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Bariatric Surgery: When Obesity Requires Major Surgery
Table of Contents
Introduction
Bariatric surgery emerges as a pivotal intervention for individuals combatting severe obesity, a condition increasingly prevalent across the globe and associated with numerous health risks and reduced quality of life[1]. This surgical approach is not merely about weight loss; it is about transforming lives by mitigating the risk of obesity-related comorbidities such as type 2 diabetes, hypertension, and certain cancers, thereby extending longevity and enhancing life quality[2]. The choice to undergo bariatric surgery, however, is profound, requiring careful consideration and a multidisciplinary evaluation to ensure that it is the most suitable option for the patient[3].
The procedures, including Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding, each have distinct mechanisms of action and potential outcomes. They necessitate a lifelong commitment to nutritional management and physical activity to maintain weight loss and health benefits[4]. Eligibility for surgery typically requires a body mass index (BMI) of 40 or higher, or a BMI of 35 or higher with at least one significant obesity-related condition[5].This article aims to explore the critical aspects of
bariatric surgery as a major intervention for severe obesity. It will delve into the historical evolution of surgical techniques, discuss the eligibility criteria and the preparatory steps required before surgery, and highlight the transformative impact of these procedures on patients’ lives. Furthermore, it will examine the potential risks and challenges associated with bariatric surgery, underscoring the importance of a multidisciplinary approach to patient care and the necessity for patients to adhere to significant lifestyle changes post-surgery. Through this comprehensive overview, readers will gain insight into when and why bariatric surgery becomes a necessary step in the journey toward health and well-being for individuals facing severe obesity.
Understanding Obesity
Obesity is a complex, multifaceted condition characterized by excessive fat accumulation that poses a significant risk to an individual’s health. It is typically measured by the Body Mass Index (BMI), where a BMI of 30 or above signifies obesity[6].
Prevalence and Causes
The prevalence of obesity has seen an alarming rise globally, doubling in 73 countries since 1980 and continuously affecting both developed and developing nations[7]. This increase is attributed to a combination of genetic, environmental, and lifestyle factors, including poor diet, physical inactivity, and socio-economic determinants[8]. The condition is not merely about aesthetic concerns but is a major risk factor for chronic diseases such as diabetes, cardiovascular diseases, and certain cancers, significantly burdening public health systems[9].
Impact on Health
Obesity profoundly impacts an individual’s health, leading to a myriad of complications. It is closely linked with the development of type 2 diabetes, as excess weight influences insulin resistance[10]. Furthermore, obesity is associated with higher risks of hypertension, dyslipidemia, and obstructive sleep apnea, conditions that contribute to cardiovascular disease. The psychosocial effects of obesity, including stigma and reduced quality of life, are equally concerning and necessitate comprehensive management strategies[11].
What is Bariatric Surgery?
Bariatric surgery encompasses a variety of procedures designed to assist in significant weight loss for individuals struggling with severe obesity. This surgical intervention is considered when traditional methods such as diet, exercise, and behavioral therapies have not resulted in substantial weight loss[2].
Types of Procedures
The most common types of bariatric surgery include the Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding. Roux-en-Y gastric bypass involves creating a small pouch from the stomach and connecting it directly to the small intestine, bypassing a large portion of the stomach and duodenum[12]. Sleeve gastrectomy, on the other hand, involves removing a portion of the stomach to reduce its size and limit food intake[13]. Adjustable gastric banding involves placing a band around the upper part of the stomach to create a small stomach pouch, which can be adjusted to control the size of the opening between the pouch and the rest of the stomach[14].
Outcomes and Benefits
Bariatric surgery has resulted in significant long-term weight loss, improvement or resolution of obesity-related comorbidities, and increased life expectancy[15]. Patients typically experience a 50-70% reduction in excess weight within two years following the surgery. The reduction in body weight also leads to significant improvements in type 2 diabetes, hypertension, and hyperlipidemia, and a reduction in the overall mortality rate of obese patients[16].
Types of Bariatric Surgery Offered in the UK
In the United Kingdom, the National Health Service (NHS) and private healthcare providers offer several types of bariatric surgery to combat severe obesity. These procedures are recognized for their effectiveness in achieving significant weight loss and improving obesity-related health conditions[17].
NHS Criteria for Surgery
The NHS sets strict criteria for eligibility for bariatric surgery, including a BMI of 40 or higher, or a BMI between 35 and 40 coupled with a serious health condition that could be improved with weight loss, such as type 2 diabetes or high blood pressure[18]. Patients must also have tried and failed to lose weight through diet, exercise, and lifestyle changes.
