Frequently Asked Questions About Weight Loss Surgery

Assuming the qualifications are met for a bariatric procedure, is weight-loss surgery the right choice for everyone?

I often meet people from all walks of life who suffer from the same problem and have tried the same things only to unfortunately obtain the same disappointing results. Repeatedly doing the same things while hoping for something better but not achieving better results is extremely disappointing and, for a lot of people, demoralizing. It causes people to give up on not just dieting and exercise but also life in general.

For those who have not had success with diet and exercise, bariatric surgery remains the safest and most effective method for weight loss. I would add, though, that surgery is for the committed patient who can provide a lifelong commitment toward improving his or her nutrition and following up with the medical specialist.

Can bariatric surgery actually cure obesity?

It's a treatment for obesity. When patients have body mass indices over 35, it's almost impossible to lose weight down to a normal body mass index, and, compared to surgery, the best diets or medical therapy come nowhere close to being as effective, a lot of times due to patient compliance issues.

Overall, most patients have a baseline level of hunger that becomes altered once they have attained a high body mass index. It's like living like a billionaire your whole life and then being put on a budget. Your body's going to know something has changed dramatically, and it's not going to let you forget it. That's why a lot of times when we diet, we know we're on a diet, and to sustain that for the 15 or 20 years necessary with a BMI that high is improbable because the inertia is too great. It's possible but not probable because people just feel like they're on a diet.

America's obesity epidemic is well documented. Are there now more bariatric surgeries performed than ever?

There's on average annually about 220,000 bariatric operations in the United States alone, but at the same time, there are more than 18 million Americans who are morbidly obese. If you do the math, that's only 1 percent of morbidly obese people who are getting the operations. Why only 1 percent, we really don't know. Some of it has to do with finances, but increasingly insurance companies are now covering bariatric surgery because all the evidence supports surgery's benefits related to the associated health problems, so that percentage may increase.

Do you have any clinical trials or other research under way?

My primary interest is patient care, and I'm participating with other researchers on a project that's seeking to uncover the root causes of obesity. The project's primary investigator is a gastroenterologist who is trying to understand exactly why bariatric operations work because we actually do not understand that yet. Of the hundreds of hormones involved in regulating hunger and metabolism, we've identified only about a dozen, so I and other physician-scientists are collecting samples of adipose tissue and subcutaneous fat, comparing differences between the two and looking for hormones, trying to make baby steps toward understanding the bigger picture. The research parallels UT Southwestern's overall philosophy of not just doing these operations but also working to understand the underlying problem.

I've tried everything. Will bariatric surgery really help me lose weight?

There are several types of bariatric operations, but none work without a substantial degree of knowledge and effort on your part and the help and guidance of an expert team. Help and guidance after surgery is key to both losing weight and keeping the weight off in a healthy way.

The most important concept for patients to remember is that these operations only help you comply with your diet. They don't replace the need to actively work at managing the amount and type of food you eat. Bariatric surgery may help with reducing the perception of hunger, an issue few diets and exercise programs address and why they often fail.

Diets often fail because it's impossible to function or perform properly in a perceived caloric deficit. A complex symphony between the brain, fat cells, muscle fibers, and the gastrointestinal tract regulates hunger and energy expenditure. This is where bariatric surgery helps beyond medical therapy, diet, and exercise.

Success depends on the individual, and each individual has a different goal. Bariatric surgery is only a tool for weight loss. The new anatomy makes you eat slower and eat less and provides feeback when the wrong foods are eaten or if too much food is eaten.

Weight loss is important, but the metabolic effects from weight loss are really important in order to get rid of adult onset diabetes, high blood pressure, acid reflux disease, and obstructive sleep apnea.

The whole purpose is to live longer and to live better.

Who is a good candidate for bariatric surgery?

Those with a BMI of 35 or greater with a medical problem directly related to obesity are candidates for bariatric surgery. To put things in perspective, a normal BMI ranges from 18-25. In 2011 the Food and Drug Administration approved Lap-Band placement for patients with a BMI of 30 or greater, in special circumstances. Whether someone is an appropriate candidate for surgery depends on the patient's overall medical condition and commitment.  

How long does the whole process take?

Depending on medical clearances and insurance/financial clearances, the whole process may take one to six months so it is important to start the process early or keep track of your prior medical weight loss sessions. Most insurance companies require 1-3 months of medically managed weight loss sessions prior to surgery.

The best patient is the educated and committed patient who prepares diligently in anticipation of surgery for the best long-term results. There is no scientific evidence to support that delaying already optimized patients 1-6 months results in better outcomes. Cash paying patients typically meet for counseling sessions as needed and are accommodated to have surgery within a week or two.

