• The Normal Digestive Process
• How Does Surgery Promote Weight Loss?
• What Are the Surgical Options?
• Explore Benefits and Risks
• Medical Costs
• Is the Surgery for You?
• Additional Reading

Body Mass Index. Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. Then look to find your weight group.

Restrictive operations serve only to restrict food intake and do not interfere with the normal digestive process. To perform the surgery, doctors create a small pouch at the top of the stomach where food enters from the esophagus. Initially, the pouch holds about 1 ounce of food and later expands to 2-3 ounces. The lower outlet of the pouch usually has a diameter of only about ? inch. This small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only ? to 1 cup of food without discomfort or nausea. Also, food has to be well chewed.

Restrictive operations for obesity include adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG).

• Adjustable gastric banding. In this procedure, a hollow band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach (figure 2). The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.

• Vertical banded gastroplasty. VBG has been the most common restrictive operation for weight control. As figure 3 illustrates, both a band and staples are used to create a small stomach pouch.

Although restrictive operations lead to weight loss in almost all patients, they are less successful than malabsorptive operations in achieving substantial, long-term weight loss. About 30 percent of those who undergo VBG achieve normal weight, and about 80 percent achieve some degree of weight loss. Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the patient’s willingness to adopt a long-term plan of healthy eating and regular physical activity.

A common risk of restrictive operations is vomiting, which is caused when the small stomach is overly stretched by food particles that have not been chewed well. Band slippage and saline leakage have been reported after AGB. Risks of VBG include wearing away of the band and breakdown of the staple line. In a small number of cases, stomach juices may leak into the abdomen, requiring an emergency operation. In less than 1 percent of all cases, infection or death from complications may occur.

Malabsorptive Operations

Malabsorptive operations are the most common gastrointestinal surgeries for weight loss. They restrict both food intake and the amount of calories and nutrients the body absorbs.

• Roux-en-Y gastric bypass (RGB). This operation, illustrated in figure 4, is the most common and successful malabsorptive surgery. First, a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the amount of calories and nutrients the body absorbs.

• Biliopancreatic diversion (BPD). In this more complicated malabsorptive operation, portions of the stomach are removed (see figure 5). The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure successfully promotes weight loss, it is less frequently used than other types of surgery because of the high risk for nutritional deficiencies. A variation of BPD includes a “duodenal switch” (see figure 6), which leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway.

Malabsorptive operations produce more weight loss than restrictive operations, and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally lose two-thirds of their excess weight within 2 years.

In addition to the risks of restrictive surgeries, malabsorptive operations also carry greater risk for nutritional deficiencies. This is because the procedure causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion surgery must also take fat-soluble (dissolved by fat) vitamins A, D, E, and K supplements.

RGB and BPD operations may also cause “dumping syndrome.” This means that stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and sometimes diarrhea after eating. Because the duodenal switch operation keeps the pyloric valve intact, it may reduce the likelihood of dumping syndrome.

The more extensive the bypass, the greater the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require close monitoring and life-long use of special foods, supplements, and medications.

• Right after surgery, most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. Although most patients regain 5 to 10 percent of the weight they lost, many maintain a long-term weight loss of about 100 pounds.
• Surgery improves most obesity-related conditions. For example, in one study blood sugar levels of 83 percent of obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had lived with diabetes for a long time.

• Ten to 20 percent of patients who have weight-loss surgery require follow-up operations to correct complications. Abdominal hernia was the most common complication requiring follow-up surgery, but laparoscopic techniques seem to have solved this problem. In laparoscopy, the surgeon makes one or more small incisions through which slender surgical instruments are passed. This technique eliminates the need for a large incision and creates less tissue damage. Patients who are superobese (>350 pounds) or have had previous abdominal surgery may not be good candidates for laparoscopy, however. Less common complications include breakdown of the staple line and stretched stomach outlets.
• Some obese patients who have weight-loss surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, a person’s risk of developing gallstones increases. Taking supplemental bile salts for the first 6 months after surgery can prevent gallstones.
• Nearly 30 percent of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies usually can be avoided if vitamin and mineral intakes are high enough.
• Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.

• a BMI of 40 or more
• a life-threatening obesity-related health problem such as diabetes, severe sleep apnea, or heart disease and a BMI of 35 or more
• obesity-related physical problems that interfere with employment, walking, or family function.

• unlikely to lose weight successfully with nonsurgical measures?
• well informed about the surgical procedure and the effects of treatment?
• determined to lose weight and improve your health?
• aware of how your life may change after the operation (adjustment to the side effects of the surgery, including the need to chew well and inability to eat large meals)?
• aware of the potential for serious complications, dietary restrictions, and occasional failures?
• committed to lifelong medical follow-up?