Major Weight Loss Surgery: The Comprehensive Guide for 2024
For numerous individuals striving to shed a considerable amount of weight, diet and exercise alone might not suffice. If you encounter serious medical issues and have exhausted all other weight loss alternatives, a major surgical intervention could be the answer.
What constitutes a weight loss surgery as major? According to Dr. Elizabeth Godshall, a bariatric surgeon with practices across New York, these operations are all carried out in a hospital, under general anesthesia, and entail a physical alteration to a patient's stomach and/or intestinal tract. While they are typically more efficacious than non-major weight loss surgeries, they also come with a set of risks – but we'll delve into those later.
Currently, there are four accessible options for major weight loss surgery, all of which are laparoscopic or performed through several small incisions: sleeve gastrectomy, gastric bypass surgery, lap band, and duodenal switch.
"The sleeve gastrectomy is the most frequently conducted major weight loss surgery," remarks Dr. Godshall. "It involves dividing the stomach to create a long, slender tube with a shape resembling a banana. This not only reduces portion sizes due to a decrease in stomach size but also curbs hunger between meals because of a decline in the hunger hormone ghrelin." Gastric bypass is a procedure that shrinks stomach size and bypasses a portion of the intestinal tract. "This enables both smaller portions and a change in absorption capacity," she states.
Lap band surgery involves strapping a prosthetic band around the upper part of the stomach to limit portion sizes. "The gastric band is later adjusted in the office via a port beneath the skin of the abdominal wall," says Dr. Godshall. "These adjustments permit customization of the degree of restriction to each patient's needs." Finally, the duodenal switch is a procedure that combines a sleeve gastrectomy and an intestinal bypass. "This procedure is particularly beneficial for patients with a higher BMI," she asserts.
Each of these surgeries enables patients to achieve substantial and sustainable weight loss over time. For instance, sleeve gastrectomy can assist patients in losing 60–70% of their excess weight. But as previously mentioned, they also carry rather significant risks. "Specific to bariatric surgery, a leak or bleed from the cut edges or connection points created during the operation is a primary concern," she says. "There is also a risk of complications following the procedure that patients would encounter after any other surgical procedure, including infection or an anesthesia reaction."
While the risks of bleeding, infection, and even death are very real, Dr. Joseph Naim, a bariatric surgeon in Culver City, California, emphasizes that the probabilities of encountering these issues are relatively low. Nevertheless, due to these risks, surgeons demand a rather extensive evaluation for patients prior to surgery to ensure the procedure is conducted as safely as feasible.
Although all available options differ in terms of the procedure, the general checklist of all requirements before obtaining approval and how to prepare for bariatric surgery generally remains the same. Before even considering any of them, you'll need to initially fall within the appropriate BMI range.
As Dr. Godshall elaborates, all patients must meet the National Institute of Health's body mass index (BMI) criteria to be eligible for surgery. (It's also worth noting that your current BMI might play a role in determining the type of pre-op diet for bariatric surgery your doctor prescribes.) "For patients with a BMI ranging from 35 to 40, the presence of a comorbid condition is necessary," she says. "A patient must have a diagnosis of diabetes, hypertension, sleep apnea, or heart disease. While there are other conditions associated with weight, these are the only four that insurance companies will consider for approval."
However, if your BMI exceeds 40, no comorbid condition is requisite, she explains. Additionally, patients with a BMI above 32 and one of the four comorbid conditions might be approved for lap band surgery, but it will hinge on the patient's insurance provider.
There are numerous tests and evaluations between your initial consultation and actual approval and scheduling for surgery; patients are expected to complete a comprehensive evaluation before surgery to optimally prepare them and identify any additional risk areas. You'll also need to adhere to a dedicated diet before bariatric surgery.
Ahead, experts share how to prepare for bariatric surgery, regardless of the specific type. Keep reading for details on the pre-op appointments you'll need to schedule and how to plan for adjusting your diet before weight loss surgery.
Dietitian Consultation
One of the initial steps you'll be obligated to undertake before undergoing any major weight loss surgery is meeting with a dietitian to assess your eating habits. "This is to obtain a history of what the patient has been consuming, the nature of their diet, and if they've attempted any weight-loss-oriented diets (such as Jenny Craig or Weight Watchers) – and if so, how much weight they've lost," explains Dr. Naim. The dietitian will also assist you in modifying your current eating habits and calorie intake and devise a dietary plan that aligns with your personal requirements after the bariatric procedure. A gastric bypass post-op diet (or one for any type of weight loss surgery, for that matter) is highly specific and likely profoundly different from your present one.
This evaluation doesn't necessarily imply that your dietitian will mandate you to achieve certain weight loss goals or put you on a particular pre-bariatric surgery diet, although it's possible. Dr. Godshall states that her practice doesn't routinely require any pre-op weight loss, although a patient's surgeon might make specific pre-surgery diet requests on a case-by-case basis. (You will, however, need to embark on a special liquid diet for bariatric surgery beforehand, more on that shortly.)
Psychological Evaluation
To be cleared for surgery, you'll also need to meet with a psychologist and undergo a psychological assessment. "This is more of a screening," says Dr. Naim. "Patients are evaluated to determine if there is any history of eating disorders, such as bulimia or food addiction, as well as any significant psychological concerns, like bipolar disorder, depression, or suicidal thoughts." If the patient suffers from any of these mental health issues (or has in the past), this doesn't necessarily mean they won't be considered candidates for surgery. "We check to ensure they have them under control and that they are adhering to any prescribed medication so that they don't encounter any problems after surgery," he says.
Major weight loss surgery is, indeed, significant and will require quite dramatic lifestyle alterations, both in preparation for and after the surgery. The psychologist will also better prepare you for the necessary postoperative weight loss plans and lifestyle changes or determine if you need better education and preparation before the surgery.
Testing by an Internist or Specialist
Next, you'll need to undergo basic tests to be cleared for surgery. The type of doctor you meet with might vary from office to office; Dr. Godshall's patients must be evaluated by a cardiologist and pulmonologist, while Dr. Naim's patients will meet with an internist for assessment.
Regardless of the kind of doctor you encounter, you'll undergo the same preoperative tests and screenings. As Dr. Naim explains, all patients will require a routine blood test, a complete blood count, an electrolyte panel, an EKG, and chest X-rays, which he states are the standard for any surgery involving anesthesia. "Even in the case of a facelift, you'll need to check for any underlying heart or lung problems."
If you have specific underlying conditions, you might need to undergo additional evaluations. "If the patient has other issues, like heart problems, diabetes, or high blood pressure, we might prescribe tests such as an echocardiogram, a stress test, or a more invasive test like a coronary angiogram to ensure that their heart is robust enough to withstand the surgery," says Dr. Naim.
If the test results are not satisfactory for surgery, Dr. Naim says, other measures might need to be implemented before proceeding. "They might need to have their medication adjusted, or in some cases – such as if the patient has coronary heart disease – they might need to undergo heart surgery before they can have weight loss surgery."
In any case, Dr. Godshall clarifies that these consultations and tests are not intended to exclude any patients from being able to undergo surgery but rather to guarantee that the surgery is as safe as can be.
Upper Endoscopy
According to Dr. Godshall, an upper endoscopy (also known as an esophagogastroduodenoscopy, or EGD) is also necessary. An EGD is a procedure where an endoscope – a thin hose with a tiny camera attached – is inserted through the mouth and fed down the throat into the esophagus, stomach, and upper gastrointestinal tract while the patient is under sedation.
During this procedure, your doctors will examine the interior linings of the esophagus, stomach, and the first part of the small intestine to check if you don't suffer from gastroesophageal reflux disease, a hiatal hernia, bacterial infections, ulcers, or tumors.
While this might vary from office to office, Dr. Godshall explains that you might be able to meet with all the aforementioned healthcare providers and receive your endoscopy during the same appointment, allowing for a one-day surgical clearance and making the process considerably less intimidating.
A Pre-Surgery Liquid Diet
Once you've completed the above and your surgery is approved and scheduled, you'll be obligated to follow a liquid diet leading up to your procedure – a dedicated bariatric surgery pre-op diet, so to speak. "This helps patients get accustomed to the postoperative diet and reduces liver size, making the surgical procedure more straightforward," says Dr. Godshall.
Liquid diets encompass clear liquids (water, diluted fruit and vegetable juices, broth-based soups); full liquids (hot cereals, creamed soups, yogurts, milk); and daily protein shakes as well as several supplements, such as multivitamins, calcium, and vitamin D, but no solid foods.
While a two-week liquid diet is often recommended, this can vary depending on your surgeon, the type of bariatric procedure you're undergoing, and your current BMI. For example, a gastric sleeve pre-op diet or gastric bypass pre-op diet might include a longer period of cutting back on items such as carbohydrates, sugar, dairy, and alcohol and focusing on easily digestible, high-protein foods. This pre-bariatric surgery diet might last up to four weeks and involve switching to liquids only for a few days prior to the procedure. In the end, the specifics of your bariatric surgery diet plan – both before and after the surgery itself – will depend on your particular circumstances.
The Bottom Line:
It's essential to understand that undergoing a major weight loss procedure demands numerous steps before final approval and will involve substantial lifestyle changes, both before and after the surgery, to minimize the risk of any life-threatening risks and other complications. (This is why proper preparation for bariatric surgery is so crucial.) But it's also highly effective and might be the best – or the only – option for some. "It's an important choice for patients to achieve significant and lasting weight loss that cannot be achieved through diet and exercise alone," says Dr. Godshall. "Patients who qualify not only benefit from resolving current diagnoses such as diabetes or obstructive sleep apnea but also by reducing the risk of developing other medical conditions over time. Obesity impacts far more than an individual's physical health – social and psychological health are also affected."
