Philip Schauer, M.D., Director of Advanced Laparoscopic and Bariatric Surgery, Cleveland Clinic Bariatric and Metabolic Institute, answers questions about weight loss surgery.
Sixty-six out of every 100 people are overweight, and 60 million Americans are classified as obese. Overweight and obese people are more likely than people of average weight to develop Type 2 diabetes, fatty liver disease, sleep apnea, high cholesterol, gallbladder disease and kidney disease, as well as cardiovascular diseases and cancer. For severely overweight people, weight loss surgery can help them reclaim their life and their health.
Why is bariatric surgery more successful than dieting or weight loss medications?
For most people, dieting yields temporary results. And while weight loss medications work, they are only modestly effective. On average, people lose only about 10 to 15 pounds while on the medications. Bariatric surgery currently is the only effective method to achieve significant, long-term weight loss. Most patients lose from 50 to 70 percent of their excess weight, depending on the bariatric procedure they receive. And the pounds usually stay off.
Is bariatric surgery an option for all overweight people?
Generally, bariatric surgery is for people who are 100 pounds or more overweight and have obesity-related medical conditions. It's not for someone who wants to lose 30 pounds or who wants to look good for a beach vacation. Candidates for bariatric surgery must be between the ages of 18 and 60 and have a Body Mass Index [BMI] of 40 or greater. Patients in this age range with a BMI between 35 and 40 also are candidates if they have obesity-related conditions such as Type 2 diabetes or hypertension. Carefully selected older patients and adolescents also can benefit significantly from bariatric surgery.
How does bariatric surgery work?
Weight loss surgery does one of three things: shrinks the stomach, shortens the digestive tract [small intestine or bowel], or combines these two therapies. With smaller stomachs, people eat less; and with shorter intestines, they digest less. Shrinking the stomach is called restrictive surgery, and shortening the small intestine is known as malabsorption, because a shortened intestine can't absorb as many calories and nutrients.
To shrink the stomach, surgeons separate a small part of the upper stomach from the rest of the organ either by stapling it into a pouch shape or by wrapping a constrictive or laparoscopic band around it to form an open-ended pouch. This pouch, which is stapled to the esophagus [food pipe], becomes the patient's functional stomach. To achieve malabsorption, the surgeon bypasses part of the small intestine where most digestion occurs.
The most common bariatric procedure performed in the United States, and at Cleveland Clinic, is the Roux-en-Y gastric bypass, which is the combination approach mentioned earlier. More than 95 percent of our bariatric surgery patients undergo the Roux-en-Y gastric bypass procedure using minimally invasive surgical techniques.
Does bariatric surgery cure weight-related diseases?
Resolution or improvement of obesity-related conditions is dramatic after bariatric surgery. No other medical or surgical intervention simultaneously treats as many diseases as bariatric surgery does.
Diabetes traditionally has been viewed as a condition without a cure that gradually worsens. We want doctors to see bariatric surgery as a treatment - and a likely cure - for Type 2 diabetes. One-third of diabetic patients discontinue their medication immediately after surgery, even before weight loss. The other two-thirds of patients experience steady improvement, so that within a year after surgery, 83 percent of patients no longer have diabetes.
What risks are associated with bariatric surgery?
Overall, the risks of bariatric surgery are fewer than those related to obesity. All patients run the risk of nutritional deficiencies after surgery, including iron deficiency, vitamin B-12 deficiency and fat-soluble vitamin deficiencies. But these deficiencies are preventable or easily managed with regular monitoring and routine supplementation with multivitamins, iron and calcium.
Anastomotic leaks [a leak at the juncture of the pouch and the esophagus] are a serious complication after Roux-en-Y gastric bypass and can lead to peritonitis. The rate at which leaks occur at Cleveland Clinic is currently less than 5 percent. Leaks are checked at the end of each surgery by flooding the suture line between the pouch and esophagus with water. It's like checking the inner tube of a bicycle tire for leaks: you look for air bubbles. Precautions also are taken to help detect and drain leaks that may arise after surgery. If a major leak is discovered, the patient needs to return to the operating table.
Gallstones develop in about 30 percent of patients within a few months after bariatric surgery because of rapid weight loss. Many surgeons remove the gallbladder during bariatric surgery to prevent patients from developing gallstones. To reduce the incidence of gallstones, we give patients a medication manufactured from naturally made bile salts.
Other possible complications arising from a Roux-en-Y gastric bypass include blood clots, internal hernias, small bowel obstruction, marginal ulcers, pancreatitis, esophagitis and malnutrition. About 0.2 percent of patients suffer blood clotting after Roux-en-Y. To prevent clots, patients are given blood thinners and are required to walk the day after surgery to ensure healthy circulation in their legs.
What's the future of bariatric surgery?
In five to 10 years, I believe that bariatric surgery will be performed without incisions, using an endoscope inserted through the patient's mouth. This approach will dramatically reduce pain and recovery time. Patients may be able to go home the same day and back to work the day after the procedure.
Though still early in development, advances in endoscopic stitching and stapling may allow surgeons to create stomach pouches from inside the body, without having to make an incision. Other technology on the horizon includes the use of tubes or stents placed directly in the duodenum [the first part of the small intestine] and intragastric balloons placed in the stomach to serve as a temporary pouch. Another promising advance involves implanting a device into the intestines or stomach that can send an electric current into the duodenum to stimulate the feeling of fullness.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 9/1/2006
