Weight loss surgery

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Weight loss surgery

Weight loss surgery

Weight-loss surgery is also known as bariatric surgery (“bariatric” means “related to treatment for heavy weight”) or metabolic surgery, is a type of surgery that helps you lose weight by making changes to your digestive system ¹. Some types of weight-loss surgery make your stomach smaller, limiting how much you can eat and drink at one time, so you feel full sooner. Other weight-loss surgery changes your small intestine, the part of your digestive system, that absorbs calories and nutrients from foods and beverages. Weight-loss surgery reduces the number of calories your body can absorb from your digestive tract. Weight-loss surgery also can affect the hormones or bacteria in your gastrointestinal tract in ways that may reduce your appetite and hunger and improve how your body breaks down fat and makes use of insulin.

In the United States, surgeons most often perform three types of weight loss surgeries (see Figure 1) ², ³, ⁴, ⁵, ⁶:

Adjustable gastric band (gastric banding or lap band). Laparoscopic adjustable gastric banding (gastric banding) is the least invasive of the weight loss surgical procedures and involves laparoscopic placement of an adjustable silicone band around the top part of your stomach (the gastric fundus) to create a very small pouch that increases the time food remains in the top part of your stomach (Figure 1A). Advantages of gastric band procedure are that it can be done in an outpatient setting, has the least complications, and is reversible. Laparoscopic adjustable gastric banding (gastric banding) results in 14–30% weight loss after a year ⁷. Although weight regain is more common with gastric banding when compared to other weight loss procedures, laparoscopic adjustable gastric banding offers long-lasting benefit for some patients ⁸, ⁷.
1. The advantages of the laparoscopic adjustable gastric banding (gastric banding) are ³:
  - it has the lowest rate of complications early after surgery;
  - there is no division of the stomach or intestines;
  - patients can go home on the day of surgery;
  - the band can be removed if needed;
  - it has the lowest risk for vitamin and mineral deficiencies.
2. The disadvantages of the laparoscopic adjustable gastric banding (gastric banding) are ³:
  - the band may need several adjustments and monthly office visits during the first year;
  - it is slower for weight loss and less weight loss than with other surgical procedures;
  - there is a risk of band movement (slippage) or damage to the stomach over time (erosion);
  - it requires a foreign implant to remain in the body;
  - it has a high rate of re-operation;
  - it can result in swallowing problems and enlargement of the esophagus.
Gastric sleeve surgery (sleeve gastrectomy or vertical sleeve gastrectomy). In gastric sleeve surgery, a staple line is placed along the greater curvature of the stomach followed by removal of approximately 80% of the lateral aspect of the stomach including the part that makes a hormone that creates hunger in a vertical fashion (Figure 1B). Gastric sleeve surgery has gained popularity in the past decade due to procedural ease and less frequency of serious complications ⁶.
1. The advantages of the gastric sleeve surgery are ³, ⁶:
  - it is technically simple and shorter surgery time;
  - it can be performed in certain patients with high risk medical conditions;
  - it may be performed as the first step for patients with severe obesity;
  - it may be used as a bridge to gastric bypass or single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) procedures;
  - it is effective for weight loss and improvement of obesity related conditions.
2. The disadvantages of the gastric sleeve surgery are ³:
  - it is a non-reversible procedure;
  - it may worsen or cause new onset reflux and heart burn;
  - it has less impact on metabolism compared to bypass procedures.
Gastric bypass surgery (Roux-en-Y gastric bypass). Gastric bypass surgery also called Roux-en-Y gastric bypass refers to procedures in which a small (∼30 to 60 mL) gastric pouch at the top of your stomach is created just distal to the gastroesophageal junction with surgical staples (Figure 1C). Most of your stomach is therefore disconnected (but not cut out) from your digestive tract so food won’t go to it. The small pouch at the top of your stomach is the only part of your stomach that receives food. This greatly limits the amount that you can comfortably eat and drink at one time. Gastric bypass surgery (Roux-en-Y gastric bypass) permits ingested food to pass directly from your esophagus through the small stomach pouch and proceed directly into the jejunum, with little or no gastric or duodenal phase of digestion, because food never enters the body of the stomach or the duodenum. Gastric bypass surgery (Roux-en-Y gastric bypass) became a predominant weight-loss procedure in the 1990s and is used worldwide today. The development and demonstration of the safety and efficacy of minimally invasive (laparoscopic) techniques, the recognition of severe obesity as a disease, and the health benefits of bariatric surgery have led to a progressive increase in the number of gastric bypass procedures performed ⁹, ¹⁰, ¹¹, ¹².
1. The advantages of the gastric bypass surgery or Roux-en-Y gastric bypass procedure are ³, ¹³, ¹⁴:
  - it is reliable for long-lasting weight loss;
  - it is effective for remission of obesity-associated conditions;
  - it is a refined and standardized technique.
2. The disadvantages of the gastric bypass surgery or Roux-en-Y gastric bypass procedure are ³:
  - it is technically more complex when compared to sleeve gastrectomy or gastric band;
  - more vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding;
  - there is a risk for small bowel complications and obstruction;
  - there is a risk of developing ulcers, especially with non-steroidal anti-inflammatory drugs (NSAIDs) or tobacco use;
  - may cause “dumping syndrome”, a feeling of sickness after eating or drinking, especially sweets.
Surgeons less commonly use a fourth operation, biliopancreatic diversion with duodenal switch (Figure 2). The biliopancreatic diversion with duodenal switch begins with creation of a tube-shaped stomach pouch (shaped like a banana) similar to the sleeve gastrectomy. The tube-shaped stomach pouch makes patients eat less food. Following creation of the sleeve-like stomach, the first portion of the small intestine is separated from the stomach. A part of the small intestine is then brought up and connected to the outlet of the newly created stomach, so that when you eat, the food goes through the sleeve pouch and into the latter part of the small intestine. The food stream bypasses roughly 75% of the small intestine. Biliopancreatic diversion with duodenal switch resembles the gastric bypass, where more of the small intestine is not used. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after biliopancreatic diversion with duodenal switch surgery. Even more than gastric bypass and sleeve gastrectomy, the biliopancreatic diversion with duodenal switch affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control. The biliopancreatic diversion with duodenal switch is considered to be the most effective approved weight loss surgery for the treatment of type 2 diabetes in patients with obesity ¹⁵.
1. The advantages of the biliopancreatic diversion with duodenal switch procedure are ³:
  - among the best results for improving obesity;
  - affects bowel hormones to cause less hunger and more fullness after eating;
  - it is the most effective procedure for treatment of type 2 diabetes
2. The disadvantages of the biliopancreatic diversion with duodenal switch procedure are ³:
  - has slightly higher complication rates than other procedures;
  - highest malabsorption and greater possibility of vitamins and micro-nutrient deficiencies;
  - reflux and heart burn can develop or get worse;
  - risk of looser and more frequent bowel movements;
  - more complex surgery requiring more operative time.
The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) (Figure 3) is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery ³. While similar to the biliopancreatic diversion with duodenal switch, the single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is simpler and takes less time to perform as there is only one surgical bowel connection. The operation starts the same way as the sleeve gastrectomy, making a smaller tube-shaped stomach ³. The first part of the small intestine (the duodenum) is divided just after the pylorus of the stomach. A loop of intestine is measured several feet from its end (the distal ileum) and is then connected to the gastric pouch. This is the only intestinal connection performed in this procedure ³. When the patient eats, food goes through the gastric pouch and directly into the latter portion of the small intestine (the distal ileum). The food then mixes with digestive juices from the first part of the small intestine (the duodenum). This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) surgery offers good weight loss along with less hunger, more fullness, blood sugar control and diabetes improvement.
1. The advantages of the single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) procedure are ³:
  - it is highly effective for long-term weight loss and remission of type 2 diabetes;
  - it is simpler and faster to perform (one intestinal connection) than gastric bypass or biliopancreatic diversion with duodenal switch;
  - it is an excellent option for a patient who already had a sleeve gastrectomy and is seeking further weight loss;
  - there is less risk of “dumping syndrome” that can occur after the gastric bypass, because the pylorus muscle is preserved in this operation.
2. The disadvantages of the single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) procedure are ³:
  - vitamins and minerals are not absorbed as well as in the sleeve gastrectomy or gastric band;
  - it is a newer operation with only short-term outcome data;
  - there is a potential to worsen or develop new-onset reflux;
  - there is also risk of looser and more frequent bowel movements.

There were 256,000 weight loss operations conducted in the United States in 2019 ¹⁶. The most common types of weight loss surgery in United States are gastric sleeve surgery (sleeve gastrectomy) around 53.8%, followed by gastric bypass (Roux-en-Y gastric bypass) 23.1%; laparoscopic adjustable gastric banding (gastric banding) 5.7%; biliopancreatic diversion with or without duodenal switch, 0.6%; and revision and others, 16.8% ¹⁷, ¹⁸. Gastric sleeve surgery (sleeve gastrectomy) and gastric bypass (Roux-en-Y gastric bypass) together are the most popular procedures (77%), whereas laparoscopic adjustable gastric banding (gastric banding) has become less popular due to poor long-term results ⁴.

Weight-loss surgery is mostly done as a keyhole procedure (laparoscopic procedure), in which there are a number of small cuts in your abdomen, under general anesthesia. Through these small cuts, the surgeon can insert thin tools and a small scope attached to a camera that projects images onto a video monitor. Laparoscopic surgery has fewer risks than open surgery and may cause less pain and scarring. Recovery may also be faster with laparoscopic surgery. But sometimes, open surgery with larger cuts is needed. Open surgery involves a single large cut in your abdomen may be a better option than laparoscopic surgery for certain people. You may need open surgery if you have a high level of obesity, had stomach surgery before, or have other complex medical problems.

The type of weight loss surgery that may be best to help you lose weight depends on a number of factors. You should discuss with your surgeon what kind of surgery might be best for you. In general, most people lose weight for 1 to 2 years after gastric bypass or gastric sleeve surgery, then they stop losing weight. With gastric band surgery, the process usually takes longer.

Weight loss surgery does not just treat the disease of obesity, but it treats other conditions like type 2 diabetes, heart disease, high blood pressure, dyslipidemia (abnormally elevated cholesterol or fats in the blood), arthritis, and acid reflux ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵. In addition, weight loss surgery greatly reduces the risk of death from cancer (i.e., post-menopausal breast, endometrial, and colon cancer), diabetes, heart disease, and other diseases ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³².

Serious complication rates for weight loss surgery rates have decreased over the years with recent studies showing perioperative morbidity and mortality rates of 5% and 0.3%, respectively ³³, ³⁴.

Figure 1. The three most commonly performed weight loss operations

Footnote: (A) The laparoscopic gastric band is placed around the upper stomach to restrict the transit of ingested food. (B) Laparoscopic sleeve gastrectomy involves separation of the greater curvature from the omentum and splenic attachments. (C) Gastric bypass surgery (Roux-en-Y gastric bypass) involves the rearrangement of the alimentary canal, such that food bypasses most of the stomach, all of the duodenum, and a portion of the proximal jejunum.

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Figure 2. Biliopancreatic diversion with duodenal switch

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Figure 3. Single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S)

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Who are good candidates for weight-loss surgery?

You may be a good candidate for weight-loss surgery if you are an adult who has extreme obesity (Body Mass Index (BMI) > 40 kg/m²) and you have not been able to lose your excess weight, or you keep gaining back weight you have lost using non-surgical methods such as diet and exercise or medications ²².

Weight-loss surgery may also be offered to people who are obese (BMI over 35 kg/m²) and who have other serious health problems like type 2 diabetes, high blood pressure or severe obstructive sleep apnea.

In general, weight loss surgery could be an option for you if ³⁷, ³⁸, ³⁹, ⁴⁰:

Your body mass index (BMI) is 40 kg/m² or higher (extreme obesity).
Your BMI is 35 to 39.9 kg/m² (obesity), and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe obstructive sleep apnea.
In some cases, you may qualify for certain types of weight-loss surgery if your BMI is 30 to 34 kg/m² and you have serious weight-related health problems.

Body Mass Index (BMI) is a measure of obesity used to determine who are good candidates for weight-loss surgery. Body Mass Index (BMI) measures body fat based on your weight in relation to your height.

The formula for Body Mass Index (BMI) = weight (kg) / [height (m)]²

Body Mass Index (BMI) is weight in kilograms divided by height in meters squared.

Example: Weight = 68 kg, Height = 165 cm (1.65 m)
Calculation: 68 ÷ (1.65)² = 24.98 kg/m² = BMI

You can also use an online BMI calculator:

For Adults go here: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html
For Children go here: https://www.cdc.gov/healthyweight/bmi/calculator.html

You could consider weight loss surgery, but only after trying non-surgery alternatives. The first step is usually to try changes to what you eat and drink, and what daily activity and exercise you do. There are some medicines that can help people lose weight. Surgery is usually thought about only after these other options have been tried.

For people with a BMI of 35 kg/m² or higher, obesity can be hard to treat with diet and exercise alone, so health care professionals may recommend weight-loss surgery. For people with a BMI of 30-35 kg/m² who have type 2 diabetes that is difficult to control with medications and lifestyle changes, weight-loss surgery may be considered as a treatment option.

Weight-loss surgery also may be an option to consider if you have serious health problems related to obesity, such as type 2 diabetes or sleep apnea. Weight-loss surgery can improve many of the medical conditions linked to obesity, especially type 2 diabetes ⁴¹, ⁴².

You must also be willing to make permanent changes to lead a healthier lifestyle. You may be required to participate in long-term follow-up plans that include monitoring your nutrition, your lifestyle and behavior, and your medical conditions.

Can a teenager have weight-loss surgery?

Yes. Health care professionals sometimes use weight-loss surgery to treat teens who have severe obesity and obesity-related health problems ⁴³, ⁴⁴, ⁴⁵, ⁴⁶, ⁴⁷, ⁴⁸, ⁴⁹, ⁵⁰, ⁵¹. Weight-loss surgery often improves health problems that could worsen in adulthood if the teen still has obesity.

Guidelines recommend that teens be evaluated for surgery by a multidisciplinary team with expertise in pediatrics and have ⁵², ⁵³:

BMI of 40 kg/m²
OR
BMI of 35 kg/m² or more with serious obesity-related health problems, such as type 2 diabetes, severe obstructive sleep apnea (apnea hypopnea index (AHI) >5 per hour), idiopathic intracranial hypertension, nonalcoholic steatohepatitis (NASH), Blount’s disease, slipped capital femoral epiphysis, gastroesophageal reflux disease (GERD) or high blood pressure (hypertension).

Contraindications for adolescent weight loss surgery include ⁵³:

A medically correctable cause of obesity.
An ongoing substance abuse problem (within the preceding year).
A medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens.
Current or planned pregnancy within 12 to 18 months of the procedure.

A multidisciplinary team must also consider whether the patient and family have the ability and motivation to adhere to recommended treatments pre- and postoperatively, including consistent use of micronutrient supplements ⁵³.

Like adults, teens who are thinking about weight-loss surgery should be prepared for the lifestyle changes they will need to make after the surgery. A surgical center that focuses on the unique needs of youth may help the teen patient prepare for and adjust to these changes. Parents and caregivers also should be prepared and ready to support their child.

A study conducted by Teen-LABS (Longitudinal Assessment of Bariatric Surgery), found that at 5 years after the operation, patients who had gastric bypass surgery lost between 51 and 64 pounds ⁵⁴. This represented about 26 percent of their starting weight. The teens also had improved overall health and quality of life. The Teen-LABS study is continuing for several more years, to gain information on the longer-term benefits and risks of weight-loss surgery with teens ⁵⁵.

What are the benefits of weight-loss surgery?

Weight-loss surgery can help you lose weight and improve many health problems related to obesity. These health problems include ¹⁹, ²⁰, ²¹, ²², ²³, ²⁴, ²⁵, ²⁶, ²⁷, ²⁸, ²⁹, ³⁰, ³¹, ³²:

type 2 diabetes
high blood pressure
heart disease
unhealthy cholesterol levels
sleep apnea
urinary incontinence
knee, hip, or other body pain

In addition, weight loss surgery greatly reduces the risk of death from cancer (i.e., post-menopausal breast, endometrial, and colon cancer), diabetes, heart disease, and other diseases.

For people with severe obesity, weight-loss surgery can extend years of life ⁵⁶.

You may be better able to move around and be physically active after surgery. You might also notice your mood improve and feel like your quality of life is better. As an added benefit, you may be able to take fewer prescription medications as you move into a healthier weight, which can reduce the cost burden ⁵⁷.

What are the side effects of bariatric surgery?

Side effects of weight-loss surgery may include:

bleeding
infection
leaking from the site where the sections of the stomach, small intestine, or both are stapled or sewn together
injury to your stomach, intestines, or other organs during surgery
a bad reaction to anesthesia
allergic reactions to medicines
diarrhea
blood clots in the legs that can move to the lungs or heart
lung or breathing problems
gastritis (inflamed stomach lining), heartburn, or stomach ulcers
risk of vitamin and iron deficiency (shortage)
scarring inside your belly that could lead to a blockage in your bowel in the future
vomiting from eating more than your stomach pouch can hold
risk of acid reflux and hiatal hernia (caused by the stomach pushing up against the diaphragm)
rarely, surgery-related problems can lead to death.

Thirty days after weight loss surgery, the Longitudinal Assessment of Bariatric Surgery (LABS) researchers found that ⁵⁸, ⁵⁹:

30-day overall weight loss surgery death rate was 0.3 percent.
2.1 percent of participants who had open gastric bypass and 0.2 percent of participants who had laparoscopic gastric bypass died. No participants who had gastric band surgery died.
4.1 percent of participants had at least one major bad outcome, such as death, development of blood clots, repeat surgeries, or failure to be released from the hospital.
No significant differences in complication risk were found based on the type of gastric bypass procedure.
Factors that predicted a major complication include high BMI, extreme obstructive sleep apnea, inability to walk 200 feet, and a history of deep vein thrombosis (DVT).
Studies consistently report that the experience of both the surgeon and the surgical center are predictors of safety ⁵⁹.

