Bariatric Surgery for Weight Loss and How It Has Evolved
What is bariatric surgery?
Obesity is now known to be a chronic disease. Bariatric surgery is a procedure performed by a surgeon that affects your food intake, helping you to lose weight. While bariatric surgery is not a cure, it is the most effective and long-lasting treatment for obesity.
Bariatric weight loss surgery:
- is an effective treatment for weight loss
- has proven to reduce a patient's risk of premature death by 30 to 50 percent
- is known to improve or cure certain obesity-associated co-morbidities such as high cholesterol, high blood pressure, type 2 diabetes, and sleep apnea
What are the different types of bariatric surgery procedures for weight loss?
There are different choices to consider when discussing weight loss surgery: sleeve gastrectomy, Roux-en-Y gastric bypass, and duodenal switch.
The sleeve gastrectomy removes a portion of the stomach to create a "sleeve" or tabularized stomach.
This procedure assists patients with weight loss in three main ways, by:
- decreasing the volume of the stomach and therefore limiting food intake
- decreasing the amount of time food remains in the stomach which leads to reduced calorie absorption
- altering hormones which cause patients to become hungry less often
Patients who undergo sleeve gastrectomy lose approximately 50% of their excess weight.
Roux-en-Y gastric bypass
The Roux-en-Y gastric bypass procedure is considered the "gold standard" surgery for weight loss as it has been around the longest. During a gastric bypass, a portion of the stomach is made into a small pouch approximately one ounce in size, or that of a golf ball. A portion of the intestine is then connected to this pouch, thereby bypassing the first few feet of the intestine.
This helps patients lose weight by:
- creating restriction, because the patient is unable to eat large meals due to the size of the pouch
- causing less calories to be absorbed, as the food eaten is not absorbed as efficiently due to the bypass of the first segment of the intestine
Patients who undergo Roux-en-Y gastric bypass lose 60 to 70 percent of their excess weight. It is also worth noting that, when compared to sleeve gastrectomy, the gastric bypass has slightly higher rates of improvement or resolution of the dangerous conditions associated with obesity mentioned above.
The duodenal switch is most easily described as a combination of the above two procedures. In the duodenal switch, the stomach is tabularized, and a longer segment of the intestine is bypassed. This assists patients with weight loss by creating restriction, malabsorption and hormonal changes as described above.
The duodenal switch procedure has the greatest weight loss and co-morbidity resolution of the three procedure choices. Patients undergoing duodenal switch lose 80 to 98 percent of their excess weight and have the highest rates of resolution of their associated conditions.
It is important to remember that bariatric surgery is not a cure for obesity but a tool to assist in weight loss. Treatments must be personalized for each patient's individual needs. Only through a discussion with your surgeon can you decide which procedure is right for you.
When was the first bariatric surgery performed and what was it called?
The first operation designed specifically to assist patients in weight loss was the jejunoileal bypass. First performed in the 1950s at the University of Minnesota, this procedure bypassed nearly all of the intestine. Unfortunately, patients developed significant nutritional and vitamin-related complications with this procedure, and it is no longer performed.
Failure of the jejunoileal bypass, however, led to the development of the Roux-en-Y gastric bypass. That procedure has proven successful for weight loss and for eliminating most of the nutritional complications observed in patients with the jejunoileal bypass.
How has bariatric surgery changed over the past 10 years?
Bariatric surgery has evolved significantly over the last 10 years. Historically, bariatric surgery was performed using an "open" technique with a large incision in the abdomen, giving the surgeon access to the abdominal cavity to perform the procedure. While an open procedure is very safe, there is a high rate of complications in patients, including wound infections and other problems with this large incision.
Improved outcomes for patients led to the first “minimally invasive,” or laparoscopic, bariatric surgery in 1994. Since that time laparoscopic bariatric surgery has become the standard of care and has led to significant improvements in outcomes for patients by reducing pain, recovery time, and complications.
How have outcomes improved as bariatric surgery has evolved?
Complications related to bariatric surgery have continued to improve over the last 10 years. In fact, the rate of major complications from bariatric surgery (1.2%) is about half the rate of complications following cholecystectomy (the removal of the gallbladder), one of the most performed operations in the United States.
How has the patient experience changed?
At the Lifespan Center for Bariatric Surgery, our team continuously strives to improve the experience for patients. We recognize the process to be considered for bariatric surgery does take some time and requires commitment. Our team is committed to walking patients through the process.
Over the last 10 years we have:
- streamlined the pre-operative evaluation and testing that is required before surgery
- reduced hospital length of stay through changes in operative techniques and certain medications for pain and nausea, allowing most patients to leave the hospital after an overnight stay
- ensured our patients are in contact with our outpatient team following surgery for a swift and smooth recovery
In fact, our Center for Bariatric Surgery continues to receive national recognition for its outstanding patient care. In 2021, we became the only center in Rhode Island to earn national Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accreditation for obesity medicine, adult weight loss surgery, and adolescent weight loss surgery. This rigorous accreditation highlights the center’s long-term successes, high-quality program, patient-centric approach, and experienced, compassionate staff.
What does the future of bariatric medicine look like?
While bariatric surgery remains a highly effective treatment for obesity, as surgeons, it is our hope that a therapy for weight loss will be discovered, and weight loss surgery will no longer be needed.
There have been several medications and diet strategies that have shown some promise; however, all fall short of what most patients struggling with obesity need to lose to live a long and healthy life.
Until that time bariatric surgeons will continue to innovate in the field and improve outcomes for patients struggling with obesity. Even now, novel procedures such as robotic and incision-free surgery techniques are being studied, which could lead to faster recovery and hopefully improved outcomes.
The Center for Bariatric Surgery
About the Author:
Andrew R. Luhrs, MD
Andrew R. Luhrs, MD is a bariatric surgeon at the Center for Bariatric Surgery and an assistant professor of surgery at The Warren Alpert Medical School of Brown University. He specializes in general surgery with a focus on weight loss, foregut, and hernia surgery.
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