What Types of Weight-Loss Surgery or Weight Procedures Are Available?

What Is Weight-Loss (Bariatric) Surgery?

Weight-loss surgery has been proven to offer long-lasting effects for weight loss for those with moderate to severe obesity. Contrary to what many might say, weight-loss surgery is not the easy way out. It requires a life-long commitment to diet, exercise, and medical care. Given the commitment required to benefit from surgery, it is essential to understand all available surgical options as you embark on this journey.

Weight-loss surgery, also called bariatric surgery, includes several operations that change the digestion of food and the absorption of nutrients by making the stomach smaller and at times by rerouting the intestine, which leads to a significant and lasting amount of weight loss over time. Several studies have shown that bariatric surgery increases life expectancy and decreases the risk of death from diabetes by 92%, from cancer by 60%, and from coronary artery disease and heart attacks by 56% as compared to those with obesity who do not have surgery (Sjöström et al, 2007). In addition, over the past 60 years since it was first performed, bariatric surgery has become much safer. As per the United States Agency of Healthcare Research and Quality (AHRQ), the risk of death from bariatric surgery is now about 0.1% (1 of every 1,000 patients) which is considerably lower than the risk of death from other common surgeries (such as gallbladder removal); the overall probability of having a major complication from bariatric surgery is about 4% (AHRQ, 2007). This decrease in risk can be attributed to technological advancements in the use of minimally invasive techniques. Today, most bariatric surgeries are done laparoscopically. This means that the surgery is performed by making very small surgical incisions in the abdomen (with surgeons using special tools to see and work inside the body). The minimally invasive technique allows for faster recovery, shorter hospital stays, less pain, and a lower risk of complications.

Is Weight-Loss Surgery for Me?

By the time someone makes the decision to go forward with surgery, they have typically made many attempts to lose weight and have either not lost the amount of weight that they expected, or they regained the weight they had lost. There can be self-blame or shame for “lack of self-control or will-power”; however, our genetics, human evolution, and the environment each play a significant role in making it easy to gain and to maintain weight and extremely difficult to lose weight. These mechanisms function like a spring: As soon as we lose a certain amount of weight our bodies release hormones to make us feel hungrier, increase our cravings for higher caloric foods, and decrease our metabolism. This pulls our weight back to its baseline, where it was previously. This regulation of our bodies’ metabolism at a higher weight is called the set point, and some of the weight-loss surgeries (such as the vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and distal gastric bypass) can help reset our metabolism and overcome this set point (Müller et al, 2010).

There is more to weight-loss surgery than just decreasing the size of the stomach causing someone to eat less; removing part of the stomach changes the communication between the gut and the brain, affecting hunger and satiety (the sensation of feeling full). This happens via a complex mechanism of hormones that are released from the stomach and the intestines and then sensed by the brain leading to a decreased sensation of hunger and improving satiety even when eating smaller amounts of food. In addition, these surgeries induce changes in hormones released by the stomach and intestine to help better metabolize sugars. These changes often lead to improvement in diabetes shortly after surgery, even before significant weight loss is achieved. Other benefits of weight-loss surgery include improvements of multiple serious medical conditions such as hypertension, obstructive sleep apnea, and high cholesterol. In addition, quality of life can markedly improve.

Am I a Suitable Candidate for Weight-Loss Surgery?

The National Institute of Health (NIH) has created clinical guidelines with specific criteria about who should have surgery in the United States. Bariatric surgery is available for those with obesity, meaning a body mass index greater than or equal to 40 or a body mass index greater than or equal to 35 with diagnosis of type 2 diabetes, or two other medical problems associated with having overweight or obesity with the most commonly approved diseases of heart disease and obstructive sleep apnea. But there can also be consideration for diseases, such as hypertension, high cholesterol, arthritis, and non-alcoholic fatty liver (NAFLD) (Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement Online, 1991) who have had unsuccessful attempts to lose weight.

Why Does My Body Mass Index Matter?

Body mass index (BMI) is a more accurate calculation of body size and fat than is weight alone. It is often used as a tool to help health-care providers assess the risk of developing certain diseases related to having overweight or obesity, and to help decide who qualifies for bariatric surgery. However, this is only one aspect of a very complex equation used in the assessment of who is a good candidate for surgery. BMI can be calculated by using the following equation:

BMI = weight in pounds (____) × 703/height in inches squared (______).

