Surgery for Weight Loss: What Are Your Options?
Why Consider Weight Loss Surgery?
Losing weight with diet and exercise is an option for many patients. However, some patients may fail diet and exercise and be at a high risk for disease-related complications due to obesity. In these patients, weight loss surgery may be an option.
There are several types of weight-loss surgery, known collectively as bariatric surgery. However, not everyone is a candidate for weight-loss surgery. Patients should consult with a surgeon who performs bariatric surgery to discuss their options. Weight loss surgery is a permanent procedure that requires a lifetime commitment to maintaining a healthy lifestyle and a proper diet.
The advantages to weight loss surgery are many:
- Improved overall health
- Lowered risk of weight-associated diseases, such as high blood pressure, heart disease, diabetes, osteoarthritis and sleep apnea
- Decreased need for medications
- Easier mobility
- Enhanced self-esteem and quality-of-life
- Potentially a longer lifespan
Experts state that in some diabetic patients, surgery plus medication works better than either treatment alone, although not all patients will achieve remission status, meaning they no longer require diabetes medications.
Surgical Weight Loss: Who is a Candidate?
It is important to determine with your physician if you are a candidate for weight loss surgery. Most people who are candidates for weight loss surgery have tried to lose weight through traditional diet and exercise and have not had success. Candidates for weight loss surgery include those patients that have a serious, potentially life-threatening condition from obesity, a genetic propensity towards obesity, a high body mass index, and long-standing obesity.
Does Insurance Pay for Weight Loss Surgery?
Health insurance is increasingly covering many of the costs of weight loss surgery, depending upon a patient’s individual plan. However, specific requirements may need to be met. One of the requirements is that a patient is a certain body mass index (BMI) to qualify for the surgery. In addition, some patients may need to have at least one major medical comorbidity, such as high blood pressure, diabetes, or sleep apnea. Some insurance plans also require documentation that a patient has attempted weight loss in the previous two years through traditional methods such as diet and exercise.
- Underweight = BMI under 18.5
- Normal weight = BMI 18.5 - 24.9
- Overweight = BMI 25 - 29.9
- Obese = BMI 30 to 39.9
- Morbidly Obese = BMI 40 or greater
BMI calculations can be calculated here.
To qualify for insurance coverage for weight loss surgery, patients typically must have either:
- A body mass index greater than or equal to 40
- Body mass index between 35 and 39 and at least one major medical comorbidity, such as respiratory problems (i.e., sleep apnea), diabetes, or hypertension
- Certain patients may qualify for weight-loss surgery if your BMI is below 35 with serious health problems due to excess weight.
Before a patient considers weight loss surgery as an option in managing obesity they should discuss this procedure with a qualified surgeon. In addition, the insurance company should be contacted to determine:
- If weight loss surgery is covered by the insurance policy, Medicare or Medicaid
- Which local surgeons/hospitals are covered under the insurance
- If a coinsurance or deductible payment for the weight loss surgery is required by the patient.
How Much Does Weight Loss Surgery Cost?
As reported in 2018, gastric bypass and sleeve gastrectomy each costs between $20,000 and $30,000, although rates can vary. Adjustable gastric banding is less costly and averages around $15,000, as it is a much less invasive surgery. Check with your insurance company for coverage rates. Your surgeon will also have a team that will help to determine your qualification before surgery.
Types of Weight Loss Surgery
The four most common types of weight loss surgery are:
Gastric Bypass Surgery
Gastric bypass surgery, the most common of which is the Roux-en-Y gastric bypass procedure, results in a portion of the stomach being stapled to reduce appetite and food intake. A small stomach pouch is formed, but no portion of the stomach is removed surgically. The top section of the stomach (called the pouch - about the size of an egg or a walnut) is where food is digested. It holds only about one ounce of food.
The pouch is then connected to the small intestine. Fewer nutrients and calories are absorbed. Hunger and food intake are reduced, and 55% to 65% of excess weight can be lost, usually within one year. Gastric bypass may be performed by either a traditional incision that will leave a permanent scar or more commonly with a laparoscopic procedure that may leave less scarring and allow for a quicker recovery.
One study published in the New England Journal of Medicine evaluating weight loss in adolescents found that an average weight loss of 40 kgs (90 lbs) after this type of surgery, about double the weight loss expected with a gastric band procedure. However, weight loss is individual for each person and can vary. Although many people will regain some weight, it is usually much less than before surgery.
Gastric bypass surgery will require two to three days stay in the hospital for recovery. General anesthesia is utilized during surgery, which typically takes several hours. Full recovery may take two to five weeks before a patient can return to normal activities.
Complications with gastric bypass surgery may include:
- leaking or dumping syndrome.
- Higher chance of vitamin shortage than with the gastric band or gastric sleeve procedures.
- vitamin deficiencies may occur if supplements are not taken.
Gastric Band Surgery
Adjustable Gastric Band Surgery, often referred to as lap band or band surgery, is usually performed as an outpatient procedure. In the surgery, an adjustable silicone band is placed around the upper portion of the stomach. Small incisions are made in the skin to allow the band to be placed (laparoscopic procedure). The band creates a small stomach pouch at the top of the stomach - the stomach is not surgically reduced in size.
The smaller pouch that is created with the band results in smaller amount of food intake, and a feeling of fullness after eating smaller portions of food. Surgery typically takes 45 minutes to an hour during which general anesthesia is used. Patients will go home the same day. Recovery is roughly two weeks.
After surgery, the tightness of the band can be adjusted by injecting saline into a small port. The port is implanted in the skin during the surgery and is attached to the gastric band. Injection of the saline can be done in the doctor’s office. The band can be loosened or tightened to meet weight loss goals.
