Surgery for Severe Obesity

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KEY POINTS

• If you are severely obese, surgery may help you lose weight when other treatments have not worked.
• There are many types of bariatric surgery. Your healthcare provider will work closely with you to figure out the best type of surgery for you.
• Ask your provider how long it will take to recover and how to take care of yourself at home.
• Make sure you know what symptoms or problems you should watch for and what to do if you have them.

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What is surgery for severe obesity?

Surgery for severe obesity may be done to help you lose weight when other treatments have not worked. The aim of surgery is to change your stomach or intestines to limit the amount of food you can eat before you feel full. It is also called bariatric surgery.

Severe obesity is defined as being more than 100 pounds overweight or having a body mass index (BMI) of 40 or higher. BMI is a number that takes into account both your height and your weight. A BMI of 25 or more indicates that you are overweight. A BMI of 30 or more means that you are obese. Severe obesity is when you have a BMI of more than 40, or of more than 35 when you have a serious health problem related to your weight.

When is it used?

Severe obesity is a serious condition. It increases your risk of poor health and major illnesses, such as heart disease, stroke, cancer, high cholesterol, and diabetes.

Usually bariatric surgery is done only if:

• You have tried other treatments, including low-calorie diets and exercise, but you have not lost enough weight
• You have a BMI greater than 40 or a BMI greater than 35 with an illness related to obesity. This surgery can:
  • Lower blood sugar levels
  • Lower blood pressure and cholesterol
  • Lessen the workload on your heart
  • Improve sleep apnea, which is a problem where you stop breathing for more than 10 seconds at a time many times while you sleep

Before you can have bariatric surgery, you need to be ready to change your lifestyle. Your provider will recommend that you:

• Meet with a dietitian about changing the way you eat. For example, after surgery you need to make sure that you get the nutrients you need. You will be eating smaller amounts, drinking lots of liquid, and eating slowly. You may also need to take protein and vitamin supplements.
• Follow a supervised diet before surgery to show that you are willing to make changes to improve your health.
• Get counseling and support before and after surgery. It’s a big change that will affect your mind and emotions, as well as your body. You need to understand that surgery doesn’t mean your weight loss is permanent. You will need to eat a healthy diet and exercise, or you will likely gain back the weight.

How do I prepare for this procedure?

• Talk to your healthcare provider and to other people who have had the surgery. Knowing what to expect can help lessen anxiety about the operation.
• Make plans for your care and recovery after you have the procedure. Find someone to give you a ride home after the procedure. Allow for time to rest and try to find other people to help with your day-to-day tasks while you recover.
• Your healthcare provider will tell you when to stop eating and drinking before the procedure. This helps to keep you from vomiting during the procedure.
• Tell your healthcare provider if you have any food, medicine, or other allergies such as latex.
• Follow your provider's instructions about not smoking before and after the procedure. Smokers may have more breathing problems during and after the procedure and heal more slowly. It’s best to quit 6 to 8 weeks before surgery.
• You may or may not need to take your regular medicines the day of the procedure. Tell your healthcare provider about all medicines and supplements that you take. Some products may increase your risk of side effects. Ask your healthcare provider if you need to avoid taking any medicine or supplements before the procedure.
• Follow any other instructions your healthcare provider gives you.
• Ask any questions you have before the procedure. You should understand what your healthcare provider is going to do. You have the right to make decisions about your healthcare and to give permission for any tests or procedures.
• Contact your insurance company to find out if it will pay for this surgery for you. If not, you need to make payment arrangements.

What happens during the procedure?

Before the procedure, you will be given a general anesthetic to keep you from feeling pain. A general anesthetic relaxes your muscles and puts you into a deep sleep.

• Obesity surgery may be done in the following ways:
  • Gastric banding (LAP-BAND): A band is placed around the upper part of your stomach. A soft cap (port) connected to the band is placed under the skin near your stomach. Fluid can be injected or removed with a needle inserted through the port. The fluid tightens the band to control the size of the stomach and limit the amount of food you can eat at one time. Fluid can be removed to relax the band if necessary.
  • Roux-en-Y gastric bypass surgery (RYGB): Much of the stomach, which is normally the size of a football, is stapled shut. A small pouch of stomach, about the size of an egg, is then connected to the small intestine.
  • Vertical sleeve gastrectomy (VSG): Most of the stomach is removed, leaving a small tube of stomach, called a gastric sleeve, connected to the intestine as it was before the surgery.
  • Biliopancreatic diversion with a duodenal switch (also called BPD-DS or duodenal switch): A large part of the stomach is removed, leaving a gastric sleeve. The stomach will still move food into the top part of the small intestine called the duodenum. The duodenum will be connected to the top part of the large intestine.
  • Vagal nerve blockade (VBLOC): Electrodes are placed onto the lower part of the stomach and attached to a battery pack. Electrical signals block the vagus nerve in the stomach to decrease feelings of hunger.
  • Intragastric balloon system: One or two balloons filled with salt water are placed in the stomach to take up space. The balloons make you feel full and decrease the amount of food you can eat.

These procedures may be done in 2 ways:

• Laparoscopic surgery is done through several small cuts in the belly. A laparoscope is a lighted tube with a camera. Your provider can put the scope and tools into your belly through the small cuts. Most surgeries are done this way.
• Open surgery (with bigger cuts in the belly) may be needed if you are very obese, have had belly surgery before, or if you have certain medical problems.

What happens after the procedure?

Depending on the type of procedure you have, you will stay at the hospital for several days. You may be able to return to your normal activities in 3 to 5 weeks.

You will need follow-up visits for the rest of your life. Depending on which procedure you have, your diet may need to change in the following ways:

• You may need to eat very small servings. At first, eat just a few tablespoons at a time and then up to a little over half a cup by the end of a year. If you eat too much, you may vomit and gag on food, or injure the new stomach pouch. It may be hard to eat tough foods like steak, or foods that are hard, like carrots or apples.
• You may not be able to eat foods high in sugar because your body may not be able to digest it well. After some procedures, eating or drinking too fast, or eating too much fat or sugar can cause dumping syndrome. This means that you will have nausea, vomiting, diarrhea, dizziness, and sweating after eating. Dumping syndrome is usually not a problem if the gastric band procedure is used.
• You may need to keep track of what you eat to be sure you get enough protein.
• You may need to take protein, vitamin, and mineral supplements for the rest of your life.

What are the risks of this procedure?

Every procedure or treatment has risks. Some possible risks of this procedure include:

• You may have problems with anesthesia.
• You may have infection, bleeding, or blood clots.
• Other parts of your body may be injured during the procedure.
• You may tire of the very restricted eating, and you may gain some weight back.

Ask your healthcare provider how these risks apply to you. Be sure to discuss any other questions or concerns that you may have.