Or an easier way is to use the online calculator at the NIH site (https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm).

Or, download the free “NIH BMI” APP on your smart phone.

You can also look at your height and weight in a BMI chart, as shown in

Figure 12-1. For example, for someone who is 5 feet 6 inches (66 inches) and has a weight of 223 lbs, their BMI is 36.

Why Do I Have to Go Through a Screening for Different Bariatric-Surgery Programs?

Most bariatric surgical programs have their own criteria for approving patients for bariatric surgery. Although these steps can delay the process or be merely a bureaucratic step, they have been developed to assure patients’ safety; they are extremely important for weight-loss surgery candidates. Most programs follow the national recommendations for bariatric surgery and screen patients for contraindications for bariatric surgery as well as their readiness for this life- altering procedure. Patients are typically evaluated by a registered dietician who works with patients to change their eating habits while preparing them for post- operative dietary adjustments and nutritional requirements, such as appropriate amounts of proteins and fluids. Dietitians will also educate patients about the use of post-op vitamins and the requirements for mineral supplements. Most programs require a few visits with a dietitian, who is likely to become the patient’s best ally through the weight-loss journey during the pre-operative and post-operative phases.

Are There Any Weight-Loss Requirements Before Bariatric Surgery?

Health insurance companies often require that patients lose weight before being approved for bariatric surgery. Most will aim for 5% to 10% (so for someone who weighs 250 lbs., around 12.5 to 25 lbs. must be lost before having surgery). Although multiple studies have shown inconclusive results regarding the long- term benefits of pre-operative weight loss, some have shown that for those who lose more than 5% of their weight before undergoing a laparoscopic Roux-en-Y gastric bypass, the risk of surgical complication decreases by 13% (Anderin et al, 2015), and it can decrease the length of hospital stay post-operation (Van Nieuwenhove et al, 2011; Giordano and Victorzon, 2014). Some bariatric surgery programs have different preoperative weight-loss requirements.

Psychological Evaluation

Most bariatric surgical programs require a psychological evaluation prior to being approved for bariatric surgery. This is done as a safety measure, given that there are some behavioral and psychiatric conditions (e.g., depression, substance abuse, and binge eating) that can have an adverse effect on postoperative recovery and success (Fabricatore et al, 2006). Although most patients view bariatric surgery as a positive event with many psychological benefits, there is a small subset of patients with depression who might develop more depressive symptoms following bariatric surgery. There is also an increase in the number of suicides after bariatric surgery (Omalu et al, 2007). Some reports have suggested that this worsening depression might be due to the added stress of surgery and possibly difficulty taking anti-depressant medications in the post-operative period (Kodama et al, 1998). In addition, there is an increased risk of substance (especially alcohol) abuse (King et al, 2018). Reasons for this include psychological and physiological changes after weight-loss surgery. Addiction transfer (when one trades their “addiction for food” to an addiction to drugs and alcohol) can occur (McFadden, 2010). Another possible reason is that after bariatric procedures (such as gastric bypass surgery), alcohol absorption and sensitivity can heighten its affect in the body. Studies have also suggested that patients who have had problems with binge eating tend to lose less weight and to re-gain more weight after surgery (Rowston et al, 1992).

Given the potential risk posed to some individuals with associated behavioral and psychological conditions, the NIH established pre-operative psychiatric evaluation recommendations (Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement Online 1991). These recommendations help bariatric surgical teams determine a patient’s safety and readiness for surgery. This evaluation is often completed by a psychologist who assesses multiple aspects of a patient’s life; for example, their support system, living conditions, understanding of the surgery, expectations regarding surgical results, ability to adhere to medical recommendations, eating-related behaviors (prior weight-loss attempts, diet, exercise), and psychiatric conditions such as depression and substance abuse (Flores et al, 2014).

Even if someone has one of the aforementioned problems, it is important to remember that medical and behavioral health treatments are available. Often, when someone is followed by a member of the behavioral health team (and these problems are well controlled), the individual might qualify for bariatric surgery.

