Bariatric Surgery Overview

Bariatric surgery is increasingly recognized as an attractive and viable treatment option for those who are morbidly obese. Clinically morbid obesity is a true disease state. It is a disease with a strong genetic component (25 to 50%), often characterized by an overactive appetite center in the brain that results in excessive fat stores in the body. It is not a disorder of willpower, as sometimes implied.

Morbid obesity affects four million adults in the U.S. and is identified in a person who has a Body Mass Index (BMI) of 40 kg/m2, or is 100 pounds overweight. Being severely overweight is dangerous to your health because it is associated with a variety of medical conditions as well as an increased mortality rate. Most morbidly obese people have struggled endlessly with failed attempts at weight loss and the frustration of limited alternatives.

Surgical treatment is the only proven method of achieving potential long-term weight control for the morbidly obese, greatly impacting health and longevity. While there are several bariatric or gastric bypass procedures, the laparoscopic approach to bariatric surgery is demonstrated to have clear advantages over other procedures, including:

• Shorter hospital stay
• Earlier return to normal activities
• Less pain and discomfort

Here at CBSI, Dr. Brown has performed over 2,000 laparoscopic bariatric surgeries and 99% of them have been performed laparoscopically.

Treatment Goals and Medical Risk Factors

The laparoscopic bariatric surgery treatment goals for morbid obesity are to achieve improvement in health by inducing significant weight loss that reduces life-threatening risk factors. Such a desirable outcome allows patients to experience improvement and satisfaction in nearly all activities of daily living.

Medical risk factors related to clinically morbid obesity:

• Obesity is especially linked to an increase in cardiovascular risk factors such as:
  • hypertension
  • diabetes
  • hypertriglyceridemia
  • hyperinsulinemia
  • and, low levels of high-density lipoprotein (HDL) cholesterol.

These risk factors increase your risk of heart disease and stroke.

• Joints and bones can undergo strain and become a chronic source of pain and may include:
  • arthritis
  • stress fractures
• Diseases or conditions related to the digestive tract often associated with obesity include:
  • GERD (gastroesophageal reflux disease)
  • hernias
  • gallstones
  • fatty liver
• Respiratory problems increase with obesity such as:
  • sleep apnea
  • hypoventilation
• Hormonal imbalances may also occur, resulting in:
  • infertility
  • abnormal hair growth
• Psychological problems are common, such as:
  • depression
  • anxiety
  • substance abuse
• Increased mortality is a concern, since there is a 15-year reduction in life expectancy
• Obesity also increases complications associated with:
  • pregnancy
  • surgery
  • and, it may increase the incidence of certain cancers (ie, uterus, colon, breast, prostate).

With sustained weight reduction, however, these risk factors can be reduced substantially, markedly improving quality of life and, at the same time, potentially prolonging life.

Possible Candidates for Bariatric Surgery

Bariatric surgery is an elective procedure for clinically morbidly obese people for whom substantive long-term weight loss is desired, but other weight loss approaches have failed.

Those who are potential candidates for surgery include people who:

• People who have a body mass index (BMI) of 40
• Or, people who have a BMI of 35-40, but have a co-morbid condition such as:

These people have not had not had success with other nutritionally and medically sound nonsurgical approaches to weight loss and, do not have any metabolic disease that may be responsible for their obesity.

CBSI Approach to Treatment

People who are likely candidates for laparoscopic bariatric surgery will undergo a thorough team evaluation prior to any treatment. To encourage a successful outcome, patients will undergo a multidisciplinary medical evaluation prior to being accepted and scheduled for surgery.