 

Weight loss does not begin after bariatric surgery; weight loss begins once you are committed and trust the process that's been proven to work.

 
Is bariatric surgery typically covered by insurance?

Yes. The obesity epidemic has become a great burden on our health care system. More than $150 billion is spent annually on obesity-related medical problems in the U.S. alone.

Most insurance carriers, including Medicare, have recognized this concern and typically cover bariatric operations if you are a good candidate for surgery.

I don't have insurance, but I want a bariatric operation to help with my weight loss and my obesity-related medical problems. What are my options?

The total cost of bariatric surgery depends on several factors such as hospital fees, professional fees, and anesthesia fees. The cost can range from $10,000 to $20,000, depending on the type of operation.

 

With the rising cost of health care to the individual patient due to obesity-related illness, resulting in sick days, decreased productivity, hospitalizations, and rising medication costs, the average return on investment is about two years. This means that in one's lifetime, surgery will pay for itself in about two years due to savings in potential cost.

Which bariatric operation is most effective?

For most people, the gastric bypass is most effective risk/benefit balance for weight loss. By creating a small gastric pouch and bypassing the first portion of the small intestine, portion sizes must be smaller and fats tend to get absorbed later than they normally would. Ingesting highly concentrated simple sugars or fats may cause "dumping syndrome." Symptoms include panic attack-like sensations with severe headache, dizziness, nausea, abdominal cramping, and diarrhea. "Dumping" is a very unpleasant sensation but can be avoided by avoiding foods with high simple sugar or high fat content, which are the foods that cause weight gain in the first place.

Patient must avoiding "dumping" for gastric bypass and sleeve gastrectomy to be effective. Most patients reach their weight loss goal in one year or one-and-a-half years. Overall effectiveness and success depend on the habits and tendencies of the individual patient, and the best operation for each person may be different.

 
What results can I expect after having a Lap-Band placed?

Lap-Band is highly effective for the right patient. The procedure forces patients to eat smaller portions and chew each bite more than 20 times before swallowing. Pills must also always be crushed to avoid irritating the stomach lining. It may take two to five years for patients to lose their desired weight. Success for this operation is highly dependent on patients' compliance with their diets and patients who eat too much or too fast will vomit. This repetitive behavior will cause damaging effects to the stomach and esophagus.

I've recently been hearing more things about the laparoscopic sleeve gastrectomy. Is the gastric sleeve effective?

More and more insurance carriers are providing coverage for the sleeve gastrectomy. The medical community is embracing this operation as an alternative to the band and bypass procedures because the results and the risks are in the middle. There is excellent midterm scientific data from the past five-plus years to prove the effectiveness of the sleeve, with results almost comparable to the bypass yet with a lower risk profile. 

In the past, the sleeve gastrectomy was often the first part of a staged bypass-type operation in high-risk patients. The idea behind it was to perform a sleeve in high-risk patients so that they would lose weight. The patient would then return for a second operation once they lost the weight. Many patients did well after only a sleeve, often deciding against an additional operation because of the satisfactory results. This is why the scientific data is currently behind what's already been published about the band and bypass. What we’re discovering is that the results are good and the sleeve gastrectomy is another excellent option for the right patient.

 
How do you determine which bariatric operation is best for a patient?

The type of surgery that's best for you will be determined by a team looking out for your best interest – not the surgeon's best interest or the hospital's best interest. Our multidisciplinary team consists of bariatric surgeons, clinical psychologists, registered dietitians, and physician assistants with expertise in bariatrics.

Unlike most bariatric practices, the team, not just one surgeon, collectively recommends the safest and best operation for each patient. Our team considers each patient individually, taking into account the patient's physical condition and ability to exercise, dietary habits, lifestyle, emotional concerns, etc. The team guides each patient into making an informed decision and provides individualized long-term care after an operation is complete.

Are patient follow-up visits typically required after bariatric surgery?

Absolutely. Follow-up care remains key to successful and safe weight loss. Most problems are easy to take care of if identified early. We encourage interval follow-up. Unlike other types of surgery, bariatric surgery is a lifelong commitment. A patient will only achieve long-term successful results with diligence and proper guidance. Each type of operation requires a series of follow-up visits, which are spread over three months in the first year for sleeves and bypass patients and over several weeks for band patients. Vitamin levels are checked at regular intervals. After the first year, annual checkup visits are recommended for all patients. 

Is bariatric surgery reversible?