Mid-term and longer term complications have been well described, although determining their incidence is limited by a progressively greater number of patients lost to follow-up ⁶⁰. These include, but are not limited to, intestinal obstruction, marginal ulcer, ventral hernia, and gallstones. Metabolic complications reported include kidney stones (nephrolithiasis), osteoporosis, and low blood sugar level (hypoglycemia). Mineral and vitamin deficiencies and weight regain are reported in variable numbers of patients. Micronutrient deficiencies following gastric bypass include: iron, 33% to 55%; calcium and vitamin D, 24% to 60%; vitamin B12, 24% to 70%; copper, 10% to 15%; and thiamine, <5% ⁶¹. Established guidelines recommend routine nutrient supplementation to include multivitamins, vitamin B12, iron, minerals, calcium, and vitamin D ⁶², ⁶³.

Follow-up interventions, surgery, and hospitalizations are relatively common within 5 years of weight-loss surgery, affecting about one-third of patients. Follow-up procedures are required more frequently after gastric bypass compared with gastric sleeve ⁶⁴.

Other side effects may occur later. Your body may not absorb enough nutrients, especially if you don’t take your prescribed vitamins and minerals. Not getting enough nutrients can cause health problems, such as anemia and osteoporosis. Gallstones can occur after rapid weight loss. Some health care professionals prescribe medicine for about 6 months after surgery to help prevent gallstones. Gastric bands can move out of position or erode into the stomach wall and need to be removed.

Does weight-loss surgery always work?

Studies show that many people who have weight-loss surgery lose on average 15 to 30 percent of their starting weight, depending on the type of surgery they have ⁶⁵. However, no method, including surgery, is sure to produce and maintain weight loss. Some people who have weight-loss surgery may not lose as much as they hoped. Over time, some people regain a portion of the weight they lost. The amount of weight people regain may vary. Factors that affect weight regain may include a person’s weight before surgery, the type of operation, and adherence to changes in exercise and eating. The single best predictors of sustained postoperative weight loss identified by the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium are postoperative eating and lifestyle behaviors ⁵⁹. Specifically, people who self-monitor (e.g., frequent weighing), avoid eating when full, and who avoid snacking between meals appear to experience the greatest weight loss ⁶⁶.

Weight-loss surgery can make it easier for you to eat fewer calories and be more physically active. Choosing healthy foods and beverages before and after the surgery may help you lose more weight and keep it off over the long term. Regular physical activity after surgery also helps keep the weight off. To improve your health, you must commit to a lifetime of healthy lifestyle habits and follow the advice of your health care professionals.

Which type of weight loss surgery is right for me?

Many factors will determine which type of weight loss surgery is the best type for you, including how much weight you need to lose and any illnesses you might have.

Your doctor will do a detailed assessment and discuss with you the best option, including the risks.

What are the alternatives to weight loss surgery?

The alternatives to weight loss surgery are lifestyle changes, such as diet and exercise, or lifestyle changes combined with weight-loss medicines. You can get professional help with this: ask your doctor.

Where to find a weight loss surgeon near me?

To find a board certified weight loss surgeon (the American Society for Metabolic and Bariatric Surgery) please go here https://asmbs.org/patients/find-a-provider

How much does weight-loss surgery cost?

Weight-loss surgery can cost between $15,000 and $25,000 or even more, depending on what type of surgery you have and whether you have surgery-related complications ⁶⁷. Weight-loss surgery costs may be higher or lower depending on where you live. The amount your medical insurance will pay varies by state and insurance provider.

Medicare and some Medicaid programs may cover the major types of weight-loss surgery if you have a health care professional’s recommendation and you meet certain criteria (for example, if you have a Body Mass Index (BMI) of 35 kg/m² or greater and obesity-related health problems). Some insurance plans may require you to use approved surgeons and facilities. Some insurers also require you to show that you were unable to lose weight by completing a nonsurgical weight-loss program or that you meet other requirements.

Your health insurance company or your regional Medicare or Medicaid office will have more information about weight-loss surgery coverage, options, and requirements.

How much weight can I expect to lose after my surgery?

The number of pounds people lose after weight-loss surgery depends on the individual and on the type of surgery. One study found that after 1 year, people undergoing adjustable gastric banding, gastric sleeve, and gastric bypass lost between 38 and 87 pounds ⁶⁸. Of the three most common procedures, gastric bypass produced greater weight loss, on average, but had more complications in the month after surgery. Most people regained some weight over time, but that amount was usually small compared with their initial weight loss ⁶⁸.

Your weight loss could be different. Remember, reaching your goal depends not only on the surgery but also on sticking with healthy lifestyle habits.

When weight-loss surgery doesn’t work

It’s possible to not lose enough weight or to regain weight after any type of weight-loss procedure, even if the procedure itself works correctly. Up to 18% of patients fail to achieve a body mass index (BMI)<35kg/m², and unsuccessful weight loss has been reported in 10–30% of patients who have undergone weight loss surgery ⁶⁹. This weight gain can happen if you don’t follow the recommended lifestyle changes. To help avoid regaining weight, you must make permanent healthy changes in your diet and get regular physical activity and exercise.

What should I expect before my weight loss surgery?

Before your weight loss surgery, you will meet with several health care professionals, such as an internist, a dietitian, a psychiatrist or psychologist, and a bariatric surgeon.

The internist will ask about your medical history, perform a thorough physical exam, and order blood tests. If you smoke, you may benefit from stopping smoking at least 6 weeks before your surgery.
- Preoperative nutritional assessment recommendations ⁷⁰, ⁷¹:
  - All people should have a comprehensive nutritional assessment prior to weight loss surgery
  - Check full blood count including hemoglobin, ferritin, folate and vitamin B12 levels
  - Check serum 25‐hydroxyvitamin D levels
  - Check serum calcium levels
  - Check serum/plasma parathyroid hormone (PTH) levels
  - Seek advice from a specialist with expertise in primary hyperparathyroidism if primary hyperparathyroidism is suspected
  - Consider checking serum vitamin A levels in individuals going forward for malabsorptive procedures such as biliopancreatic diversion with duodenal switch or where vitamin A deficiency may be suspected
  - Consider checking serum zinc, copper and selenium levels in individuals going forward for malabsorptive procedures such as biliopancreatic diversion with duodenal switch or if a deficiency is suspected
  - Routinely screen HbA1c, lipid profile, liver and kidney function tests and treat as necessary
  - Treat and correct nutritional deficiencies preoperatively as individuals have an increased risk of deficiencies postoperatively
The dietitian will explain what and how much you will be able to eat and drink after surgery and help you prepare for how your life will change after surgery.
The psychiatrist or psychologist may assess you to see if you are ready to manage the challenges of weight-loss surgery.
The surgeon will tell you more about the surgery, including how to prepare for it and what type of follow-up you will need.

These health care professionals also will advise you to become more active and adopt a healthy eating plan before and after surgery. Many weight loss surgical centers recommend that people follow a low calorie or low carbohydrate diet immediately prior to surgery to reduce the size of their liver ⁷². As these diets are not always nutritionally complete, a multivitamin and mineral supplement are needed ⁷³

Losing weight and bringing your blood glucose, also known as blood sugar, levels closer to normal before surgery may lower your chances of having surgery-related problems.

Some weight-loss surgery programs have groups you can attend before and after surgery to help answer questions about the surgery and offer support.

How is the weight loss surgery performed?

Weight-loss surgery is mostly done laparoscopically, which requires only small cuts, under general anesthesia. Through these incisions, the surgeon can insert thin tools and a small scope attached to a camera that projects images onto a video monitor. Laparoscopic surgery has fewer risks than open surgery and may cause less pain and scarring. Recovery may also be faster with laparoscopic surgery.

Open surgery, which involves a single, large cut in the abdomen, may be a better option than laparoscopic surgery for certain people. You may need open surgery if you have a high level of obesity, had stomach surgery before, or have other complex medical problems.

What should I expect after my weight loss surgery?

After weight loss surgery, you will need to rest and recover. Walking and moving around the house may help you recover more quickly. Start slowly and follow your health surgeon’s advice about the type of physical activity you can do safely. As you feel more comfortable, add more physical activity.

After weight loss surgery, you will probably be started on a liquid diet. Over several weeks, you will move to a soft diet that includes such foods as cottage cheese, yogurt, or soup. Eventually you will begin consuming solid foods again. Your surgeon will tell you which foods and beverages you may have and which ones you should avoid. You will need to eat small meals and chew your food well. You will need to take dietary supplements that your surgeon prescribes to make sure you are getting enough vitamins and minerals.

How effective is weight loss surgery?

Quantifying the comparative outcomes of weight loss surgery have been challenging because of the evolution of surgical procedures, the availability of laparoscopic vs. open techniques, categorization of short- vs. long-term consequences and the difference in presurgical risk among patients ⁷⁴. The National Institutes of Health–initiated Longitudinal Assessment of Bariatric Surgery Consortium is conducting prospective, multicenter, cohort studies using standardized techniques to assess the safety and clinical response of bariatric surgery ⁷⁵.

In general, gastric bypass surgery (Roux-en-Y gastric bypass) is associated with the most weight loss in long-term follow-up studies, followed by laparoscopic sleeve gastrectomy and laparoscopic adjustable gastric banding (Table 1). It is unclear if there is a significant long-term difference in weight loss between gastric bypass surgery (Roux-en-Y gastric bypass) and laparoscopic sleeve gastrectomy ⁷⁶, ⁷⁷. In one study of 2410 patients, weight losses at 4-year follow-up for gastric bypass surgery (Roux-en-Y gastric bypass), gastric sleeve surgery and laparoscopic adjustable gastric banding were 27%, 18%, and 11%, respectively ²³.

Increasing evidence that laparoscopic adjustable gastric banding results in more long-term complications, more reoperations, and less weight loss has made this procedure less common ⁷⁸. Dyslipidemia, type 2 diabetes, hypertension, and perception of quality of life improved after weight loss surgery ⁷⁹. In this cohort study ⁸⁰, patients undergoing Roux-en-Y gastric bypass lost 21% more of their baseline weight than matched nonsurgical patients at 10 years, and Roux-en-Y gastric bypass induced significantly greater weight loss than sleeve gastrectomy or adjustable gastric banding at 4 years.

Remission of type 2 diabetes occurs in 60% to 80% of Roux-en-Y gastric bypass patients at one to two years postsurgery ⁸¹. Recent longer-term studies indicate that this remission is retained in approximately 40% of patients at 10 years and 30% at 15 years ⁸². Several recent reviews support bariatric surgery for the treatment of diabetes in patients with a BMI less than 35 kg/m² ⁸³.

The Swedish Obese Subjects prospective cohort study found that surgery was associated with a 29% lower mortality risk from any cause after 16 years ⁸⁴. In a retrospective cohort study of almost 8,000 patients undergoing bariatric surgery, mortality from disease, including cardiovascular disease and cancer, decreased by 40% compared with the control group ⁸⁵. In a more recent retrospective cohort study of 2,500 surgical patients and 7,462 matched controls receiving care in the Veterans Administration system, the surgical patients had a significant reduction in 10-year all-cause mortality ⁸⁶.

In 2017, investigators in the United States ⁸⁷ and Sweden ⁸⁸ simultaneously reported long-term outcomes for weight loss and comorbidities in adolescents who underwent gastric bypass surgery. Eight-year (United States) and 5-year (Sweden) post-gastric bypass surgery follow-up assessments indicated 30% and 28% BMI reductions, respectively. Both research groups documented important improvements in health. In summary, the two long-term, prospective studies demonstrate excellent durability of weight loss and response of comorbidities for adolescents who have gastric bypass surgery. These studies also reported the typical nutritional consequences of gastric bypass surgery that are commonly seen in studies in adults, and this must be taken into consideration when counseling patients about long-term risks of gastric bypass surgery.

In the U.S. study, remission of type 2 diabetes occurred in 88% (n = 7) ⁸⁷. The study did not report any incident type 2 diabetes during the 8 years ⁸⁷. The study also reported dyslipidemia (abnormally elevated cholesterol or fats in your blood) remission in 64% (n = 29) and incident dyslipidemia in four of eight subjects who did not have dyslipidemia at baseline ⁸⁷. The study reported high blood pressure (hypertension) remission in 76% (n = 19) and incident hypertension in only 10% (3 of 29) participants without hypertension at baseline ⁴.

The Swedish study reported similar health improvements, with remission of comorbid conditions in 74% to 100% of participants ⁸⁸. The study reported remission of type 2 diabetes in 3 of 3 participants, disturbed glucose homeostasis in 18 of 21, dyslipidemia in 43 of 52, elevated blood pressure in 11 of 12, inflammation (high-sensitivity C-reactive protein ≥ 2 mg/L) in 45 of 61, and elevated liver enzymes in 19 of 19 participants ⁸⁸.

Both studies also reported long-term nutritional effects. The U.S. study reported mild anemia in 46% (n = 25), hyperparathyroidism in 45% (n = 22), and low vitamin B12 levels in 16% (n = 8) at long-term follow-up. At 5 years in the Swedish study, 63% (46 of 73) had vitamin D (25-hydroxy vitamin D) insufficiency (<50 nmol/L) and 66% (51 of 77) had low ferritin and/or iron levels. The prevalence of anemia rose from 10% (8 of 78) to 32% (25 of 77), and 22% had low vitamin B12 levels.

Weight regain is a concern in a subset of patients following weight loss surgery; the cause appears to be multifactorial. A systematic review from 2013 identified nutritional indiscretion, mental health issues, endocrine and metabolic alterations, physical inactivity, and anatomic surgical failure as principal causes ⁸⁹. Endoscopic or surgical revision is an option in some patients who experience weight regain. Further study is necessary to determine predictors of suboptimal weight loss and weight regain, as well as the effectiveness of treatment with surgical revision or other modalities ⁹⁰.

Recently, the Longitudinal Assessment of Bariatric Surgery (LABORATORIES) (a multicenter bariatric surgery research consortium funded by the National Institutes of Health) reported a 30-day overall bariatric surgery mortality rate of 0.3%. For laparoscopic gastric bypass surgery, it reported a 30-day mortality rate of 0.2% ⁵⁹.

A serious complication occurred in 4.1% of all patients ⁴. Factors that predicted a major complication include high BMI, extreme obstructive sleep apnea, inability to walk 200 feet, and a history of deep vein thrombosis. Other studies have reported different risk profiles. Studies consistently report that the experience of both the surgeon and the surgical center are predictors of safety ⁵⁹.

Mid-term and longer term complications have been well described, although determining their incidence is limited by a progressively greater number of patients lost to follow-up ⁶⁰. These include, but are not limited to, intestinal obstruction, marginal ulcer, ventral hernia, and gallstones. Metabolic complications reported include kidney stones, osteoporosis, and low blood sugar levels (hypoglycemia). Mineral and vitamin deficiencies and weight regain are reported in variable numbers of patients. Micronutrient deficiencies following gastric bypass include: iron, 33% to 55%; calcium/vitamin D, 24% to 60%; vitamin B12, 24% to 70%; copper, 10% to 15%; and thiamine, <5% ⁶¹. Established guidelines recommend routine nutrient supplementation to include multivitamins, vitamin B12, iron, minerals, calcium, and vitamin D ⁶², ⁶³.

Perioperative complications specific to laparoscopic gastric band are less frequent, with near zero mortality ⁴. Longer term complications, however, continue to occur at a rate of ∼2% per year ⁴. These longer term complications include erosion of the gastric wall by the band and slippage or herniation of the body of the stomach, thereby creating obstructions within the band. Inadequate weight loss is the most common cause of laparoscopic gastric band failure. Complications following other device placement procedures occur but are infrequent and generally less severe. However, there is a tradeoff between reduced complication rates and the severity of complications vs efficacy of weight loss.

In summary, both perioperative and longer term complications occur after all weight loss surgical procedures ⁴.

Table 1. Weight loss surgery effectiveness

Procedure	Weight Loss ^⁹¹		Pros and Cons ^³³
	1-Year	≥ 6 years	Pros	Cons
Laparoscopic adjustable gastric banding	14–30%	13–14%	Short outpatient procedure Adjustable and reversible Low rate of complications Low risk of malabsorption of vitamins and minerals	Less long-term weight loss than other bariatric procedures High rates of reoperation for band slippage, obstruction or erosion Possible progressive dilation of esophagus due to band obstruction
Gastric bypass surgery	23–43%	25–28%	Large and sustained long-term weight loss High rates of type 2 diabetes remission	Complex procedure requiring skill Requires hospital stay of 1–2 days Higher rate of perioperative complications compared with laparoscopic adjustable gastric banding and gastric sleeve surgery Late complications that include marginal ulcer, internal hernia, and small bowel obstruction. Needs long-term vitamin and mineral supplementation
Gastric sleeve surgery	20–28%	22%	Significant weight loss Less complex procedure compared with gastric bypass surgery Can be converted to gastric bypass surgery at a later stage Less risk of vitamin and mineral deficiencies	Somewhat higher risk of weight regain compared with gastric bypass surgery Higher rate of complications compared to laparoscopic adjustable gastric banding Post-operative gastroesophageal reflux disease (GERD) Late complications that include chronic obstructive symptoms

Footnote: Biliopancreatic diversion with duodenal switch is not listed in the table because it accounts for ~1% of bariatric surgeries.

[Source ¹⁸ ]

Table 2. Comparison of outcomes for bariatric surgical procedures

Table 3. Supplementation After Weight Loss Surgery

Stomach anatomy

The stomach is a muscular J-shaped pouchlike hollow organ that hangs inferior to the diaphragm in the upper left portion of the abdominal cavity and has a capacity of about 1 liter or more (Figure 4) ⁹². The stomach’s shape and size vary from person to person, depending on things like people’s sex and build, but also on how much they eat.

At the point where the esophagus leads into the stomach, the digestive tube is usually kept shut by muscles of the esophagus and diaphragm (Figure 5). When you swallow, these muscles relax and the lower end of the esophagus opens, allowing food to enter the stomach. If this mechanism does not work properly, acidic gastric juice might get into the esophagus, leading to heartburn or an inflammation (Figure 5).