Adjustable gastric band surgery is a reversible procedure and is considered the least invasive of all of the weight-loss surgeries. Patients who follow instructions on diet can usually lose between 30 and 40 percent of excess weight with the gastric band procedure. However, weight loss is slower with gastric band surgery and it may take up to five years for complete weight loss. In one study, adolescent patients undergoing gastric band surgery lost an average of about 45 lbs.
- complications with adjustable gastric band surgery may include band slippage, band erosion into the stomach, and port-related problems.
- problems such as bleeding or infection may occur.
- frequent visits are required to adjust the band
- additional surgery may be needed to remove or replace the band system.
In some cases, the use of the gastric band may be appropriate for people with a BMI of 30 or more who also have at least one health problem linked to obesity, such as heart disease or diabetes. However, this procedure has fallen out of favor in more recent years.
Gastric Sleeve Surgery
In a gastric sleeve procedure (sleeve gastrectomy), roughly 80 percent of the stomach is removed during surgery. The remaining narrow portion of the stomach is attached to the intestines. The volume of the stomach is reduced, but rerouting around the intestine does not occur, thus preserving nutrient absorption.
Surgery typically lasts 60 minutes and general anesthesia will be used. The gastric sleeve procedure is not reversible. Sleeve gastrectomies may be appropriate as an alternative to gastric banding in certain patients.
The in-hospital recovery period is about two days, with a two to three week period for a full recovery. Patients will lose 40 to 55 percent of their excess weight which is generally seen one to two years after surgery. Weight loss is typically greater than that seen with gastric band surgery.
Complications with vertical sleeve gastrectomy may include:
- acid reflux (heartburn or GERD)
- development of strictures.
Biliopancreatic Diversion with Duodenal Switch
This more complex procedure requires two separate surgeries. The first surgery is similar to gastric sleeve surgery. In the second surgery, connections are made in your intestine to allow food to bypass most of the small intestine (duodenum) and allow digestive juices to flow into this part of the intestine. This is known as the biliopancreatic diversion.
This type of surgery allows you to lose more weight than the other three. As a result of this procedure, weight loss is achieved because the size of the stomach is smaller and food bypasses most of the small intestine, limiting the absorption of calories and nutrients. Surgeons do not perform this surgery as often because of the higher risk of complications such as a shortage of vitamins, minerals, and protein in your body.
What Diet and Vitamin Changes Are Required After Weight Loss Surgery?
Immediately after surgery, most patients will need to be on a liquid-only diet for several weeks, then will transition to soft foods for the next six to eight weeks, and finally, return to solid foods over the next nine months. Dieticians specialized in meal planning for bariatric surgery patients will consult with patients after surgery and throughout the weight-loss period.
Changes in meal plans after bariatric surgery are significant. Proper eating habits must be incorporated into the daily routine. Patients will need to adjust their calorie intake to roughly 800 to 1,000 calories per day, including 40 to 60 grams of protein to help maintain muscle mass. A multivitamin with at least 18 milligrams of zinc and 400 micrograms of folic acid will be required daily. Some patients will require additional vitamins and minerals, including the fat-soluble vitamins A, D, E and K.
Avoid high-fat foods and sweets that can lead to dumping syndrome. Dumping syndrome occurs when food moves down from your stomach into your small intestine too quickly after you eat It can lead to abdominal side effects such as weakness, nausea, stomach pain, and severe and rapid diarrhea.
Which Weight Loss Surgery is Best?
Which weight loss surgery to have is an individual decision you should make with your surgeon, and results will vary from person-to-person. However, a 2018 study from Kaiser Permanente evaluated the average weight loss with the most common procedures: gastric bypass, gastric sleeve, and gastric band. The average person in this study weighed 126 kg. (277 lb.) before surgery. The study found:
- Gastric bypass surgery yielded an average 31% weight loss in the first year and 25% after five years.
- The gastric sleeve led to a 25% weight loss in year one and 19% loss after five years.
- The gastric band led to a 14% total weight loss after one year and 12% at five years.
After 5 years, there was an 8.6 kg (19 lb.) weight loss difference between the gastric bypass procedure and the gastric sleeve procedure. However, serious complications after 30 days was twice as likely for gastric bypass compared to gastric sleeve (5% vs. 2.6%).
Complications in the study included:
- reoperation/repair procedures
- blood clots
- failure to be discharged from the hospital within 30 days.
Risks Associated with Weight Loss Surgery
Weight-loss surgical procedures require major surgery and may be associated with significant risks. It is important to discuss these risks with your surgeon.
- complications from surgery or anesthesia
- allergies to medicines
- bowel obstruction
- blood clots
- vitamin or other nutritional deficiencies
- risk of weight regain
- gastroesophageal reflux disease (GERD)
- dumping syndrome
- psychological problems after surgery
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- Arterburn D, Wellman R, Emiliano A, et al. Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study. Ann Intern Med. [Epub ahead of print 30 October 2018]169:741–750. doi: 10.7326/M17-2786. Accessed August 30, 2019.
- Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. The New England Journal of Medicine. 2016;374(2):113–123. Accessed September 3, 2019.
- Bariatric Surgery - National Institute of Diabetes and Digestive and Kidney Diseases. Accessed September 3, 2019 at https://www.niddk.nih.gov/health-information/weight-management/bariatric-surgery
- Consumer Guide to Bariatric Surgery - Ceatus Media Group. Accessed September 3, 2019 at https://www.yourbariatricsurgeryguide.com/
- Weight Loss Surgery - National Library of Medicine. Accessed September 3, 2019 at https://medlineplus.gov/weightlosssurgery.html
- Guide to types of weight-loss surgery - Mayo Clinic. Accessed September 3, 2019 at https://www.mayoclinic.org/tests-procedures/gastric-bypass-surgery/in-depth/weight-loss-surgery/art-20045334
Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.