Should I have weight loss surgery?

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Weight loss surgery such as lap bands, gastric sleeves and bypasses, have been increasing in popularity in the private health sector. They are now procedures that are partly covered by some insurance providers and they are now offered in some hospitals under Medicare in Australia.

Although bariatric surgery has been coined as “the most successful weight management intervention”, there is a lot to consider before you go under the knife. The journey through to surgery can be long and tedious in the public sector, but more importantly the journey post-surgery can be just as tricky.

What types of weight loss surgery are available?

  • Lap band

A lap band is a medical device. It’s placed around the top of the stomach restricting how much food you can eat, whilst simultaneously creating a feeling of fullness. The pressure of the band on the top of the stomach increases the sense of satiety, leaving you feeling full most of the time. The band can be filled or loosen once it’s inserted by check-ups with your surgeon. This was once the most popular procedure, but has been slowly phased out in favour for the gastric sleeve.

  • Gastric sleeve

The sleeve is now one of the most popular weight loss procedures because it gets the same, if not better results that the lap band and you only need to visit your surgeon once after the procedure. Your stomach can normally hold about 1.5-2L of volume. During a sleeve procedure 90% of your stomach is removed, and you are left with a 100-200ml stomach pouch. This procedure is restrictive; it restricts your ability to eat, removes hunger and gives you a quick sense of satiety after only a few mouthfuls of food. The gastric sleeve is the staging step prior to a gastric bypass, note that this is not reversible.

  • Gastric bypass

This is the most severe of the procedures and there are several different types of bypasses that occur within this category. The most popular procedure at the moment is called the omega-loop, which produces less complications and unlikely to cause dumping syndrome (more on dumping syndrome later).

You may have also heard of procedures such as Roux-en-Y or duodenal switch with biliopancreatic diversion. Ultimately in a bypass procedure 90% of the stomach is removed (gastric sleeve), then the top of the stomach is reconnected to another part of the small intestine. This is done so there is a degree of malabsorption that occurs when you eat. The result being you are restricted in how much you can eat, you feel full very quickly, and then you don’t absorb all the nutrients you consume.

As this is the most severe procedures it has a long list of medical complications that can occur, but it produces the most amount of weight loss long term. The procedure can be partly reversible depending on your health and internal scaring that may have occurred during the surgery.

All of the procedures are done under keyhole surgery, so down time due to the surgery is only 4-5 days. It’s recommended that you don’t lift anything or drive for 6 weeks post- surgery to avoid developing an abdominal hernia.

What is dumping syndrome?

Dumping syndrome is a condition that is caused by gastric bypass surgery, and less commonly post gastric sleeve. The occurrence of dumping syndrome has been estimated to affect 50% of all gastric bypass patients (Chaves & Destefani, 2016).

Dumping syndrome can occur after eating carbohydrate rich or sugary foods, the food moves very quickly through the stomach to the small intestine. There are two types of dumping syndrome; early and late dumping.

Early dumping syndrome occurs 30-60minutes after eating, you may feel symptoms such as abdominal cramping, pain, vomiting or diarrhoea. Late dumping syndrome occurs 1-3hours post eating. People often feel very ill, shaky, rapid heartbeat and nauseous. It can be very debilitating and can affecting a person’s ability to drive.

Dumping syndrome can have real consequences to how you live your life, and something you should really consider a possibility. Currently, it’s unpredictable who will have dumping syndrome post-surgery and who won’t, the good news is symptoms of dumping syndrome can be partially managed by diet.

Dietary issues you must consider

For some people, the idea of having bariatric surgery is the ultimate goal. I am often surprised at how adamant people are about this without knowing what they’re getting themselves in for. It’s very common for patients of mine to regret having the surgery in certain situations or decide not to have the surgery when they become aware of the dietary limitations it imposes. On the flip side a lot of people also invite the idea that they will never be able to eat the same again. Everyone is different; however you need to be fully informed about how the surgery may affect you.

There are three key points you need to be aware of prior to surgery;

  1. You’ll never be able to eat in a rush ever again
  2. Social events that involve eating will change because you will not be able to eat like everyone else
  3. There will be problematic foods you will not be able to eat ever again. This often includes bread, apple skin and dry meat

Bariatric surgery and health outcomes

Weight loss surgery is a well-established medical procedure. There is now a significant amount of research that shows a majority of people have long lasting weight loss success post-surgery.

In a recent study, it was found that 12years post Roux-enY gastric bypass the average weight lost is 45kg (Adams et al., 2017). In the group of 418 people who had surgery 88 had type 2 diabetes. After bypass surgery, type 2 diabetes went into remittance in 66 of these people (Adams et al., 2017).  This is a fantastic result for people who have type 2 diabetes who will no longer require diabetic medications.

