diarrhea, weakness, and feelings of faintness or dizziness. Also, because gastric-bypass operations keep your body from absorbing essential nutrients, you run the risk of not getting enough vitamins and minerals, especially vitamin B-12, iron, and folic acid. Nutritional supplements are a must for people who have gastric-bypass surgeries.

People who have any type of weight-loss surgery are at a higher risk to develop gallstones, and 10% to 20% of patients must have additional surgeries to correct complications such as hernias or rebanding stomach outlets that have stretched. Also, bands and staples used in restrictive surgeries can break down, and the stomach's smaller pouch can eventually expand, especially if you don't chew well or graze instead of eating set meals.

One more thing to consider about any surgery is who is doing the operation. Getting an unqualified or inexperienced surgeon is possible, so you should always be sure you do your homework before choosing a doctor. You should pick someone who is board-certified and has years of experience in obesity surgery.

How successful are these surgeries?

Not many people would risk such invasive procedures if they didn't work. Weight loss usually starts immediately after surgery and is very drastic. About half the people who have gastroplasty will lose about half of their weight in 12 weeks. And gastric-bypass procedures are even more successful; one study discovered bypass surgery helped some patients shed 50% to 64% of their pre-surgery weight. Typically, about 80% of those who have vertical banded gastroplasty lose at least some weight, and about 30% lose enough to put them in the "normal" weight.

This weight tends to stay off for at least two years. People who undergo bypass procedures lose, on average, two-thirds of their pre-surgery weight within two years. Half of those who had gastric bypass surgery maintain their weight loss after five years.

A word about cosmetic procedures

You've shed 50-plus pounds, but now where you used to have flab your skin sags. As you gain weight your skin has to stretch to accommodate your extra stuffing. Unfortunately, when you lose weight, your skin doesn't snap back in place. Some people who lose a lot of weight are frustrated to find that they may also have caused some cosmetic problems, like skin folds around the stomach and upper arm.

There are certain cosmetic surgeries that won't help you lose weight but they can help you fit into your new body a bit better. These include panniculectomy (reducing the flap of skin around the stomach and hips), thighplasty (removal of excess skin around the inner thigh), brachioplasty (removal of excess skin around the upper arms), and mammoplasty (removal of excess skin around breasts).

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