Bariatric surgery: Before, during and after

Many have been on that endless treadmill of the latest diet fads. You lose 20 pounds only to find yourself putting it back on, and then some, three months later. You may be in this rut wondering if there is a different way. Metabolic and bariatric surgery may be that option.

Surgical weight loss treats much more than obesity. In fact, many obesity-related health conditions improve significantly or even resolve. Compared to medical treatment, metabolic and bariatric surgery has impressive outcomes in terms of weight loss, but also for improvement or resolution of:

• Diabetes mellitus type 2
• Hypertension
• Hyperlipidemia
• Obstructive sleep apnea

Reducing your weight can also reduce your chances of heart disease, arthritis of weight bearing joints, multiple cancers, fatty liver disease, metabolic syndrome, gastroesophageal reflux disease, polycystic ovarian syndrome, recurrent abdominal hernias, recurrent skin fold infections and many other conditions.

“Bariatric surgery is the best treatment option for weight loss and metabolic conditions like diabetes and fatty liver disease,” said Dr. Vijaya Nirujogi, surgeon and director of bariatric and metabolic surgery for Marshfield Clinic Health System. “On average, it is expected to add up to 6-10 years to your life and reduce the risk for up to 12 different cancers.”

Changing how you feel

The effects of surgery not only modify what and how much one can eat, but also resolves multiple metabolic issues so the body uses energy effectively, decreases insulin resistance, decreases hunger and improves feelings of fullness via changes in gut hormones and neurobiology among others. Patients frequently express delight in not feeling hungry or craving food as they did before surgery when trying to diet via traditional methods.

While part of this effect may be temporary, the majority of patients are able to keep off 50 percent or more of the initial weight lost even after 10 years. Weight loss surgery is the only option that shows prolonged weight loss. Most people lose 75 percent or more of their excess weight and are at their desired weight within two years.

“Metabolic and bariatric surgery is the only option to date that improves many medical conditions along with obesity. No medical or other surgical treatment can claim this,” Nirujogi said. “The changes in hormones, metabolism, insulin sensitivity and energy utilization are truly profound even before substantial weight is lost. Even when some regain weight over the years, they still have improved metabolic health.”

Before the surgery

Most programs and insurance providers require weight loss counseling before you have the surgery.

This typically includes working with a dietitian and participating in a medically supervised weight-loss program. This is to make sure you understand the lifestyle changes you will need to keep the weight off. It commonly takes six months to a year to complete all the prerequisites for metabolic and bariatric surgery and is surely not the easy way out. Preparation and lifelong commitment is required for long-term success. You must be willing and able to complete multiple visits while implementing lifestyle changes during this time. Before the surgery, other health conditions must be at their best state possible.

“Unlike other surgeries, weight loss surgery is only a tool. The results do not just depend on the surgery, but also whether the patient keeps on track with the diet and plan beforehand,” Nirujogi said” Most of the bad experiences around weight loss surgery are because of a lack of follow-up or understanding of the new lifestyle needed after the surgery to succeed.”

Many programs and insurance providers require participants to lose or maintain their weight before moving forward with the surgery.

Nirujogi recommends treating obesity type II (body mass index greater than 35) with significant health issues such as poorly controlled diabetes mellitus type 2 or morbid obesity (body mass index greater than 40) with or without comorbid health conditions sooner rather than later. Resolution of medical problems is higher in those who have had the problem for a shorter amount of time.

“As with any treatment, multiple factors are taken into consideration to determine candidacy both medically and behaviorally,” Nirujogi said.

The bariatric surgery procedure

Many different weight loss surgeries are available. These surgeries work by either restricting calories or not allowing the calories to be absorbed. Some surgeries are a combination of both. Common weight loss procedures include:

• Sleeve gastrectomy
• Roux-en-Y gastric bypass
• Laparoscopic gastric band surgery
• Duodenal switch (BPD-DS)

“I typically perform Roux-en-Y gastric bypass or sleeve gastrectomy because they are the most effective at losing weight with the least amount of long-term nutritional deficiencies and complications,” Nirujogi said.

All of these procedures can be performed laparoscopically under general anesthesia. This reduces the recovery time to 1-2 days. Nirujogi said that complications from bariatric surgery are really low – lower than the more common procedures like gall bladder surgery, hip replacement or colon surgeries.

After the surgery

If the procedure is laparoscopic, you can return to work in a couple of weeks. If you have a manual or physical job, your surgeon may require you to wait 4-6 weeks. Most patients stop using pain medication within a week.

For the first two weeks after surgery, you will be on a full liquid diet. You will then advance to pureed foods, soft foods and then regular food. You should eat according to the plan provided by your care team. This plan will be high in protein so that you do not lose muscle. Your care team will discuss this with you before the surgery to make sure you understand the plan.

“Most patients don’t feel hungry because of the metabolic changes caused by the surgery and the fact that the stomach pouch is pretty much the size of an egg,” Nirujogi said.

After about a month, your body will have fully adjusted to the change in the intestines and reduced calorie count.

After a year

You will have extensive follow-up for the first year and then Nirujogi recommends annual check-ups.

“Follow-up is really important because your surgeon is best able to catch issues stemming from your surgery. A regular follow up with the bariatric team will also help in keeping the patients on track and decrease the risk of regaining weight and long-term nutritional deficiencies,” Nirujogi said.

With weight loss, many patients experience excess skin. Nirujogi recommends waiting to surgically remove the excess skin until the maximum weight loss is achieved and you have maintained at that weight for at least three months or more. Most excess skin removal surgeries are not covered by insurance unless it is medically necessary.

Marshfield Medical Center in Marshfield is the only accredited Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence in north central Wisconsin and provides follow-up care for the life of a patient. To learn more, go here.