Thick folds (rugae) of mucosal and submucosal layers mark the stomach’s inner lining and disappear when the stomach wall is distended. The stomach receives food from the esophagus, mixes the food with gastric juice, initiates protein digestion, carries on limited absorption, and moves food into the small intestine (Figure 6).

Figure 4. Stomach

Figure 5. Gastroesophageal junction

Figure 6. Parts of the small intestine

Parts of the Stomach

The stomach has 5 parts (Figure 7):

The cardia is a small area near the esophageal opening.

The fundus, which balloons superior to the cardia, is a temporary storage area. It is usually filled with air that enters the stomach when you swallow.

The dilated body region, called the body (corpus), which is the main part of the stomach, lies between the fundus and pylorus. In the body of the stomach food is churned and broken into smaller pieces, mixed with acidic gastric juice and enzymes, and pre-digested.

The antrum – the lower portion (near the intestine), where the food is mixed with gastric juice

The pylorus is the distal portion and the last part of the stomach where it approaches the small intestine. The pyloric canal is a narrowing of the pylorus as it approaches the small intestine. At the end of the pyloric canal the muscular wall thickens, forming a powerful circular muscle, the pyloric sphincter. This muscle is a valve that controls gastric emptying.

The first 3 parts of the stomach, the cardia, fundus, and body, are sometimes called the proximal stomach. Some cells in these parts of the stomach make acid and pepsin (a digestive enzyme), the parts of the gastric juice that help digest food. They also make a protein called intrinsic factor, which the body needs to absorb vitamin B12.

The lower 2 parts, the antrum and pylorus, are called the distal stomach. The stomach has 2 curves, which form its inner and outer borders. They are called the lesser curvature and greater curvature, respectively.

Figure 7. Parts of the stomach

Stomach function

The stomach takes in food from the esophagus (gullet or food pipe), mixes it, breaks it down, and then passes it on to the small intestine in small portions. Following a meal, the mixing movements of the stomach wall aid in producing a semifluid paste of food particles and gastric juice called chyme. Peristaltic waves push the chyme toward the pylorus of the stomach. As chyme accumulates near the pyloric sphincter, the sphincter begins to relax. Stomach contractions push chyme a little at a time into the small intestine.

The rate at which the stomach empties depends on the fluidity of the chyme and the type of food present. Liquids usually pass through the stomach rapidly, but solids remain until they are well mixed with gastric juice. Fatty foods may remain in the stomach from three to six hours; foods high in proteins move through more quickly; carbohydrates usually pass through faster than either fats or proteins.

As chyme enters the duodenum (the proximal portion of the small intestine), accessory organs—the pancreas, liver, and gallbladder—add their secretions.

Gastric secretions

The mucous membrane that forms the inner lining of the stomach is thick. Its surface is studded with many small openings called gastric pits located at the ends of tubular gastric glands (Figure 8).

Gastric glands generally contain three types of secretory cells. Mucous cells, in the necks of the glands near the openings of the gastric pits, secrete mucus. Chief cells and parietal cells are in the deeper parts of the glands. The chief cells secrete digestive enzymes, and the parietal cells release a solution containing hydrochloric acid. The products of the mucous cells, chief cells, and parietal cells together form gastric juice.

Pepsin is by far the most important digestive enzyme in gastric juice. The chief cells secrete pepsin in the form of an inactive enzyme precursor called pepsinogen. When pepsinogen contacts hydrochloric acid from the parietal cells, it breaks down rapidly, forming pepsin. Pepsin begins the digestion of nearly all types of dietary protein into polypeptides. This enzyme is most active in an acidic environment, which is provided by the hydrochloric acid in gastric juice.

The mucous cells of the gastric glands (mucous neck cells) and the mucous cells associated with the stomach’s inner surface release a viscous, alkaline secretion that coats the inside of the stomach wall. This coating normally prevents the stomach from digesting itself.

Another component of gastric juice is intrinsic factor, which the parietal cells secrete. Intrinsic factor is necessary for the absorption of vitamin B12 in the small intestine. Table 1 summarizes the major components of gastric juice.

Figure 8. Stomach cells (gastric glands)

Note: Lining of the stomach. Gastric glands include mucous cells, parietal cells, and chief cells. The mucosa of the stomach is studded with gastric pits that are the openings of the gastric glands.

Table 3. Major components of Gastric Juice

Component	Source	Function
Pepsinogen	Chief cells of the gastric glands	Inactive form of pepsin
Pepsin	Formed from pepsinogen in the presence of hydrochloric acid	A protein-splitting enzyme that digests nearly all types of dietary protein into polypeptides
Hydrochloric acid	Parietal cells of the gastric glands	Provides the acid environment needed for the production and action of pepsin
Mucus	Mucous cells	Provides a viscous, alkaline protective layer on the stomach’s inner surface
Intrinsic factor	Parietal cells of the gastric glands	Necessary for vitamin B12 absorption in the small intestine

Gastric sleeve

Gastric sleeve surgery, also called “vertical sleeve gastrectomy” (VSG) or “sleeve gastrectomy“, is a newer type of weight loss surgery (bariatric surgery) where a surgeon removes most of your stomach (removing approximately 80 to 85% of the greater curvature of stomach) and makes a narrow tube or “gastric sleeve” out of the remaining stomach, leaving only a banana-shaped section that is closed with staples (Figure 9) ⁹³, ², ⁹⁴, ⁹⁵. Your new, banana-shaped stomach is much smaller than your original stomach. After the gastric sleeve surgery, your stomach will hold only about a tenth of what it did before, making you feel full sooner after eating a small amount of food and be less hungry. You might also feel less hungry because your smaller stomach will produce lower levels of a hormone called ghrelin, which causes hunger and you may lose from 50 to 90 pounds. Taking out part of your stomach may also affect other hormones and bacteria in your gastrointestinal system that affect appetite and metabolism. Gastric sleeve surgery cannot be reversed because some of your stomach is permanently removed. Endoscopic gastric sleeve surgery is less invasive and cheaper than other forms of bariatric surgery.

Gastric sleeve surgery is done as a laparoscopic surgery, with small incisions in the upper abdomen. Most of the left part of the stomach is removed. The remaining stomach is then a narrow tube called a sleeve. Food empties out of the bottom of the stomach into the small intestine the same way that it did before surgery. The small intestine is not operated on or changed. After the surgery, less food will make you full when eating.

Like other weight-loss procedures, endoscopic gastric sleeve surgery requires commitment to a healthier lifestyle. Gastric sleeve surgery isn’t a “fix it and forget it” kind of surgery. To be considered for gastric sleeve surgery, a person must be committed to changing his or her eating and exercise habits over the long term to help ensure the long-term success of endoscopic gastric sleeve surgery. Not everyone who wants the gastric sleeve surgery will be eligible to get it.

Gastric sleeve surgery is typically done only after you’ve tried to lose weight by improving your diet and exercise habits.

Doctors consider a number of things when deciding if weight loss surgery is the right choice for you. These include whether you are:

at least 14 years old and near adult height with more than 100 pounds of extra weight to lose
healthy enough to handle surgery
have medical problems that could improve with significant weight loss, such as sleep apnea, diabetes, or heart problems
have proved that you can stick to a healthy diet and get regular exercise
have family members who will provide emotional and practical support (like driving to every doctor’s visit or buying healthy food)

In general, gastric sleeve surgery could be an option for you if ³⁷, ³⁸, ³⁹, ⁴⁰:

Your body mass index (BMI) is 40 kg/m² or higher (extreme obesity).
Your BMI is 35 to 39.9 kg/m² (obesity), and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe obstructive sleep apnea. In some cases, you may qualify for certain types of weight-loss surgery if your BMI is 30 to 34 kg/m² and you have serious weight-related health problems.

Check with your health insurance plan or your regional Medicare or Medicaid office to find out if your policy covers weight-loss surgery.

Endoscopic gastric sleeve surgery can lead to significant weight loss. The amount of weight you lose also depends on how much you can change your lifestyle habits.

But studies have shown promising results. A recent study of people with an average body mass index (BMI) around 38 kg/m² found that endoscopic sleeve gastroplasty led to an average weight loss of 39 pounds (17.8 kilograms) after 6 months. After 12 months, weight loss was 42 pounds (19 kilograms).

In a study of people with an average body mass index (BMI) of about 45 kg/m², the procedure resulted in an average weight loss of about 73 pounds (33 kilograms) during the first six months.

As with other weight loss procedures and surgeries that lead to significant weight loss, endoscopic gastric sleeve surgery may improve conditions often related to being overweight, including:

Gastroesophageal reflux disease (GERD)
Heart disease
Stroke
High blood pressure
High cholesterol
Obstructive sleep apnea
Type 2 diabetes
Stroke
Cancer
Infertility

Figure 9. Gastric sleeve surgery

Gastric sleeve surgery disadvantages

When you get gastric sleeve surgery, you’re making a huge change to the way your body handles food. It can take a while to get used to your body’s new normal.

Here are some of the problems you might have in the months after gastric sleeve surgery:

If you eat too much food or eat too fast, you might throw up, have diarrhea, or get acid reflux.
Food might move too fast through your digestive system, causing nausea, cramps, and diarrhea (doctors call this “dumping syndrome”).
If you don’t eat enough nutritious food and don’t take your daily vitamin and mineral supplements, you might develop vitamin and mineral deficiencies. This also may happen if your body can’t absorb enough nutrients.
After you lose lots of weight, you may have loose skin.

If you have a lot of pain or bloating in your belly or you throw up a lot, call your doctor right away. It could be a sign there’s a problem that needs medical attention.

Gastric sleeve surgery is not for everyone. But it can really help people who have serious health problems or are at risk for health problems because of their weight. If you’re worried about your weight or think you may benefit from weight loss surgery, talk to your doctor.

Gastric sleeve vs Gastric bypass surgery

Gastric sleeve surgery, also called “vertical sleeve gastrectomy” (VSG) or “sleeve gastrectomy“, is a newer type of weight loss surgery (bariatric surgery) where a surgeon removes most of your stomach (removing approximately 80% of the stomach) and makes a narrow tube or “sleeve” out of the remaining stomach, leaving only a banana-shaped section that is closed with staples. Your new, banana-shaped stomach is much smaller than your original stomach. After the gastric sleeve surgery, your stomach will hold only about a tenth of what it did before, making you feel full sooner after eating a small amount of food and be less hungry. You might also feel less hungry because your smaller stomach will produce lower levels of a hormone called ghrelin, which causes hunger and you may lose from 50 to 90 pounds. Taking out part of your stomach may also affect other hormones and bacteria in your gastrointestinal system that affect appetite and metabolism. Gastric sleeve surgery cannot be reversed because some of your stomach is permanently removed. Endoscopic gastric sleeve surgery is less invasive and cheaper than other forms of bariatric surgery.

In contrast, a gastric bypass surgery also called Roux-en-Y gastric bypass is a type of weight-loss surgery (bariatric surgery) where surgical staples are used to create a small pouch at the top of your stomach (Figure 2). This pouch will hold about 1 cup of food. The pouch is then connected to your small intestine, bypassing (missing out) the rest of the stomach. This means it takes less food to make you feel full and you’ll absorb fewer calories from the food you eat because the food you eat will bypass most of your stomach and the upper part of your small intestine. Gastric bypass surgery is one of the most common types of bariatric surgery in the United States. Gastric bypass surgery is done when diet and exercise haven’t worked or when you have serious health problems because of your weight.

Unlike gastric sleeve, in gastric bypass surgery or Roux-en-Y gastric bypass surgery, the rest of your stomach will still be there, but food won’t go to it. The small pouch at the top of your stomach is the only part of your stomach that receives food. This greatly limits the amount that you can comfortably eat and drink at one time.

Next, your small intestine is then cut a short distance below the main stomach and connected to the new pouch. Your surgeon will attach one end of your small intestine to the small stomach pouch and the other end lower down on the small intestine, making a “Y” shape. That’s the bypass part of the procedure. This allows digestive juices in your stomach to flow from the bypassed part of the small intestine to the lower part of the small intestine, so that food can be fully digested. The main part of the stomach, however, continues to make digestive juices. The portion of the small intestine still attached to the main stomach is reattached farther down. This allows the digestive juices to flow to the small intestine. Because food now bypasses the first portion of your small intestine called the duodenum, fewer nutrients and calories are absorbed.

The gastric bypass surgery also changes hormones, bacteria, and other substances in the gastrointestinal tract that may affect appetite and metabolism. The rest of your stomach is still there. It delivers chemicals from the pancreas to help digest food that comes from the small pouch. Doctors use the laparoscopic method for most gastric bypasses.

Gastric bypass is difficult to reverse, although a surgeon may do it if medically necessary.

Gastric bypass surgery can provide long-term weight loss. The amount of weight you lose depends on your type of surgery and your change in lifestyle habits. It may be possible to lose 60 percent, or even more, of your excess weight within two years.

Most people lose weight for 1 to 2 years after gastric bypass or gastric sleeve surgery, then they stop losing weight. However, neither gastric bypass surgery nor gastric sleeve surgery is a miracle procedure — and it isn’t for everyone. Having gastric bypass or other weight-loss surgery doesn’t guarantee that you’ll lose all your excess weight or that you’ll keep it off over the long term. Nor is it a way to avoid making changes in your diet and exercise habits. In fact, you can regain the weight you lose with gastric bypass surgery if you don’t stick with the lifestyle changes. But if you think gastric bypass surgery or gastric sleeve surgery might be right for you, talk with your doctor ⁹⁶.

Many factors will determine which type of surgery is the best type for you, including how much weight you need to lose and any illnesses you might have.

Your doctor will do a detailed assessment and discuss with you the best option, including the risks.

Iron deficiency and anemia are more common after a gastric bypass than after a sleeve gastrectomy or an adjustable gastric band. This is especially true in women. In fact, iron deficiency can occur in more than half of women who are past menopause when they have gastric bypass surgery.

Figure 10. Gastric sleeve vs Gastric bypass

Gastric sleeve vs Gastric bypass surgery

When should I consider gastric sleeve surgery?

Gastric sleeve is a form of bariatric surgery, also called weight loss surgery, and you should only consider gastric sleeve surgery after trying non-surgical alternatives.

The first step is usually to try changes to your food intake and your daily activity and exercise. There are also some medications that can help people lose weight. Surgery is usually thought about only after these other options have been tried.

Gastric sleeve surgery is used to treat severe obesity. It’s advised for people who have tried other weight loss methods without long-term success. Your doctor may advise gastric sleeve surgery if you are severely obese with a body mass index (BMI) over 40 kg/m². Your doctor may also advise it if you have a BMI between 35 and 40 kg/m² and a health condition such as obstructive sleep apnea, high blood pressure, heart disease, or type 2 diabetes.

Endoscopic gastric sleeve surgery is performed to help you lose weight and potentially lower your risk of serious weight-related health problems, including:

Gastroesophageal reflux disease (GERD)
Heart disease
Stroke
High blood pressure
High cholesterol
Obstructive sleep apnea
Type 2 diabetes
Stroke
Cancer
Infertility

Losing weight after gastric sleeve surgery can help reduce problems with type 2 diabetes, asthma episodes and blood pressure, and can help improve heart health.

Who is gastric sleeve surgery for?

Endoscopic gastric sleeve surgery is often an option for people who aren’t candidates for other bariatric surgeries. The procedure is available to people whose body mass index (BMI) is above 30 who haven’t been successful maintaining weight loss with other methods.

But endoscopic gastric sleeve surgery isn’t for everyone who is overweight. A screening process helps doctors see if the procedure might be beneficial for you. And you must be willing to commit to healthy lifestyle changes, regular medical follow-up and participate in behavioral therapy.

Endoscopic gastric sleeve surgery isn’t appropriate for anyone who has gastrointestinal bleeding, a hiatal hernia larger than 3 centimeters or who’s had prior stomach surgery.

Weight-loss surgery isn’t advised for people who abuse medicines or alcohol, or who are not able to commit to a lifelong change in diet and exercise habits.

Given that endoscopic gastric sleeve surgery is a new procedure, it might not be covered by your health insurance.

Gastric sleeve complications

Bleeding, infection, and blood clots in your legs are possible side effects that may occur after any surgery. General anesthesia may also cause breathing problems or other reactions.

Gastric sleeve surgery has some risks, including ⁹⁷, ⁹⁸, ⁹⁹, ¹⁰⁰, ¹⁰¹, ¹⁸, ⁴, ¹⁰²:

too much bleeding
leaking of stomach contents into the belly from where parts of the stomach have been stapled together
injury to your stomach, intestines, or other organs during surgery
a bad reaction to anesthesia
allergic reactions to medicines
blood clots
infection
lung or breathing problems
gastritis (inflamed stomach lining), heartburn, or stomach ulcers
risk of vitamin and iron deficiency (shortage)
scarring inside your belly that could lead to a blockage in your bowel in the future
vomiting from eating more than your stomach pouch can hold
risk of acid reflux and hiatal hernia (caused by the stomach pushing up against the diaphragm). Development of gastroesophageal reflux disease (GERD) is one of the most frequent complications of sleeve gastrectomy with up to 26% of patients experiencing new symptoms after surgery ¹⁰³ and up to 30% requiring reoperation due to GERD or weight increase caused by dilatation of the gastric tube ¹⁰⁴, ¹⁰⁵.

Over time, you may also have some trouble absorbing certain nutrients. Or you may develop a narrowing (stricture) in your stomach sleeve. Some people may have heartburn or reflux after the surgery. If you already have moderate to severe reflux, a gastric sleeve could make that worse. You may want to consider a gastric bypass surgery instead. That type of surgery can stop reflux and heartburn.

You may have other risks based on your health. Make sure to talk with your healthcare team about any concerns before the surgery.

Gastric sleeve surgery risks

As with any major surgery, vertical sleeve gastrectomy poses potential health risks, both in the short term and long term. In early studies on endoscopic gastric sleeve surgery, the procedure has shown a favorable safety profile. Pain and nausea may occur for several days after the surgery. These symptoms are usually managed with pain and nausea medications. Most people feel better after two days.

In addition, although it’s not designed to be a temporary procedure, endoscopic gastric sleeve surgery can be reversed. In some cases, it can also be converted to bariatric surgery.

