Weight Loss Surgery (Bariatric Surgery)

About Bariatric Surgery

Bariatric surgery had its beginnings in the 1960s, when doctors first noticed that people who had portions of their stomach or intestines removed due to ulcers or cancer tended to lose a lot of weight after surgery, regardless of what they ate.

Doctors soon realized why: Not only could a smaller stomach hold less food at one time, but a shorter intestine couldn't absorb as many calories and nutrients for the body to use.

The field of weight loss surgery has come a long way since then, but is still based on those same two principles:

1. Restriction: restricting the amount of food a person can comfortably eat by reducing the size of the stomach
   
2. Diversion: diverting food around a portion of the small intestine (usually about 2 feet) so that less is absorbed by the body. Diversion also changes the levels of hormones and enzymes in the digestive tract that signal hunger and fullness, so a person feels fuller sooner.

Gastric Bypass vs. Gastric Banding

Today, there are two main surgical techniques for weight loss: gastric bypass and gastric banding.

Gastric bypass (also called "Roux-en-Y" gastric bypass) is more common, accounting for 80% off all weight loss surgeries. It involves creating a small pouch, about the size of an egg, at the top of the stomach using surgical staples or a plastic band. This pouch, which will serve as the "new" stomach, is then connected directly to the middle part of the small intestine (the jejunum).

So not only will the pouch hold a lot less food — just 1 cup as opposed to the 8 cups or more that a normal-sized stomach can hold after stretching to accommodate a really big meal — the food will also bypass the larger part of the stomach and the upper part of the small intestine (the duodenum).

The pros of gastric bypass are that it has a high rate of success and a longer track record than gastric banding.

The cons are that even though it can often be done laparoscopically (using a few small incisions and a camera to guide the doctor's movements instead of opening up the abdomen), it still involves cutting the intestine — which makes it a more complex procedure than banding, and associates it with more complications and a longer recovery time. The lack of intestinal absorption also tends to cause vitamin deficiencies and, unlike gastric banding, the procedure is not reversible.

Gastric banding also works by decreasing the amount of food that can be comfortably eaten. It does this with the help of an adjustable silicone device (called the Lap-Band) placed at the very top of the stomach to create a small pouch. Like bypass, this band reduces the size of the stomach and makes people feel fuller sooner. Unlike bypass, though, banding does not interfere with food absorption in the small intestine.

The pros of gastric banding, which is done laparoscopically, are that it has a lower complication rate than the more invasive gastric bypass, and vitamin deficiencies are rare because the intestine is not affected.

The band can be tightened or loosened to increase or decrease weight loss. Doctors adjust the band at periodic visits by inflating or deflating it through a port placed under the skin. The band may even be removed entirely if necessary, allowing the stomach to return to its normal size.

The cons are that it may not initially take off as much weight as surgical bypass — which can help people lose 60%-70% of their excess body weight — and it may require replacement surgery at a later date. The Lap-Band is not an approved device for people younger than 18, though clinical trials are under way.

Who Is a Candidate?

Figuring out if a teen is a candidate for weight loss surgery is a big decision that requires a team approach, including the teen, his or her family, doctors, nutritionists, and psychologists.

Generally, a teen candidate's body mass index (BMI) — the number calculated from a person's height and weight that measures body fat — should be 40 or higher, which constitutes severe obesity.

A teen with a slightly lower BMI (35 or higher) also may be a candidate for surgery if suffering from potentially life-threatening medical complications, like diabetes or heart disease. He or she must also be physically mature, which generally means at least 13 for girls or 15 for boys (though the average age of the surgery is 16).

The team will consider other things, too: Is the teen healthy enough for surgery? Have other weight loss options failed? Does he or she understand what's involved? Weight loss surgery is serious stuff — both physically and emotionally.

In fact, having the operation is only one step in losing weight. Teens need to cultivate a new relationship with food by eating very small amounts, chewing thoroughly, and evenly spacing out food consumption throughout the day. For many, adjusting to this whole new way of eating and living — in a "new" body — can be overwhelming.

That's why doctors tend to take a conservative approach when it comes to weight loss surgery for teens, and only recommend it for those who have what it takes to make it a success: the motivation to make lifelong changes and the support of their family to help them do so.

Risks and Side Effects

Weight loss surgery, like any surgery, does come with risks. Uncommon but serious risks include:

• bleeding
• reaction to anesthesia
• infection at the incision site
• a leaky stomach or intestine that can lead to peritonitis, an infection of the abdominal cavity
• a blood clot in the lung
• bowel obstruction

Other side effects are more common and not quite as serious, but still unpleasant nonetheless. For example, many people who've had weight loss surgery experience pain, vomiting, diarrhea, and acid reflux after eating — especially if they eat too much or too quickly. This is why they have to change their approach to mealtime. If they don't, not only will they continue to feel sick, but in time they can regain weight.

"Dumping syndrome" is a common problem associated mainly with gastric bypass. This is when food moves too quickly through the stomach and intestines, causing nausea, weakness, sweating, abdominal cramping, and diarrhea. Because dumping can be made worse by eating high-sugar or high-fat foods, teens need be especially careful about the types of food they eat as their bodies get used to a different mode of digestion. This can be especially difficult for teens, since fast food and sugary snacks can seem like their own food group at this age, and the pressure to fit in can make it harder to make good nutritional choices.

And last but not least, there are the emotional side effects. For example, it can be hard for some teens to figure out a new, healthy relationship with food, especially if they and others in their family have relied on food for comfort in the past.

Some teens also undergo an identity crisis of sorts and have trouble relating to others in their new, thinner body. Still others have such high expectations — thinking that the surgery will boost their popularity or bring them more attention — that they're disappointed to find that old problems still exist even at a smaller size.

To be sure, weight loss surgery is not a quick fix and is not considered an "easy way out." There's a lot of hard work involved. But for teens whose health is compromised by obesity and who are willing to make the commitment to a new way of life, the effort may well be worth it.

Reviewed by: Mary L. Gavin, MD
Date reviewed: January 2011
Originally reviewed by: George A. Datto III, MD