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Bariatric Surgical Treatment

The occurrence of obesity has become a national epidemic, now affecting the majority of Americans. The end stage result of this, termed “morbid obesity”, now affects 15 million people, or 5% of the US population.

All available studies indicate that this condition almost never responds to “medical therapy” (diets, exercise, medications) with “failure” rates upwards of 99%. Conversely, bariatric surgery has been shown to successfully treat this problem 80-90% of the time. Indeed, when performed correctly and with recommended change in lifestyle, surgical therapy offers a lifeline for millions of Americans afflicted with this condition.

Bariatric surgery in the US has become a standardized and mainstream treatment for this disease. Once considered a “fringe” specialty, it is now recognized as the only successful treatment for morbid obesity.

Surgical Mechanisms
It is very important to understand that not all procedures are equivalent and one does not “fit all”. There is no one perfect procedure, and it is really one’s commitment to disciplined lifestyle changes that will influence their success.

Based on our understanding of how surgery works to produce such significant and long-term weight loss, several specific mechanisms have been found to come into play with any given surgical procedure. In general, the more mechanisms of action any given procedure offers, the more likely it is that the surgery will result in greater weight loss and success. These mechanisms are as follows:

• Restriction
o This concept is paramount to all weight loss surgeries. It essentially means that the stomach is somehow made much smaller, often decreasing its capacity up to 80-90%. This can be by way of dividing the stomach with staples, by creating a small pouch (Roux-en-y gastric bypass), by creating a long, slender tube (gastric sleeve), or by putting a band around the top of the stomach, separating it into a pouch above from the remainder of the stomach below.

• Malabsorption
o The intestine is re-routed so that food consumed is not sufficiently mixed with pancreatic enzymes, therefore creating a less efficient absorption of nutrients. This effect is dependent on the amount of intestine that is re-routed and can be minimally effective (as with the gastric bypass surgery), or it can be profound (as with the biliopancreatic diversion method of surgery). In general, when more intestine is bypassed, more weight loss tends to occur; but this is at the expense of increased complications. For the most part, the amount of intestine bypassed for the gastric bypass is less than that which can cause serious consequences. This is why most bariatric surgeons defer performing the BPD (biliopancreatic diversion) in the United States.

• Hormonal Changes
o This is the primary focus of current research in bariatric surgery and a mechanism that many believe may attribute greatly to long-term success. When the stomach is divided and/or the intestine is re-routed, it’s been found that the levels of certain gastrointestinal hormones are modified. For reasons that are not fully understood, this has profound effects on the body. Specifically, two effects occur. First, hunger is markedly reduced. Secondly, certain disease processes are cured within days of the surgery; the most obvious example of this is the resolution of diabetes myelitis. In over 85% of patients, the condition resolved after gastric bypass surgery. It resolved in 98% of patients after biliopancreatic diversion, often within days of surgery. The gastric sleeve will also show these changes, but to a lesser degree. The gastric band has not been shown to significantly affect hormonal changes.

• Dumping Syndrome
o This is often referred to as a “side effect” or “complication” of the gastric bypass procedure. This effect is unique to this particular operation and, in fact, represents a very effective tool that aids in maintaining a healthy diet. Because the bowel is attached to the gastric pouch, food goes directly into the intestine rather than being held in the stomach. This is important to know because food that hits the intestine without being diluted or processed by the stomach may cause gastrointestinal irritation: specifically very rich foods, like sweets. This irritation of the intestines can cause unpleasant side effects such as nausea, cramping, diarrhea and sweating. Essentially, foods high in sugar don’t agree with you after this procedure. As a result, 90% of gastric bypass patients develop an aversion to sweets. Many believe that this, along with the previously mentioned hormonal changes, are the reasons that weight loss after gastric bypass tends to be more robust and consistent than that seen in purely restrictive procedures, such as gastric banding.

Again, note that one or more of these four mechanisms are utilized by any given weight loss surgery, and every operation does not possess each mechanism. Further, weight loss tends to be greater in those procedures where more than one mechanism is utilized. Detailed discussion concerning each one of these procedures and which mechanisms are utilized can be found elsewhere on this site.