• Surgical evaluation--the surgeon will discuss with a patient whether or not they meet the requirements for undergoing the surgical procedure and whether they are a satisfactory operative risk.
•  Medical evaluation--it is important for the patient to have a thorough medical evaluation, complete with specialty consultations when indicated.
• Nutritional evaluation--our nutritionist will help motivate the patient towards making the necessary lifelong changes in eating habits and exercise that must complement the surgery. Each patient will meet with the nutritionist one-on-one preoperatively and at postop visits to address individual dietary needs. Close nutritional monitoring during rapid weight loss is critical as certain vitamins and minerals are poorly absorbed and need to be supplemented.
• Psychological evaluation--there are two reasons for preoperative evaluation --one to identify those in whom surgery would be contraindicated and others in whom surgery is likely to be a success. The psychologist or clinical social worker will discuss with the patient issues that are not unique, but certainly common, among many obese adults such as frustration, food cravings and obsessions, self-esteem or confidence issues, anxiety, and depression, and how surgery may realistically impact their life.

Bariatric surgery requires a long-term commitment to positive change on the part of the patient, which will involve modifying eating habits, physical activity habits, and overall lifestyle habits. Clearly, the patient must be prepared and ready for such a challenge. Utilizing such a team approach to bariatric surgery increases the likelihood of success in achieving desirable and realistic weight loss, as well as improvement and satisfaction in daily life for the patient long-term. We also provide and encourage involvement in our CBSI support group to assist patients in continuing to maintain their modified lifestyle they have chosen.

How Bariatric Surgery Results in Weight Loss

To better understand how bariatric surgery results in weight loss, it is helpful to understand how food is digested.

• The digestive process involves breaking food into simple soluble substances so tissues can absorb them.
• The process starts in the mouth when your food is mixed with salivary secretions.
• Within seconds, it travels down the esophagus in peristaltic waves to the stomach.
• The stomach normally holds about 20 to 30 oz (600-1000 cc) at one time.
• Once food enters the stomach, it is sent into the digestive tract in small increments.
• The digestive process continues in the first part of the small bowel (duodenum) where food comes into contact with bile and enzymes secreted by the liver, as well as the pancreas.
• The small bowel is where most of the absorption of food, minerals, and vitamins occurs and consists of a progression from duodenum to jejunum to ileum.
• Eventually, the unusable residue in the small bowel empties into the large bowel (colon) for excretion from the body.

Most bariatric procedures have two components that contribute to their effectiveness in contributing to weight loss:

1. a restrictive component, and/or
2. a malabsorptive component.

Restrictive component

During bariatric surgery a portion of the stomach is made into a small compartment bypassing the majority of the stomach. The volume of the stomach is greatly reduced. Consequently, only a limited amount of food can be eaten before a person is full and their hunger satisfied.

Malabsorptive component

Because of the anatomical restructuring that is done during bariatric surgery, the bile and pancreatic secretions that are necessary for digestion now reach the food further downstream in the small bowel. This delays the digestion of food and causes incomplete digestion and absorption. These structural and mechanical modifications allow patients to satisfy their hunger with less food that reduces caloric intake and ultimate storage of fat.

Bariatric Procedures

Roux-en-Y Gastric Bypass

At CBSI, 99% of our Roux-en-Ys are performed laparoscopically, allowing patients less pain and scarring, a reduced hospital stay, and faster recovery and mobility.
During gastric bypass surgery, a small pouch from your stomach is created.  A piece of small intestine is attached to the pouch so food can come out of the pouch directly into a segment of small intestine, thereby causing a part of the stomach and small intestine to be bypassed.  The mechanism of weight loss is two-fold: the small pouch restricts the amount of food, while the bypass of the stomach and duodenum restricts the body's ability to absorb calories, while still providing adequate nutrition.  As a result of the surgery, changes in eating habits are required.  These included restricted portions of food, as well as food choices that optimize nutritional requirements.
Following gastric bypass surgery, all patients have obesity-related co-morbidities that improve or resolve completely.  Weight loss is initially dramatic with an average weight loss of 90 lbs at 6 months and 117 lbs at 1 year, and weight loss can be anticipated for up to 18 months if patients are compliant with the lifestyle and dietary changes required.
The gastric Roux-en-Y is proven to be safe and effective in morbidly obese patients.  The gastric bypass allows these patients to:

• Lose significant weight and maintain weight loss long-term
• Reverse many obesity-related health problems
• Favorably impact longevity and quality of life

Brief Description of the Gastric Bypass

The laparoscopic Roux-en-Y gastric bypass procedure is a combination of a restrictive and malabsorptive procedure.

