Obesity Surgery or Bariatric Surgery - The Pro & Cons

Everything you need to know before you consider getting weight loss surgery

Bariatric surgery isn’t for everyone. There are risks, financial considerations and medical issues to take into account.

Weight loss surgery isn’t a magic wand – If you choose to undergo surgery, you will still have to modify your diet and eating habits before and after the procedure.

Our LifeShape programs are an excellent alternative to bariatric surgery. We can help you make healthy lifestyle changes to achieve long term health and weight loss.

Obesity surgery, also known as bariatric surgery, may be used to assist in weight loss in severely obese patients and for the control of Diabetes.  It can be either a restrictive or diversion (malabsorptive) type of surgery. An important fact is that in obese people there is no clinical disease of the stomach or intestines which requires surgical change or removal. These major and mostly irreversible procedures are done to in order to reduce food intake or speed up its process through the body to elimination. These changes require a lifetime of careful management.  No one should undertake bariatric surgery without first seriously attempting a lifestyle weight loss program with the input of a multidisciplinary team of clinicians, such as Doctors, Dietitians, Exercise Physiologists and Psychologists. Bariatric surgery is expensive and can cost at least $10,000 – $15,000 for patients without private health insurance and often these costs do not cover the necessary follow up care which is highly recommended.

Recent FY17 data from the Australian Bariatric Surgery Register BRS* shows that the most common procedure is the Sleeve Gastrectomy at 65% with Gastric Bands now falling to 9% of procedures. Patients are 80% female, have a BMI of 43 (morbidly obese category) and 14% reporting Diabetes. BRS also shows that of the 30,000 patients in its records, over 8,000 have had multiple procedures indicating failures of the initial surgeries to provide satisfactory weight loss.

The purpose of Gastric Bands and Sleeve Gastrectomies is to reduce the volume of a normal stomach from one liter to a very small volume (30 mls with a band and 180 mls in a sleeve) leading to dramatically reduced food intake and early satiety.  Overeating or consuming certain food types will lead to immediate discomfort and regurgitation.

The other type of surgery, diversion surgery such as Roux-Y Gastric Bypass RYGB and Single Anastomosis Gastric Bypass SAGB, involves intestinal diversion bypassing a large absorptive region of the small intestine.  This type of surgery reduces the digestion and absorption of foods and is best described as weight loss through malabsorption of food passing rapidly through the intestinal tract to elimination.

What are the Potential Risks?
Complications rates vary from leakage of stomach contents internally, infections and in low instances death (less than 0.1%).  Complications vary according to the type of procedures with reported rates of 2.4% for primary procedure and 7.3% for secondary procedures (revisions).  A person’s age, weight and medical conditions affect the risk entailed in having an anaesthetic and undergoing surgery.
Who Is It For?
Bariatric surgery is an option in carefully selected patients with clinically severe obesity, meaning a BMI greater than 40 (morbidly obese), or BMI greater than 35 with associated conditions such as uncontrolled Diabetes Type 2.  Surgery is considered in patients where properly conducted lifestyle behavior change programs have been unsuccessful and where the client is at a high risk for obesity related morbidity (illness) or mortality.

Bariatric surgery is not a ‘silver bullet’ as it is treatment therapy that still requires extensive lifestyle changes.  Post-surgery, there are specific eating strategies that need to be followed by patients, as well as some foods that must be strictly avoided.  Food-related issues such as overeating and binge eating, excessive alcohol intake and a range of non-hunger eating cues must be examined prior to surgery and continue to be managed post-surgery in order for bariatric surgery to be successful.  Bariatric surgery is only a tool and the patient must be prepared to make the necessary changes for it work.  The patient must follow the nutritional and exercise recommendations and make appropriate lifestyle and behavior modifications around food composition and activity.

What Behavioural & Lifestyle Changes are Still Required?
In terms of behavioural change, patients will have definite eating restrictions in place.  Patients are required to eat meals slowly over a period of 20-30 minutes, stopping when satisfied and before feeling full or overfull.  All foods need to be chewed very well and some foods that are difficult to chew finely may continue to be a problem in the long term.  Common problem foods include dry-cooked meats (especially red meats), chicken breast and all meat consumed must be tender and moist. White bread and stringy fibrous foods generally need to be avoided.

It is important that foods and fluids are consumed separately to avoid food being ‘washed’ down.  Consuming food and fluids together tends to result in reduced satiety and often a greater energy intake.  Grazing and unstructured snacking is not recommended and patients need to pay close attention to meal timing.  It can be a balancing act to ensure that meals are of sufficient volume and quality to help reduce grazing habits, yet small enough to avoid physical discomfort and/or vomiting and weight stabilization or gain.  Patients still need to manage their energy intake.  For example, milk and ice cream are easy to manage with a Gastric Band, however their high-caloriecontent make it easy to consume too much energy, therefore leading to poor weight loss or even weight gain.

Rate of Weight Loss and Follow Up
The rate of weight loss is slow, between half and one kg per week following bariatric surgery and will plateau between 12 to 24 months following surgery provided the nutritional guidelines are followed. It is important to remember patients become lifetime patients for life, as they are required to engage in lifelong behavioral change. The BSR shows weight loss at 24 months stabilizing at 20% of initial body weight. BMI decreases of up to 10 points are reported at 12 months which still places the average patient in the obese category.

After bariatric surgery, provided the guidelines are adhered to, blood glucose levels may return to normal in up to 50% of people without diabetes medication. Depending on the type of surgery undertaken improved glucose control is achieved by different mechanisms. Following Gastric Bands is related to weight loss which is relatively slow but following more extreme bypass procedures it is related to the effects of surgery on the stomach and its mechanical and hormonal pathways. This is not clearly understood.

Do People Fail to Lose Weight
Yes there is a failure rate with bariatric surgery with 5 year data showing that bariatric surgery fails in up to 33% of patients through re-expansion of the stomach from its restricted size in Sleeve Gastrectomy and the failure to adhere to the nutritional guidelines around food composition and calorie intake. Excess liquid calories and high calorie soft foods are the main danger.  The changes are life long and if patients are not in the frame of mind to make those changes then bariatric surgery may not be successful.

The Great Irony

The irony of bariatric surgery is that if the necessary recommendations around eating behaviour post surgery were implemented prior to surgery – bariatric surgery would not be needed. The effects of the surgery are mechanically forcing them to adjust their eating behaviours from the resulting significantly reduced stomach volumes. The act of surgery is a de facto block on previous eating behaviours. For those that don’t change and learn to ingest high calorie soft foods, weight loss and health improvements won’t occur. For those that do the ensuing health benefits are the same that can be achieved by changing to a sustainable healthy eating and activity pattern. The key learning is that no one should undertake bariatric surgery without seriously undertaking a well designed lifestyle and behaviour change weight loss program with a qualified team of clinicians.

Conclusion

There is a role for bariatric surgery in people that simply have no other option; but it comes with procedural risk and the price of permanent change to food composition, texture and eating style far beyond that of a healthy eating pattern.  Those requirements should be considered carefully by any person thinking of bariatric surgery.

*Bariatric Surgery Registry, School of Public Health and Preventive Medicine, Monash University, link.

“I had tried other programs in the past, but they only worked to a certain extent. I was facing surgery as my only other option which I really didn’t want to resort to. When I found out the weight loss was supervised by Doctors, I finally decided to give it a try.” – Peter

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