Medical Evaluation

A medical evaluation helps to determine whether you are healthy enough for weight-loss surgery and decide what would be the best procedure to perform. In addition, many tests are performed to assess whether there are obesity-related diseases (e.g., obstructive sleep apnea, diabetes, high blood pressure, high cholesterol) that can be better managed before surgery to decrease your surgical risk and to improve your outcome.

Some of the pre-bariatric surgical tests that are required include the following:

  • Blood work: complete blood count (CBC), kidney function tests (creatine and blood urea nitrogen), electrolytes, thyroid-stimulating hormone (TSH), liver function tests (ALT/AST), cholesterol levels, Helicobacter pylori (H. pylori) antibody (this is a common bacterial infection in the stomach that can pre-dispose you to gastric ulcers), iron levels, vitamin levels (vitamin D, vitamin B12, thiamine)
  • Urine analyses
  • Electrocardiogram (EKG)
  • Abdominal ultrasound (US)
  • Upper-gastrointestinal evaluation (either by endoscopy or by drinking a contrast fluid and having an X-ray)
  • Pulmonary function tests (if you have a history of lung problems such as asthma or a history of smoking)
  • Sleep study
  • Echocardiogram and cardiac stress test (if you have a history of heart attack or heart problems)
  • Medical clearance

Contraindications to Bariatric Surgery (AAFP 2016: Obesity: Indications and Contraindications):

  • Bariatric surgery might be contraindicated when the risk of the surgery outweighs its health benefits.
  • Pregnancy, or plans to become pregnant within 2 years of surgery, is a contraindication for surgery. Pregnancy within 2 years of having bariatric surgery can place both you and the baby at significant risk due to changes in the anatomy of the stomach and issues with nutrient absorption. It is important that you plan to avoid pregnancy after surgery because weight loss often enhances fertility.
  • Smoking can increase your risk of serious surgical complications. Most bariatric-surgery programs recommend stopping smoking at least 2 months before surgery.
  • Ongoing drug and alcohol abuse can affect post-operative healing, increase your risk of ulcers and life-threating nutrient deficiencies as well as worsen addiction and depression.
  • Portal vein hypertension, often associated with certain liver conditions (such as chronic hepatitis and alcoholic cirrhosis), can lead to an increase in portal hypertension and serves as a contraindication to surgery.
  • Advanced cancer.
  • Severe psychiatric conditions. Untreated eating disorders.
  • Significant cognitive impairment that would prevent someone from fully understanding the risks and implications of having bariatric surgery serves as a contraindication to surgery.

In addition, each procedure has its own contraindications. Laparoscopic adjustable gastric banding is contraindicated in those who take steroid medications for long periods (e.g., inflammatory bowel diseases [Crohn’s disease, chronic pancreatitis]) (AAFP 2016: Obesity: Indications and Contraindications). Laparoscopic sleeve gastrectomy is contraindicated for those with Barrett’s esophagus and severe gastroesophageal reflux disease (Gagner, 2016). 

Roux-en-Y gastric bypass and distal gastric bypass (duodenal switch and biliopancreatic division) are relatively contraindicated for those with inflammatory bowel disease (Maloney et al, 2011).

What Types of Weight-Loss Surgery Are Available

Operations that make the stomach smaller are called restrictive surgeries because these procedures restrict or limit the amount of food and calories that you can eat (which leads to weight loss). The restrictive procedures include gastric banding and the vertical sleeve gastrectomy.

Gastric Banding (“Lap-Band”)

Gastric banding uses an adjustable silicone band that is placed with minimally invasive surgery around the upper part of the stomach, thereby reducing the size of the stomach. A small port, the size of a coin, rests under the skin in the abdomen, and it is attached to the silicone band. The band size can be adjusted after the surgery by injecting fluid into this port. Filling the band with more fluid causes it to further restrict the passage of food and liquids through the rest of the digestive system, decreasing the amount of food you can eat and thereby leading to weight loss (O’Brien et al, 2002).

The lap-band procedure is indicated for those older than 18 years and who have a BMI greater than 40 or a BMI greater than 35 with other diagnoses (e.g., diabetes, hypertension, obstructive sleep apnea) associated with having overweight or obesity. Lap-band surgery is a safe procedure with a low risk of severe side effects and mortality, just 0.02% (AAFP 2016: Obesity: Indications and Contraindications). It causes more gradual weight loss than other bariatric procedures; the average weight loss is 47% of excess body weight (Excess body weight = ideal body weight – current weight) (O’Brien et al, 2013). For a woman (ideal body weight is 100 lbs. for the first 5 feet, plus 5 lbs. for each additional inch; for a man it is 106 lbs. for the first 5 feet, plus 6 lbs. for each additional inch (Peterson et al, 2016).

Although lap-band surgery is safe and can lead to long-term weight loss, it has fallen out of favor in the United States; many surgical centers no longer do this procedure. One reason for this is that it has a higher rate of complications and a more frequent need for re-operation. Some recent studies have noted that almost half of patients who have the lap-band had a follow-up procedure for complications (such as pouch enlargement, erosion, and port and tube problems). Six percent of patients have also had the band removed (O’Brien et al, 2013). Another reason why the lap band has fallen out of favor is because it is not a metabolic procedure. This means that it does not change the communication between the brain and the gut, which leads to more sustainable weight loss.

Vertical Sleeve Gastrectomy

The vertical sleeve gastrectomy has become the most common weight-loss surgical procedure in the United States, with more than 100,000 surgeries done each year. This procedure has been found to be safe and effective for long-term effects on weight loss. Studies have shown that patients lose an average of 55% of their excess body weight (i.e., if a patient has 100 pounds of excess weight, they will lose on average 55 lbs.) after having a gastric sleeve placed (American Society for Metabolic and Bariatric Surgery [ASMBS] website, sleeve gastrectomy as bariatric procedure. https://asmbs.org/resources/sleeve- gastrectomy-as-a-bariatric-procedure. 2012). There is also a significant improvement or resolution of some obesity-related diseases (e.g., obstructive sleep apnea, high blood pressure, high cholesterol, fatty liver, arthritis, infertility, polycystic ovarian syndrome [PCOS]). One study showed that diabetes resolved in two-thirds of patients and improved in approximately one-fourth after 1 year in those who had a sleeve gastrectomy (Gill et al, 2010). In addition, numerous studies have shown improvement in quality of life.

This procedure is typically performed laparoscopically whereby most of the stomach (approximately three-fourths) is removed. The remainder of the stomach is reattached with surgical staples forming a long tube, or “sleeve,” leaving a banana-shaped stomach (Shi et al, 2010). This procedure takes roughly 1 to 2 hours in the operating room. The recovery time varies; it often takes 1 to 3 days before you can leave the hospital (Sucandy et al, 2013). Some bariatric programs send patients home on the day of the surgery. Patients can return to work within 1 to 3 weeks depending on their type of work; however, heavy lifting (i.e., more than 10 lbs.) is not allowed for 4 to 6 weeks.

Patients are thought to lose weight via two mechanisms: by decreasing the stomach size and by restricting the amount of food someone can consume. The other mechanism is by decreasing appetite, given that the surgery removes the part of the stomach that produces a hunger hormone, called ghrelin (Gumbs et al, 2007). Therefore, patients not only feel full after eating a smaller amount of food, but they also feel less hungry.

The sleeve gastrectomy is a safe procedure; the risk of mortality is 0.2% according to the ASMBS. The risk of post-operative complications is also low (e.g., leakage from the staples in the stomach [2.2%], bleeding [1.2%], and narrowing of the passage of the stomach, called stricture [0.6%]). The most commonly reported longer-term complication related to this procedure is gastro- esophageal reflux (manifest by heartburn and regurgitation), which is seen in 21% of patients (Himpens et al, 2010). This complication is often treated with a class of medication called proton pump inhibitors. Nutritional deficiencies (thought to be due to the decreased absorption of nutrients and vitamins from the stomach with a smaller stomach pouch and a decrease in food intake) are less commonly seen in those with the sleeve gastrectomy than with gastric bypass surgery. Some of the more common mineral and vitamin deficiencies include deficiency of vitamin B12, vitamin D, folate, iron, calcium, and zinc (Sarkosh et al, 2013). This makes it extremely important to follow-up with the surgical bariatric team at 3, 6, and 12 months after surgery and at least yearly after that. Patients are often unaware that life-long follow-up is essential.

Restrictive and Malabsorptive

Other procedures (such as Roux-en-Y gastric bypass and distal gastric bypass with duodenal switch, and biliopancreatic division) are a combination of restrictive and malabsorptive procedures. The restrictive aspect of this procedure is accomplished by making the stomach smaller; it restricts or limits the amount of food you can eat at one time. The malabsorptive component is caused by bypassing part of the intestine that affects the absorption of food and nutrients. Therefore, when you eat, a smaller percentage of the food will be absorbed. This in turn leads to a lower intake of food and calories and to a long-term effect on weight loss.

Roux-en-Y Gastric Bypass

Until recently, gastric bypass had been one of the most common weight-loss surgeries in the United States, when it became second in popularity to the sleeve gastrectomy. It remains an excellent option for those looking for long-term and sustained weight loss. One study showed an average excess weight loss of 77.6% at 18 months (i.e., if a patient has 100 lbs. of excess weight, they will lose on average 77.6 lbs). For example, if a woman is 5 feet 5 inches tall and weighs 250 lbs., she is 125 lbs. above her ideal weight (excess body weight = ideal body weight – current weight). Post-gastric bypass, she would lose an average of 98 lbs. (125 lbs. × 0.78) in 18 months; her weight would drop to 152 lbs. and her BMI would decrease from 42 to 25. Like the sleeve gastrectomy, there is significant improvement and or resolution of many obesity-related co- morbidities (e.g., hypertension, high cholesterol, osteoarthritis, diabetes). Some studies have shown that remission or resolution of diabetes was higher in patients who had a gastric bypass as compared to those who had the sleeve (with a diabetes remission rate of 80%) (Li et al, 2013). In addition, several studies have shown improvement in the quality of life for those who had this surgery with a decrease in the mortality rate. Patients are not only living longer, they are living better.

Roux-en-Y gastric bypass as with the sleeve gastrectomy is also commonly performed laparoscopically, with minimally invasive techniques, in which the surgeon makes five to six small cuts in the abdomen and inserts a small camera and tools to remove 60% to 80% of the stomach; what is left of the stomach is made into a small pouch that holds approximately 30 ml (roughly the size of a lemon). The newly formed pouch is then attached to the distant part of the intestine, “bypassing” part of it. The purpose of bypassing part of the intestine is that food will have a shorter distance to travel through the digestive tract and, therefore, will not be fully absorbed (Schauer et al, 2000). This surgery leads to changes in the hunger hormone; cutting part of the stomach decreases the amount of hunger hormone released, causing a decrease in appetite.

As previously discussed, gastric bypass surgery has come a long way from its beginnings as an open surgical procedure (which required prolonged time in the operating room and long hospital stays) to its laparoscopic, minimally invasive approach. This has led to shorter operating times, fewer complications, faster recovery, and safer surgery. The average operating time for the laparoscopic gastric bypass is 1.5 to 3.5 hours and the average patients’ hospital stay is 2 to 3 days. Recovery time is like that of the sleeve gastrectomy, for which patients can return to work within 2 to 4 weeks depending on the type of work they do; however, heavy lifting (more than 10 lbs.) is not allowed for 4 to 6 weeks.

The mortality rate for the laparoscopic procedure is also low and like that of the sleeve gastrectomy. One study, involving multiple bariatric centers with 2,458 participants, showed a 30-day post-laparoscopic gastric bypass surgery mortality rate of 0.2%. The mortality rate for open procedures, in which the surgeon opens the abdomen to perform the procedure, increases to 2.1% (Belle et al, 2013). The rates of complications have been slightly higher than with the sleeve gastrectomy, with rates ranging from 1% to 5%. Some of the immediate complications include surgical site leaks, bleeding, bowel obstruction, deep vein thrombosis, and pulmonary embolism. Long-term side effects include nutritional deficits with protein as well as with multiple vitamins and minerals, including iron (20%–49%), vitamin B12 (26%–70%), and folate (9%–35%), in addition to calcium and vitamin D (Nandagopal et al, 2010). The reason for the nutritional deficits post–gastric bypass is that the stomach is now very small and part of the intestine has been bypassed, allowing food to travel faster through the digestive tract, preventing the absorption of vitamins and nutrients. Some of these deficiencies can lead to life-threating conditions, and it is imperative that patients take their vitamins after having had weight-loss surgery and continue to follow-up with the surgical team.