Main Surgical Procedures
Gastric Bypass
Gastric bypass, one of the most commonly performed types of bariatric surgery in the UK, involves creating a small pouch at the top of the stomach and connecting it directly to the small intestine. This procedure not only reduces the amount of food the stomach can hold but also changes gut hormones, affecting hunger and satiety[19].
Sleeve Gastrectomy
Sleeve gastrectomy, another prevalent procedure, involves removing a portion of the stomach to significantly reduce its size. As a result, patients feel full more quickly and consume less food[20].
Gastric Band
The gastric band procedure involves placing an adjustable band around the upper portion of the stomach, creating a small pouch above the band. The size of the opening to the rest of the stomach can be adjusted to control food intake[21].
These surgical options reflect the UK’s commitment to providing medically necessary interventions for individuals with severe obesity, focusing on improving long-term health outcomes and quality of life.
Who is a Candidate for Bariatric Surgery?
Bariatric surgery is not a one-size-fits-all solution. It is reserved for individuals who have not achieved significant weight loss through diet, exercise, and medication and meet specific medical criteria[18].
Criteria for Eligibility
The primary criteria for bariatric surgery candidacy include a Body Mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with at least one or more obesity-related comorbid conditions, such as type 2 diabetes, hypertension, or obstructive sleep apnea[22]. These criteria are based on guidelines established by leading health organizations to ensure that the benefits of surgery outweigh the risks for each patient[23].
Assessment and Evaluation
Candidates must undergo a thorough multidisciplinary assessment to evaluate their suitability for surgery. This includes a comprehensive medical evaluation, psychological assessment, and nutritional counseling. The aim is to assess the patient’s ability to adhere to postoperative lifestyle changes and to identify any psychological factors that may affect the outcome of the surgery[24]. The evaluation process also helps to prepare the patient for the significant lifestyle adjustments required after surgery, ensuring they are fully informed and committed to the journey ahead[25].
The Surgical Process
Embarking on the journey of bariatric surgery is a profound decision that involves a series of meticulous steps, designed to ensure the safety and effectiveness of the procedure for individuals grappling with severe obesity.
Preoperative Preparation
The preoperative phase is pivotal, entailing a thorough medical evaluation to assess the patient’s overall health and readiness for surgery. This period also includes psychological assessments and nutritional counseling, aiming to prepare the patient for the significant lifestyle changes post-surgery. Education on the dietary adjustments necessary after the procedure is critical, setting the groundwork for successful, long-term weight management[26].
The Surgery
Bariatric operations are conducted under general anesthesia, predominantly using minimally invasive techniques such as laparoscopy. These methods significantly reduce recovery times and lower the risk of postoperative complications[27]. Depending on the individual’s specific health profile and weight loss objectives, a particular procedure is selected, be it Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding. The surgery typically spans a few hours, during which surgical modifications are made to the digestive system to facilitate weight reduction[28].
Postoperative Care
In the aftermath of surgery, patients receive extensive care to manage pain, avert complications, and promote healing. Initially, a liquid diet is introduced, gradually transitioning to solid foods over several weeks[29]. The long-term success of bariatric surgery hinges on the patient’s adherence to nutritional guidelines, engagement in regular physical activity, and the utilization of support networks, including ongoing consultations with healthcare professionals such as dietitians and psychologists. These measures are indispensable for navigating the behavioral and emotional challenges that may arise[30].
Risks and Complications
Bariatric surgery, while highly effective, is not without its risks and potential complications. These can vary depending on the type of procedure, the patient’s overall health, and adherence to postoperative guidelines.
Short-term Risks
In the immediate aftermath of surgery, patients may face various short-term risks such as infection, bleeding, and adverse reactions to anesthesia[29]. There is also the potential for complications directly related to the surgery, such as leaks at the surgical site. These risks necessitate close monitoring in the postoperative period to manage any complications promptly[30].
Long-term Complications
Over the longer term, patients may experience nutritional deficiencies due to the altered digestive process, particularly if they do not adhere to dietary guidelines[28]. These deficiencies can lead to conditions such as anemia, osteoporosis, and vitamin deficiencies. Furthermore, there is a risk of weight regain if patients do not maintain the lifestyle changes required after surgery[31]. Other long-term complications can include issues related to the surgical alterations of the digestive system, such as bowel obstruction, gallstones, or ulcers at the site of the surgery[16].
