Weight loss surgery has become one of the most common operations performed in the United States. This trend began about 20 years ago in response to the growing epidemic of obesity and the introduction of laparoscopy procedures. Obesity is the number one public health issue today. Nearly two thirds of Americans are either overweight or obese and over 20 million are considered candidates for a weight loss operation. Interestingly, the incidence of obesity has steadily and rapidly increased only since the 1980’s. The etiology of this phenomenon is multifactorial. While high calorie, inexpensive and readily available foods are contributing factors, the genetic predisposition of humans to eat as much as they can- whenever they have the opportunity- is a survival mechanism that cannot be ignored. Non-operative methods of weight loss, at least for individuals who have morbid obesity, have provided dismal long term results. In fact, only about 5% of individuals with a BMI of > 35 will be able to lose weight and keep it off long term with a non-operative approach that includes diet, exercise and counseling.
Surgery for weight loss is not new. The first operations designed to help individuals lose weight were performed in the 1960s. The earliest professional endorsement of weight loss surgery occurred in 1991 when the NIH Consensus Conference on Obesity declared that weight loss surgery was a good option for those who had been unable to lose weight by non-operative methods. Today, weight loss surgery is considered the “standard of care” for individuals with morbid obesity who have failed non-operative attempts at weight loss. The vast majority of weight loss (metabolic and bariatric) surgeons perform one or more of three key operations; the adjustable gastric band, the sleeve gastrectomy or the gastric bypass.
With this operation, about 2/3 of the stomach is removed to create a tube or “sleeve” of the remainder of the stomach. This operation is also performed with a laparoscope and patients typically spend one or two nights in the hospital after the operation.
The stomach is divided to create a small proximal pouch that is then anastomosed [connected] to a limb of small intestine. Food that enters the gastric pouch “bypasses’ the remainder of the stomach and first portion of the small intestine. The operation is performed with a laparoscope and there is a one or two day hospital stay.
Adjustable Gastric Band
The gastric band is an inflatable silastic ring that is placed around the proximal stomach. It is attached by tubing to a reservoir or port that is placed under the skin on the abdomen. This port can be accessed with a Huber needle, infused with fluid, and the band inflated or deflated (adjusted) to limit or slow the passage of food into the stomach. The band is placed with a laparoscope, as an outpatient procedure.
In general, success after weight loss surgery is more dependent on the patient than on the operation. However, there are observations and research that can be applied to the decision making process of which operation is best for a patient.
The average weight loss after a gastric sleeve and gastric bypass are similar at about 65% of excess weight after 5 years, while the average weight loss after a gastric band is 50% of excess weight after 5 years. The gastric sleeve and bypass tend to provide better weight loss for patients with higher BMI’s and the “super obese”. They also tend to offer better outcomes, with improvement or resolution of the condition, in diabetic patients. The gastric band requires a more intensive follow up regimen since adjustments to the band are required for optimal weight loss.
While complications after a gastric band tend to be less frequent and less severe than the “stapled” procedures (gastric sleeve and bypass), the incidence of complications following all bariatric surgery options has declined dramatically in the past decade. The laparoscopic approach to weight loss surgery has had the most significant impact on post-operative recovery and return to work. It is quite remarkable that patients who undergo a laparoscopic sleeve gastrectomy (a two thirds gastrectomy) may go home on the day after their operation and return to work within a week.
Recently, robotic-assisted techniques have been incorporated into the laparoscopic platform. Robotic technology applied to laparoscopic instrumentation translates the gross wrist and finger movements of the surgeon into fine and more controlled movements. This allows for a more precise movement of the instruments and, in most surgeons hands, a safer alternative for the patient.
The criteria for weight loss surgery are:
1. BMI of >40, or >35 with any “co-morbid” conditions
2. Attempted, and failed, a medically supervised weight loss program
3. Ability to tolerate a general anesthetic
4. Passing a psychological assessment
5. Completion of the pre-operative educational program.
Obesity is typically defined by body mass index (BMI). This is a formula that takes into account an individual’s weight and height [(weight in pounds/height in inches x height in inches)] x 703. A simpler method of finding BMI is to use a chart like the one below.
The following definitions are given to a range of BMIs:
Healthy Weight 18-24
Morbidly Obese 35-50
Super Morbid Obesity >50
The term morbid obesity is used when the BMI is greater than 35 because it is with these weights that individuals begin to have medical or “morbid” conditions that are either due to, or made worse by, their obesity. The list of medical problems or “co-morbidities” that accompany obesity is long, but the most common examples include diabetes, hypertension, sleep apnea, arthritis, gastro-esophageal reflux, hyperlipidemias, menstrual irregularities, urinary incontinence and infertility. Another morbid outcome of obesity is that it reduces an individual’s life span.
One of the most important aspects of weight loss surgery is the evaluation and preparation of patients prior to their operation. I see each patient at their initial visit and perform a thorough history and physical examination. It is not unusual for patients to tell me that they have avoided their primary care physician because of embarrassment or shame. I encourage them to revisit their doctor so their physician can be a part of their support network. We have a comprehensive program that includes a dietitian, psychologist and registered nurse who functions as educator and coach.
This support staff provides an essential element to every patient’s success. Finally, we emphasize the importance of long-term follow up. We ask each patient to commit to regular appointments with us for 5 years after surgery. This follow up has been shown to have a positive influence on their weight loss.
In summary, weight loss surgery is the most effective and safest treatment available today for obesity. It is an operation that can “cure” several conditions, both the obesity and the co-morbidities of obesity, at the same time. It can prolong life and is truly a life changing opportunity for those interested in improving their health.
John A. Dietrick, M.D., is the Medical Director of the Surgical Weight Loss Program at Florida Hospital Tampa. He board certified by the American Board of Surgery and a Fellow of the American College of Surgeons, and is a member of the American Medical Association, the American Society for Bariatric and Metabolic Surgeons and the Hillsborough County Medical Association. He received his M.D. at Wright State University in Dayton, Ohio, and completed both his internship and surgical residency at Loyola University in Chicago, Illinois. He previously served on the faculty at the University of Toledo Medical Center where he was appointed Chief of Trauma Surgery and Associate Director of the Surgical Training Program.
By John Dietrick, MD