• A laparoscopy is a long tube with a small camera lens at one end connected by fiber optics to a television camera at the other end. Several small incisions are made through which instruments are passed to conduct the procedure.
• The upper portion of the stomach is freed and a row of staples is placed horizontally (side to side) a few centimeters below the esophagus--stomach junction.
• A tiny pouch is created at the top of the stomach and is about 1-2 ounces in size. The pouch is totally separated from the rest of the stomach.
• The small bowel (jejunum) is brought up and attached to the stomach pouch, establishing a food channel. The duodenum and first part of the jejunum are separated from this portion of the food channel.
• The upper small bowel which contains the duodenum, bile, and pancreas is attached to the side of the food channel forming a Y-shaped arrangement of the bowel.
• A surgical anastamosis/connection is performed to precisely and accurately secure the stomach pouch.

The procedure results in restricted food intake because of the small size of the stomach pouch and poor absorption of food, because now the bile and pancreatic secretions come into contact with food well beyond the stomach.

Laparoscopic Adjustable Band (Lap-Band)

The Laparoscopic Adjustable Band was approved by the FDA in 2001, and since that time has become a popular alternative to the gastric bypass surgery in this country. Attractive attributes of the Lap Band System are:

• Less invasive surgical option
• Safe - no stomach stapling, cutting or intestinal re-routing
• Effective weight-loss and resolution of co-morbidities over time
• Low re-operation/revision
• Minimal side effects
• Easily reproducible
• Adjustable - customized by our surgeons to meet each individual's unique needs
• Reversible if necessary
• Low malnutrition risk
• Satiety-inducing procedure
• Overnight hospital stay in most cases and early return to work (1 week or less)
• OR time of one hour or less

Weight loss occurs slower with the Lap Band as compared to the gastric bypass with most patients reaching their maximum weight loss at 3 years. The expected long-term weight loss with the Lap Band ranges from 50-60% of the excess body weight. Multiple studies have documented resolution of a majority of the weight-related co-morbidities. Follow up with your surgeon or physician assistant for adjustments, especially in the first year, is vital to the success of the Band.

Brief Description of the Lap-Band Procedure

The Lap Band is a hollow silicone tube that is wrapped around the upper portion of the stomach and then attached to a small port buried beneath the skin and adipose tissue on the abdominal wall. To perform the procedure requires five small incisions through which we place our laparoscopic instruments. We then create a small tunnel around the upper portion of the stomach through which we pass the Band and lock it into place. Several sutures are also placed on the stomach to hold the Band in the correct position.

Once the Band is secured in the correct position, the amount of food that you can eat is diminished considerably. By adding or removing saline through the port, we can adjust the size of the Band to allow you to eat more or less food. The actual adjustment of the Band takes place in our office. It is a quick and simple procedure that is performed by placing a needle into the access port and adding or removing a small amount of saline. During your first year after surgery, you will meet with your surgeon or physician assistant several times to make sure the adjustment is perfect for you. A well adjusted Band will provide a sense of satiety (satisfaction) with small portions and allow you to lose 1.5-2.0 pounds per week.

Lap-Band Clinic - Aftercare and Fill Clinic

The Colorado Bariatric Surgery Institute (CBSI) provides a comprehensive aftercare and fill clinic for all patients with the Lap-Band. If you are a Lap-Band patient in need of routine adjustments or fills, or if you are new to the Denver area seeking an experienced bariatric surgery practice, we can provide immediate and long-term care to support your overall success with the Lap-Band System.

CBSI is recognized as an ASBS Bariatric Surgery Center of Excellence in conjunction with Presbyterian/St. Luke's Medical Center (P/SL). Our experienced and compassionate healthcare team headed by bariatric surgeon, Dr. Tom Brown, has demonstrated a high standard of care in bariatrics with highly favorable patient outcomes, as well as a low incidence of complications. Please contact us if you are a Lap-Band patient in need of assistance in meeting your weight loss goals.

