Is weight loss surgery right for you?

How does weight affect your life?

a.  Are you obese, or morbidly obese?

Individuals are considered severely overweight, or obese, if their Body Mass Index (BMI) is 30 or higher. (Refer to the BMI chart at the back of this brochure.) Today, one in three Americans is considered obese.

Morbidly obese means that your excess weight is putting your life at risk. You are considered morbidly obese if you are:

•  More than 100 pounds over your ideal weight. (The chart at the back of this brochure indicates ideal weight; based on your height and gender).

Or your BMI is 40 or greater. (Refer to BMI chart at the back of this brochure).

Or your BMI is 35 or greater and you have life-threatening conditions related to obesity.

b. Do you suffer from any of these co-morbidities?

Morbidly obese individuals typically suffer from numerous health problems, putting them at risk for a shortened life span. Life-threatening conditions related lo obesity are known as co-morbidities.

The most common co-morbidities associated with morbid obesity are:

•  Type 2 diabetes: Elevated blood sugar can damage tissue throughout the body.

High blood pressure: Can cause stroke and damage lo the heart and kidneys.

Osteoarthritis: A painful, rapid wear and tear of the hip and knee joints. Disk problems in the back are also common, making it difficult lo get around.

Sleep apnea: Excess fat blocks air passages, making sleep difficult and causing daytime drowsiness and headaches.

Heartburn and gastroesophageal reflux (GERD): Extra weight weakens the valve at the top of the stomach, causing acid lo return lo the esophagus. The result can be severe heartburn and acid indigestion.

Depression: Frequent ridicule and stares from others, along with the inability lo keep weight off through diet and exercise, make depression common.

Infertility: The inability lo produce offspring is common.

c. Have you failed to lose weight through diet and exercise?

A healthier diet, exercise, and positive behavioral changes are potential ways lo lose weight. They involve eating moderate amounts of nutrient-rich, low-fat, low-calorie foods and putting more activity into your day. Doing so requires a change in the way you think, feel, and act.

While a healthier diet and exercise can result in weight loss, the real challenge is keeping the weight off. Unfortunately, studies show a nearly 100 percent failure rate during a five-year period for obese persons who diet for weight control.' Even worse, a continuous cycle of weight loss and gain (yo-yo dieting) can cause serious health risks.

If you've tried diet and exercise, but remain seriously obese, weight loss (bariatric) surgery may be the best way to regain your health.

Health risks associated with obesity

• Diabetes • Congestive heart failure
• Cardiovascular disease • Caattstones
• Sleep apnea • Coronary hear disease
• Hypertension • Stroke
• Urinary stress incontinence • Osteoarthritis
• Asthma/pulmonary disorder • Cancer
• Gastroesophageal reflux disease (GERD)      • Amenorrhea
• Degenerative joint disease (DJD) • Polycystic ovary syndrome
• Hyperlipidemia • Infertility
• Depression • Dysmenorrheal
• High total cholesterol

Who is eligible for weight loss surgery?

• BMI OF 35 OR GREATER WITH CO-Morbidities

Which weight loss surgery option is right for you?

There are two basic approaches to weight loss surgery: restrictive and malabsorptive.

Restrictive surgery

Bands or staples are used to section off a part of the stomach, creating a pouch. Because this stomach pouch is so small, the amount of food one can eat is limited. Food continues to be digested through the normal digestive and absorption process.

Most restrictive procedures involve the use of a polymeric silicone ring or mesh band around the stomach. This band provides stability by not allowing the pouch outlet to expand.

Vertical banded gastroplasty

Vertical banded gastroplasty

One such procedure is called Vertical Banded Gastroplasty. In this procedure, the upper stomach near the esophagus is stapled vertically about 2 '/2 inches to create a small stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of food and thus creates a feeling of fullness. Food digestion occurs through the normal digestive process. After five years, studies show that patients can maintain 50 percent of targeted weight loss.