Biliopancreatic Diversion with Duodenal Switch

Biliopancreatic diversion with duodenal switch (BPD-DS) is a sleeve gastrectomy combined with a gastric bypass in which a larger portion of the intestine is bypassed. This procedure is also most often performed laparoscopically with minimally invasive techniques in which the surgeon makes small openings in the abdomen through which a camera and tools are inserted to remove 70% to 75% of the stomach, forming a tubular, “banana-shaped” stomach. The newly formed stomach is then attached to the furthest part of the small intestine, bypassing almost three-fourths of the intestine. The part of the intestine that was bypassed is the part that carries some of the digestive enzymes (that help to break-down and absorb protein and fats) from the pancreas. This part of the intestine is reattached to the last portion of the intestine; therefore, after surgery, the patient can digest and absorb some of those nutrients (Ren et al, 2000). The benefit of this procedure over the previous two procedures, is that biliopancreatic diversion can lead to more weight loss while allowing patients to eat near-normal amounts of food. Initially this procedure causes a decrease in food intake, like the sleeve gastrectomy and gastric bypass, given the small size of the stomach; however, over time, patients are able to eat almost normal amounts of food. The contributing factor to the long-term weight loss is that even when someone is eating normal amounts, he or she will absorb only a small amount of these calories because most of the intestine is bypassed. Like both sleeve and the bypass surgeries, this procedure also changes the hormone communication to the brain that effects appetite and sugar metabolism.

Although weight-loss results and resolution of obesity-related co-morbidities are greater with this procedure, BPD-DS is a more complex surgery, leading to longer operating times and to potentially more complications. The average operating time is around 4 hours and the hospital stay is on average 4 days, with rates of complications as high as 62% (Ren et al, 2000) and 37% of patients having complications that require surgery (Sethi et al, 2016). Some of these complications were related to nutritional deficiencies (in particular, of vitamin D), anemias, and changes in the hormone (called parathyroid hormone) that controls bone metabolism. However, with technological advancements, the mortality rate with laparoscopic procedure is now like that of the other two procedures, about 0.1%, and more recent reports have noted a decrease in risk of complications of 3% to 7.4%. Excess weight loss (EWL) was 67.9% at 10 to 15 years after the surgery with a resolution of type 2 diabetes of 87.5% (Bolckman et al, 2016).

This is a technically more difficult surgery, and it is very important that it be done by an experienced surgeon. This procedure is offered only at selected bariatric-surgery sites. As with the other two procedures it is quite important to have close follow-up with the surgical team, to take all vitamins as recommended, and to continue having blood work monitored initially at 3, 6, and 12 months, and at least yearly thereafter.

Endoscopic Options

Endoscopic Intragastric Balloon

Placement of an intragastric balloon is a non-surgical option for those with obesity (i.e., with a BMI of 30 to 40) who have failed to lose weight through diet and exercise. Patients are typically placed under light sedation, and medication is given through a vein to make patients feel sleepy and relaxed while not remembering the procedure. This is done by an anesthesiologist who is likely to use the same medications as are used during an endoscopy or colonoscopy. A biocompatible silicone (silicone made of materials that can be used inside the body) deflated balloon is placed in the stomach via the mouth with the help of an endoscope (a small tube with a camera in the tip), and it is then inflated with a saline solution. These procedures usually take only 20 to 30 minutes and patients return home the same day.

There are currently three types of balloons approved by the US Food and Drug Administration (FDA) for the treatment of obesity. The first two were approved by the FDA in 2015 and use a liquid to fill the balloon in the stomach.

One is the single balloon called Orbera, and the other is a dual-balloon system, called ReShape. Both balloons are filled with a saline solution in the stomach.

