Bariatric surgery comes in a variety of shapes, but surgeries currently performed can be primarily divided into three key procedures, known colloquially as "banding", "the sleeve" and bypass. Each works by restricting stomach capacity, creating a small pouch in place of the stomach- the size of this pouch will vary with the type of surgery; with the band or the sleeve, the stomach is reduced to about 15% of its original size, with a bypass, to 10%. When this pouch is full the brain registers that sufficient food has been consumed, and because the pouch is also quite slow to empty the feeling of fullness persists. Hunger is thereby kept at bay and the person who has had the procedure eats less and loses weight. It is generally only available to the seriously obese, who have tried and failed to lose weight through diet and exercise over a number of years.
The least instrusive procedure is banding. It does not require cutting or removal of any part of the digestive system and is fully reversible, with the stomach returning to normal after band removal. It is performed laparoscopically (through small incisions - usually 0.5–1.5 cm - in the abdomen); this approach is also known as keyhole surgery.
An inflatable, and adjustable, silicone device is placed around the top portion of the stomach to create a small pouch. Gastric bands are composed of biocompatible materials so they don’t cause harm in the body, even if left in indefinitely. As the patient loses weight, the band needs to be adjusted for comfort and effectiveness by introducing saline.
Weight loss is generally slower for patients using the band approach, and weight regain is more common, but it avoids issues with gastric dumping and nutrient malabsorption that are encountered with other surgeries.
The gastric sleeve is a laparoscopic, non reversible procedure in which a large part of the stomach is removed, following its major curve and the open edges are attached together, usually with surgical staples. This leaves the stomach shaped like a curved tube, or sleeve – hence the name. It is generally a highly successful surgery, but, if insufficient weight loss is achieved, it can be converted into a full gastric bypass.
Gastric bypass can also be performed laparascopically, but is often carried out as open surgery. This is the most extreme form of bariatric surgery, is non reversible, and is the most likely to kill the patient (though it has a Roux-en-Y gastric bypass. A very small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shape. This restriction may be combined with placing a small ring (a silastic ring) around the entry to the pouch to restrict the size of food pieces that can reach the stomach. Long term, bypass is the most successful of surgeries, with more patients losing a greater proportion of their overweight and keeping the weight off.
Bariatric surgery has a number of downsides, however. It’s expensive, and not available on insurance or public health systems in most cases, so the patient will often have to pay for a large proportion of cost themselves. It’s not something you should do with the aim of being svelte and beautiful. You will lose weight rapidly – with the result that you will get the kind of quantities of loose skin that make you look like a shar pei puppy naked; stomach tucks and other cosmetic surgery often follow weight-loss surgery. Food tolerance varies from person to person, and post bypass, especially, people may find themselves severely restricted in what they can eat, with intolerance showing itself in a number of ways such as instant vomiting, stomach discomfort over a period of hours, diarrhoea, or “dumping” – an extremely unpleasant feeling of dizziness, faintness and/or sudden energy loss. Patients who have had the sleeve or gastric bypass need to take daily vitamin supplements to overcome nutrient malabsorption and restriction, and often need vitamin B12 injections and may need to take vitamin D supplements to avoid osteoporosis in later life.
Of course, surgery cannot address any emotional or food addiction issues that may have led to overeating in the past, either, and if patients with these issues don’t find alternative coping strategies they may either suffer depression or begin “grazing” (eating small amounts of undesirable food frequently) which will cause them to regain weight.
It’s not a route to take for reasons of vanity. If you are fat but healthy and active you will probably be better off trying to love who you see in the mirror, and making sure you keep the activity up to hang on to that health.
However, if obesity is causing health problems, such as restricted mobility, type 2 diabetes, sleep apnoea and so on, obesity surgery can have miraculous results. Studies have showed that Type 2 diabetes completely resolves in 77% of patients post surgery, with all the benefits that arise from that – including reversing any risk of blindness or loss of extremities, hypertension resolves in 62% of patients and obstructive sleep apnoea (which can often result in death) resolves in 86%.
I had a gastric bypass 2 years ago. I’m one of those people who are severely diet restricted post-op; I can’t eat meat that hasn’t been ground or cooked twice (can’t eat the roast chicken, can eat the soup made by the carcass) or bread, pasta or rice. I can eat a little fruit, but fruit juice makes me dump – big time. Oddly, I can eat a number of “bad” foods – chocolate, cookies, sweets – but have largely lost the taste for them, since I was restricted to low sugar foods for the first three months after surgery. I get very, very bored by my diet and CRAVE bread.
On the other hand, before the op I had arthritis in both knees and walked with a stick, and the asthma I have suffered from as a child was severe, especially when walking. I also showed signs of sleep apnoea. I was diabetic and had hypertension. Within five weeks of the operation all my diabetes symptoms had gone. Within two months I lost the stick. I’m not sure when the hypertension went away, but it has done so. I can now walk for literally hours at a time, and can’t remember where I put my asthma inhaler (though I need to find it – hay fever season is coming). Yes, I’m much smaller too, but that’s the least of the things I celebrate; I never really cared that I was fat – I cared that I’d got sick.
Bariatric surgery is not a silver bullet, nor a bed of roses: nobody should enter into it lightly (though no surgeon – in New Zealand, at least – would allow you to). It won’t make you a different person, though it might make you a healthier one. If you’ve got emotional shit to sort out it’s still going to be there after surgery. If you hate yourself for being fat, chances are, down the track, you’ll hate your saggy arse.
Each individual considering this extreme kind of treatment needs to realistically balance costs and benefits before deciding whether or not to go ahead.
Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery.
Foo J, Toomath R, Wickremesekera SK, Bann S, Stubbs R. Bariatric surgery: a dilemma for the health system?
Perry CD, Hutter MM, Smith DB, et al. Survival and changes in comorbidities after bariatric surgery.
Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects.
Wakefield Clinic. Obesity Surgery Information Pack.