Psychological Impact
It’s important to note the potential psychological impact of bariatric surgery. While many patients experience significant improvements in their quality of life, some may struggle with the psychological adjustments required post-surgery. Issues such as body dysmorphia, depression, or difficulties adapting to a new lifestyle can emerge, underscoring the need for comprehensive psychological support as part of the bariatric care continuum[32].
Benefits Beyond Weight Loss
Bariatric surgery contributes to significant improvements in overall health and well-being, extending far beyond the mere reduction of body weight. These benefits are instrumental in enhancing the quality of life for individuals suffering from severe obesity.
Improvement in Obesity-Related Conditions
One of the most notable benefits of bariatric surgery is the substantial improvement or even resolution of obesity-related comorbidities. Conditions such as type 2 diabetes, hypertension, and obstructive sleep apnea have been shown to improve markedly following surgery. Studies have reported that bariatric surgery can lead to the remission of type 2 diabetes in a significant proportion of patients, reducing their dependence on medication and the risk of diabetes-related complications[31]. Similarly, improvements in blood pressure and cholesterol levels contribute to a decreased risk of cardiovascular disease[32].
Enhanced Quality of Life
Patients undergoing bariatric surgery often experience a dramatic enhancement in their quality of life. This includes improvements in mobility, self-esteem, social interactions, and overall psychological health[33]. The weight loss achieved through surgery can facilitate greater participation in physical activities and social events, reducing feelings of isolation and depression. Additionally, the reduction in obesity-related health issues further contributes to a more active and fulfilling life[34].
Economic Benefits
There are also economic benefits associated with bariatric surgery, stemming from reduced healthcare costs and increased productivity. As the health of the patient improves and the need for medication and treatment for obesity-related conditions diminishes, there is a significant reduction in healthcare expenditures. Moreover, the improvement in physical and mental health can lead to better job performance and fewer days missed from work, thereby enhancing economic productivity[35].
Life After Bariatric Surgery
Life after bariatric surgery entails significant lifestyle changes and adjustments, with a focus on maintaining the weight loss achieved and improving overall health. The journey post-surgery is one of transformation, requiring dedication and support.
Dietary Changes and Nutrition
Following bariatric surgery, patients must adhere to a strict dietary regimen, initially starting with liquid diets and gradually transitioning to solid foods[28]. It is imperative to follow nutritional guidelines provided by healthcare professionals to ensure adequate intake of vitamins and minerals and to avoid nutritional deficiencies[36]. Patients learn to eat smaller portions and to focus on high-protein, low-carbohydrate foods to support weight loss and muscle maintenance[31].
Activity and Exercise
Incorporating regular physical activity into daily life is essential after bariatric surgery. Exercise helps in maintaining weight loss, improving cardiovascular health, and enhancing mood and well-being[37]. Patients are encouraged to start with light exercises and gradually increase intensity as their recovery progresses, under the guidance of a healthcare professional.
Psychological Support
The psychological adjustment to the changes after bariatric surgery is significant. Many patients experience improved self-esteem and quality of life; however, some may struggle with body image issues or the emotional aspects of dealing with significant lifestyle changes[32]. Ongoing support from psychologists or support groups can be invaluable in navigating these challenges, ensuring a successful long-term outcome.
Follow-up Care
Regular follow-up appointments with the bariatric surgery team are crucial to monitor the patient’s health, nutritional status, and weight loss progress. These appointments provide an opportunity to adjust dietary plans, address complications, and offer continuous support and guidance[38].
Conclusion
In conclusion, bariatric surgery stands as a beacon of hope for individuals grappling with severe obesity, where traditional weight loss methods have fallen short. This surgical intervention not only offers a pathway to significant weight loss but also paves the way for a healthier, more active lifestyle, significantly improving the quality of life for patients[2]. The decision to undergo such a procedure, however, is not to be taken lightly. It requires a comprehensive evaluation, a commitment to profound lifestyle changes, and an understanding of the potential risks and rewards involved[3].
The benefits of bariatric surgery extend beyond weight loss, including the remission of type 2 diabetes, improved cardiovascular health, and a marked enhancement in psychological well-being[29]. Nevertheless, the journey does not end with surgery; it demands lifelong dedication to dietary management, physical activity, and regular follow-up care to maintain the gains achieved[31].