The ReShape balloons also have a non-toxic dye, called methylene blue; in case the balloon were to rupture, you would be able to see the blue dye in the urine. A third balloon, which was approved by the FDA in 2016, is called Obalon, consists of three balloons filled with air. These balloons are swallowed in a capsule, one at time, over a few weeks. After the capsule is in the stomach, it is inflated with gas via a small tube. The purpose of the balloons is to fill a portion of the stomach, giving the sensation of feeling full, which leads to a decrease in appetite and in food intake, causing weight loss. Studies report weight loss for the intragastric balloons, averaging a 28.7% loss of excess weight at 6 months and of 39.2% at 12 months (Kim et al, 2016). All currently available balloons are safe in the stomach for 6 months and must be removed using a minimally invasive endoscopic procedure with light sedation. The most common side effect noted with the balloons is initial abdominal discomfort; nausea, and vomiting can occur for the first few days after the balloon is inserted and tend to improve.

One report looked at patients treated with balloons and found that nausea occurred in 72% of patients with the balloon; more serious side effects, such as ulcer, occurred in 5% of those who had the balloon. However, no serious or fatal complication has been reported in these studies (Zheng et al, 2015). Earlier this year the FDA reported acute pancreatitis (inflammation of the pancreas), which can be a very serious health condition, in several patients following insertion of both liquid-filled balloons (Orbera and ReShape) due to compression of the pancreas (which is located behind the stomach) by the balloon. All of the cases required sooner-than-expected removal of the balloon, and four of the patients required hospitalization. The FDA also issued an updated alert to health-care providers with five reports of unanticipated deaths in 2016 of patients who had liquid-filled intragastric balloons, four were reported with Orbera and one was with ReShape. This happened within 1 month after the balloon insertion; however, there is no clear evidence that the patient death was related to the balloon placement (Liquid-filled Intragastric Balloon Systems: Letter to Healthcare Providers Potential Risks. Feb 9, 2017 and Aug 10, 2017. https://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalPro

Intragastric balloons are an effective non-surgical option for weight loss; however, this is currently approved for 6 months only and some studies have shown that the weight-loss results are not long lasting. Patients tend to regain weight following balloon removal (Kim et al, 2016). In addition, the balloons are currently not covered by health insurance and require out-of-pocket costs of approximately $7,000 to $10,000 depending upon where it is done. However, this can be a great tool, especially for those who are not surgical candidates and who might consider using the balloon with other medical treatments.

Long-Term Effects of Bariatric Surgery

Weight Loss and Decrease in Mortality

A common misconception is that most patients who have weight-loss surgery will regain their weight. This is untrue; according to the ASMBS, as many as 50% of patients regain a small portion of their weight loss (just 5%) 2 years or more following surgery. However, long-term studies have demonstrated that most patients who have bariatric surgery maintain their weight loss. The Swedish study is one of the largest and longest-running studies on bariatric surgery with more than 2,000 people who had bariatric surgery and were followed for more than 10 years. This study showed that most of the weight loss occurred within the first 2 years after the surgery: 32% of weight loss was found 2 years after gastric bypass, 25% was noted after vertical-banded gastroplasty, and 20% after gastric banding. Most of the weight loss was maintained and stable at 10 years after surgery, with 25% found for gastric bypass, 16% for vertical-banded gastroplasty, and 14% for gastric banding (Sjostrom et al, 2007). In addition, it found that there were more deaths in the group that didn’t have bariatric surgery than those who did. The patients who had bariatric surgery had fewer heart attacks, strokes, and cancer. This indicates that bariatric surgery for severe obesity leads to long-term weight loss and to a decreased risk of death.

Decrease in Incidents and Resolution of Co-Morbidities

In addition, there are other benefits to weight-loss surgery, including a lower occurrence of new diagnoses of diabetes, high blood pressure, and elevated cholesterol among those who had weight-loss surgery. There was also resolution or significant improvement of many obesity-related co-morbidities, such as hypertension (by 34% at 2 years), diabetes (by 68% in 2 years, and 33% with long-term remission and significant reduction of anti-diabetic medications) (https://asmbs.org/resources/long-term-survival-benefit-after-metabolic-and- bariatric-surgery). Other conditions, such as obstructive sleep apnea and fatty liver, were also shown to improve in the bariatric-surgery group. There are also reports of increased mobility and physical activity in the post-bariatric group along with improvement in the measures of quality of life (Sjostrom et al, 2007).