Because the gastric sleeve surgery is still new and not in wide use, questions remain about its long-term effectiveness and risks ¹⁰⁶.

Risks associated with sleeve gastrectomy can include ⁹⁷, ⁹⁸, ⁹⁹, ¹⁰⁰, ¹⁰¹, ¹⁸, ⁴, ¹⁰²:

Excessive bleeding
Infection
Adverse reactions to anesthesia
Blood clots
Lung or breathing problems
Leaks from the cut edge of the stomach

Longer term risks and complications of sleeve gastrectomy surgery can include:

Gastrointestinal obstruction
Hernias
Gastroesophageal reflux
Low blood sugar (hypoglycemia)
Malnutrition
Vomiting

Very rarely, complications of sleeve gastrectomy can be fatal resulting in dealth.

Preparing for Gastric Sleeve Surgery

If you qualify for endoscopic gastric sleeve surgery, your health care team will give you specific instructions on how to prepare for your surgery. You may need to have various lab tests and exams before surgery. You may have restrictions on eating, drinking and which medications you can take. You also may be required to start a physical activity program.

Preparing for this major operation takes months of work. You need to show that you are willing and able to make big changes in your eating and exercise habits before the surgery.

Before having surgery, you’ll need to enroll in a bariatric surgery education program. This will help you get ready for surgery, and life after surgery. You’ll have nutritional counseling. And you may have a psychological evaluation. You’ll also need physical exams and tests. You will need blood tests. You may have imaging studies of your stomach, or have an upper endoscopy.

If you smoke, you will need to stop several months before surgery. Your surgeon may ask you to lose some weight before surgery. This will help make your liver smaller, and make surgery safer. You’ll need to stop taking aspirin, ibuprofen, and other blood-thinning medicines in the days before your surgery. You shouldn’t eat or drink anything after midnight before surgery.

If you’re a candidate for gastric sleeve surgery, the best place to get it is at a hospital with a bariatric surgery program that involves a team of specialists. Members of the team will explain what’s involved, help you prepare for your surgery, and care for you after surgery. For several months before surgery, you will work with the medical team to build the skills needed for success.

Here are some of the people who work as a team to help teens prepare for gastric sleeve surgery:

Doctors and surgeons

Several months before your surgery, you’ll meet with a medical doctor and surgeon. They will explain what happens during surgery, examine you, and talk about what to expect before and after surgery. Your doctors will also let you know about some of the things that can go wrong (you’ll probably hear doctors call these “complications”).

Psychologists

People go through lots of emotions before and after surgery. A psychologist can help you understand your feelings and help you prepare emotionally for surgery and the changes that will follow. For example, when you’re out with friends after your surgery, you won’t be able to eat the way you used to.

The psychologist will help you develop coping strategies as you learn to change your relationship with food. He or she also will help you with things like worry, stress, or emotional eating. It’s always a good idea to take advantage of a psychologist’s expertise as you prepare for gastric sleeve surgery.

Dietitians

Because patients often depend on other family members for meals, a dietitian will teach you and your family healthy eating basics like good nutrition, how to get regular meals, and the right portion sizes.

Gastric sleeve surgery permanently decreases the size of your stomach. You will have to eat less than you did before. Your dietitian will explain what and how much you can eat after surgery, both immediately after the operation and for the rest of your life.

Exercise specialists

These experts help patients get more active. They’ll work with you to develop an exercise program you’ll like and workouts you can stick with. It’s like having a personal trainer. Exercising during the months before surgery helps patients get in better shape for the operation. This will make recovery easier.

There’s another reason why it’s good to exercise regularly before surgery: After the operation, it will be easier to get back into working out if you’ve already made a habit of it. Lots of patients find that having a workout routine helps them feel better after surgery, but you will have to go slow. Talk to your doctor and exercise specialist to get their advice on how to gradually get back into your exercise routine.

How do I prepare for my gastric sleeve surgery?

In the weeks leading up to your vertical sleeve gastrectomy, you may be required to start a physical activity program and to stop any tobacco use. If you smoke, you should stop several weeks before surgery and not start smoking again after surgery. Smoking slows recovery and increases the risk for problems. Ask your doctor for help quitting.

Your surgeon will ask you to have tests and visits with your other health care providers before you have this surgery. Some of these are:

A complete physical exam.
Blood tests, ultrasound of your gallbladder, and other tests to make sure you are healthy enough to have surgery.
Visits with your doctor to make sure other medical problems you may have, such as diabetes, high blood pressure, and heart or lung problems, are under control.
Nutritional counseling.
Classes to help you learn what happens during the surgery, what you should expect afterward, and what risks or problems may occur afterward.
You may want to visit with a counselor to make sure you are emotionally ready for this surgery. You must be able to make major changes in your lifestyle after surgery.

Now is a good time to plan ahead for your recovery after surgery. For instance, arrange for help at home if you think you’ll need it.

Tell your surgeon:

If you are or might be pregnant
What medicines, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription

During the week before your surgery:

You may be asked to stop taking blood thinning medicines. These include aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin, Jantoven), and others.
Ask your doctor which drugs you should still take on the day of your surgery.

On the day of your surgery:

Right before your procedure, you may have restrictions on eating and drinking and which medications you can take. Follow instructions about when to stop eating and drinking.
Take the drugs your doctor told you to take with a small sip of water.
Arrive at the hospital on time.

What happens during gastric sleeve surgery?

Endoscopic gastric sleeve surgery is done in the endoscopy unit as an outpatient procedure. General anesthesia is used for the procedure, so you’ll be unconscious throughout the surgery.

The gastric sleeve surgery is done using an endoscope, a flexible tube with a camera and an endoscopic suturing device attached. The endoscope is inserted down your throat into the stomach. The tiny camera allows the doctor operating the endoscope (endoscopist) to see and operate inside your stomach without making incisions in your abdomen.

Using the endoscope, the doctor places approximately 12 sutures in the stomach. The sutures change the structure of your stomach, leaving it shaped like a tube. This restricts the amount of calories your body absorbs.

The procedure takes about 90 minutes. After the endoscopic sleeve gastroplasty, you’ll be awaken in a recovery room, where medical staff monitors you for any complications.

You can probably go home 2 days after your surgery. The majority of people leave go home the same day after recovering from sedation.

You should be able to drink clear liquids on the day after surgery, and then go on a pureed diet by the time you go home.

When you go home, you will probably be given pain pills or liquids and a drug called a proton pump inhibitor.

When you eat after having this surgery, the small pouch will fill quickly. You will feel full after eating a very small amount of food.

The surgeon, nurse, or dietitian will recommend a diet for you. Meals should be small to avoid stretching the remaining stomach.

Laparoscopic gastric sleeve surgery

In other surgical centers, your surgeon will use laparoscopy instead of the endoscope. In the laparoscopic gastric sleeve surgery (keyhole surgery), your surgeon will make several small cuts (incisions) in your upper abdomen. The surgeon will then insert a laparoscope and put small surgery tools into these incisions.

In laparoscopic gastric sleeve surgery:

Your surgeon makes 2 to 5 small cuts (incisions) in your belly.
The laparoscope and instruments needed to perform the surgery are inserted through these cuts.
The camera is connected to a video monitor in the operating room. This allows the surgeon to view inside your belly while doing the operation.
A harmless gas is pumped into the belly to expand it. This gives the surgeon room to work.
Your surgeon will then use a laparoscopic stapler to divide the stomach, leaving a narrowed vertical sleeve. The part of the stomach that was removed is then taken out of the abdomen through an incision. Your surgeon may then test for any leaks in the sleeve using a dye study or an upper endoscopy.
The remaining portions of your stomach are joined together using surgical staples. This creates a long vertical tube or banana-shaped stomach.
The surgery does not involve cutting or changing the sphincter muscles that allow food to enter or leave the stomach.
The laparoscope and other tools are removed. The cuts are stitched closed.

The laparoscopic gastric sleeve surgery takes 60 to 90 minutes.

Weight-loss surgery may increase your risk for gallstones. Your surgeon may recommend having a surgery to remove your gallbladder (cholecystectomy). The surgery to remove your gallbladder (cholecystectomy) may be done before your weight-loss surgery or at the same time.

During gastric sleeve procedure

The specifics of your surgery depend on your individual situation and the hospital’s or doctor’s practices. Some gastric sleeve surgery are done with traditional large (open) incisions in the abdomen. But sleeve gastrectomy is typically performed laparoscopically, which involves inserting small instruments through multiple small incisions in the upper abdomen.

You are given general anesthesia before your surgery begins. Anesthesia is medicine that keeps you asleep and comfortable during surgery.

To perform a sleeve gastrectomy, the surgeon creates a narrow sleeve by stapling the stomach vertically and removing the larger, curved part of the stomach.

Surgery usually takes one to two hours. After surgery, you awaken in a recovery room, where medical staff monitors you for any complications.

After gastric sleeve procedure

After gastric sleeve surgery, your diet begins with sugar-free, noncarbonated liquids for the first seven days, then progresses to pureed foods for three weeks, and finally to regular foods approximately four weeks after your surgery. You will be required to take a multivitamin twice a day, a calcium supplement once a day, and a vitamin B-12 injection once a month for life.

You’ll have frequent medical checkups to monitor your health in the first several months after weight-loss surgery. You may need laboratory testing, bloodwork and various exams.

You may experience changes as your body reacts to the rapid weight loss in the first three to six months after sleeve gastrectomy, including:

Body aches
Feeling tired, as if you have the flu
Feeling cold
Dry skin
Hair thinning and hair loss
Mood changes

Gastric sleeve surgery recovery time

After the gastric sleeve surgery, you generally won’t be allowed to eat for about eight hours. People usually recover from gastric sleeve surgery in a week. But it will take several weeks before you can eat regular food again. Gastric sleeve surgery makes your stomach smaller — permanently. To ease into having a much smaller stomach, you’ll need to follow a special diet that starts with liquids only, wich you need to continue for at least two weeks. Over four weeks, you’ll move on to semi-solid foods, and then to a regular healthy diet. You’ll also have medical checkups and meet with a nutritionist and psychologist frequently after your gastric sleeve surgery.

Gastric sleeve diet

Your surgery team will give you a schedule of types of meals over the next weeks. After the surgery, you’ll start with liquid foods. Over the next few weeks you will change to pureed food, then to solid food. Your meals will be much smaller and you may have to stop drinking with meals due to your small stomach. Each meal needs to be very small.

You should make sure to eat slowly and chew each bite well. Don’t move too quickly to regular food. This can cause pain and vomiting. Work with your healthcare team to figure out what’s best for you to eat. After your stomach heals, you will need to change your eating habits. You’ll need to eat small meals for your small stomach.

Your dietitian will give you an eating plan that gradually works up to solid foods; for example:

For the first 2 to 3 weeks after surgery, you’ll get all your nutrition from high-protein drinks.
For the next 2 weeks or so, you’ll eat puréed foods.
Finally, you’ll move on to soft foods for another couple of weeks before you can eat regular food.

How quickly someone moves from one stage to the next depends on the person. Your medical team will advise you based on what’s best for you.

If you rush a stage or eat something before your body’s ready for it — or if you eat too much — you’ll feel very uncomfortable. You may throw up. Eventually you’ll be able to eat more of the foods you’re used to. But for the rest of your life, you’ll always have to eat much smaller portions. You’ll also feel full faster.

Because you can’t eat as much, the foods you choose to eat really matter. Your dietitian will help you put together a lifelong healthy diet that includes fruits and vegetables and emphasizes protein. Your dietitian also will recommend vitamin and mineral supplements so you don’t miss out on key nutrients.

Your new diet will limit the amount of processed foods and snacks like chips and candy that you can eat. This is because these foods don’t have a lot of nutritional value (dietitians sometimes call them “empty calories”).

In addition to eating a sensible diet, exercising is a key part of staying healthy and maintaining weight loss after surgery.

People who follow the recommended diet and exercise plan often lose a large amount of weight in the months after gastric sleeve surgery. After that, weight begins to stabilize. Your team of specialists will keep seeing you for several months after surgery to monitor your diet and health, and to help you stay on track.

You will need to make significant lifestyle changes after bariatric surgery to lose weight and keep it off. For example, you’ll get nutritional advice from a dietitian on how to change your eating habits to keep healthy while losing weight.

People who have weight-loss surgery may have trouble getting enough vitamins and minerals. This is because they take in less food, and may absorb fewer nutrients. You may need to take a daily multivitamin, plus a calcium-vitamin D supplement. You may need additional nutrients, such as vitamin B-12 or iron. Your medical team will give you instructions.

You’ll need to have regular blood tests every few months in the year after surgery. This is to make sure you don’t have low blood iron (anemia), high blood glucose, or low calcium or vitamin D levels. If you have heartburn, you may need to medicine to reduce stomach acid.

After losing weight, it’s possible to regain some of the weight that you lose. To avoid this, make sure to follow a healthy diet and get regular exercise. The sleeve may widen (dilate) over time. This will let you eat more. But keep in mind that if you eat all you can, you can regain weight. You may want to join a weight-loss surgery support group to help you stick with your new eating habits.

You will also have to, and be able to, increase the amount of physical activity you do.

Gastric bypass surgery

A gastric bypass surgery or Roux-en-Y gastric bypass is a type of weight-loss surgery (bariatric surgery) where surgical staples are used to create a small pouch at the top of the stomach. This pouch will hold about 1 cup of food. The pouch is then connected to your small intestine, bypassing (missing out) the rest of the stomach. This means it takes less food to make you feel full and you’ll absorb fewer calories from the food you eat. Gastric bypass surgery is one of the most common types of weight loss surgery in the United States. Gastric bypass surgery is done when lifestyle intervention (diet and physical activity) and drugs haven’t worked or when you have serious health problems because of your weight.

In Roux-en-Y gastric bypass surgery, the rest of your stomach will still be there, but food won’t go to it. The pouch is the only part of the stomach that receives food. This greatly limits the amount that you can comfortably eat and drink at one time.

Next, the small intestine is then cut a short distance below the main stomach and connected to the new pouch. Your surgeon will attach one end of it to the small stomach pouch and the other end lower down on the small intestine, making a “Y” shape. That’s the bypass part of the procedure. The rest of your stomach is still there. It delivers chemicals from the pancreas to help digest food that comes from the small pouch. Doctors use the laparoscopic method for most gastric bypasses.

Food flows directly from the pouch into this part of the intestine. The main part of the stomach, however, continues to make digestive juices. The portion of the intestine still attached to the main stomach is reattached farther down. This allows the digestive juices to flow to the small intestine. Because food now bypasses a portion of the small intestine, fewer nutrients and calories are absorbed.

In addition to weight loss, gastric bypass surgery may improve or resolve conditions often related to being overweight, including:

Gastroesophageal reflux disease
Heart disease
High blood pressure
High cholesterol
Obstructive sleep apnea
Type 2 diabetes
Stroke
Infertility

Gastric bypass surgery can also improve your ability to perform routine daily activities, which could help improve your quality of life.

Figure 11. Gastric bypass before and after

Footnote: Before gastric bypass, food (see arrows) enters your stomach and passes into the small intestine. After surgery, the amount of food you can eat is reduced due to the smaller stomach pouch. Food is also redirected so that it bypasses most of your stomach and the first section of your small intestine (duodenum). Food flows directly into the middle section of your small intestine (jejunum), altering the secretion of gastrointestinal hormones and thereby affecting your appetite and metabolism.

Figure 12. Gastric bypass surgery or Roux-en-Y gastric bypass

Why is gastric bypass surgery done?

Gastric bypass surgery is done to help you lose excess weight and reduce your risk of potentially life-threatening weight-related health problems, including:

Gastroesophageal reflux disease (GERD)
Heart disease
High blood pressure
High cholesterol
Obstructive sleep apnea
Type 2 diabetes
Stroke
Infertility

Gastric bypass surgery is typically done only after you’ve tried to lose weight by improving your diet and exercise habits.

Gastric bypass alternative

The alternatives to gastric bypass surgery are lifestyle changes such as diet and exercise, or lifestyle changes combined with weight-loss medications or lap band surgery (adjustable gastric banding) or gastric sleeve surgery. You can get professional help with this: ask your doctor. A prospective, cross-sectional study ¹⁰⁷ assessed weight loss, food tolerance and diet quality in 130 subjects (14 obese pre-surgical controls, 13 adjustable gastric banding, 62 gastric sleeve and 41 Roux-en-Y gastric bypass) found the obese pre-surgical controls and adjustable gastric banding groups consumed significantly more high-calorie extra foods, resulting in poor weight loss and food tolerance outcomes for the adjustable gastric banding group. The control and adjustable gastric banding groups consumed significantly more high-calorie extra foods (9.2 and 7.7 daily serves respectively) compared with the gastric sleeve (3.4 serves) and Roux-en-Y gastric bypass (4.0 serves) groups. There were several significant correlations between food tolerance and dietary intake including breads and cereals and meat and meat alternatives.

Laparoscopic adjustable gastric banding or Lap Band

In laparoscopic adjustable gastric banding, a hollow, flexible silicone band is placed around the upper stomach, which causes a restrictive effect, reduces stomach capacity, and produces rapid feelings of satiety. The band is tightened by injecting saline into it through a subcutaneous port, which is located just inferior to the sternum or lateral to the umbilicus (Figure 8). Because of a higher complication rate and less weight loss compared with the other two most common procedures (gastric sleeve and Roux-en-Y gastric bypass), the demand for gastric banding is decreasing in the United States ¹⁰⁸.

Figure 13. Adjustable Gastric Banding

Who is gastric bypass surgery for?

Gastric bypass and other weight-loss surgeries are major, life-changing procedures. While weight-loss surgery can help reduce your risk of weight-related health problems — such as type 2 diabetes, high blood pressure, heart disease and obstructive sleep apnea — it can also pose major risks and complications. You may need to meet certain medical guidelines to qualify for weight-loss surgery. You likely will have an extensive screening process to see if you qualify.