Similar results have been found for the vertical banded gastroplasty, and lap band procedures. A vertical gastroplasty is an older procedure that’s has been replaced by the newer gastric sleeve, which is thought to be more effective.

In a land mark 2007 paper called the Swedish Obesity Study they followed weight loss surgery patients for 15years. They found on average patients lost the most amount of weight in the first 1-2years, with patients reducing their weight by -25% in the vertical banded gastroplasty group and 20% in the banding group.

After 10years, although a majority of patients slowly regained weight they still remained -16% (vertical gastroplasty) and -14% (lap band) lower in weight (Lars Sjöström, 2007). Read this article on how to combat weight regain.

There is no other dietary or lifestyle therapy treatment that has shown results like this now or in the past. The weight lost from having surgery has the potential to improve mobility, lower cholesterol, blood pressure and improve overall health (Lars Sjöström, 2007). If you want this type of success it is recommended that you get support, constant follow up and advice from a dietitian who specialises in bariatric surgery.

Ultimately surgery will give you a helping hand to lose weight by keeping you feeling full, but you still need to do the work choosing healthy food and exercising to see the best results. I have personally seen patients who perform even better reducing up to 100kg in weight. Their success can be attributed to following a highly regimented healthy eating plan and being physically active every day.

One important point to remember is that weight loss surgery doesn’t give you a magic wand to wish weight off.  You still have to do the ground work if you want it to lose weight and keep it all off long term.

For the young women reading this article, if you are considering having children or would like more children, then bariatric surgery may also impact this to a certain extend. To read more about the considerations of weight loss surgery on pregnancy take a look at this article.

Untold stories surrounding weight loss surgery

Whilst most websites create an overly optimistic picture about surgery and only provide the evidence of successful weight loss cases, the opposite can also occur. Any medical procedure or surgical intervention is not without health risk.

Before you have surgery, you need to be completely aware of the dietary changes you’ll need to make for the rest of your life. Six weeks post-surgery and beyond, it is likely that you will only be able to consume ½- 1 cup volume of food at any one sitting. This surprisingly is a big shock to people.

There is also a strict dietary regime to follow pre-operatively and for 6 weeks after surgery. This includes following a texture modified diet, slowly getting your stomach used to food again. You will be required to use meal replacement shakes for 2 weeks prior to surgery and stick to a liquid diet for 2 weeks post-surgery. There after this will change to pureed food, soft food and eventually graduating to normal eating.

You may never feel “normal” at social occasion again. This is an area where people feel the most uncomfortable, as they are unable to partake in eating in a social environment. For some it may mean sitting at the dinner table watching people eat until they finish.

Despite these obvious socially awkward situations it is not uncommon to not lose as much weight as you thought you would. In my clinical experience, I have seen patients recommence gain weight 2 weeks post-surgery. In other cases, I have seen patients lose 30-40kg and then begin to gain weight again, only to put it all back on a year later. In less dramatic cases patients have lost smaller amounts of weight than they had hoped 5-10kg in a year post surgery.

Why some don’t well post weight loss surgery

To be clear the majority of people who undergo bariatric surgery do really well. Their health improves, they lose quite a bit of weight. However, there are also others who don’t do as well. It’s difficult to predict who will do, well and who won’t, however there are a variety of common observations I have made from those who don’t do as well as others.  These observations are;

  • The person had an unrealistic expectation about what weight loss surgery would do for them

For example, they thought that losing weight through surgery would help them find an intimate partner or gain employment. Unfortunately, if this doesn’t eventuate, motivation to continue healthy eating behaviours decline and emotional eating starts again. It’s important to realise that surgery will not help you build relationships, it will not make you more employable. These aspects of your life are typically unrelated to your body weight, it has more to do with your interactions with people, your self-esteem, confidence and self-efficacy.

  • The person was not mentally ready to change their eating patterns

The person continued to eat energy rich processed food, which is easy to digest. Bariatric surgery doesn’t stop you from eating processed food. Processed food is energy rich, breaks down easily and therefore can circumvent some of the restrictive attributes of bariatric surgery.  You can still eat, and eat to the point of being physically sick. I have seen patients who have melted down bars of chocolate so they can consume them easily and in large amounts. Where there is a will, there is a way. You need to change your eating patterns prior to surgery, if you want the best results.

  • The person struggled with binge eating or emotionally ate

Binge eating and emotional eating need to be dealt with prior to surgery. It’s a myth that surgery will stop you from binge eating.  Surgery doesn’t fix your emotions. If you believe that weight loss will boost your self-esteem enough to make you stop emotionally eating, note that the boost in self-esteem from weight loss is only short lived. It’s also important to note that if you don’t lose as much weight as you have hoped, then this may also cause self-esteem issues.