Not exactly. In most circumstances, Lap-Bands are easily taken out and the anatomy is usually left undisturbed. However, anytime you have surgery, scar tissue is left behind and nothing is exactly the same as it was before. Sleeve gastrectomies can be converted to a bypass. Band patients can have their bands removed and be converted to a sleeve or bypass or duodenal switch.

 

In general, it’s always safest and most effective to pick and choose the right operation the first time rather than viewing your surgical options as second- or third-choice alternatives. Diligent counseling to thoroughly review risks and benefits will help patients decide the best operation so that their first bariatric operation is their last bariatric operation.

What is a biliopancreatic diversion or duodenal switch? Do you recommend it?

The biliopancreatic diversion (BPD) is an extreme form of surgery somewhat similar to the Roux-en-Y gastric bypass that was first performed in 1976 by Dr. Scopinaro. The duodenal switch (DS) is a variation of the biliopancreatic diversion, which was first performed in 1990 by Dr. Marceau.

Duodenal switch patients will lose on average 85% of their excess weight. It is an effective operation to control diabetes however malnutrition and unpleasant diarrhea are risks of this operation. A well informed patient must always weigh risks and benefits to finding his or her own optimal procedure.

Is there anything new or improved in bariatric surgery to help with my weight loss?

Metabolism is a lot more complex than we once thought. Bariatric surgery is not simply cutting out the stomach and making it smaller or just rerouting it. In fact, the medical and surgical community refers to these operations as metabolic surgery because surgery effectively treats many of the medical problems related to weight gain.

Scientists have isolated dozens of hormones involved in metabolism. In reality, there may be hundreds of hormones involved in regulating hunger and metabolism. Everything, including medications and surgery, involves risk. No magic pill for weight loss without major serious side effects currently exists.

Medications and endoscopic procedures are more likely to be useful as a bridge to lose weight for patients with extremely high BMIs or patients who are no longer good candidates for surgery because of advanced age and medical problems. Some endoscopic procedures are currently being researched.

An earlier permanent solution is the safest and most effective way to minimize the damaging wear and tear on our bodies. Nothing has been studied and scrutinized as much as bariatric surgery. Bariatric surgery remains the best tool for weight loss and for eliminating problems associated with weight gain because of its long-proven safety and effectiveness.

What is robotic surgery?

We do not utilize robot-assisted bariatric surgery. Lowering cost for patients and surgeons’ preference to operate with conventional laparoscopy for bariatric surgery are the major reasons at our institution.

 

From a technical standpoint alone, I prefer minimizing the complexity of setting up my cases and relying less on equipment. As a minimalist when it comes to cost and improving efficiency, I prefer conventional laparoscopy. Unlike the pelvis, operating near the hiatus only requires about a 30 degree conical workspace which can be easily achieved with trocars placed a handbreadth apart to facilitate hand sewing or additional two handed dissection. Additionally, robot trocars are 7mm in size and additional ports will need to be placed for staplers which pass through a 12mm trocar. One can still achieve a high level of haptic feedback with the simplest laparoscopic instrument and much faster hand motion without signal delay which is not substantial with the robot but still significant. This is also true not only for tissue manipulation and dissection but also with camera driving which is only static during a robotic operation.

 

Although the robot offers potential application benefits such as less surgeon fatigue and improved ergonomics, it comes so at the expense of time for the vast majority of robotic surgeons. A laparoscopic band or sleeve takes about an hour and a linear stapled hand-sewn gastric bypass takes about twice that for actual operating time with a novice resident surgeon assistant. I do see potential for the solo surgeon with inadequate help in need of a third hand in order to operate but then this would be negated by the reliance of having a skilled person to remain scrubbed to pass suture, staplers, sponges, etc into the abdomen.

 

Given the substantial initial cost over $1 million to purchase the robot without any difference in reimbursement for the same procedure, I do not see much of a change in surgeons’ choice to continue laparoscopic bariatric surgery without the robot due to reasons of efficiency and cost. The robot is a great idea however with limited application in bariatrics. I’m unsure that this luxury will make me a faster surgeon or a better surgeon. We should all find ways to innovate and to be safer and more cost-effective surgeons however, I find that if the wheel spins fast enough, there’s no point in reinventing it.

What is NOTES and SILS?

NOTES stands for Natural Orifice Transluminal Endoscopic Surgery. NOTES is an experimental surgical technique that avoids incisions or scars by placing an endoscope through a natural orifice such as the stomach or vagina. The viable application in humans has not been regarded within the standard of care and exists within research studies.

SILS is single incision laparoscopic surgery. SILS requires a moderate sized incision placed around the umbilicus/belly button to allow multiple instruments to pass through into the patient’s body.