In general, gastric bypass and other weight-loss surgeries could be an option for you if:

Your efforts to lose weight with diet and exercise have been unsuccessful
Your body mass index (BMI) is 40 or higher (extreme obesity).
Your BMI is 35 to 39.9 (obesity), and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea.
In some cases, you may qualify for certain types of weight-loss surgery if your BMI is 30 to 34 and you have serious weight-related health problems.
You’re a teenager who’s gone through puberty, your BMI is 35 or more, and you have serious obesity-related health problems, such as type 2 diabetes or severe sleep apnea

Even if you meet these general guidelines, you still may need to meet certain other medical guidelines to qualify for weight-loss surgery. You likely will have an extensive screening process to see if you qualify.

A team of health professionals — usually including a doctor, dietitian, psychologist and surgeon — evaluate whether gastric bypass or one of the other forms of weight-loss surgery is appropriate for you. This evaluation generally determines if the health benefits of the surgery outweigh the potentially serious risks, and if you’re medically ready to undergo the procedure.

The evaluation also determines if you’re psychologically ready to undergo weight-loss surgery. The procedure may increase certain risks in people with existing mental health conditions that aren’t effectively managed.

For example, recent studies have identified an increased risk of suicide in people who have had weight-loss surgery. This risk is greatest in those who have attempted suicide in the past. More research is needed to understand whether changes related to the surgery itself play a role in increasing suicide risk.

A history of suicidal thoughts or attempts does not necessarily mean bariatric surgery isn’t right for you, but your health care team should carefully evaluate your history and plan for close monitoring and support before and after the surgery.

When conducting an evaluation for gastric bypass surgery, the health care team considers:

Your nutrition and weight history. The team reviews your weight trends, diet attempts, eating habits, exercise regimen, stress level, time constraints, motivation and other factors.
Your medical condition. Some health problems increase the risks associated with having surgery or may be worsened by surgery, such as blood clots, liver disease, heart problems, kidney stones and nutritional deficiencies. The team evaluates what medications you take, how much alcohol you drink and whether you smoke. You will be evaluated for sleep apnea and receive a thorough physical exam and laboratory testing. The results of these tests and exams may help determine eligibility for weight-loss surgery.
Your psychological status. Certain mental health conditions may contribute to obesity or make it more difficult for you to maintain the health benefits of gastric bypass surgery. These may include binge-eating disorder, substance abuse, anxiety disorders, major depression, schizophrenia, severe bipolar disorder and issues related to childhood sexual abuse. While these conditions may not prevent you from having gastric bypass surgery, your doctors may want to postpone surgery to ensure that any condition or significant sources of stress are appropriately treated and managed.
Your motivation. The team will also assess your willingness and ability to follow through with recommendations made by your health care team and to carry out prescribed changes in your diet and exercise routine.
Your age. There’s no specific age limit for gastric bypass surgery, but, until recently, the procedure was considered too risky for teenagers and older adults. Newer studies have found gastric bypass surgery can be safe and effective for adults ages 60 and older. The procedure is also now considered an option for some teenagers with a BMI of 35 or more and serious obesity-related health problems.

Check with your health insurance plan or your regional Medicare or Medicaid office to find out if your policy covers weight-loss surgery. If you plan to rely on health insurance coverage for your gastric bypass surgery, you will need to get preapproval from your health insurance company. The preapproval process typically requires documentation from your team of doctors that justifies your medical need for gastric bypass surgery.

Different health insurers have different requirements to prove your medical need for gastric bypass surgery. Your health insurer may not cover gastric bypass surgery at all or may cover only parts of the process. To avoid unpleasant financial surprises, it’s a good idea to check to see what specific services are covered before starting the evaluation process. You may have to pay for some portion of the costs yourself.

When weight-loss surgery doesn’t work

It’s possible to not lose enough weight or to regain weight after weight-loss surgery. This weight gain can happen if you don’t follow the recommended lifestyle changes. If you frequently snack on high-calorie foods, for instance, you may have inadequate weight loss. To help avoid regaining weight, you must make permanent healthy changes in your diet and get regular physical activity and exercise.

It’s important to keep all of your scheduled follow-up appointments after weight-loss surgery so that your doctor can monitor your progress. If you notice that you aren’t losing weight or you develop complications after your surgery, see your doctor immediately.

What happens if you gain back weight after gastric bypass surgery?

If you begin to regain weight after gastric bypass surgery, talk to your doctor. You may have a sense of what’s causing your weight gain. However, you may need a more thorough evaluation to determine what factors — medical, psychological, lifestyle — are involved in the weight gain.

You may have gained weight after gastric bypass surgery because of changes in your stomach and intestine that allow you to eat more and absorb more calories.

It’s also possible that your diet and exercise habits have slipped, in which case you must typically lose the regained weight the old-fashioned way — both by reducing your calorie intake and increasing your physical activity.

In some cases, a second surgery to repair — or redo — a gastric bypass may be appropriate. This is especially true if the anatomy of your stomach and small intestine have changed, such as with a fistula (additional connection between the stomach and intestine).

However, a second surgery has an increased risk of complications, including infection, bleeding and leaks in the gastrointestinal tract. Because of these risks, gastric bypass surgery usually isn’t redone if you regain weight because of poor diet or exercise habits.

Gastric bypass surgery can be an effective treatment for obesity, and most people do lose weight after the procedure if they are adequately prepared for the changes that are necessary. But you’ll always be at risk of regaining weight, even years later.

To help reach your weight-loss goal and prevent weight regain, it’s crucial to make lifestyle changes along with having gastric bypass surgery.

Gastric bypass surgery risks

As with any major surgery, gastric bypass and other weight-loss surgeries pose potential health risks, both in the short term and long term.

Risks associated with the surgical procedure are similar to any abdominal surgery and can include:

Excessive bleeding
Infection
Adverse reactions to anesthesia
Blood clots
Lung or breathing problems
Leaks in your gastrointestinal system

Longer term risks and complications of gastric bypass surgery can include:

Bowel obstruction
Dumping syndrome, causing diarrhea, nausea or vomiting
Gallstones
Hernias
Low blood sugar (hypoglycemia)
Malnutrition
Stomach perforation
Ulcers
Vomiting
Anastomotic leaking

Rarely, complications of gastric bypass can be fatal.

Risks of anastomotic leaking

Anastomotic leaks happen in 1.5% to 6% of gastric bypass procedures, depending on the type of surgery. A leak may happen up to several weeks later. Most develop within 3 days after surgery.

A leaking anastomosis may cause bleeding and infection until it is treated. These leaks are serious and can be life-threatening. Long-term complications may include ulcers, scarring, and narrowing of the anastomosis (where the intestine is connected to the gastric pouch), known as a stricture. A drainage tract through the skin called a fistula may also develop. A fistula could develop between the gastric pouch and the bypassed stomach. Pneumonia is another dangerous complication, because digestive juices can spill into the lungs.

If you are considering gastric bypass surgery for obesity, discuss the procedure carefully with your healthcare provider. The overall risk of serious complications should be weighed against the risk of continued obesity. Remember that gastric bypass surgery works best when combined with long-term, healthy lifestyle choices. These involve good nutritional eating habits and regular exercise.

Symptoms of an anastomotic leak include:

Rapid heart rate
Fever
Stomach pain
Drainage from a surgical wound
Nausea and vomiting
Pain in the left shoulder area
Low blood pressure
Decreased urine output

The more obese you are, the more at risk you are for an anastomotic leak. Other risk factors include being male, having other medical problems besides obesity, and having a history of previous abdominal surgery.

Diagnosis and treatment of anastomotic leaking

A diagnostic test used to look for anastomotic leaking is an upper GI or a CT scan. Both involve swallowing some liquid contrast dye and then taking X-rays to see if the dye is leaking through the anastomosis. Even if you have a negative exam but still have symptoms, your healthcare provider may recommend an emergency operation to look for a leak.

The medical team treating an anastomotic leak will likely take these steps:

Give you antibiotics through an intravenous line (IV).
Drain any infection caused by the leak, repair the leak, or make a new anastomosis by operating again.
Use an upper endoscopy to place a temporary stent across the leaking area, from the inside of the gastric pouch or the small intestine.
Stop all oral feedings. You may be fed through a tube that goes directly into your intestine until the leak has healed.

How you prepare for gastric bypass surgery

If you qualify for gastric bypass surgery, your health care team gives you instructions on how to prepare for surgery. You may need to have various lab tests and exams before surgery.

Food and medications

Before your gastric bypass surgery, give your doctor and any other health care providers a list of all medicines, vitamins, minerals, and herbal or dietary supplements you take. You may have restrictions on eating and drinking and which medications you can take.

If you take blood-thinning medications, talk with your doctor before your surgery. Because these medications affect clotting and bleeding, your blood-thinning medication routine may need to be changed.

If you have diabetes, talk with the doctor who manages your insulin or other diabetes medications for specific instructions on taking or adjusting them after surgery.

Other precautions

You will be required to start a physical activity program and to stop any tobacco use.

You may also need to prepare by planning ahead for your recovery after surgery. For instance, arrange for help at home if you think you’ll need it.

Gastric bypass surgery is done in the hospital. Depending on your recovery, your hospital stay may last around three to five days.

Gastric bypass procedure

Before you go to the operating room, you’ll change into a gown and be asked several questions by both doctors and nurses. In the operating room, you are given a general anesthetic before your surgery begins. The anesthetic is medicine that keeps you asleep and comfortable during surgery.

During the gastric bypass surgery

The specifics of your gastric bypass surgery depend on your individual situation and the doctor’s practices. Some surgeries are done with traditional large (open) incisions in your abdomen. However, most are performed laparoscopically, which involves inserting instruments through multiple small incisions in the abdomen.

After making the incisions with the open or laparoscopic technique, the surgeon cuts across the top of your stomach, sealing it off from the rest of your stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. Normally, your stomach can hold about 3 pints of food.

Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch. Food then goes into this small pouch of stomach and then directly into the small intestine sewn to it. Food bypasses most of your stomach and the first section of your small intestine, and instead enters directly into the middle part of your small intestine.

Surgery usually takes a few hours. After surgery, you awaken in a recovery room, where medical staff monitors you for any complications.

After the gastric bypass surgery

Immediately after gastric bypass surgery, you may have liquids but no solid food as your stomach and intestines begin to heal. You’ll then follow a special diet plan that changes slowly from liquids to pureed foods. After that, you can eat soft foods, then move on to firmer foods as your body is able to tolerate them.

You may have many restrictions or limits on how much and what you can eat and drink. Your doctor will recommend you take vitamin and mineral supplements after surgery, including a multivitamin with iron, calcium and vitamin B-12.

You’ll also have frequent medical checkups to monitor your health in the first several months after weight-loss surgery. You may need laboratory testing, blood work and various exams.

You may experience changes as your body reacts to the rapid weight loss in the first three to six months after gastric bypass, including:

Body aches
Feeling tired, as if you have the flu
Feeling cold
Dry skin
Hair thinning and hair loss
Mood changes

Gastric bypass diet

A gastric bypass diet is for people who are recovering from gastric bypass surgery to help them heal and change their eating habits.

Diet recommendations after gastric bypass surgery vary depending on where the surgery is performed and your individual situation.

Your doctor or a registered dietitian will talk with you about the diet you’ll need to follow after surgery, explaining what types of food and how much you can eat at each meal. Closely following your gastric bypass diet can help you lose weight safely.

A gastric bypass diet typically follows a staged approach to help you ease back into eating solid foods as you recover. How quickly you move from one step to the next depends on how fast your body heals and adjusts to the change in eating patterns. You can usually start eating regular foods about three months after surgery.

After gastric bypass surgery, you must be careful to drink enough fluids to avoid dehydration, and to pay extra attention to signs that you feel hungry or full.

Liquids

For the first day or so after surgery, you’ll only be allowed to drink clear liquids. Sip slowly and drink only 2 to 3 ounces (59 to 89 milliliters) at a time. Once you’re handling clear liquids, you can start having other liquids, such as skim or low-fat milk.

Liquids you can have during stage 1:

Broth
Unsweetened juice
Decaffeinated tea or coffee
Milk (skim or 1 percent)
Strained cream soup
Sugar-free gelatin or popsicles

Pureed foods

Once you’re able to tolerate liquids for a few days, you can begin to eat strained and pureed (mashed up) foods. During this phase, you can only eat foods that have the consistency of a smooth paste or a thick liquid, without any solid pieces of food in the mixture.

To puree your foods, choose foods that will blend well, such as:

Lean ground meats
Beans
Fish
Eggs
Soft fruits and cooked vegetables
Cottage cheese

Blend solid foods with a liquid, such as:

Water
Skim milk
Juice with no sugar added
Broth

It’s important that you don’t eat and drink at the same time. Wait about 30 minutes after a meal to drink anything. Also keep in mind that your digestive system might still be sensitive to spicy foods or dairy products. If you’d like to eat these foods during this phase, add them into your diet slowly and in small amounts.

Soft foods

After a few weeks of pureed foods, and with your doctor’s okay, you can add soft foods — in the form of small, tender, easily chewed pieces — to your diet.

During this stage, your diet can include:

Ground or finely diced meats
Canned or soft fresh fruit (without seeds or skin)
Cooked vegetables (without skin)

Solid foods

After about eight weeks on the gastric bypass diet, you can gradually return to eating firmer foods. But foods must still be chopped or diced. Start slowly with regular foods to see what foods you can tolerate. You may find that you still have difficulty eating spicier foods or foods with crunchy textures.

Even at this stage, there are foods you should avoid because they may cause gastrointestinal symptoms, such as nausea, pain or vomiting.

Foods to avoid:

Nuts and seeds
Popcorn
Dried fruits
Carbonated beverages
Granola
Stringy or fibrous vegetables, such as celery, broccoli, corn or cabbage
Tough meats or meats with gristle
Fried foods
Breads

Over time, you may be able to try some of these foods again, with the guidance of your doctor.

A new healthy diet

Three to four months after weight-loss surgery, you may be able to start eating a normal healthy diet, depending on your situation and any foods you may not be able to tolerate. It’s possible that foods that initially irritated your stomach after surgery may become more tolerable as your stomach continues to heal.

Throughout the diet

To ensure that you get enough vitamins and minerals and keep your weight-loss goals on track, at each stage of the gastric bypass diet, you should:

Eat and drink slowly. Eating or drinking too quickly may cause dumping syndrome — when foods and liquids enter your small intestine rapidly and in larger amounts than normal, causing nausea, vomiting, dizziness, sweating and eventually diarrhea. To prevent dumping syndrome, choose foods and liquids low in fat and sugar, eat and drink slowly, and wait 30 to 45 minutes before or after each meal to drink liquids. Take at least 30 minutes to eat your meals and 30 to 60 minutes to drink 1 cup (237 milliliters) of liquid.
Keep meals small. During the diet progression, you should eat several small meals a day and sip liquids slowly throughout the day (not with meals). You might first start with six small meals a day, then move to four meals and finally, when following a regular diet, decrease to three meals a day. Each meal should include about a half-cup to a cup of food. Make sure you eat only the recommended amounts and stop eating before you feel full
Drink liquids between meals. Expect to drink at least 6 to 8 cups (48 to 64 ounces, or 1.4 to 1.9 liters) of fluids a day to prevent dehydration. Drinking liquids with your meals can cause pain, nausea and vomiting as well as dumping syndrome. Also, drinking too much liquid at or around mealtime can leave you feeling overly full and prevent you from eating enough nutrient-rich food.
Chew food thoroughly. The new opening that leads from your stomach into your intestine is very small, and larger pieces of food can block the opening. Blockages prevent food from leaving your stomach and can cause vomiting, nausea and abdominal pain. Take small bites of food and chew them to a pureed consistency before swallowing. If you can’t chew the food thoroughly, don’t swallow it.
Focus on high-protein foods. Immediately after your surgery, eating high-protein foods can help you heal. High-protein, low-fat choices remain a good long-term diet option after your surgery, as well. Try adding lean cuts of beef, chicken, pork, fish or beans to your diet. Low-fat cheese, cottage cheese and yogurts also are good protein sources.
Avoid foods that are high in fat and sugar. After your surgery, it may be difficult for your digestive system to tolerate foods that are high in fat or added sugars. Avoid foods that are high in fat (such as fried foods, ice cream and candy bars). Look for sugar-free options of soft drinks and dairy products.
Try new foods one at a time. After surgery, certain foods may cause nausea, pain and vomiting or may block the opening of the stomach. The ability to tolerate foods varies from person to person. Try one new food at a time and chew thoroughly before swallowing. If a food causes discomfort, don’t eat it. As time passes, you may be able to eat this food. Foods and liquids that commonly cause discomfort include meat, bread, raw vegetables, fried foods and carbonated beverages.
Take recommended vitamin and mineral supplements. Because a portion of your small intestine is bypassed after surgery, your body won’t be able to absorb enough nutrients from your food. You’ll likely need to take a multivitamin supplement every day for the rest of your life. Talk to your doctor about what type of multivitamin might be right for you and whether you might need to take additional supplements, such as calcium.

The greatest risks of the gastric bypass diet come from not following the diet properly. If you eat too much or eat food that you shouldn’t, you could have complications. These include:

Dumping syndrome. This complication occurs most often after eating foods high in sugar or fat. These foods travel quickly through your stomach pouch and “dump” into your intestine. Dumping syndrome can cause nausea, vomiting, dizziness, sweating and eventually diarrhea.
Dehydration. Because you’re not supposed to drink fluids with your meals, some people become dehydrated. You can prevent dehydration by sipping 48 to 64 ounces (1.4 to 1.9 liters) of water and other low-calorie beverages throughout the day.
Nausea and vomiting. If you eat too much, eat too fast or don’t chew your food adequately, you may become nauseated or vomit after meals.
Constipation. If you don’t follow a regular schedule for eating your meals, don’t eat enough fiber or don’t exercise, you may become constipated.
Blocked opening of your stomach pouch. It’s possible for food to become lodged at the opening of your stomach pouch, even if you carefully follow the diet. Signs and symptoms of a blocked stomach opening include ongoing nausea, vomiting and abdominal pain. Call your doctor if you have these symptoms for more than two days.
Weight gain or failure to lose weight. If you continue to gain weight or fail to lose weight on the gastric bypass diet, it’s possible you could be eating too many calories. Talk to your doctor or dietitian about changes you can make to your diet.