Revisional Bariatric Surgery

Some patients who have had a previous gastric bypass may require a second, or revisional bariatric surgery to get the desired outcome.  There have been multiple bariatric procedures through the years utilizing various techniques with variable outcomes.  Sometimes, these procedures have resulted in insufficient weight loss; the failure to lose weight may be related to mechanical or behavioral reasons.  A thorough workup is necessary to better understand why a patient is not losing weight.  Only after we do that, can we tailor a plan for surgical therapy.

Possible Reasons for Revisional Bariatric Surgeries

• Some patients may have had weight-loss surgery with a good outcome, but have now regained a sufficient amount of weight for some reason, and are in need of a "revision".
• Side effects of surgery, such as persistent ulcers or strictures (narrowing of the anastomosis) may indicate the need for revisional surgery.
• A patient after some weight loss may still be morbidly obese and require a second operation.
• There may be a mechanical failure from the previous operation, such as a Lap-Band slip or problems due to gastric bypass stomach stapling's from the 1980's and 1990's.

Important Factors to Consider with Revisional Surgery

The best outcomes from revisional bariatric surgeries are achieved by the most experienced bariatric surgeons, those who have had experience with both laparoscopic and open surgeries.  A surgeon inadequately trained to do open procedures should not be performing revisional bariatric surgery.  Dr. Brown has performed a significant number of both laparoscopic and open revisional surgeries.

Preoperative Testing for Bariatric Surgery Patients

The following tests or work-ups may be recommended prior to surgery:

• Test to check for gallstones. If necessary, the gallbladder can be removed at the time of surgery
• Heart work-up, including an electrocardiogram (ECG) and/or stress test
• A bone density scan may be performed to check level of bone calcium
• Laboratory tests, including:
  • Hemoglobin--measure of red blood cells
  • Electrolytes--measure of the various salts in the blood such as sodium, potassium, and calcium
  • Glucose--measure of blood sugar, hemoglobin A1C
  • Cholesterol and triglyceride levels--indicators of fat content in the blood
  • Vitamin and mineral levels, such as iron, folic acid, vitamins A, D, E, and K
  • Thyroid and cortisone levels
  • Pulmonary function tests

Other preparation for surgery includes:

• Clear liquid diet for 3 days prior to surgery
• Abstain from aspirin use 2 weeks prior to surgery
• Stop birth control pills and estrogen hormone therapy 2 weeks prior to surgery

No eating or drinking after midnight the night before surgery

Potential Complications of Surgery

• The intricacies of the bariatric procedure itself, which may include:

• Bowel or stomach leaks that results in an abscess that requires operative repair
• Obstruction of the stomach at the point of the anastamosis that may require dilatation through a gastroscope
• Wound infections
• Formation of ulcers at the attachment of the small bowel to the stomach
• Development of gallstones

• Or, events related to an major abdominal operation, such as:

• blood clots
• infection
• pneumonia
• bleeding
• development of hernias
• Wound infection

It is important to understand that several complications related to surgery are more prevalent in obese patients, often due to poor heart and lung function. These include myocardial infarction or heart failure and pulmonary complications such as respiratory failure or pulmonary embolus, lung collapse, or pneumonia.

Postoperative Care

Immediate Post-op care for the Roux-en-Y Gastric Bypass

• A hospital stay of 2-3 days is expected for laparoscopic gastric bypass; if the procedure was open, a slightly longer stay of 5 to 7 days is expected.
• In the first few days postoperatively, oral pain medication will be provided as needed.
• Walking is very important and we'll encourage and assist you in doing so within hours of waking from surgery; moving your legs and pumping your feet while in bed is important to prevent blood clots.
• For the gastric bypass, the initial diet is usually started soon after surgery, and consists of broth, sugar-free Jello, and hot tea.
• Once these clear liquids are tolerated, small meals of pureed preparations are introduced followed by high protein foods.
• When eating it is important to not "overload" since nausea, pain, vomiting, and possible injury to the surgical site can occur.
• Solid food is introduced at approximately 4 weeks, reducing eating habits to three meals a day.
• Water intake is only between meals, and small, frequent sips are recommended.
• Vitamin and mineral supplements are recommended: Initially, two chewable vitamins will be taken daily , whereas later, one prenatal vitamin with extra supplemental calcium daily is recommended.