Laparoscopic adjustable gastric banding

Another restrictive procedure is Laparoscopic Adjustable Gastric Banding. A band is placed around the uppermost part of the stomach, separating the stomach into one small and one large portion. In this procedure, the band can be adjusted to increase or decrease restriction, surgery can be reversed, and digestion and absorption are normal. In a U.S. study, the mean weight loss three years after surgery was 36.2% of excess weight.

Malabsorptive surgery

Biliopancreatic Diversion

Biliopancreatic Diversion

Malabsorptive procedures, such as Biliopancreatic Diversion (BPD) techniques, involve rearrangement of the small intestine to decrease the functional length or efficiency of the intestinal mucosa for nutrient absorption. Malabsorptive procedures restrict both food intake and the amount of calories and nutrients the body absorbs.

During a BPD procedure, approximately ;/a of the stomach is removed to restrict food intake and reduce acid output. The small intestine is divided, attaching one end to the stomach pouch to create an alimentary limb. Food moves through this alimentary limb with little absorption.

Biliopancreatic Diversion with Duodenal Switch

An alternate version of BPD includes a Duodenal Switch, where a lower level of restriction is achieved with a higher degree of malabsorption. In this variation, stapling is used to create a sleeve of stomach, retaining the natural stomach outlet. The majority of the small intestine is bypassed, causing nearly complete malabsorption of food contents.

Restrictive with malabsorption

This procedure restricts both food intake and the amount of calories and nutrients the body absorbs. In addition to creating a stomach pouch, the surgery disrupts the body's normal digestive process. As a result, food bypasses a large part of the stomach and most of the small intestine.

Roux-en-y gastric bypass: a combined approach

Roux-en-y gastric bypass

The Roux-en-Y Gastric Bypass procedure combines restrictive and malabsorptive procedures and is the most popular technique, comprising 75 percent of bariatric surgical procedures. During the Roux-en-Y procedure, stapling is used to create a small, upper-stomach pouch, which restricts the amount of food able to be consumed. A portion of small bowel is bypassed, thus delaying food from mixing with digestive juices to avoid complete calorie absorption. In most cases, patients report an early sense of fullness, combined with a sense of satisfaction, that reduces the desire to eat.

A comprehensive clinical review of bariatric surgery data showed that patients (22,094 patients) who underwent a bariatric surgical procedure experienced complete resolution or improvement of their co-morbid conditions, including diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea.

Gastric bypass patients typically lose 60 percent of excess weight in the first year following surgery.' Many health problems (back pain, sleep apnea, high blood pressure, diabetes, and depression) improve or are resolved following surgery.

Laparoscopic or open incision?

Weight loss surgery is performed in one of two ways.

A laparoscopic procedure is performed by making several small incisions in the abdominal wall. A tiny video camera is inserted through one incision, letting the surgeon view the procedure on a video monitor. Small instruments, used to perform the surgery, are placed in the other incisions. No other incisions are necessary to complete the procedure. For this reason, laparoscopic surgeries are considered "minimally invasive" as compared to open surgeries. Patients who undergo laparoscopic gastric bypass surgery report experiencing less pain and the ability to breathe more easily following surgery than patients who undergo an open procedure.

An open surgery involves a single, vertical incision down the center of the abdominal wall. Although the size of the incision varies from surgeon to surgeon, it must be large enough to allow the surgeon to view the stomach and perform the procedure. Open surgery generally requires a longer hospital stay than laparoscopic surgery.

What happens if the operation cannot be performed or completed by the laparoscopic method?

In a small number of patients, the laparoscopic method does not work effectively. Factors that may increase the possibility of choosing or converting to the open procedure may include:

• Obesity
• A history of prior abdominal surgery causing dense scar tissue
• Inability to visualize organs
• Bleeding problems during the operation
• Specific state of a disease

What are the results of weight loss surgery?