What is dumping syndrome after gastric bypass surgery?

Dumping syndrome after gastric bypass surgery is when food gets “dumped” directly from your stomach pouch into your small intestine without being digested. There are 2 types of dumping syndrome: early and late. Early dumping happens 10 to 30 minutes after a meal. Late dumping happens 1 to 3 hours after eating. Each has slightly different symptoms, such as abdominal cramping, fast heartbeat, lightheadedness, and diarrhea.

What causes dumping syndrome after gastric bypass surgery?

Early dumping syndrome can occur because of the dense mass of food that gets dumped into your small intestine at an earlier stage of digestion. The intestines sense that this food mass is too concentrated, and release gut hormones. Your body reacts by shifting fluid circulating in your bloodstream to the inside of your intestine. As a result, your intestines become fuller and bloated. Diarrhea often occurs 30 to 60 minutes later. In addition, certain substances are released by your intestine that affect heart rate and often blood pressure, causing many of the symptoms of early dumping. This can lead to lightheadedness or even fainting.

Symptoms of late dumping happen because of a decrease in blood sugar level (reactive hypoglycemia). Reactive hypoglycemia is low blood sugar caused 1 to 3 hours after a large surge of insulin. You are more likely to have dumping syndrome if you eat a meal heavy in starches or sugars. The sugars can be either fructose or table sugar (sucrose). Insulin levels can increase to high levels, then lower your blood sugar too much.

Who is at risk for dumping syndrome after gastric bypass surgery?

Dumping syndrome can happen in at least 3 out of 20 people who have had a part of their stomach removed for any reason.

What are the symptoms of dumping syndrome after gastric bypass surgery?

Most people have early dumping symptoms. Typical early dumping symptoms can include:

Bloating
Sweating
Abdominal cramps and pain
Nausea
Facial flushing
Stomach growling or rumbling
An urge to lie down after the meal
Heart palpitations and fast heartbeat
Dizziness or fainting
Diarrhea

About 1 in 4 people have late dumping symptoms. The symptoms of late dumping syndrome can include:

Heart palpitations
Sweating
Hunger
Confusion
Fatigue
Aggression
Tremors
Fainting

How is dumping syndrome after gastric bypass surgery diagnosed?

Your healthcare team will likely diagnose dumping syndrome based on your symptoms and when they occur. Tell him or her which foods or liquids give you symptoms. You may also need to have a glucose tolerance test or hydrogen breath test to help your healthcare provider diagnose you.

How is dumping syndrome after gastric bypass surgery treated?

The main treatment for dumping syndrome is changes in your diet. These include

Don’t drink liquids until at least 30 minutes after a meal.
Divide your daily calories into 6 small meals.
Lie down for 30 minutes after a meal to help control the symptoms.
Choose complex carbohydrates such as whole grains.
Avoid foods high in simple carbohydrates, such as those made white flour or sugar.
Add more protein and fat to your meals.
Stop eating dairy foods, if they cause problems.

Another option is to slow gastric emptying by making your food thicker. Your healthcare provider may advise adding 15 grams of guar gum or pectin to each meal. But many people don’t tolerate these additions to their food.

If dietary changes don’t help, your healthcare provider may give you some slow-release prescription medicines. In rare cases, these may help, but they often don’t work. In severe cases of dumping syndrome, your healthcare provider may suggest tube feeding or corrective surgery.

What causes iron deficiency after gastric bypass surgery?

Iron deficiency is a side effect that results from the changes made during the surgery. Most of the iron from foods such as meats, legumes, and iron-fortified grains is absorbed in the first part of your small intestine (duodenum). But after a gastric bypass procedure, food bypasses the duodenum. This can lead to iron deficiency and other nutrition problems.

The amount of iron in a standard multivitamin (18 mg) may not be enough to prevent anemia if you have this kind of surgery. You will need to take more iron if you are iron deficient after a gastric bypass.

Who is at risk for iron deficiency after gastric bypass surgery?

Iron deficiency is more common in women who have this surgery after menopause. It can occur in more than half of women in this age group. Men who have had gastric bypass also may develop iron deficiency. But this side effect happens much less often in men.

What are the symptoms of iron deficiency after gastric bypass surgery?

Iron has many important roles in your body. It’s important for the health of your hair, skin, and nails. It also helps make hemoglobin. This is the substance inside red blood cells that carries oxygen throughout your body. When you are anemic because of iron deficiency, you may have:

Lack of energy
Weakness
Headache
Rapid heartbeat
Hair loss
Brittle nails
Pale or yellow skin
Shortness of breath
Chest pain
Strange pounding sensation in your ears
Craving for ice or clay (pagophagia)

How is iron deficiency after gastric bypass surgery diagnosed?

Your healthcare provider will note any of the above symptoms. He or she will also order blood tests to find out if you have iron deficiency or anemia. In its early stages, iron deficiency begins to use up the stores of iron in your body. This can be seen by testing your levels of ferritin. Ferritin is a protein that stores iron in your body. If your ferritin levels are low, your iron is likely low.

If your iron deficiency has turned into iron deficiency anemia, you will need a complete blood count test to find any other problems. These might include low hemoglobin, lower numbers of red blood cells, and smaller red blood cell size.

For men, or for women past menopause, iron deficiency anemia might not be related to the gastric bypass surgery. Your healthcare provider will need to be certain that you are not anemic from blood loss elsewhere, such as from your intestine. You may need a colonoscopy to look for a source of blood loss from your large intestine.

How is iron deficiency after gastric bypass surgery treated?

Many people can raise their iron levels by making some changes to their diet. If your iron deficiency is related to a gastric bypass procedure, your healthcare team probably will prescribe iron supplements. This extra iron should come from a prescription from your provider, not from an over-the-counter (OTC) supplement you pick yourself. The exception to this is if your healthcare provider recommends a certain over-the-counter iron product for you. Your provider may recommend a certain type of iron that you could absorb better after a gastric bypass.

If you are a teen boy or girl, or a woman of childbearing age, you may need 2 multivitamins plus 50 mg to 100 mg of iron each day. You may also need a vitamin C supplement or other supplements to help your body absorb more iron. Your healthcare provider will tell you the right amount of iron that you need.

Iron supplement can cause side effects. Many people have constipation and nausea.

For some people, supplements aren’t enough. This is usually true for women with heavy menstrual periods. You may need iron through an IV (intravenous) line or blood transfusion. Or you may need more surgery on your bypass to increase the amount of iron you absorb.

Can iron deficiency after gastric bypass surgery be prevented?

You should have a blood tests before weight-loss surgery to find out if you have any vitamin or mineral deficiencies. These might be low levels of iron, vitamin B-12, or folate. Getting treatment for these deficiencies before your surgery will help your quality of life after surgery.

After gastric bypass surgery, you will need to monitor your level of iron and other nutrients for the rest of your life. You can develop iron deficiency and anemia years or decades after your gastric bypass surgery. Your healthcare provider should measure your iron levels 6 months after weight-loss surgery and at least once a year after that. You should also have a complete blood count test.

Red meat, poultry, seafood, leafy greens, legumes, iron-fortified grains, and other iron-fortified foods are all good sources of iron. Drinking more than 2 to 3 cups of milk a day may decrease how much iron you absorb. But dietary changes alone may not be enough to prevent or fix an iron deficiency related to a gastric bypass procedure. Work with your healthcare provider to find the right iron supplement plan for you.

Lap band surgery

Lap band surgery is also called laparoscopic adjustable gastric banding, gastric banding or the LAP-BAND system, is used to help someone lose weight. Lap band surgery involves putting a ring called a “lap band” around the top part of your stomach. This creates a small stomach pouch above the band with a very narrow opening to the rest of the stomach. The ring slows the entry of food to the main part of your stomach and you’ll feel full after eating only a small amount of food, but it doesn’t reduce the absorption of calories and nutrients.

A lap band is a small inflatable balloon ring that contains salt water. The lap band can be made larger or smaller by the injection or removal of salt water.

A port is then placed under the skin of the abdomen. A tube connects the port to the band. By injecting or removing fluid through the port, the balloon can be inflated or deflated to adjust the size of the band.

Lap band surgery restricts the amount of food that your stomach can hold, so you feel full sooner. Lap band surgery is used for weight loss in severely obese adults who have been obese for at least five years and for whom non-surgical weight loss methods have not been successful. The patients must be willing to make major changes in their eating habits and lifestyle. Patients must have a Body Mass Index (BMI) of at least 40, a BMI of at least 35 with one or more severe morbid (unhealthy) conditions, or be at least 100 pounds over their estimated ideal weight. Updates to these criteria have included patients with a BMI of 30 to 35 with obesity-related comorbidities as an indication for laparoscopic adjusted gastric banding ¹⁰⁹.

Lap band surgery has been shown to effectively cause weight loss in morbidly obese patients. The average patient will lose 87% of their excess weight after having the LAP-BAND System inserted. This should be compared to a person trying to lose weight by diet, exercise and medication therapy – where the average person will only lose 21% of their excess weight.

Large studies have shown that the average person will lose 23 kg following this surgery at 2 years, and up to 43 kg at 5 years post-operatively.

Losing weight after lap band surgery can help reduce problems with type 2 diabetes, asthma episodes and blood pressure, and can help improve heart health.

Lap band surgery has the lowest mortality of all the bariatric procedures, ranging from 0.02% to 0.1% ¹¹⁰. Lap band surgery carries a 3% 30 day morbidity ¹¹¹ and a 12% rate of late complications, though this varies among the literature ¹¹².

How does gastric banding work?

In a surgical procedure, the band is placed around the upper part of your stomach, creating a small pouch that can hold only a small amount of food. The narrowed opening between the stomach pouch and the rest of the stomach controls how quickly food passes from the pouch to the lower part of the stomach. The system helps the patient eat less by limiting the amount of food that can be eaten at one time and increasing the time it takes for food to be digested.

Depending on the patient’s needs, after the device is implanted the narrowed opening between the pouch and the lower part of the stomach can be adjusted in size by inflating or deflating the hollow band. Inflating the band makes the opening smaller, causing food to pass more slowly. Deflating the band makes it wider, causes food to pass more quickly. This adjustment is made by adding or removing fluid inside the hollow band. The doctor does this by injecting or removing the fluid through a small button-like part called the access port. This access port is placed under the skin in a muscle in the chest wall. The port is connected to the band by the tubing.

What are the benefits of lap band surgery?

The major benefit of the lap band surgery is weight loss. The operation to insert the LAP-BAND System is called gastric banding surgery. Lap band surgery is the simplest of all types of surgery performed for obesity. It is also considered the safest surgery for weight loss. In most cases, patients who have this surgery will only be in hospital for 24 hours.

Following the lap band surgery, a number of other medical problems will be improved in conjunction with weight loss. Studies of patients who have received gastric banding surgery show improvements in the following diseases after 2 years:

Blood pressure
Cholesterol
Asthma
Diabetes
Gastro-esophageal reflux
Heart failure
Sleep apnoea
Depression
Infertility
Blood clots

When should lap band surgery not be used?

Lap band surgery should not be used for people who are poor candidates for surgery, have certain stomach or intestinal disorders, have an infection, have to take aspirin frequently, or are addicted to alcohol or drugs. Lap band surgery should not be used on patients who are not able or willing to follow the rules for eating and exercise that are recommended by the doctor after surgery.

Lap band surgery contraindications

Lap band surgery is contraindicated for patients unable to tolerate general anesthesia. It is also contraindicated for those with uncontrollable coagulopathy or those at a prohibitive operative risk ¹¹³.

Relative contraindications include Prader-Willi syndrome, malignant hyperphagia, untreated severe psychiatric illness, pregnancy, cirrhotics with portal hypertension, autoimmune connective tissue disorders, chronic inflammatory conditions, and the need for chronic corticosteroid use ¹⁰⁹.

Lap band surgery requirements or qualifications

Lap band weight-loss surgery may be an option if you are severely obese and have not been able to lose weight through diet and exercise.

The U.S. Food and Drug Administration (FDA) has approved use of the lap band surgery or gastric banding 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 ¹¹⁴.

Lap band surgery is not a “quick fix” for obesity. Lap band surgery will greatly change your lifestyle. You must diet and exercise after this surgery. If you do not, you may have complications or poor weight loss.

People who have this lap band surgery should be mentally stable and not be dependent on alcohol or illegal drugs.

Doctors often use the following body mass index (BMI) measures to identify people who may be most likely to benefit from lap band weight-loss surgery. A normal BMI is between 18.5 and 25. Lap band weight-loss surgery procedure may be recommended for you if you have:

A BMI of 40 or more. This most often means that men are 100 pounds (45 kg) overweight and women are 80 pounds (36 kg) over their ideal weight.
A BMI of 35 or more and a serious medical condition that might improve with weight loss. Some of these conditions are sleep apnea, high cholesterol, heart attacks or stroke, type 2 diabetes, high blood pressure, heart disease, depression, and osteoarthritis.

The following are some of the main criteria are used to assess if the lap band surgery is appropriate:

Have been very overweight for at least 5 years.
Multiple, previous attempts to lose weight.
Motivation to lose weight.
Willingness to change current exercise and eating patterns.
Understanding of what the surgery involves. (See page on laparoscopic surgery).
Able to attend regular follow-up appointments.

Before the lap band surgery procedure

Your surgeon will ask you to have tests and visits with your other health care providers before you have lap band surgery. Some of these are:

Blood tests and other tests to make sure you are healthy enough to have surgery.
Classes to help you learn what happens during the surgery, what you should expect afterward, and what risks or problems may occur.
Complete physical exam.
Nutritional counseling.
Visit with a mental health provider to make sure you are emotionally ready for major surgery. You must be able to make major changes in your lifestyle after surgery.
Visits with your provider to make sure other medical problems you may have, such as diabetes, high blood pressure, and heart or lung problems, are under control.

If you are a smoker, you should stop smoking several weeks before surgery and not start smoking again after surgery. Smoking slows recovery and increases the risk of problems. Tell your provider if you need help quitting.

Always tell your doctor:

If you are or might be pregnant
What medicines, vitamins, herbs, and other supplements you are taking, even ones you bought without a prescription

During the week before your lap band surgery:

You may be asked to stop taking aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and any other medicines that make it hard for your blood to clot.
Ask which medicines to take on the day of your surgery.

On the day of your lap band surgery:

DO NOT eat or drink anything for 6 hours before your surgery.
Take the medicines your doctor told you to take with a small sip of water.

Your doctor will tell you when to arrive at the hospital.

Lap band surgery procedure

You will receive general anesthesia before your lap band surgery. You will be asleep and unable to feel pain.

The lap band surgery is done using a tiny camera that is placed in your belly. This type of surgery is called laparoscopy. The camera is called a laparoscope. It allows your surgeon to see inside your belly. In this surgery:

Your surgeon will make 1 to 5 small surgical cuts in your abdomen. Through these small cuts, the surgeon will place a camera and the instruments needed to perform the surgery.
Your surgeon will place a band around the upper part of your stomach to separate it from the lower part. This creates a small pouch that has a narrow opening that goes into the larger, lower part of your stomach.
The surgery does not involve any cutting or stapling inside your belly.
Your surgery may take only 30 to 60 minutes if your surgeon has done a lot of these procedures.

When you eat after having lap band surgery, the small pouch will fill up quickly. You will feel full after eating just a small amount of food. The food in the small upper pouch will slowly empty into the main part of your stomach.

Lap band surgery recovery

You will probably go home the day of lap band surgery. Many people are able to begin their normal activities 1 or 2 days after going home. Most people take 1 week off from work.

You will stay on liquids or mashed-up foods for 2 or 3 weeks after your lap band surgery. You will slowly add soft foods, then regular foods, to your diet. By 6 weeks after lap band surgery, you will probably be able to eat regular foods.

The band is made of a special rubber (silastic rubber). The inside of the band has an inflatable balloon. This allows the band to be adjusted. You and your doctor can decide to loosen or tighten it in the future so you can eat more or less food.

The band is connected to an access port that is under the skin on your belly. The band can be tightened by placing a needle into the port and filling the balloon (band) with water.

Your surgeon can make the band tighter or looser any time after you have this surgery. It may be tightened or loosened if you are:

Having problems eating
Not losing enough weight
Vomiting after you eat

Lap band surgery recovery at home

You may lose weight quickly over the first 3 to 6 months. During this time, you may have:

Body aches
Feel tired and cold
Dry skin
Mood changes
Hair loss or hair thinning

These problems should go away as your body gets used to your weight loss and your weight becomes stable. Weight loss may be slower after this.

Wound care

Keep your dressings (bandage) on your wounds clean and dry. If you have sutures (stitches) or staples, they will be removed about 7 to 10 days after surgery. Some stitches can dissolve on their own. Your provider will tell if you have this kind.

Change the dressings (bandages) every day if you were told to do so. Be sure to change them more often if they get dirty or wet.

You may have bruising around your wound. This is normal. It will go away on its own. The skin around your incisions may be a little red. This is normal, too.

DO NOT wear tight clothing that rubs against your incisions while they heal.

Unless you are told otherwise, DO NOT shower until after your follow-up appointment with your provider. When you can shower, let water run over your incision, but DO NOT scrub it or let the water beat down on it.

DO NOT soak in a bathtub, swimming pool, or hot tub until your doctor tells you it is OK.

Activity

Being active soon after surgery will help you recover more quickly. During the first week:

Take short walks and going up and down stairs.
Try getting up and moving around if you are having some pain in your belly. It may help the pain.

If it hurts when you do something, stop doing that activity.

If you have laparoscopic surgery, you should be able to do most of your regular activities in 2 to 4 weeks.

Lap band surgery diet

Laparoscopic gastric banding made your stomach smaller by closing off part of your stomach with an adjustable band. After surgery you will eat less food, and you will not be able to eat quickly.

Your health care provider will teach you about foods you can eat and foods you should avoid. It is very important to follow these diet guidelines.

You will eat only liquid or puréed food for 2 to 3 weeks after your lap band surgery. You will slowly add in soft foods, and then regular foods.

