Get Your Bariatric Surgery Questions Answered
What is bariatric surgery?
Bariatric surgery is the medical term for weight loss surgery.
Why do they call it bariatric surgery?
The Latin root baros means "weight". Bariatric Surgery is surgery for weight. The first barometers (Torricellian) that measured barometric pressure consisted of a container of mercury with an inverted glass tube. As barometric pressure rises, it pushes the pool of mercury higher up the inverted glass tube. The tube had markings to read the barometric pressure. Due to the heavy weight of mercury, higher barometric pressures are required to push the mercury up the tube. Modern barometers (aneroid) use an air-tight box that moves a needle as the box is squeezed by increasing pressure.
What is the history of bariatric surgery?
In the 1960s, operations for stomach ulcer complications were very common. Acid suppressing medications and the ulcer causing bacteria Helicobacter pylori had not been discovered. Patients suffered pain, bleeding and perforation from gastric (stomach) ulcers. The common operation for ulcer complications were to remove the acid producing section of the stomach and reconnect the remaining stomach to the small intestine. These resections removed the pylorus (stomach valve) and patients then suffered from alkaline reflux gastritis (bile bathing the stomach lining). These patients were miserable, and surgeons needed a solution. A Swiss surgeon, Cesar Roux, first had the idea in the early 1900s to route the bile farther down the GI tract to keep it out of the stomach. He diverted the bile by disconnecting the small intestinal limb containing bile and pancreatic juices and reconnecting it downstream. This intestinal rerouting operation proved to be very successful and surgeons around the world began performing the Roux operation to treat severe alkaline reflux gastritis. The operation became known as the Roux-en-Y operation as the reconfigured intestine formed the letter "Y". Surgeons were impressed by the Roux-en-Y operation's success at alleviating symptoms from alkaline reflux gastritis. They were also impressed that the patients struggled to maintain their weight.
In 1966, Dr. Edward Mason, a surgeon at the University of Iowa, was the first to offer the Roux-en-Y operation to obese patients for the purpose of weight loss. He also made the stomach smaller for these patients and the operation became known as the gastric bypass. The original operations were performed using an open incision. The first laparoscopic gastric bypass in the United States was performed in 1993 in San Diego, California by Dr. Alan Wittgrove.
The VBG (vertical banded gastroplasty) operation was first performed in the US in 1982. The VBG was designed to reduce the high complication rate associated with gastric bypass. VBG involves stapling the stomach into a small upper pouch but the stomach remains connected and there is no intestinal bypass. VBG was commonly called "stomach stapling". The early results of the VBG were promising but many patients regained weight over time as the staples opened and the stomach regained its normal capacity.
The Lap Band was the first adjustable gastric band approved by the FDA in the US in 1995. Adjustable gastric bands are placed around the upper stomach and have an adjustable inner balloon that can squeeze or relax its pressure on the stomach. The band is connected via tubing to an adjusting port under the skin. The band is adjusted by accessing the port with a needle and adding or removing saline to tighten or loosen the band. Gastric banding became very popular in the early 2000s due to its safety and adjustability. It was the first bariatric operation that could be done as an outpatient with significant cost savings compared to hospital-based procedures. The popularity of gastric banding has declined due to long-term device issues and weight regain.
The laparoscopic sleeve gastrectomy was first performed in 1988 by Dr. Doug Hess in Bowling Green, OH. The sleeve is performed with surgical staplers by removing about 80% of the stomach leaving behind a smaller banana-shaped stomach. The term suggests that surgeons install a "sleeve" but the term sleeve simply describes the small tube of stomach left behind. The sleeve gastrectomy was first performed as part of a larger malabsorptive operation called the biliopancreatic diversion with duodenal switch. The duodenal switch bypasses large portions of the small intestine, which causes significant weight loss but also has significant potential complications (diarrhea, vitamin deficiencies) due to the extent of malabsorption. Due to the high complication rate of duodenal switch, surgeons began performing the sleeve operation as an initial stage with plans to perform the malabsorptive portion later after patients lose some initial weight. Surgeons were surprised at how much weight sleeve patients lost so they started offering sleeve gastrectomy as a primary weight loss operation. At the time, surgeons thought the sleeve simply had a restrictive effect, made patients full on a smaller portion of food. We now realize that the sleeve operation causes powerful changes in metabolic hormones that help weight loss. The sleeve operation blunts the appetite hormone, ghrelin, after a meal. It also increases the hindgut hormones, peptide YY and GLP-1 after a meal which is very successful at resolving type-2 diabetes. This powerful metabolic effect changed the name of the professional organization ASBS (American Society for Bariatric Surgery) to ASMBS (American Society for Metabolic and Bariatric Surgery). The sleeve operation has rapidly become the most popular weight loss operation in the United States because it has no implanted device like the gastric band and no malabsorption issues like the gastric bypass.