As we move forward, the role of bariatric surgery in the management of severe obesity continues to evolve, underscored by ongoing research and the development of less invasive techniques. For many, it represents a vital surgical intervention that not only extends lifespan but enriches the quality of life, offering a new lease on life to those who have battled with the profound challenges of obesity[42].
References
- Flegal, K. M., Kruszon-Moran, D., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2016). Trends in obesity among adults in the United States, 2005 to 2014. *JAMA*, 315(21), 2284-2291.
- Sjöström, L. (2013). Review of the key results from the Swedish Obese Subjects (SOS) trial – a prospective controlled intervention study of bariatric surgery. *Journal of Internal Medicine*, 273(3), 219-234.
- Mechanick, J. I., Youdim, A., Jones, D. B., Timothy Garvey, W., Hurley, D. L., McMahon, M. M., … & Kushner, R. F. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update. *Obesity*, 21(S1), S1-S27.
- Courcoulas, A. P., Christian, N. J., Belle, S. H., Berk, P. D., Flum, D. R., Garcia, L., … & Mitchell, J. E. (2014). Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. *JAMA*, 310(22), 2416-2425.
- National Institutes of Health. (1991). Gastrointestinal surgery for severe obesity: NIH Consensus Statement Online 1991 Mar 25-27; 9(1): 1-20.
- World Health Organization. (2020). Obesity and overweight. [Online] Available at: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
- NCD Risk Factor Collaboration (NCD-RisC). (2017). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. *Lancet*, 390(10113), 2627-2642.
- Hill, J. O., Wyatt, H. R., Reed, G. W., & Peters, J. C. (2003). Obesity and the environment: where do we go from here? *Science*, 299(5608), 853-855.
- Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications. *Nature Reviews Endocrinology*, 9(1), 13-27.
- Kahn, S. E., Hull, R. L., & Utzschneider, K. M. (2006). Mechanisms linking obesity to insulin resistance and type 2 diabetes. *Nature*, 444(7121), 840-846.
- Puhl, R., & Brownell, K. D. (2001). Bias, discrimination, and obesity. *Obesity Research*, 9(12), 788-805.
- Higa, K., Ho, T., Tercero, F., Yunus, T., & Boone, K. B. (2011). Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up. *Surgery for Obesity and Related Diseases*, 7(4), 516-525.
- Rosenthal, R. J., Diaz, A. A., Arvidsson, D., Baker, R. S., Basso, N., Bellanger, D., … & Higa, K. (2012). International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. *Surgery for Obesity and Related Diseases*, 8(1), 8-19.
- O’Brien, P. E., MacDonald, L., Anderson, M., Brennan, L., & Brown, W. A. (2013). Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature. *Annals of Surgery*, 257(1), 87-94.
- Adams, T. D., Gress, R. E., Smith, S. C., Halverson, R. C., Simper, S. C., Rosamond, W. D., … & Hunt, S. C. (2007). Long-term mortality after gastric bypass surgery. *New England Journal of Medicine*, 357(8), 753-761.
- Mingrone, G., Panunzi, S., De Gaetano, A., Guidone, C., Iaconelli, A., Leccesi, L., … & Rubino, F. (2015). Bariatric surgery versus conventional medical therapy for type 2 diabetes. *New England Journal of Medicine*, 366(17), 1577-1585.
- National Institute for Health and Care Excellence (NICE). (2014). Obesity: identification, assessment and management. [Online] Available at: https://www.nice.org.uk/guidance/cg189
- NHS England. (2020). Who can have weight loss surgery? [Online] Available at: https://www.nhs.uk/conditions/weight-loss-surgery/who-can-have-it/
- Welbourn, R., Pournaras, D. J., Dixon, J., Higa, K., Favretti, F., & Berry, M. A. (2018). Bariatric surgery worldwide: Baseline demographic description and one-year outcomes from the second IFSO Global Registry Report 2013-2015. *Obesity Surgery*, 28(2), 313-322.
- Gagner, M., & Hutchinson, C. (2016). Sleeve gastrectomy for type 2 diabetes mellitus. *Nature Reviews Endocrinology*, 12(7), 394-402.
- Angrisani, L., Santonicola, A., Iovino, P., Formisano, G., Buchwald, H., & Scopinaro, N. (2015). Bariatric surgery and endoluminal procedures: IFSO Worldwide Survey 2014. *Obesity Surgery*, 25(9), 1822-1832.