A dietitian will advise you on how to change your eating habits to keep healthy while losing weight after lap band surgery.

You’ll need to visit your doctor to have the band adjusted, possibly several times, to the size that works for you for both weight loss and how you feel. You don’t need any anesthesia for the adjustment.

Follow-up care

By the time you leave the hospital, you will likely have a follow-up appointment scheduled with your surgeon within a few weeks. You will see your surgeon several more times in the first year after your surgery.

You may also have appointments with:

A nutritionist or dietitian, who will teach you how to eat correctly with your smaller stomach. You will also learn about what foods and drinks you should have after surgery.
A psychologist, who can help you follow your eating and exercise guidelines and deal with the feelings or concerns you may have after surgery.

The band around your stomach is filled with saline (saltwater). It is connected to a container (access port) that is placed under your skin in your upper belly. Your surgeon can make the band tighter or looser by increasing or decreasing the amount of saline in the band. To do this, your surgeon will insert a needle through your skin into the access port.

Your surgeon can make the band tighter or looser any time after you have this surgery. It may be tightened or loosened if you are:

Not losing enough weight
Having problems eating
Vomiting after you eat

Lap band surgery risks

Lap band surgery is a very safe procedure. Sometimes infection or bleeding occurs at the wound. Very rarely, the ring can slip out of place or damage your stomach.

Risks for anesthesia and any surgery includes:

Allergic reactions to medicines
Breathing problems
Blood clots in the legs that may travel to your lungs
Blood loss
Infection, including in the surgery site, lungs (pneumonia), or bladder or kidney
Heart attack or stroke during or after surgery

Risks for lap band surgery are:

Gastric band erodes through the stomach (if this happens, it must be removed).
Stomach may slip up through the band. (If this happens, you may need urgent surgery.)
Gastritis (inflamed stomach lining), heartburn, or stomach ulcers.
Infection in the port, which may need antibiotics or surgery.
Injury to your stomach, intestines, or other organs during surgery.
Poor nutrition.
Scarring inside your belly, which could lead to a blockage in your bowel.
Your surgeon may not be able to reach the access port to tighten or loosen the band. You would need minor surgery to fix this problem.
The access port may flip upside down, making it impossible to access. You would need minor surgery to fix this problem.
The tubing near the access port can be accidentally punctured during a needle access. If this happens, the band cannot be tightened. You would need minor surgery to fix this problem.
Vomiting from eating more than your stomach pouch can hold.

When to call your doctor

Call your doctor if:

Your temperature is above 101°F (38.3°C).
Your incisions are bleeding, red, warm to the touch, or have a thick, yellow, green, or milky drainage.
You have pain that your pain medicine is not helping.
You have trouble breathing.
You have a cough that does not go away.
You cannot drink or eat.
Your skin or the white part of your eyes turns yellow.
Your stools are loose, or you have diarrhea.
You are vomiting after eating.

Lap band surgery side effects

Most patients experienced at least one side effect after lap band surgery. Common lap band surgery side effects include nausea and vomiting, heartburn, abdominal pain, and slippage of the band. The most serious side effects required either another operation or hospitalization.

Early complications include:

Deep vein thrombosis (DVT): Pulmonary embolism is the leading cause of death following laparoscopic adjusted gastric band surgery in many series ¹¹⁵. These patients should receive appropriate venous thromboembolism prophylaxis.
Esophageal or gastric perforation: The most common location for this is the retrogastric space. It is usually associated with an undiagnosed hiatal hernia. If a perforation occurs and is in close proximity to where the band will be placed, the procedure should be aborted.
Esophagogastric obstruction: This can be an immediate postoperative obstruction caused by a tight gastric band. It is not typically seen due to the larger diameter of later band designs. This can be prevented by removing the perigastric fat pads to allow for adequate room for the gastric band ¹¹⁶.

Late complications include:

Gastric prolapse, or a “slipped band”: This is characterized by the lower stomach herniating superiorly through the device. It can be classified as an anterior or posterior slippage of the fundus past the band; anterior is more common. The patient will experience sudden-onset food intolerance or reflux symptoms. Diagnosis begins with a plain abdominal radiograph. Normally the band is oriented diagonally from 2 to 8 o’clock and points towards the left shoulder. A slipped band will appear oriented more horizontally from a 10 to 4 o’ clock position and will point towards the left hip. Confirmation is generally done with an esophagram. Treatment should be initial deflation of the band to temporarily alleviate the patient’s symptoms. Definitive management includes a reoperation and one of the following techniques: laparoscopic band repositioning, removal with or without replacement of the band, and conversion to another bariatric procedure such as a sleeve gastrectomy or Roux-en-Y gastric bypass ¹¹⁷. Rarely, gastric ischemia and necrosis may ensue. Gastric prolapse had a much higher prevalence in the 1990s secondary to the laparoscopic adjusted gastric band procedure being done with the perigastric technique. This procedure involved a retro-gastric tunnel that entered the lesser sac, resulting in much more freedom and movement of the stomach. This freedom of movement allowed for posterior fundal herniation through the band. With the advent of the pars flaccida technique, the rate of prolapse has decreased from 15% to 4% ¹¹⁸.
Band erosion: Incidence of band erosion into the stomach wall increases with time but remains between 1% and 2% in the literature ¹¹⁹. These are typically manifested by delayed port site infections, abdominal pain, or failure to suppress the appetite despite band adjustment. The diagnosis is confirmed with endoscopy. Treatment involves an operation, removal of the band, repair of the gastric wall, and drainage. Delayed replacement of the gastric band should be done in three months.
Device malfunctions: These can be characterized by a variety of complications including device leak leading to failure of band adjustment, tube kinking, port dislodgment, and port site infection. Leaks can occur via tubing disconnection, port puncture, or band puncture. The port may become dislodged from the fascia and flip, rendering the port inaccessible.
Band obstruction: This can be secondary to an overinflated band, which is most common, or a low placement of the band due to technical errors or a missed hiatal hernia. This will lead to the gastric pouch and esophageal dilation with esophagitis that can result in esophageal dysmotility, such as megaesophagus or pseudo-achalasia, in chronic cases ¹²⁰. Diagnosis is with an esophagram demonstrating esophageal and gastric pouch dilation. Treatment is the deflation of the band and imaging to monitor for the resolution of the gastroesophageal dilatation. If conservative management fails, an operation to revise or remove the band is required ¹²¹.

Lap band surgery results

The final weight loss with gastric banding is not as large as with other weight loss surgery. The average weight loss is about one-third to one-half of the extra weight you are carrying. This may be enough for many people. Talk with your surgeon about which procedure is best for you.

In most cases, the weight will come off more slowly than with other weight loss surgery. You should keep losing weight for up to 3 years.

In the U.S. study, the average weight loss was 36% of a patient’s excess weight three years after the device was implanted. More than half of the patients lost at least 25% of their excess weight; some patients lost over 75%, but some lost no weight ¹²². Many publications demonstrate a low risk of reoperation and band removal, ranging from 1.2% to 3.7%, when evaluating long-term data for laparoscopic adjusted gastric banding ¹²³. These results may be attributed to surgeon experience and advances in techniques that limit complications. However, other studies showed extremely high long-term reoperation rates requiring gastric band removal, ranging from 8% to 60% ¹²⁴.

Losing enough weight after lap band surgery can improve many medical conditions you might also have, such as:

Asthma
Gastroesophageal reflux disease (GERD)
High blood pressure
High cholesterol
Sleep apnea
Type 2 diabetes

Weighing less should also make it much easier for you to move around and do your everyday activities.

This surgery alone is not a solution to losing weight. It can train you to eat less, but you still have to do much of the work. To lose weight and avoid complications from the procedure, you will need to follow the exercise and eating guidelines that your provider and dietitian gave you.

Biliopancreatic diversion with duodenal switch

Biliopancreatic diversion with duodenal switch begins with creation of a tube-shaped stomach pouch (shaped like a banana) similar to the sleeve gastrectomy. The tube-shaped stomach pouch makes patients eat less food. Following creation of the sleeve-like stomach, the first portion of the small intestine is separated from the stomach. A part of the small intestine is then brought up and connected to the outlet of the newly created stomach, so that when you eat, the food goes through the sleeve pouch and into the latter part of the small intestine. The food stream bypasses roughly 75% of the small intestine. Biliopancreatic diversion with duodenal switch resembles the gastric bypass, where more of the small intestine is not used. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after biliopancreatic diversion with duodenal switch surgery. Even more than gastric bypass and sleeve gastrectomy, the biliopancreatic diversion with duodenal switch affects intestinal hormones in a manner that reduces hunger, increases fullness and improves blood sugar control. Biliopancreatic diversion with duodenal switch can cause a lot of weight loss. It can cause more weight loss than a gastric bypass or a sleeve gastrectomy. The biliopancreatic diversion with duodenal switch is considered to be the most effective approved weight loss surgery for the treatment of type 2 diabetes in patients with obesity ¹⁵.

Biliopancreatic diversion with duodenal switch is mostly done as a keyhole procedure (laparoscopic procedure), in which there are a number of small cuts in your abdomen, under general anesthesia. Through these small cuts, the surgeon can insert thin tools and a small scope attached to a camera that projects images onto a video monitor. Laparoscopic surgery has fewer risks than open surgery and may cause less pain and scarring. Recovery may also be faster with laparoscopic biliopancreatic diversion with duodenal switch. But sometimes, open surgery with larger cuts is needed. Open biliopancreatic diversion with duodenal switch involves a single large cut in your abdomen may be a better option than laparoscopic biliopancreatic diversion with duodenal switch for certain people. You may need open surgery if you have a high level of obesity, had stomach surgery before, or have other complex medical problems.

Biliopancreatic diversion with duodenal switch is done in the hospital. The length of your hospital stay will depend on your recovery and which procedure you’re having done. When performed laparoscopically, your hospital stay may last around two days.

After a biliopancreatic diversion with duodenal switch, it may be possible to lose 70 to 80 percent of your excess weight within two years. However, the amount of weight you lose also depends on your change in lifestyle habits.

In addition to weight loss, a biliopancreatic diversion with duodenal switch may improve or resolve conditions often related to being overweight, including:

Gastroesophageal reflux disease (GERD)
Heart disease
High blood pressure
High cholesterol
Obstructive sleep apnea
Type 2 diabetes
Stroke
Infertility

A biliopancreatic diversion with duodenal switch can also improve your ability to perform routine daily activities, which could help improve your quality of life.

The advantages of the biliopancreatic diversion with duodenal switch procedure are ³:
- among the best results for improving obesity. Topart P. et al. ¹²⁵ and Sethi et al. ¹²⁶ reported excellent weight loss results after a follow-up of 2, 5 and 10 years.
- affects bowel hormones to cause less hunger and more fullness after eating;
- it is the most effective procedure for treatment of type 2 diabetes with obesity ¹⁹, ¹⁵
The disadvantages of the biliopancreatic diversion with duodenal switch procedure are ³, ¹²⁵, ¹²⁶:
- has slightly higher complication rates than other procedures;
- highest malabsorption and greater possibility of vitamins and micro-nutrient deficiencies;
- reflux and heart burn can develop or get worse;
- risk of looser and more frequent bowel movements;
- more complex surgery requiring more operative time.

While a biliopancreatic diversion with duodenal switch is very effective for weight loss and the reversal of obesity-related comorbidities, it has more risks, including protein malnutrition, vitamin deficiencies and it’s more technically complex to perform with the operation being time consuming ¹²⁷, ¹²⁸, ¹²⁹, ¹³⁰, ¹³¹, ¹³², ¹³³. Biliopancreatic diversion with duodenal switch procedure is the least-common weight-loss procedure performed in the United States ¹⁷, ¹⁸, ¹⁶. The most common types of weight loss surgery in United States are gastric sleeve surgery (sleeve gastrectomy) around 53.8%, followed by gastric bypass (Roux-en-Y gastric bypass) 23.1%; laparoscopic adjustable gastric banding (gastric banding) 5.7% with biliopancreatic diversion with or without duodenal switch at 0.6% ¹⁷, ¹⁸, ¹⁶.

You may be a good candidate for biliopancreatic diversion with duodenal switch if you are an adult who has extreme obesity (Body Mass Index (BMI) > 40 kg/m²) or super obesity (Body Mass Index (BMI) > 50 kg/m²) and you have not been able to lose your excess weight, or you keep gaining back weight you have lost using non-surgical methods such as diet and exercise or medications ²², ¹³⁴, ¹³⁵, ¹³⁶, ¹³⁷.

Biliopancreatic diversion with duodenal switch may also be offered to people who are obese (BMI over 35 kg/m²) and who have other serious health problems like type 2 diabetes, high blood pressure or severe obstructive sleep apnea. It has also been shown that the biliopancreatic bypass with duodenal switch has a better effect on type 2 diabetes and reduction of hyperlipidemia then other weight loss procedures ¹³⁸. The caveat is that this procedure requires an adequate follow-up program because there is an increased risk of nutritional deficiencies compared with the other weight loss procedures.

In general, biliopancreatic diversion with duodenal switch could be an option for you if ³⁷, ³⁸, ³⁹, ⁴⁰:

Your body mass index (BMI) is 40 kg/m² or higher (extreme obesity). Biliopancreatic diversion with duodenal switch is recommended for super obese people with a body mass index (BMI) greater than 50 kg/m² ¹³⁴, ¹³⁵, ¹³⁶, ¹³⁷
Your BMI is 35 to 39.9 kg/m² (obesity), and you have a serious weight-related health problem, such as type 2 diabetes, high blood pressure, heart disease, severe obstructive sleep apnea, stroke, high cholesterol, lung disease, nonalcoholic fatty liver disease (NAFLD), asthma or some other breathing problems.
Patients who fail operative treatment with Roux en-Y gastric bypass surgery and gastric sleeve surgery, biliopancreatic diversion with a duodenal switch should be considered ¹³⁷, ¹³⁹

A biliopancreatic diversion with duodenal switch is typically done only after you’ve tried to lose weight by non-surgical alternatives such as improving your diet and exercise habits. The first step is usually to try changes to what you eat and drink, and what daily activity and exercise you do. There are some medicines that can help people lose weight. Surgery is usually thought about only after these other options have been tried.

But a biliopancreatic diversion with duodenal switch isn’t for everyone who is severely overweight. You likely will have an extensive screening process to see if you qualify.

You must also be willing to make permanent changes to lead a healthier lifestyle both before and after surgery. You may be required to participate in long-term follow-up plans that include monitoring your nutrition, your lifestyle and behavior, and your medical conditions.

Before your biliopancreatic diversion with or without duodenal switch procedure, you will meet with several health care professionals, such as an internist, a dietitian, a psychiatrist or psychologist, and a bariatric surgeon.

The internist will ask about your medical history, perform a thorough physical exam, and order blood tests. If you smoke, you may benefit from stopping smoking at least 6 weeks before your surgery.
- Preoperative nutritional assessment recommendations ⁷⁰, ⁷¹:
  - All people should have a comprehensive nutritional assessment prior to weight loss surgery
  - Check full blood count including hemoglobin, ferritin, folate and vitamin B12 levels
  - Check serum 25‐hydroxyvitamin D levels
  - Check serum calcium levels
  - Check serum/plasma parathyroid hormone (PTH) levels
  - Seek advice from a specialist with expertise in primary hyperparathyroidism if primary hyperparathyroidism is suspected
  - Consider checking serum vitamin A levels in individuals going forward for malabsorptive procedures such as biliopancreatic diversion with duodenal switch or where vitamin A deficiency may be suspected
  - Consider checking serum zinc, copper and selenium levels in individuals going forward for malabsorptive procedures such as biliopancreatic diversion with duodenal switch or if a deficiency is suspected
  - Routinely screen HbA1c, lipid profile, liver and kidney function tests and treat as necessary
  - Treat and correct nutritional deficiencies preoperatively as individuals have an increased risk of deficiencies postoperatively
The dietitian will explain what and how much you will be able to eat and drink after surgery and help you prepare for how your life will change after surgery.
The psychiatrist or psychologist may assess you to see if you are ready to manage the challenges of weight-loss surgery.
The surgeon will tell you more about the surgery, including how to prepare for it and what type of follow-up you will need.

Losing weight and bringing your blood glucose, also known as blood sugar, levels closer to normal before surgery may lower your chances of having surgery-related problems.

Some weight-loss surgery programs have groups you can attend before and after surgery to help answer questions about the surgery and offer support.

Lastly, check with your health insurance plan or your regional Medicare or Medicaid office to find out if your policy covers weight-loss surgery.

Figure 14. Biliopancreatic diversion with duodenal switch

[Source ³⁵ ]

Biliopancreatic diversion with duodenal switch contraindications

The contraindications for biliopancreatic diversion with a duodenal switch are similar to other weight loss procedures ¹⁴⁰.

Absolute contraindications for weight loss surgery:

Pregnancy
Severe psychiatric illness
Eating disorders
Patient-related contraindications to undergo surgery (cardiovascular risk, anesthetic risk)
Substance misuse (alcoholism)
Severe coagulopathies (blood clotting or bleeding disorders)

Biliopancreatic diversion with duodenal switch procedure

You will need to go through an in-depth process to be approved for biliopancreatic diversion with duodenal switch procedure. This is done to find out if you are ready for the surgery, and if it will help you. And you will need to find out if your health insurance plan will cover the costs of the biliopancreatic diversion with duodenal switch procedure. You’ll need to meet with healthcare providers such as a surgeon, a special bariatric nurse, and a dietitian with experience in biliopancreatic diversion with duodenal switch.

Talk with your healthcare team how to prepare for your surgery. Tell your healthcare providers about all the medicines you take. This includes over-the-counter medicines, vitamins, herbs, and other supplements. You may need to stop taking some medicines before the biliopancreatic diversion with duodenal switch procedure, such as blood thinners and aspirin.

How you prepare

If you qualify for a biliopancreatic diversion with duodenal switch, your health care team gives you instructions on how to prepare for surgery.