Are you guaranteed to lose weight after bariatric surgery?
No. The most important thing to know about bariatric surgery is that it is a tool for weight loss. It is a very powerful tool and for many patients, it was the only way for them to achieve and maintain a healthy weight. Most patients say it is the best decision they ever made, and they only wish they had done it sooner. All bariatric operations reduce appetite and make you feel full on a smaller portion of food. All bariatric operations can be defeated by inactivity, drinking calories (sweetened beverages) and eating high calorie foods. The most successful bariatric surgery patients make healthy food choices and are very intentional about burning calories by increasing their activity.
If I could eat less and exercise more why would I need surgery?
Bariatric surgery will not make you increase activity, but it will make you feel less hungry and feel fuller after smaller portions. It also changes your metabolic hormones making it much easier to lose weight. It allows your body to release stored calories instead of going into famine survival mode. Many studies comparing bariatric surgery with intensive diet and exercise programs repeatedly show that bariatric surgery patients lose significantly more weight and maintain that weight loss over time. By far, bariatric surgery is the most effective treatment for obesity.
I'm obese but my friends like me just the way I am so why should I lose weight?
This is like saying I have cancer but I'm not going to treat it because its not affecting my life right now. Obese patients die at a younger age. They develop many obesity-related medical problems over time such as, diabetes, high blood pressure, high cholesterol, heart attacks, strokes, higher risk for cancer, joint problems (hips, knees, ankles), headaches, infertility, etc, etc. For many reasons, obesity is an unhealthy state and will have serious consequences if left untreated.
Will my insurance cover bariatric surgery?
The best way to determine benefits is to call your insurance company. This can get confusing because some patients are told they have coverage, but the call center employee is looking at general coverage and not your specific policy purchased by your employer. Some patients qualify for coverage based upon their BMI but are later told they are not covered because they are only on two blood pressure medications and not three. Each policy has very specific coverage requirements and they can change. Some patients have coverage in December but lose the benefit in January. Bariatric surgery clinics have insurance experts that are familiar with most policies and know the right questions to ask your insurance company to determine true coverage of benefits and then what your policy requires before surgery before they will approve it.
I have diabetes and high blood pressure so why won't my insurance cover bariatric surgery?
You may have an exclusion on your policy. Most health insurance is purchased by employers and they frequently exclude certain benefits to save money. If your policy excludes bariatric surgery this means your employer paid less for your policy by excluding this benefit when they purchased your health insurance. Asking your insurance company to pay for bariatric surgery when it was excluded is like asking your insurance company to pay for a house fire when you didn't buy fire insurance. Insurance companies are reluctant to pay for covered benefits, so they are certainly not going to pay for something you did not purchase.
My health insurance covers bariatric surgery. Can I have surgery tomorrow?!
Health insurance coverage of bariatric surgery is unique. They typically have other qualifying criteria such as your BMI (Body Mass Index) and obesity related health problems (co-morbidities). Even if you meet these criteria, most insurance companies require a 6-month physician supervised weight loss program before you can have surgery. Other common policy requirements include smoking cessation, a psychological evaluation, nutrition evaluation and education. The psychological evaluation is to make sure you do not have treatable conditions that could affect your weight loss results such as untreated depression, binge eating, etc. Some patients pay cash for the procedure if they do not have insurance coverage. This saves time without the insurance mandated supervised weight loss plan before surgery, but you still benefit from screening and education before surgery to maximize your weight loss results.
What is BMI?
BMI=Body Mass Index. A healthy 6-foot-tall person will weigh much more than a healthy 4-foot-tall person. Therefore, BMI takes height and weight into account and is a better indicator for how unhealthy you are at a given weight. The BMI formula is your weight in kilograms divided by your height in meters squared. Most insurance policies that cover bariatric surgery will approve the surgery if your BMI is greater than 40, or 35 with two weight-related health conditions (diabetes, high blood pressure, etc).