Nutritional Deficiency

One of the main long-term complications of bariatric surgery is nutritional deficiency, mostly related to a decrease in absorption of vitamins and minerals (due to the changes in the size of the stomach and by bypassing parts of the intestine). This can be more severe and significant with procedures that bypass portions of the gastrointestinal (GI) tract where nutrients are absorbed. The most common deficiencies are of vitamin B12, vitamin D, folate, iron, calcium, and zinc (Sarkhosh et al, 2013). There are also issues with the parathyroid hormone which is related to bone metabolism and a possible consequence of vitamin D deficiency or rapid weight loss. Therefore, for most of the aforementioned procedures, you will need to take a multi-vitamin with some additional vitamins and minerals for the rest of your life. It is also extremely important to have follow-up with the bariatric surgical team, with blood work done at 3, 6, and 12 months after the surgery and at least yearly after that.

Dumping Syndrome

This is a potential side effect of procedures (such as the gastric bypass and BPD- DS) that bypass portions of the GI tract where nutrients are absorbed. This occurs only in some patients, and it is due to foods high in sugar or fat entering the end of the small intestine at a rapid rate. The reason these foods enter the last part of the intestine quickly is because with these surgeries part of the intestine is bypassed. This causes an immediate release of hormones and symptoms shortly after eating foods high in fat or sugar. These symptoms include dizziness, palpitations, sweating, nausea, vomiting, abdominal cramps, and diarrhea.

Alcohol Intake

Several studies have shown that patients who have had bariatric surgery are more likely to develop an alcohol use disorder (AUD) or suffer a relapse, especially after gastric bypass. This is likely to be due to altered alcohol metabolism due to changes in the anatomy of the stomach and intestine, which causes accelerated alcohol absorption (https://asmbs.org/resources/long-term- survival-benefit-after-metabolic-and-bariatric-surgery). 

This means that even smaller amounts of alcohol intake could cause someone to become intoxicated. In addition, liquid calories are easily absorbed and can lead to weight gain. Therefore, alcohol is not recommended after bariatric surgery.

Excess Skin

The amount of excess skin after bariatric surgery depends on how long your skin has been stretched, the amount of your weight loss, and your age. It doesn’t matter whether the weight is lost quickly or slowly, the elasticity of the skin is dependent on how long the skin has been stretched.

Weight Regain or Inadequate Weight Loss

Although many patients can maintain some weight loss after surgery, others struggle with either inadequate weight loss or weight regain. In these situations, some people undergo revision surgery, but these procedures are often unsuccessful unless there are anatomic issues associated with the initial procedure. For others, they might achieve weight loss with the use of medications in conjunction with lifestyle changes.

Should I Try Weight Loss Supplements?

Certainly, a person cannot rely on a single food or supplement to burn fat. They should also decrease their calorie intake and increase physical activity. However, when used as part of a healthy diet and lifestyle, natural fat burners may accelerate weight loss by either increasing metabolism or decreasing appetite.

Resurge is of the most popular weight loss supplements that promise to help you shed pounds and sleep better. Because studies have shown that sleep deprivation is associated with deficiencies of growth hormone and elevated levels of cortisol, both of which contribute to obesity.

While other supplements promote nutritional factors, meal replacement forms, appetite suppression, or similar effects, Resurge boosts your body’s metabolism by increasing your core temperature. However, before making any purchases, you might want to read some Resurge reviews because the supplement industry is rife with scams.

It should be noted that pills or supplements are usually not recommended for children, pregnant and breastfeeding women because some of their ingredients e.g. caffeine can have serious side effects when consumed in large amounts. For example, if a pregnant woman consumes over 200 mg of caffeine per day, her baby is at an increased risk of fetal growth restriction and/or miscarriage, though caffeine can boost your weight-loss efforts.

Besides, you should avoid taking any supplements at least two weeks before your surgery or if you have recently undergone surgery. For example, selenium, a common ingredient in weight loss supplements, may increase bleeding risk.

Although the formula of Resurge doesn’t have any stimulants, you should still talk with your doctor before you start taking the supplement, especially if you have health concerns.

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