You may need to have various lab tests and exams before surgery, such as:

Blood tests, to check your overall health
Chest X-ray to check your lungs
Electrocardiogram (ECG) to check your heart rhythm

You will generally also be told to:

Stop smoking.
Lose weight by following a special diet.
Get counseling to discuss emotional health and disordered eating habits.
Read educational material that will be given to you or attend classes about the procedure, expected results, and possible complications.

Tell your health care team if you:

Have had any recent changes in your health, such as an infection or fever
Are sensitive or allergic to any medicines, latex, tape, or anesthetic medicines (local and general)
Have a history of bleeding disorders
Are taking any blood-thinning (anticoagulant) medicines, including aspirin, ibuprofen, or other medicines that affect blood clotting
Are pregnant or think you may be pregnant
Use a CPAP or BiPAP machine for sleep apnea or another breathing disorder

Also:

Ask a family member or friend to take you home from the hospital. You can’t drive yourself.
Follow any directions you are given for not eating or drinking before surgery.
Follow all other instructions from your healthcare provider.
Ask which medicines you should stop taking before surgery and for how long, and which medicines should be taken the day of surgery.
Bring your CPAP or BiPAP machine to the hospital on the day of your surgery.

You will be asked to sign a consent form that gives your doctor permission to do the procedure. Read the form carefully. Ask questions if something is not clear.

Food and medications

Before your surgery, give your surgeon and any other health care providers a list of all medicines, vitamins, minerals, and herbal or dietary supplements you take. You may have restrictions on eating and drinking and which medications you can take.

If you have diabetes, talk with the doctor who manages your insulin or other diabetes medications for specific instructions on taking or adjusting them after surgery.

Patients are typically placed on a low carbohydrate diet before biliopancreatic diversion with duodenal switch surgery to shrink the liver as much a possible before surgery. Studies have shown that preoperative weight loss may lead to some improvements in postoperative outcomes and possibly decrease complications. Patients who can lose weight before surgery have been shown to have total weight loss following the surgery ¹⁴¹.

Other precautions

You may be required to start a physical activity program and to stop any tobacco use.

You may also need to prepare by planning ahead for your recovery after surgery. For instance, arrange for help at home if you think you’ll need it.

Before biliopancreatic diversion with duodenal switch procedure

Before you go to the operating room, you will change into a gown and will be asked several questions by both doctors and nurses. In the operating room, you are given general anesthesia before your surgery begins. Anesthesia is medicine that keeps you asleep and comfortable during surgery.

During biliopancreatic diversion with duodenal switch procedure

The specifics of your surgery depend on your individual situation and your doctor’s practices. Some surgeries are done with traditional large, or open, incisions in your abdomen, while some may be performed laparoscopically, which involves inserting instruments through multiple small incisions in your abdomen.

The first step of a biliopancreatic diversion with duodenal switch. The first step in a biliopancreatic diversion with duodenal switch involves removing a portion (about 80 percent) of your stomach. After making the incisions with the open or laparoscopic technique, your surgeon removes a large portion of your stomach and forms the remaining portion with staples into a narrow sleeve shaped like a banana similar to the sleeve gastrectomy. Your surgeon leaves intact the valve that releases food to the small intestine (the pyloric valve or pyloric sphincter), along with a limited portion of the small intestine that normally connects to the stomach (duodenum). This small stomach restricts the amount of food you can eat at one time.
The second step of a biliopancreatic diversion with duodenal switch. During the second step, your surgeon makes one cut through the first part of the small intestine just below the duodenum and a second cut farther down, near the lower end of the small intestine (the ileum). Then your surgeon brings a very short length of the last part of the small intestine (the ileum) is brought up and attached to the duodenum. This is the duodenal switch. The effect is to bypass a large segment of the small intestine.
Biliopancreatic diversion with duodenal switch is generally performed as a single procedure; however, in select circumstances, the procedure may be performed as two separate operations — sleeve gastrectomy followed by intestinal bypass once weight loss has begun.

Each part of the surgery usually takes a few hours. After surgery, you awaken in a recovery room, where medical staff monitors you for any complications.

When you eat, the food then only goes through the new stomach pouch. It empties into the last part of the small intestine (the ileum). This goes around (bypasses) a large section of the small intestine (a small segment of the duodenum and the jejunum), so that less of the food is digested. You absorb fewer calories and nutrients. This can cause a lot of weight loss. The part of the small intestine (a small segment of the duodenum and the jejunum) that has been separated is reconnected to the last part of the small intestine (the ileum). This changes the normal way that bile and digestive juices break down food. This is the biliopancreatic diversion. This cuts back on how many calories you absorb, causing still more weight loss.

After biliopancreatic diversion with duodenal switch procedure

You will wake up in a recovery room. You will be given medicine to control pain. You will then be moved to a hospital room. You will be asked to get out of bed to move around within the next day. This helps prevent blood clots in your legs. You will have liquid nutrition. Your healthcare team will tell you when you’re ready to go home.

At first, you may have stomach or bowel cramping, or nausea. Tell your healthcare team if pain or nausea is severe or doesn’t improve with time. Take pain medicines as prescribed. Your healthcare team will tell you when it’s OK to shower, drive, return to work, exercise, and lift objects.

Call your surgeon or healthcare team if you have any of the following:

A fever of 100.4°F (38°C) or higher, or as directed by your healthcare provider
A red, bleeding, or draining incision
Frequent or persistent nausea or vomiting
Increased pain at an incision
Pain or swelling in your legs
Trouble breathing or chest pain

You will get instructions about how to adapt to your new diet after your surgery. You will likely be on liquid nutrition for a few weeks after surgery. Over time, you’ll start to eat soft foods and then solid foods. If you eat too much or too fast, you will likely have stomach pain or vomiting. You’ll learn how to know when your new stomach is full.

Your healthcare provider or nutritionist will give you more instructions about your diet. You’ll need to learn good habits like choosing healthy foods and not skipping meals. Your healthcare provider or nutritionist will also need to screen you for low levels of vitamins and nutrients.

Immediately after a biliopancreatic diversion with duodenal switch procedure, you may have liquids but no solid food as your stomach and intestines begin to heal. You’ll then follow a special diet plan that changes slowly from liquids to pureed foods. After that, you can eat soft foods, then move on to firmer foods as your body is able to tolerate them.

Your diet after surgery may continue to be quite restricted, with specified limits on how much and what you can eat and drink. Your doctor will recommend that you take vitamin and mineral supplements after surgery, including a multivitamin, calcium and vitamin B12. These are vital to prevent micronutrient deficiency.

You will need to take daily supplements after biliopancreatic diversion with duodenal switch surgery. These include:

Vitamins A, D, and K
Multivitamin
Iron supplements
Calcium supplements
Vitamin B-12 supplements or injections

Work with your healthcare team after surgery to stay healthy. Make sure to:

Follow the nutrition plan set up by your dietitian.
Get regular physical activity. Start slowly and build up to more activity.
Talk with a counselor or weight-loss surgery support group to help you adjust.

You’ll also have frequent medical checkups to monitor your health in the first several months after weight-loss surgery. You may need laboratory testing, bloodwork and various exams.

You may experience changes as your body reacts to the rapid weight loss in the first three to six months after a biliopancreatic diversion with duodenal switch, including:

Body aches
Feeling tired, as if you have the flu
Feeling cold
Dry skin
Hair thinning and hair loss
Mood changes

Biliopancreatic diversion with duodenal switch complications

As with any major surgery, a biliopancreatic diversion with duodenal switch poses potential health risks, both in the short term and long term.

Risks associated with biliopancreatic diversion with duodenal switch are similar to any abdominal surgery and can include:

Bleeding, which may require transfusions and additional procedures including more surgery
Infection, such as pneumonia, intra-abdominal abscesses, or Clostridium difficile colitis, which can lead to septic shock
Adverse reactions to anesthesia
Allergic reactions to medicines
Blood clots in your legs (deep vein thrombosis or DVT) that may travel to your lungs (pulmonary embolism)
Lung or breathing problems
Leaks from the site where the sections of the stomach, small intestine, or both are stapled or sewn together (anastomotic leak)
Injury to your stomach, intestines, or other organs during surgery
Injury to the spleen that may lead to removal of the spleen, which can lead to long term problems with immunity
Heart attack
Rhythm problems with the heart (arrhythmias)
Stroke
Short-term (temporary) hair loss
Stomach cramping and diarrhea after eating fat

Rarely, complications of a biliopancreatic diversion with duodenal switch can lead to death. In a recent meta-analysis of 361 studies including 85 048 patients overall rate of death within 30 days of weight loss surgery was found to be 0.28% ¹³². Biliopancreatic diversion with duodenal switch had the highest early mortality with a rate of 0.29% to 1.23% for open and 0.0% to 2.7% for laparoscopic procedures ¹³². Postoperative mortality is most commonly associated with pulmonary embolism, respiratory failure, and anastomotic leaks. It is important to acknowledge that biliopancreatic diversion with duodenal switch is the procedure of choice for the most extremely obese patients; therefore it can be assumed that surgical risk in this group is higher at baseline ¹⁴². This was demonstrated in the Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, a prospective multicenter observational study, which included 4776 patients analyzing 30-day outcomes after bariatric surgery. It showed that extreme values of BMI were significantly associated with increased risk of major adverse outcomes (death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and length of stay greater than 30 days) ¹⁴³.

One-year complication rates as reported in the US Bariatric Outcomes Longitudinal Database are 4.6% after laparoscopic adjustable gastric banding, 10.8% after laparoscopic sleeve gastrectomy, 14.9% after Roux-en-Y gastric bypass and 25.7% after biliopancreatic diversion with duodenal switch ¹⁴⁴. This includes minor complications such as gastrointestinal side effects including flatulence, malodorous stools, and fatty stools (steatorrhea). Of major complications, gastrointestinal anastomotic leak is the most common, serious, early surgical complication. Hamoui et al. ¹⁴⁵ reviewed 701 biliopancreatic diversion with duodenal switch cases performed over a ten-year period and reported that 5% of patients developed complications necessitating revisional surgery. Protein malnutrition was the most common indication for reoperation. A postoperative complication rate of 15% was then seen in their revisional surgery group, with wound infections being the most common complication in this group ¹⁴⁵. Biertho et al. ¹³¹ analyzed a series of 1000 biliopancreatic diversion with duodenal switch patients, in which major complications occurred in 7% of patients. They showed no difference in complication rate when comparing laparoscopic to open biliopancreatic diversion with duodenal switch. Rehospitalization was required in 12.7% of patients and reoperations occurred in 6% of patients ¹³¹.

In a randomized trial of 60 patients, Sovik et al. ¹⁴⁶ compared mean operating time, median length of stay, and complication rates between Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. On average Roux-en-Y gastric bypass required 91 minutes operating time compared to 206 minutes operating time for biliopancreatic diversion with duodenal switch. Median length of stay was 2 days post-RYGB and 4 days post-biliopancreatic diversion with duodenal switch. Perioperative complication rates were comparable between groups; however this study was likely underpowered and larger studies are necessary to truly draw conclusions ¹⁴⁶. It can not be understated that a greater volume of less complex bariatric procedures could be performed in the time that it takes to complete biliopancreatic diversion with duodenal switch. With the overwhelming burden of obesity and need for weight loss surgical procedures mindful resource allocation is crucial. A staged procedure with biliopancreatic diversion with duodenal switch following laparoscopic sleeve gastrectomy for select patients may allow for better utilization of resources in those patients who would benefit most from this complex surgery ¹⁴².

Longer term risks and complications of a biliopancreatic diversion with duodenal switch may include:

Blockages in the intestines, known as bowel obstruction (scarring inside your belly that could lead to a blockage in your bowel in the future)
Dumping syndrome, causing diarrhea, nausea or vomiting and cramping
Gallstones
Dehydration if you don’t drink enough fluids
Kidney failure
Hernia at an incision site or inside the abdomen
Low blood sugar (hypoglycemia)
Not enough protein (protein malnutrition)
Biliopancreatic diversion with duodenal switch makes it hard for the body to absorb vitamins and minerals. People who have biliopancreatic diversion with duodenal switch may have vitamin and iron deficiency (shortage):
- Low levels of calcium and iron
- Low levels of fat-soluble vitamins such as A, D, E, and K
- Low level of thiamine (vitamin B1). This is rare but can damage the nervous system.
- These can lead to serious, long-term problems such as:
  - Not enough red blood cells (anemia)
  - Thinning bones (osteoporosis)
  - Kidney stones
  - Severe life-threatening protein malnutrition called Kwashiorkor (rare)
Gastritis (inflamed stomach lining), heartburn, or stomach ulcers
Stomach perforation
Ulcers
Ongoing vomiting from eating more than your stomach pouch can hold
Depressed mood or other emotional issues
Risk of acid reflux, esophagitis and hiatal hernia (caused by the stomach pushing up against the diaphragm)
Need for more surgery to fix problems.

You may also have problems such as:

Failure to meet your weight loss goals
Weight regain
Loose folds of skin that may need surgery to remove

You will need to take vitamin and mineral supplements for life. You will also need to have blood tests regularly. This is to prevent severe malnutrition and related problems. Even if you take supplements, you still may have nutrition problems and need treatment.

Biliopancreatic diversion with duodenal switch will change your eating habits for the rest of your life. Make sure you fully understand the risks and benefits for you. Your own risks and benefits may vary according to your age and your general health. Talk with your surgeon to find out what risks may apply to you.

Anastomotic leak

The incidence of a gastric or duodenal leak following biliopancreatic diversion with duodenal switch is 1.14% vs. 1.12% for Roux en-Y gastric bypass ¹⁴⁷. The leak site appears to be more common at the duodenoduodenal anastomosis ¹⁴⁸. The risk of leakage from the longitudinal gastric staple line is minimal compared to the leak rate from the gastric staple line in the gastric bypass procedure. These patients may be asymptomatic, but they frequently present with rapid heart rate (tachycardia), which is usually the first sign. They can also have rapid breathing (tachypnea) and be febrile. The diagnostic test of choice for an anastomotic leak should be a CT scan with oral and IV contrast, high sensitivity, and specificity. An upper GI series can also be used, but it has a low sensitivity. If the leak is acute (<5 days), patients should return to the operating room for exploration with repair and placement of a distal feeding tube ¹⁴⁹.

Bleeding

The reported incidence for a postoperative hemorrhage is less than 1% of all gastric bypass surgeries experience bleeding, which requires intervention or transfusion. This can present as intraluminal and extraluminal bleeding. This has likely improved due to improved staple technology. Hemorrhage is more commonly seen with laparoscopic gastric bypass over open procedures ¹⁵⁰. Postoperative hemorrhage is treated at the surgeon’s discretion, depending on the patient’s clinical picture ¹⁵¹. For intraluminal bleeding, endoscopic treatment may be necessary but is not very common ¹⁵¹. Patients who have extraluminal bleeding who are hemodynamically unstable and unresponsive to resuscitation will need to return to the operating room for exploration and repair ¹⁵¹.

Nutritional deficiencies

Biliopancreatic diversion with duodenal switch is the weight loss procedure associated with the greatest perioperative malnutrition and metabolic-related complications ¹⁵¹. All patients need to begin supplementation postoperatively ; however there is no standardized approach to replacement and sometimes deficiencies are refractory to dietary supplements ¹⁴². Following biliopancreatic diversion with duodenal switch patients can consume normal nutritional meals and continue to be malnourished ¹⁵². Common nutritional deficiencies that can be seen are iron deficiency anemia, protein-calorie malnutrition, low blood calcium (hypocalcemia), deficiency of the fat-soluble vitamins (vitamins A, D, E and K), vitamin B1 (thiamin), vitamin B12, and folate ¹⁵². Biliopancreatic diversion with duodenal switch has proven to be more malabsorptive compared to other weight loss surgeries; thus close follow-up and laboratory studies are essential for these patients. If a nutritional deficiency is detected, dietary supplementation is extremely important ¹⁴². Supplementation is of paramount importance; unfortunately in this patient population compliance is lacking ¹⁵³.

As an example, the supplements implemented by Marceau et al. ¹⁵⁴ in their uncontrolled case series with fifteen-year follow-up was as follows:

Iron 300 mg,
Calcium 500 mg,
Vitamin D 50 000 IU,
Vitamin A 20 000 IU,
1 multivitamin tablet, and
yogurt probiotics.

Adjustments were made as appropriate; consequently severe anemia and vitamin deficiencies were uncommon ¹⁵⁴.

Aasheim et al. ¹⁵⁵ randomized 60 super-obese patients to receive either Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch comparing 25-hydroxyvitamin D, vitamin A, and vitamin B1 up to 1 year postoperatively. Biliopancreatic diversion with duodenal switch patients had lower mean 25-hydroxyvitamin D and vitamin A concentrations, as well as a steeper decline in vitamin B1 compared to Roux-en-Y gastric bypass ¹⁵⁵. Decreased vitamin D and calcium levels with associated secondary hyperparathyroidism have been demonstrated ¹⁵⁶, ¹⁵⁷, ¹⁵⁸. Marceau et al. ¹⁵⁴, after prospectively analyzing 33 patients utilizing iliac crest bone biopsy, bone mineral density, and biochemical investigations, proclaimed that despite serum abnormalities in vitamin D, calcium, and PTH overall bone mineral density and fracture risk were unchanged 10 years after biliopancreatic diversion with duodenal switch. A population-based retrospective cohort study out of the United Kingdom confirmed these results, concluding that bariatric surgery (60% gastric band, 29% Roux-en-Y gastric bypass, 11% other—biliopancreatic diversion with duodenal switch was not separated) did not significantly effect fracture risk with a mean follow-up of 2.2 years ¹⁵⁹. Additionally, facture risk was independent of the specific surgical technique. Longer-term studies are necessary to ensure that results are enduring ¹⁵⁹. Clinically there have been case reports of biliopancreatic diversion with duodenal switch-related vitamin A deficiency and associated night-blindness ¹⁶⁰, ¹⁶¹, post-biliopancreatic diversion with duodenal switch peripheral neuropathies associated with B12 deficiencies ¹⁶⁰ and Wernicke’s encephalopathy as a result of vitamin B1 deficiencies ¹⁶², ¹⁶³.

Biliopancreatic diversion with duodenal switch diet

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