  • They didn’t have support

You need to ensure you maintain regular monthly appointments with a dietitian specialising in obesity management and bariatric surgery. They will support you through the process and help you maintain lifelong healthy eating behaviours. If you have deeper psychological issues relating to abuse, post-traumatic stress, anxiety or depression you may also need ongoing support from a psychologist. Suicide and self-harm affects a lot of people who undergo bariatric surgery.

I know that people never want to talk about the downsides of bariatric surgery, because people are so hopeful that it will work for them. People also see weight loss surgery as the last resort. However, I feel that talking about the untold cases helps others to understand how to do things better. The information provided in the article is not to turn you off surgery, but more of a check list to make sure you have taken care of yourself prior to surgery.

Excess skin post weight loss surgery

It’s unrealistic to think that a 150kg person will slim down to look like Kim Kardashian post-surgery. The truth is a 150kg person, will probably end up being 105kg a year or two post-surgery. Remember how I mentioned on average people lose 45kg after surgery?

That means if you believe you are going to look like an Instagram model post-surgery, unfortunately it’s not going to happen. In addition, you are going to have excess skin.

Excess skin is loose skin that has been stretched due to weight gain. Think of a rubber band, when you over stretch it, it lengthens and wrinkles never going back to its original length. The same thing happens to the collagen in your skin.

Patients often say to me “well I’ll just have it removed”. Sure, people do that, however excess skin removal is considered cosmetic, unless it causes an infection. Therefore, it’s not covered under publicly funded medical care, and if you choose to do it privately its very expensive. The average abdominal apron removal can cost around $22,000AUS, and the down time is quite long, 2-3weeks. You will need to wear compression garments and be extremely careful with wound healing.

There is also another important point you need to consider, it’s extremely invasive and therefore risky, it’s painful and you are left with big scars.

If you already have body image issues from carrying excess weight, work on this before surgery with a psychologist. Having excess skin has the potential to be just as mentally debilitating as the weight itself for some people.

Questions to ask yourself before deciding on bariatric surgery

Surgery is a big decision because it will change your life, so you need to ask yourself considered questions to make sure it’s right for you. Take the time to sit down with a family member and nut out what you think of the following questions so you can make an informed decision about surgery. I didn’t put these questions here to deter you, they are here to help you solve the tricky situations in your mind before it happens. That way you are prepared for it and it won’t impact your life as much, and you will have no regrets post-surgery.

  • Why do I want to have surgery?
  • Do I feel in control of my eating, do I binge eat or emotionally eat?
  • Do I exercise most days?
  • How will bariatric surgery impact meals with my family?
  • How will weight loss surgery impact my social life?
  • How would I feel about having excess skin?
  • How would we cope as a family if I had medical complications such as dumping syndrome or severe hernia pain?
  • Can I afford to return to hospital if medical complications arise?

For a lot of people weight loss surgery is life changing. Many people get their independence and health back, something they had lost for a very long time. This is a fabulous outcome, I wish for you to be one of these people. Do the hard work first by getting your mind set, diet and exercise right prior to surgery, and you’ll be fine!

References

Adams, T. D., Davidson, L. E., Litwin, S. E., Kim, J., Kolotkin, R. L., Nanjee, M. N., . . . Hunt, S. C. (2017). Weight and Metabolic Outcomes 12 Years after Gastric Bypass. N Engl J Med, 377(12), 1143-1155. doi:10.1056/NEJMoa1700459

Chaves, Y. d. S., & Destefani, A. C. (2016). PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENTOF DUMPING SYNDROME AND ITS RELATION TO BARIATRIC SURGERY. Arquivos Brasileiros de Cirurgia Digestiva : ABCD, 29(Suppl 1), 116-119. doi:10.1590/0102-6720201600S10028

Lars Sjöström, K. N., C. David Sjöström, Kristjan Karason, Bo Larsson, Hans Wedel, Ted Lystig, Marianne Sullivan, Claude Bouchard, Björn Carlsson, Calle Bengtsson, Sven Dahlgren, Anders Gummesson, Peter Jacobson, Jan Karlsson, Anna-Karin Lindroos, Hans Lönroth, Ingmar Näslund, Torsten Olbers, Kaj Stenlöf, Jarl Torgerson, Göran Ågren, Lena M.S. Carlsson, . (2007). Effects of Bariatric Surgery on Mortality in Swedish Obese Subjects. The New England Journal of Medicine, 357(8), 741-752.

 

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