About Weight Loss Surgery

Weight loss surgery, or bariatric surgery, is surgical intervention to treat obesity in order to correct the medical issues associated with the disease. Weight loss surgery has a long history of over six decades, however it has become more popular in recent years with the increased availability of lower-risk minimally invasive procedures coupled with a staggering rise in obesity rates in the United States. Further, enhancements in surgical techniques have meant that the traditional large incision of old has been replaced with minimally invasive techniques that allow the surgeon access to the abdomen through a few small 1/5 inch to 1/2 inch incisions.

Patients considering weight loss surgery should have   a BMI of 30 or > with poorly controlled diabetes and other comorbidities such as cardiovascular disease, BMI of 35 or > with a single significant co-morbidity or anyone with a BMI of 40 or greater.

Many insurance companies require proof that the patient has tried to lose weight through traditional means including diet and exercise before they opt to undergo bariatric surgery. In most cases an insurance company will expect to see some proof that a patient has tried all other reasonable weight loss options before considering bariatric surgery.

Bariatric surgery assists with weight loss in one or both of three ways. Restrictive bariatric procedures limit the amount of food a patient can consume at one time, contributing to a sense of fullness and eventual weight loss. Other procedures  involve malabsorption, which means that absorption of calories into the blood stream from the intestine is limited because the intestine has been re-routed in some fashion.

Metabolic changes are associated with all weight loss procedures but are inherent in the sleeve gastrectomy and BPD with duodenal switch by virtue of removing the Ghrelin (Hunger hormone) producing portion of the stomach.

Patients have several options when considering bariatric procedures. These options range from less-invasive procedures that offer a relatively lower degree of excess weight loss and are frequently not successful (Adjustable Gastric Band), to more complex combination procedures that can offer up to 85% or more long-term excess body weight loss. The procedures most often performed include:

• Gastric Bypass: a combination of restriction and malabsorption
• Gastric Sleeve: a restrictive and metabolic procedure
• Duodenal Switch: a combination of restriction, metabolic and malabsorption (Most effective weight loss procedure with best overall resolution of comordities)
• SADI-S (Single anastomosis duodeno-ileal bypass with sleeve gastrectomy); Very similar to the duodenal switch but has a single anastomosis with a loop duodeno-ileal anastamosis
• Adjustable Gastric Banding (Lap-Band®): restrictive procedure (Seldom performed now due to lack of longterm effectiveness; this procedure is not offered by most bariatric surgeons)

It is important to remember that weight loss surgery is primarily performed to eliminate the diseases associated with morbid obesity and that the resulting weight loss is simply a very positive side effect of surgery. Therefore, bariatric surgery should not be considered an aesthetic or cosmetic surgical option. Patients should expect to be evaluated for medical necessity for the surgery – i.e. obesity is causing serious medical issues such as type-2 diabetes, high cholesterol, high blood pressure and sleep apnea. Every insurance company will have their own qualifying criteria above FDA and practice guidelines.

Weight  loss surgery has grown in scope as new techniques and minimally invasive surgery have made the process safer and more effective. Patients should educate themselves on weight loss surgery and the options available to them, because there is no one-size-fits-all procedure. A patient’s weight, surgical risk, comorbidities, age and gender will all play a part in determining which procedure is right for them. it is important to note that these procedures come with some degree of surgical risk and should be considered major procedures. Patients should find an experienced surgeon and attend bariatric surgery seminars in their area to learn more about the procedures, benefits and risks.

References:
¹ Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery. A systematic review and meta-analysis. JAMA. 2004;292:1724-1737.