Surgical Treatment

For many patients, the risk of death is greater from “doing nothing” about morbid obesity than the risk of dying from weight loss surgery complications.

That is the key reason that in 2000, approximately 40,000 weight loss surgical procedures were performed and why the American Society for Metabolic & Bariatric Surgery estimates that 50,000 weight loss surgical procedures will be performed in 2001. Patients who have had the procedure and are benefiting from its results report improvements in their quality of life, social interactions, psychological well-being, employment opportunities and economic condition.

In clinical studies, candidates for the procedure who had multiple obesity-related health conditions questioned whether they could safely have the surgery. These studies show that selection of surgical candidates is based on very strict criteria and surgery is an option for the majority of patients.


Choosing Surgery

Weight loss surgery is major surgery. Although most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure.

The goal is to live better, healthier and longer.

That is why you should make the decision to have weight loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight loss surgery, require that you consult with a dietitian/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dietitians and other forms of continuing education.
Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.


How Surgery Works: The Gastrointestinal Tract

The Gastroinestinal TractTo better understand how weight loss surgery works, it is important to understand how your gastrointestinal tract functions. As the food you consume moves through the tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination. A simplified description of the gastrointestinal tract appears below. Your doctor can provide a more detailed description to help you better understand how weight loss surgery works.



  1. The esophagus is a long muscular tube, which moves food from the mouth to the stomach.
  2. The abdomen contains all of the digestive organs.
  3. The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1500 ml) of food from a single meal. Here the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate breakdown of complex proteins, fats and carbohydrates into small, more absorbable units.
  4. A valve at the entrance to the stomach from the esophagus allows the food to enter while keeping the acid-laden food from "refluxing" back into the esophagus, causing damage and pain.
  5. The pylorus is a small round muscle located at the outlet of the stomach and the entrance to the duodenum (the first section of the small intestine). It closes the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum.
  6. The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the majority of the absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum and the ileum.
  7. The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed.
  8. The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion.
  9. The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E and K and other nutrients are absorbed.
  10. Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine.
  11. In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary.


How Surgery Reduces Weight

How Surgery Reduces WeightSurgeons first began to recognize the potential for surgical weight loss while performing operations that required the removal of large segments of a patient's stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the last decade these procedures have been continually refined in order to improve results and minimize risks. Today's bariatric surgeons have access to a substantial body of clinical data to help them determine which surgeries should be used and why.


Today, the American Society for Metabolic & Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

  1. Restrictive procedures that decrease food intake.
  2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.



Surgical Treatment: Types of Bariatric Surgery

If diet and behavior modifications have failed you and surgical treatment is your next option, it is important to understand that diet and behavior modification will be instrumental to sustained weight loss after your surgery. Weight loss surgery is only a tool to get your body to start losing weight - complying with diet and behavior modifications required by most surgeons would determine your ultimate success.

Surgery should be viewed primarily as a treatment method for alleviating a debilitating, chronic disease (morbid obesity). In most cases, the minimum qualification for consideration as a candidate for the procedure is 100 lbs. above ideal body weight or those with a Body Mass Index of 40 or greater. Occasionally a procedure will be considered for someone with a BMI of 35 or higher if the patient's physician determines that obesity-related health conditions have resulted in a medical need for weight reduction and, in the doctor's opinion, surgery appears to be the only way to accomplish the targeted weight loss. In many cases, patients are required to show proof that their attempts at dietary weight loss have been ineffective before surgery will be approved. More important, however, is the commitment on the part of the patient for the required, long-term follow-up care.

Weight loss surgery is major surgery. Its growing use to treat morbid obesity is the result of three factors:


Weight Loss Surgery Options

The American Society for Metabolic & Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

  1. Restrictive procedures that decrease food intake.
  2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool

Combined Restrictive & Malabsorptive Procedure - Gastric Bypass Roux-en-Y
Laparoscopic or Minimally Invasive Surgery

Combined Restrictive & Malabsorptive Procedure - Gastric Bypass Roux-en-Y 

In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Metabolic & Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.



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Laparoscopic or Minimally Invasive Surgery  

For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still "experimental." In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.  When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures. images/content/ill-thumbs/C_incisio1-thmbnl.jpgThe camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.

Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Metabolic & Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.

Hi, I'm Rudy. It will be ten years on June 21, 2014 I started on a remarkable journey; I had gastric bypass surgery.
Five months before that day, I was at my primary care physician's and he asked me if I ever thought of having bypass surgery. I never gave it a thought. I was on three blood pressure medications, cholesterol medicine, and 100 units of insulin every day. I had trouble breathing, just walking up a slight grade I had to use an inhaler.
At the end of our conversation, the doctor said I would most likely have a heart attack or a stroke within five years. That was a real eye opener. I was just 53 years old and heart problems ran in the family. My Dad was 56 when he had his first heart attack. I could not lose weight. I had no will power. I kind of blamed by Mom for my weight problem. As a child I was taught to clean my plate, which I often over ate. That carried on into my adult years.
I was running out of medical insurance and wanted the surgery. All went well the first month. I went back to work and was losing weight. The second month I couldn't eat anything. The intestine scarred where it was joined to my pouch and shrunk shut. Nothing could pass through. I went from 283 lbs. To 137 lbs. in five months. I lived on banana popsicles. I got my medical insurance back; within two days I was in the hospital getting dilated. I could get food down for days then everything would shut down. I was dilated six times with no success.
I was getting for surgery to reconnect the intestine to my pouch when I got a bowel blockage. Out patient surgery took care of that problem. No more sever cramps. A month later I went in for the reconnection.
Before the surgery, Dr. Mike (Felix) remarked how calm I was. My wife was a nervous wreck; Dr. Mike was real concerned. He asked me why I was so calm. I said my wife was upset for the both of us. I had confidence in his skills; and there was nothing I could do anyhow except go along for the ride. So why worry about something you have no control over.
Surgery went well. Recovery didn't take long and I was eating real food. I've been around 180 lbs. for 10 years now. I went from a 44 inch waist to a 34 inch waist. I feel strong and I have a lot more energy.
I don't use an inhaler anymore. I'm off all my blood pressure medications, cholesterol medicine and I went from 100 units of insulin down to 20 units of insulin a day.
At my heaviest, I weighed 283 lbs. and I have managed to keep 100 lbs. off for 10 years.
One thing I've learned is that I can leave food on my plate when I'm full.

- Rudy

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