The BMI ranges are as follows:
20-25 Normal weight
35-40 Severe obesity
40+ Morbid obesity
Patients with BMI greater than 40 are high risk for dying at a younger age, hence the term morbid obesity.
My friend had bariatric surgery and lost a lot of weight, but why does she look unhealthy?
Some patients with malabsorptive procedures such as gastric bypass or biliopancreatic diversion with duodenal switch have muscle wasting due to severe protein malnutrition. The human body is programmed for survival and very resourceful. If you don't eat enough protein, the body will get the protein it needs from your muscle mass. Muscle wasting also lowers your metabolism. In a similar scenario, if you don't get enough calcium in your diet, your body will get the calcium it needs from the bones, but this weakens the bones. Losing muscle mass in you face gives an unhealthy malnourished appearance. You can avoid this by choosing one of the bariatric surgeries without malabsorption like the sleeve gastrectomy. If you have a malabsorptive procedure, you must eat more protein to avoid malnutrition. One of the advantages of the sleeve gastrectomy is that it creates a healthy natural weight loss without muscle wasting. Protein and vitamin absorption are normal after sleeve gastrectomy. Vitamins are absorbed in the first part of the small intestine. After malabsorptive procedures (gastric bypass, BPD) food doesn't travel through this area, so you must take a lot of vitamin supplements to avoid deficiencies. With sleeve gastrectomy, vitamin and protein absorption are normal.
What about loose skin?
A third of bariatric patients will have some type of loose skin surgery once they reach their goal weight. The common operations are abdominoplasty ("tummy tuck"), breast lift, breast reduction, breast augmentation, loose skin removal from arms and thighs. The need for loose skin surgery relates to your skin elasticity and how much weight you lose. Skin elasticity declines with age so younger patients require loose skin surgery less than older patients. If a patient goes from 600 to 200 pounds, they will have a lot of loose skin regardless of elasticity. Many young women lose 100 pounds with bariatric surgery and do not require loose skin surgery.
Why do I have to be on a liquid protein diet before and after surgery?
Before surgery, a liquid protein diet is required to reduce the size of your liver which will make your surgery easier and safer. Obesity causes hepatic steatosis ("fatty liver") and the liver can get so big that surgeons are unable to retract it to operate on your stomach. The preop liquid protein diet will reduce the size of your liver making your surgery easier and safer. Initial weight loss comes from expenditure of stored calories in the liver. After surgery, the liquid diet is to allow the surgery to heal. Staples in the stomach need time to heal for maximum strength. Eating solid food soon after bariatric surgery can lead to leaks which will make you very sick and possibly require further procedures to repair.
I need to lose weight but isn't surgery the easy way out?
Successful weight loss requires work whether you have surgery or not. Bariatric surgery makes weight loss much easier because you are less hungry and you get full on small meals. Weight loss after bariatric surgery is easier but it is not easy. Bariatric surgery is the most effective treatment for obesity. We take antibiotics for infection and blood pressure medications for hypertension because of the effectiveness of those therapies. If you learned of a successful treatment for cancer or diabetes, you would not hesitate to take advantage of that therapy. A highly successful treatment for obesity exists and you shouldn't hesitate to take advantage of this. Bariatric surgery is not the easy way out; it is the most successful treatment for obesity. Without successful treatment, you are going to die at a younger age and are higher risk for diabetes, cancer, high blood pressure and many other health conditions.
Can I get pregnant after bariatric surgery?
Weight loss after bariatric surgery is a very successful treatment for infertility. Many infertile patients are able to have children after bariatric surgery. Since pregnancy requires good nutrition and vitamins for a healthy baby, it is best to choose procedures without malabsorption like the sleeve gastrectomy if you desire to have children. If a gastric bypass patient gets pregnant, you must watch your vitamin levels very closely with blood work and take extra supplements to prevent birth defects from vitamin malnutrition.
How safe is bariatric surgery?
Having bariatric surgery in an accredited center with an experienced high-volume surgeon is much less risky than remaining obese. Most insurance companies will require you to have surgery in an accredited weight loss center because of superior outcomes.