 Immediate Postop Care for the Lap-Band

• Generally, no overnight stay is required for the Lap-Band
• Immediately postop, oral pain medication will be provided as needed.
• Walking is important and we'll encourage and assist you in doing so within hours of walking from surgery
• Initial diet is a pureed liquid diet of 2 weeks
• Water intake requires frequent sips
• Return to work usually within 1 week

Long-term Care of the Gastric Bypass

• For a few months, diarrhea with gas can be expected due to partially digested food; some may experience constipation. Keep in mind it is normal for some to have both a decrease in frequency and amount of bowel movements.
• During the first 6 months, the most rapid weight loss is experienced, followed by a slower loss of weight over the next 12 to 18 months.
• Although physical hunger may not be apparent during the first 6 months, after that a "normal" appetite will return.
• Associated illnesses (co-morbidities) improve or resolve after only a few months of weight loss.
• Multivitamins and iron supplements will be needed to make up for poor absorption.
• Follow-up visits to your health care team are important; visits include blood monitoring, as well as evaluation of nutritional parameters.
• Due to loss of fat under the skin, there may be excessive loose skin hanging from the abdomen, which may require plastic surgery.
• Daily exercise will continue to help you lose and maintain weight.
• Yearly screening should include a chemistry screen, hemogram, serum iron, vitamin B12, and folate levels to potentially detect any deficiencies such as anemia.

Long-term Care of the Lap-Band

• Transition to regular textured low-fat, low-sugar heart healthy diet
• Regular exercise
• Within the first year, most patients will need 5 to 6 adjustments of their Lap-Band

Expected Outcome of Bariatric Surgery

From the Medical Literature

Everyone loses weight in the first weeks and months following surgery. This initial weight loss is rapid and dramatic. During this time the stomach pouch created gradually increases in size to a capacity of about 5-6 ounces. Maintaining lost weight is largely dependent on adopting proper dietary habits to ensure usefulness of the stomach pouch.

Bariatric surgical patients can expect to lose up to 65- 75% of excess weight by one year and additional weight loss in the second year. Usually weight loss stabilizes at this point, on the basis of three healthy and moderate meals a day, and avoidance of calorie-containing beverages.

Weight loss usually reaches a maximum between 18 and 24 months, postoperatively. Data suggest that mean weight loss at 5 years ranged from 48 to 74% after gastric bypass, and long-term weight loss (14 years) exceeded 50% (Pories WJ. Ann Surg 1995; 222;339). Weight loss surgery has been reported to improve several co-morbid conditions such as glucose intolerance and diabetes, sleep apnea, and obesity-associated hypoventilation (Charuzi I. Am J Clin Nutr 1992; 55(2Suppl):594S; Sugarman HJ. Am J Clin Nutr 1992; 55(2Suppl): 597S).

CBSI Outcomes Data

Weight loss

• 100% of our patients lose weight
• For the gastric bypass, average weight loss at 6 months is approximately 90 lbs.; at 1 year weight loss is approximately 117 lbs.
• At 6 months, average reduction in BMI is 13.5 points (13.65) for the gastric bypass, representing a 67% reduction in excess body weight
• At 1 year, average reduction in BMI is 18 points (18.11) for the gastric bypass, representing a 71% reduction in excess body weight

Co-morbidities

• Almost 80% of patients have 4 or more co-morbidities prior to surgery; within 6 months nearly all these co-morbidities have improved or even resolved
• 94% of diabetes resolves within 1 month
• 66% of hypertension resolves within 6 months
• 64% of sleep apnea resolves at 1 year

Surgery

• 99% of our bariatric surgeries are successfully completed laparoscopically
• complications such as leaks (<1%) are very low (overall rate <4%) which is consistent or better than reported in the medical literature

Questions and Answers about Bariatric Surgery

Will my health insurance pay for surgery?
Some insurance companies do have exclusions in their policies for weight loss surgery. An exclusion means that they will not pay for the surgery even if it is proved medically necessary. However, more and more insurance carriers now provide some coverage for bariatric surgery and will at least pay a portion. We can help you determine what your benefits are, so that right from the start you know what your surgery will cost.

