Background Information:

What are the other Names for the Procedure?

• Weight Loss Surgery
• Surgery for Obesity

What is Bariatric Surgery surgical procedure?

Bariatric Surgery is a surgical procedure where the stomach size is either reduced, resected, and/or its intake volume limited, to ensure a critical weight loss. Hence, it is also known as Weight Loss Surgery.

What part of the Body does the Procedure involve?

Bariatric Surgery involves the stomach, the small intestine, and the abdominal cavity.

Why is the Bariatric Surgery surgical procedure Performed?

The primary reason to perform a Bariatric Surgery is to ensure weight loss in patients suffering from morbid obesity and whose body mass index (BMI) is over 40 with no co-morbidities (presence of other diseases or disorders), or BMI of 35 with any one of the co-morbidities, such as:

• Diabetes mellitus
• High blood pressure
• High cholesterol
• High fat
• Sleep apnea
• Back pain
• Joint pain
• Osteoarthritis
• Gastro-esophageal reflux disease
• Peripheral edema
• Fatty liver disease

What are some Alternative Choices for the Procedure?

Following are the alternative choices for the Bariatric Surgery procedure. However, both of them have not been approved in the United States yet:

• Intragastric balloons; a procedure where an inflated balloon is inserted in the stomach with the help of an endoscope and filled with either saline solution or air. It creates a constant feeling of fullness thereby reducing the food intake
• Implantable gastric simulation, where an electric pulse is sent through the stomach to induce a sense of feeling full

What are the Recent Advances in the Procedure?

In cases where individuals are suffering from morbid obesity, Bariatric Surgery remains the gold standard technique. Recent advances are variations to the surgical procedure with respect to the bypass surgery. 

What is the Cost of performing the Bariatric Surgery surgical procedure?

The cost of Bariatric Surgery procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.  

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Bariatric Surgery procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.nlm.nih.gov/medlineplus/weightlosssurgery.html (accessed on 04/05/2015)

http://www.columbiasurgery.org/news/si/2006_obesity.html (accessed on 04/05/2015)

http://www.niddk.nih.gov/health-information/health-topics/weight-control/bariatric-surgery-severe-obesity/Pages/bariatric-surgery-for-severe-obesity.aspx (accessed on 04/05/2015)

http://www.mayoclinic.org/tests-procedures/bariatric-surgery/basics/definition/prc-20019138 (accessed on 04/05/2015) 

Prior to Bariatric Surgery surgical procedure:

How is the Bariatric Surgery surgical procedure Performed?

Bariatric Surgery employs two basic surgical procedures that are broadly classified as:

• Restrictive operation (vertical banded gastroplasty, adjustable gastric band placement, vertical sleeve gastrectomy)
• Malabsorptive operation (bilio-pancreatic diversion, with or without duodenal switch)

There is also a combination of both restrictive and malabsorptive component (called Roux en Y gastric bypass surgery). All the above mentioned procedures can be performed, either by a laparoscopic approach (using few small incisions), or an open approach (through a large vertical incision in the abdomen). 

Currently, the three most commonly performed procedures are:

• Laparoscopic Roux en Y gastric bypass
• Laparoscopic adjustable gastric band placement
• Laparoscopic vertical sleeve gastrectomy

Laparoscopic Roux en Y gastric bypass:

• In Roux en Y gastric bypass surgery, the top part of the stomach is made into a small pouch and the lower portion of the small intestine is redirected and connected directly with the stomach pouch
• This procedure is done to permit the flow of food from the pouch to the lower portion of the small intestine directly, so as to prevent absorption of nutrients and calories in the upper portion of the small intestine

Laparoscopic adjustable gastric band placement:

• In a gastric band surgery, a silicone band is placed around the upper part of the stomach, thereby creating a small stomach pouch. This pouch holds less food and induces a feeling of satiety
• The band is connected to a port which is placed under the skin. The band must be evaluated every 4 to 6 weeks for adjustments through the port

Laparoscopic vertical sleeve gastrectomy:

• In a vertical sleeve gastrectomy, a portion of the stomach is stapled (to reduce its volume) leaving a small tube-like structure for the flow of food
• This restricts the amount of food a person can eat

Where is the Procedure Performed?