As the field of bariatric surgery continues to grow and develop, clinical outcomes have improved and numerous benefits have been noted. In contrast (to usual obesity treatments), at least two-thirds of patients who undergo gastric bypass surgery are able to keep off at least 50 percent of their excess weight for 10 years or longer. Weight loss surgery has been shown to influence dramatic improvement to life expectancy. Co-morbidities such as sleep apnea and hypertension are reduced, if not eliminated, following surgery.

Surgical treatment, although not without risk, is the most effective long-term treatment for extreme obesity, when all other therapies have failed, and is likely to be used more widely given that the number of Americans with BMI > 40 has nearly tripled in the last decade. The actual weight a patient will lose is dependent on the patient's age, weight before surgery, overall health, ability to exercise, and adherence to dietary guidelines.

What risks are involved in weight loss surgery?

As with any surgical procedure, weight loss surgery may present risks. Please consult with a physician to discuss which treatment is right for you. It is important that you discuss with your surgeon the specific risks for someone with your conditions and undergoing your specific procedure.

Potential Postsurgical Complications

One or all of the following conditions and complications are possible following all types of weight loss surgery procedures discussed in this booklet, as well as for all types of gastric surgical procedures:

Potentially serious complications

•  Surgical: Perforation of stomach/intestine or leakage, causing peritonitis or abscess. Internal bleeding requiring transfusion. Severe wound infection-opening of the wound-incisional hernia. Spleen injury requiring removal/other organ injury. Gastric outlet or bowel obstruction.

Pulmonary: Pneumonia-atelectasis (collapse of lung tissue)-fluid in chest. Respiratory insufficiency-pulmonary edema (fluid in lungs). Blood clots in legs/lungs (embolism).

Cardiovascular: Myocardial infarction (heart attack)-congestive heart failure. Arrhythmias (irregular heartbeats). Stroke (cerebrovascular accident, CVA).

Kidney and liver: Acute kidney failure. Liver failure-hepatitis (may progress to cirrhosis).

Psychosocial: Anorexia nervosa-bulimia. Postoperative depression-dysfunctional social problems. Psychosis.


Other complications (may become serious):

Minor wound or skin infection/scarring, deformity, loose skin. Urinary tract infection. Allergic reactions to drugs or medications. Vomiting or nausea/ inability to eat certain foods/improper eating. Inflammation of the esophagus (esophagitis)-acid reflux (heartburn). Low sodium, potassium, or blood sugar-low blood pressure. Problems with the outlet of the stomach (narrowing or stretching). Anemia-metabolic deficiency (¡ron, vitamins, minerals)-temporary hair loss. Constipation-­diarrhea-bloating-cramping-malodorous stool or gas. Development of gallstones or gallbladder disease. Stomach or outlet ulcers (peptic ulcer). Staple-line disruption-weight gain-failure to lose satisfactory weight. Penetration of foreign material (e.g., band, ring) inside the stomach. Intolerance to refined sugars (dumping), with nausea, sweating, weakness.

Important considerations

Surgery should not be considered until you and your doctor have evaluated all other options. The proper approach to weight loss surgery requires careful consideration and discussion of the following with your doctor:

•  Weight loss surgery is in no way to be considered as cosmetic surgery. The procedures do not involve the removal of fatty tissue by cutting or suction.

A decision to elect surgical treatment requires an assessment of the benefits and risks to the patient and the meticulous performance of the appropriate surgical procedure.

The weight loss surgical procedures are not reversible.

The success of weight loss surgery is dependent on long-term lifestyle changes in diet and exercise.

Problems may arise after surgery that may require reoperation.

Do you want more information on regaining your health through weight loss surgery?

The decision to have surgery should be made only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician.

Before being approved for bariatric surgery, it is likely you must:

•  Demonstrate serious motivation for weight loss. Have a clear understanding of the surgical risks. Be prepared to make a lifelong commitment to strict dietary, exercise, and medical guidelines.

To begin the journey, first talk to your primary care physician. Ask about free information sessions for people like you who are considering the surgery. These sessions usually are conducted by an experienced bariatric surgeon who can thoroughly explain the procedure and answer your questions.
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