- American Society for Metabolic and Bariatric Surgery (ASMBS). (2020). Who is a Candidate for Bariatric Surgery? [Online] Available at: https://asmbs.org/patients/who-is-a-candidate-for-bariatric-surgery
- Mechanick, J. I., Youdim, A., Jones, D. B., Garvey, W. T., Hurley, D. L., McMahon, M., … & Kushner, R. F. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update. *Obesity*, 21(S1), S1-S27.
- Livhits, M., Mercado, C., Yermilov, I., Parikh, J. A., Dutson, E., Mehran, A., … & Gibbons, M. M. (2012). Preoperative predictors of weight loss following bariatric surgery: systematic review. *Obesity Surgery*, 22(1), 70-89.
- Sogg, S., Lauretti, J., & West-Smith, L. (2016). Recommendations for the presurgical psychosocial evaluation of bariatric surgery patients. *Surgery for Obesity and Related Diseases*, 12(4), 731-749
- Parrott, J., Frank, L., Rabena, R., Craggs-Dino, L., Isom, K. A., & Greiman, L. (2017). American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. *Surgery for Obesity and Related Diseases*, 13(5), 727-741.
- Buchwald, H., & Oien, D. M. (2013). Metabolic/Bariatric Surgery Worldwide 2011. *Obesity Surgery*, 23(4), 427-436.
- Schauer, P. R., Kashyap, S. R., Wolski, K., Brethauer, S. A., Kirwan, J. P., Pothier, C. E., … & Nissen, S. E. (2012). Bariatric surgery versus intensive medical therapy in obese patients with diabetes. *New England Journal of Medicine*, 366(17), 1567-1576.
- Sarwer, D. B., Dilks, R. J., & West-Smith, L. (2011). Dietary intake and eating behavior after bariatric surgery: threats to weight loss maintenance and strategies for success. *Surgery for Obesity and Related Diseases*, 7(5), 644-651.
- Beck, N. N., Mehlsen, M., & Støving, R. K. (2012). Psychological characteristics and associations with weight outcomes 2 years after gastric bypass surgery. *Obesity Surgery*, 22(10), 1642-1648.
- Schauer, P. R., Bhatt, D. L., Kirwan, J. P., Wolski, K., Brethauer, S. A., Navaneethan, S. D., … & Nissen, S. E. (2017). Bariatric surgery versus intensive medical therapy for diabetes — 5-year outcomes. *New England Journal of Medicine*, 376(7), 641-651.
- Sjöström, L., Peltonen, M., Jacobson, P., Sjöström, C. D., Karason, K., Wedel, H., … & Sullivan, M. (2012). Bariatric surgery and long-term cardiovascular events. *JAMA*, 307(1), 56-65. https://jamanetwork.com/journals/jama/fullarticle/1103994
- Sarwer, D. B., Wadden, T. A., Moore, R. H., Baker, A. W., Gibbons, L. M., Raper, S. E., & Williams, N. N. (2010). Preoperative eating behavior, postoperative dietary adherence, and weight loss after gastric bypass surgery. *Surgery for Obesity and Related Diseases*, 6(5), 640-646.
- Adams, T. D., Davidson, L. E., Litwin, S. E., Kolotkin, R. L., LaMonte, M. J., Pendleton, R. C., … & Hunt, S. C. (2012). Health benefits of gastric bypass surgery after 6 years. *JAMA*, 308(11), 1122-1131.
- Cremieux, P. Y., Buchwald, H., Shikora, S. A., Ghosh, A., Yang, H. E., & Buessing, M. (2008). A study on the economic impact of bariatric surgery. *American Journal of Managed Care*, 14(9), 589-596.
- Mechanick, J. I., Youdim, A., Jones, D. B., Garvey, W. T., Hurley, D. L., McMahon, M. M., … & Kushner, R. F. (2013). Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update. *Obesity*, 21(S1), S1-S27.
- Bond, D. S., Evans, R. K., Wolfe, L. G., Meador, J. G., Sugerman, H. J., Kellum, J. M., & Maher, J. W. (2010). Impact of physical activity and fitness on the level of kinesiophobia in patients with severe obesity before and after bariatric surgery. *Obesity Surgery*, 20(3), 369-374.
- Odom, J., Zalesin, K. C., Washington, T. L., Miller, W. W., Hakmeh, B., Zaremba, D. L., … & McCullough, P. A. (2010). Behavioral predictors of weight regain after bariatric surgery. *Obesity Surgery*, 20(3), 349-356.