The Bariatric Surgery is performed in a hospital. The patient is admitted, undergoes the procedure and is discharged, as per the instruction of the physician/surgeon.

Who Performs the Procedure?

The Bariatric Surgery is performed by a trained general surgeon assisted by an anesthesiologist.

How long will the Procedure take?

The Bariatric Surgery procedure may take anywhere between 2-3 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Bariatric Surgery procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 12 hours prior to the surgical procedure(per physician’s advice), depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Bariatric Surgery procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Bariatric Surgery surgical procedure?

Before a Bariatric Surgery, the patient has to undergo certain tests that may include:

• Psychological testing
• Blood tests, including a complete blood count
• Urinalysis
• Ultrasound scan for gallbladder stones
• Studies of the heart, gastrointestinal system
• Lung function test

What are some Questions for your Physician?

Some basic questions that the patient could ask the physician are:

• What is a Bariatric Surgery?
• How will this procedure help?
• How soon should I get it done? Is it an emergency?
• How soon will the results (weight loss) become visible?
• Is the technique a permanent solution or can it be reversed?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed?
• What are the risks while performing the procedure?
• What are the complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• Are there any lifestyle restrictions, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• How many such procedures have you performed?

During the Bariatric Surgery surgical procedure:

What kind of Anesthesia is given, during the Procedure?

During the Bariatric Surgery procedure the patient is administered with general anesthesia.

How much Blood will you lose, during the Procedure?

• If the Bariatric Surgery procedure is performed laparoscopically, the blood loss is minimal (less than 30 ml)
• If it is an open surgery, then the blood loss may be more. Also, if there are any complications during the procedure, it could lead to a further loss of blood

What are the possible Risks and Complications during the Bariatric Surgery surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during Bariatric Surgery are:

• Infection
• Accidental injury to the neighboring tissue
• Excessive bleeding
• Anesthetic complications
• Blood clot in the legs (DVT or deep vein thrombosis)

What Post-Operative Care is needed at the Healthcare Facility after the Bariatric Surgery surgical procedure?

• After the Bariatric Surgery procedure, the patients are sent to an area of the hospital called postoperative recovery area (or PACU)
• The patient’s blood pressure, heart rate, and respiration cycle, shall be closely monitored. Any additional pain associated with the procedure will be treated
• Individuals are usually discharged from the hospital, about 2 days after the surgery is performed

After the Bariatric Surgery surgical procedure:

What are the possible Risks and Complications after the Bariatric Surgery surgical procedure?

Post Bariatric Surgery, the following complications may arise:

• Excessive bleeding
• Infection in the surgical wound
• Kidney failure
• Incisional hernia
• Adhesions
• Bowel movement difficulties
• Malabsorption
• Malnutrition
• Leak at the anastomosis (connection point between the stomach and the small intestine, or between the two different portions of the small intestine), or the staple line

What is the Prognosis after the Surgery?

The prognosis from the procedure is generally excellent, unless any complications arise.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms following a Bariatric Surgery:

• Pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage
• Fever
• Dizziness
• Signs of infection
• Prolonged constipation

What Post-Operative Care is needed at Home after the Bariatric Surgery surgical procedure?

At home, the following post-operative care is recommended, after a Bariatric Surgery procedure:

• Wash the surgical wound with a mild soap while bathing
• Resume daily activity only after complete recovery
• Use heat to reduce incisional pain, or follow steps as directed by the physician
• Avoid taking non-prescribed medications
• Abstain from sex for a period of time, as advised by the physician
• Follow a prescribed diet

How long does it normally take to fully recover, from the Procedure?

It takes about 6-8 weeks to completely recover from the Bariatric Surgery procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

Bariatric Surgery can either be performed by the banding method, in which case no tissue is taken out, or by removing a portion of the stomach. If the tissue is removed, then it is sent to a pathologist for further analysis. 

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Bariatric Surgery surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from

• The hospital
• A general surgeon
• An anesthesiologist
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before the Bariatric Surgery procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA