Going to Extremes for Weight Loss – Part Two: The basics of bariatric surgery.

The following is the second of a two-part article about bariatric surgery. This information is for educational purposes and does not replace consultation with a physician.

Contrary to popular belief, bariatric surgery is not a miracle cure that allows you to eat as much as you want and lose weight. Instead, to be successful, it requires a lifelong commitment to changes in diet and behavior. Whether contemplating bariatric surgery, either for yourself or a patient, consider both the risks associated with this invasive procedure and the lifestyle changes bariatric surgery demands.

What are the Risks and Long-term Complications?

Although there are many benefits to having bariatric surgery, there are also many risks. Essentially, the procedure alters both the anatomical organization of the digestive system as well as its physiological abilities. Risks include:

• Additional surgery may be required to correct complications such as abdominal hernia, staple line leakage or breakdown, or a stretched or narrowed stomach outlet.

• Nutritional deficits can result in the development of anemia, osteoporosis, and metabolic bone disease.

• The development of gallstones, which can be avoided by taking supplemental bile salts. Or the gall bladder may be removed during surgery.

• Kidney stones may develop as a result of the high volume of waste products, which arise from rapid weight loss. These can be avoided by consuming lots of water to flush out the waste products.

• Dumping syndrome, which occurs when food moves too quickly into the small intestine. This can be the result of eating high-sugar, highly processed foods, which consist of many small particles. The body dilutes these particles with water, causing a reduced blood volume and feelings similar to shock. Symptoms include nausea, weakness and faintness, vomiting, sweating, bloated stomach, increased bowel movements such as diarrhea, and dizziness.

• Although annual statistics vary, death occurs in approximately one out of every 200 procedures.

What Does a Candidate for Bariatric Surgery Need to Consider?

Bariatric surgery candidates must be committed to lifelong dietary and behavioral changes. Although the medical team (physician/surgeon, nutritionist, and psychologist/psychiatrist) will provide guidance and support, ultimately successful weight loss is entirely dependent on the attitude of the patient.

Dietary:

• Most importantly, eating habits will change, not only immediately following surgery, but also for the remainder of one's life.

• Initially (approximately one to two months), the diet is restricted to liquid or semi-liquid.

• Solid foods must be eaten slowly and chewed thoroughly. An improperly chewed piece of food could plug the pouch's small outlet.

• Fluid should not be taken during meals, as the size of the stomach cannot accommodate both food and drink. In addition, fluid may wash the food through the pouch faster and result in overeating.

• During the first few months, certain foods must be avoided: citrus foods, carbonated beverages, sugar, alcohol, raw fruits or vegetables, and foods with caffeine (including chocolate).

• Following surgery, the pouch will be stiff and accommodate a very small volume of food (approximately one ounce). Over time it will become more elastic and will stretch to accommodate slightly larger meals (between three to seven ounces). But the pouch will never reach a point where the patient will be able to eat 'normal'-sized portions.

• Because the absorptive function of the digestive system has been disrupted, close monitoring is required during the rapid weight-loss phase as well as lifelong medical surveillance.

Physical:

• Some degree of physical activity, e.g., walking, is recommended almost immediately following surgery to prevent the loss of muscle during weight loss.

• Excessive weight may have stretched the skin so much that it will not be able to snap back following weight loss, which can result in excess skin folds and may require cosmetic surgery.

• Some patients experience some transient hair loss, which is generally due to protein deficiency.

• Fertility may increase following weight loss, so women in their childbearing years must take care not to get pregnant during the rapid weight loss phase, as maternal malnutrition could affect fetal development.

Psychological:

• Depression and self-esteem issues may not be alleviated by surgery and weight loss alone. In fact, they may be exacerbated by the difficulties associated with surgery.

Cost:

• On average, bariatric surgery can cost between US$15,000 and US$20,000. This cost may or may not be covered by insurance. And even if the surgical procedure is covered, additional expenses may not be. These expenses can include cosmetic surgery to remove excess skin, the required ongoing medical visits, and lost wages due to time away from work.

Other Considerations

Once the decision has been made to pursue bariatric surgery, the next step is finding a qualified bariatric surgeon. Because bariatric surgery, specifically laparoscopic bariatric surgery, is a relatively new procedure, there is no specialty certification and training remains unregulated. Indeed, some surgeons receive their training over a single weekend. In addition, studies have shown that the number of procedures a surgeon has performed inversely correlates to his/her incidence of complication and death. For example, a surgeon who has performed a small number of procedures has a higher rate of complication than a surgeon who has more experience. When looking for a bariatric surgeon, the American Society for Bariatric Surgery is a good place to start. And when consulting with a surgeon, be sure to ask where they received their training and how many surgeries they've performed.

From selecting a bariatric surgeon to following dietary restrictions, ultimately, the success of bariatric surgery is up to the patient.

Want More Information on Bariatric Surgery?

• Obesity Education Initiative Electronic Textbook

• Gastrointestinal Surgery of Severe Obesity

• Gastric bypass: Is this weight-loss surgery for you? (Mayo Clinic)

• News from the AMA: Several Factors Contribute to Complications Following Weight Loss Surgery

• American Society for Bariatric Surgery

• Weight Loss Surgery Info

See Going to Extremes for Weight Loss – Part One to learn about the mechanics of bariatric surgery.

Going to Extremes for Weight Loss – Part Two

What are the Risks and Long-term Complications?

What Does a Candidate for Bariatric Surgery Need to Consider?

Other Considerations

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Lee Ann McGillivray

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