How do I know if weight loss surgery will be successful for me?
Only you can decide if the surgery is right for you. Surgery is only a tool, since strict adherence to dietary, exercise, and lifestyle changes are essential to long-term success. Weight loss surgery will only succeed when you make a life-long commitment to these changes. However, if you are motivated to make these changes, surgery can have a great impact on your life, likely improving the quality and longevity of life.

With the gastric bypass, how big will my pouch be?
The newly created pouch will be about the size of your thumb, with the capacity to comfortably hold about 2 ounces. With time, the pouch will enlarge to 6 to 8 ounces, but it must be carefully managed so that it does not enlarge too much too soon. That's why it is important to follow your dietary and nutrition guidelines that we carefully outline for you.

Is it possible to dine out and stick to your diet after your bariatric surgery?
Dining out can be a challenging event for anyone watching their diet, so it is important to be very deliberate dining out following your  bariatric surgery. However, eating out is a reality for most of us today. We have plenty of tips and advice on how to successfully "dine out" without compromising weight loss.

What does an adjustment involve with my Lap-Band?
In the first year, most patients will need 5 or 6 adjustments.  If you are feeling constantly hungry and no weight loss is occurring it is likely time for an adjustment.  Alternatively, if you are not able to eat much of anything without feeling uncomfortable of vomiting, your Band may be too tight, also requiring an adjustment.
During each adjustment, a specialized "fill" needle is placed into the port and sterile saline is either added (tightening the band) or deleted (loosening the band) depending on your individual needs.

Can I get pregnant following weight loss surgery and is it safe?
Yes, pregnancy can be very safe following surgery. It is recommended that a woman wait until she is 1 year to 18 months post-operative before getting pregnant to assure that her weight has stabilized. If a bariatric surgery patient does become pregnant, it is important that labs are monitored regularly to ensure that vitamin or mineral deficiencies do not occur. 

Why should I choose a multidisciplinary program?
A team approach to treatment results in better long-term outcomes for patients. At CBSI, people who are candidates for bariatric surgery will undergo a thorough team evaluation prior to any treatment.  In addition, patients will have extensive follow-up by both the surgeon and other health professionals as they progress. Such an approach is associated with long-term successful weight loss.

Bariatric surgery requires a long-term commitment to positive change on the part of the patient; eating habits, physical activity habits, and overall lifestyle habits will undergo significant modification. The patient must be prepared and ready for such a challenge. Utilizing such a team approach to bariatric surgery increases the likelihood of success in achieving desirable and realistic weight loss, as well as improvement and satisfaction in daily life for the patient long-term. We also provide and encourage involvement in a support group to assist patients in continuing to maintain their modified lifestyle they have chosen.

What is the value of the CBSI Support Group?
The 3rd Wednesday of each month, CBSI holds a support group for its patients. It generally follows an education seminar on a topic of interest to most bariatric surgery patients (ie, Dealing with New Body Image, Role of Plastic Surgery, Physical Therapy/Exercise Advice), and It is facilitated by our bariatric surgery professionals like our bariatric coordinator, our dietitian, and/or our clinical social workers. It is a wonderful opportunity for our patients to gain insight and guidance as they journey through this major change in life.
Participation in the CBSI bariatric surgery support groups is strongly encouraged. Support groups are a valuable aid in learning and feeling comfortable with modifications in your daily habits and lifestyle. Talking and sharing with other patients helps you realize any limitations you may feel, and that these limitations likely pale in comparison to those experienced by the person who continues to be morbidly obese. Bring your family and friends as well, as support groups can be a great source of support and encouragement to them as they assist you in achieving your goals.