Questions to Ask Before Having Bariatric Surgery, Part 1

“Is Bariatric Surgery Right for Me?”

This question may be the most important one to ask. Deciding whether or not surgery is the right thing may be a tough decision, but don’t worry, there are many resources available. The idea of having a life-changing surgery can understandably be quite intimidating; both physicians and online resources like ObesityHelp.com can give valuable information.

In 1991, criteria were developed by surgeons and medical doctors that are still used today. The most important criteria used is body mass index (BMI). Having a BMI of 40 or above (a higher number means more overweight) is the basic weight criteria we use to decide if the risk of surgery is balanced by the benefit of weight loss. But having a BMI of less than 40 does not mean you cannot have weight loss surgery.

Medical problems related to weight (obesity-related co-morbidities) are also criteria we use to decide if patients are candidates. Hypertension, diabetes, and sleep apnea are the most common medical problems that we use to determine if patients with a BMI of 35-40 would benefit from surgery. The list can vary, and this is where physicians can assist you. Below a BMI of 35, we generally consider other non-surgical or medical options.

“What are the Different Weight Loss Surgeries that are Available?”

Many surgeries for weight loss have been developed in the past, which can make decisions complicated. Fortunately, there are several standard procedures that are popular and are widely performed. A good way to think about the procedures is to classify them based on how they work. There are two ways the procedures help with weight loss are restriction and malabsorption.

To some degree, all weight loss procedures provide restriction, meaning changing (reducing) the size or shape of the stomach to make meal size (and thus calorie intake) lower.

This group includes the sleeve gastrectomy, the gastric band, as well as several older stomach stapling procedures which are no longer commonly done. The other group of surgeries, called malabsorptive procedures, involves reducing the length of the small intestine to decrease how many calories you absorb.

This is usually done by rerouting or bypassing (not removing) the small bowel, and these procedures include the gastric bypass and the duodenal switch. While malabsorptive procedures generally provide more weight loss overall, they are more complicated, and patients must be more careful with vitamins and nutrition overall.

I believe it is a good idea always to ask your surgeon why they have selected the procedures they offer and what is their experience with them. At our facility, we most commonly perform the gastric bypass and the sleeve gastrectomy and offer the lap band as well. We feel that these three surgeries provide the best results with the least amount of risk possible. (but other surgeons may feel differently, so ask them!)

“What Resources Do You Offer Before and After Surgery?”

The patients that typically do best with weight loss surgery are well prepared. This preparation involves being ready for dietary changes as well as lifestyle changes such as increased exercise and activity. At our facility, we routinely recommend that our patients take advantage of the resources that we are lucky to have, which includes physical therapy sessions both before and after surgery.

Walking and light activity are an essential part of recovery after surgery and protect patients from severe but rare complications like blood clots, so “preconditioning” with help from physical therapists is a great idea. In addition, many insurance providers require nutritional counseling before surgery, so we use that time with our dieticians to make important changes to our patient’s diets before they have their procedure. We try to get our patients to adapt to the kind of food they will likely have after their recovery; high protein and low carbohydrate.

“What are Your Complication Rates and Types of Complications?”

In general, patients do well, and most bariatric surgery patients can go home after one or two days without problems. However, there are certainly risks involved, and patients who are well-educated about the particular risks of their procedure do better.

In general, the biggest risk with weight loss surgery is the potential for a leak or injury to the stomach or intestine. With many of these procedures, there is a division or stapling of the stomach, and proper healing of this staple line is of utmost importance.

Fortunately, leak rates among large bariatric providers tend to be 1% or less, so while problems like this are uncommon, they certainly can happen. Leaks can cause infection or pain and can be very dangerous if not treated properly. Treatment options for a leak vary but can range from longer stays in the hospital all the way to returning to surgery to fix the injured area or control infection.

Another uncommon but serious risk is bleeding. Again, less than 1 in 100 (or less than 1%) of patients experience bleeding after surgery, and the risk goes down significantly after a few days. At our facility, we place drains during surgery, and they stay in place for about a week. These are not comfortable, but they provide reassurance that patients are doing well and are not suffering from bleeding or an injured staple line.

Several other concerns exist, and many of the preoperative visits are dedicated to talking about these and making strategies to avoid them. For example, the most common long-term concern with a gastric bypass is the small (1 in 40) risk of gastric ulcers, but avoidance of smoking or NSAID (aspirin-like) products can greatly reduce this risk.

“Are There Non-Surgical Options I Should Try First?”

Several other non-surgical options are available for patients besides surgery. Some of our patients are not quite overweight enough to qualify for surgery (BMI below 40 or less than 35 without co-morbidities) but have not had success with diet and exercise alone. Even with help from a physician or dietician, which includes counseling or even medicines to help with appetite, some patients may still need additional help.

One option is the intra-gastric balloon. While not a new concept, the balloon has become available for patients to have this non-surgical, outpatient procedure. The gastric balloon is placed via an endoscope (through the mouth while patients are asleep) and inflated in the stomach so that patients feel full quicker and longer than usual. It is safe and well-tolerated (some patients feel nausea at first), and usually is kept in place for six months.

While weight loss is less than with formal surgeries, it avoids some of the surgical risks and can help patients with significant weight loss over the time period it is in place. Other endoscopic techniques are less commonly done; including pinching or plication of the stomach to mimic a sleeve operation or devices to decrease absorption in the intestine.