Bariatric surgery

Bariatric surgery is surgery on the stomach and/or intestines to help a person with extreme obesity lose weight.

Some types of bariatric surgeries make your stomach smaller, allowing you to eat and drink less at one time and making you feel full sooner. Other bariatric surgeries also change your small intestine, the part of your body that absorbs calories and nutrients from foods and beverages.

Bariatric surgery may be an option if you have severe obesity and have not been able to lose weight or keep from gaining back any weight you lost using other methods such as lifestyle treatment or medications. Bariatric surgery also may be an option if you have serious health problems, such as Type 2 Diabetes or sleep apnea, related to obesity. Bariatric surgery can improve many of the medical conditions linked to obesity, especially type 2 diabetes.

Here are some FAQs answered!

What is obesity?

Obesity means the accumulation of excess fat in our body. Obesity is a non-communicable, rapidly emerging disease in the developing world. It leads to premature mortality and morbidity and impaired quality of life.

Obesity is declared a global epidemic by the World Health Organization which estimates that over 1.7 billion people around the globe are overweight and 310 million are clinically obese. CDC (Centre for Disease Control) and NIH (National Institute of Health) have documented obesity as a serious health threat.

When we say that person is obese, it does not mean that the person has increased weight, as weight alone is not a measure of obesity. Some people who are tall weigh more than people who are short of same age group. So to determine if a person is obese, a measure of both height and weight is used. This measurement is known as BMI- Body Mass Index Normal person’s BMI is between 18.5 and 24.9. One is considered being overweight if BMI is between 25 and 29.9. Obesity is defined as a Body Mass Index (BMI) = 30. The table below grades obesity into three types.

Why am I obese?

There could be two scenarios which can explain why.

i. Either you are not burning enough calories that you are eating (that is the case when your BMR is low).
For example, if you’re eating 3000 kcal per day and burning only 2600 kcal, that means every day you’re accumulating 400 kcal in your body!

ii. Or you might be burning calories normally. For example, you’re burning 3000 kcal. But is this enough if your consumption is 4000 kcal? The answer is NO because here you’re accumulating 1000 kcal.

What are the causes of obesity?

Obesity is characterized by excessive fat tissue mass. There are many factors which play a crucial role in the pathogenesis of obesity. A sedentary lifestyle with dietary factors plays a very important role in causing obesity and this type of obesity is known as exogenous obesity.

  • Sedentary lifestyle
  • Dietary factors
  • Heredity
  • Endocrinological causes like
  • Cushing syndrome
  • Hypothyroidism
  • Hypogonadism in men
  • Polycystic Ovarian Disease (PCOD)

Medications
Some medications like Corticosteroids, Antidepressants, Anti-seizure also causes obesity by slowing the BMR, increasing water retention and appetite.

Lifestyle Factors

  • Smoking
  • Lack of Sleep
  • Psychological
  • Age
  • Pregnancy

What are the effects of obesity?

  • High blood pressure – Additional fat tissue in the body needs oxygen and nutrients in order to live, which requires the blood vessels to circulate more blood to the fat tissue. This increases the workload of the heart because it must pump more blood through additional blood vessels. More circulating blood also means more pressure on the artery walls. Higher pressure on the artery walls increases the blood pressure. In addition, extra weight can raise the heart rate and reduce the body’s ability to transport blood through the vessels.
  • Diabetes – obesity is the major cause of type 2 diabetes. This type of diabetes usually begins in adulthood but, is now actually occurring in children. Obesity can cause resistance to insulin, the hormone that regulates blood sugar. When obesity causes insulin resistance, the blood sugar becomes elevated. Even moderate obesity dramatically increases the risk of diabetes.
  • Heart disease – atherosclerosis (hardening of the arteries) is present 10 times more often in obese people compared to those who are not obese. Coronary artery disease is also more prevalent because fatty deposits build up in arteries that supply the heart. Narrowed arteries and reduced blood flow to the heart can cause chest pain (angina) or a heart attack. Blood clots can also form in narrowed arteries and cause a stroke.
  • Joint problems, including osteoarthritis – obesity can affect the knees and hips because of the stress placed on the joints by extra weight. Joint replacement surgery, while commonly performed on damaged joints, may not be an advisable option for an obese person because the artificial joint has a higher risk of loosening and causing further damage.
  • Cancer – in women, being overweight contributes to an increased risk for a variety of cancers including breast cancer, colon, gallbladder, and uterus. Men who are overweight have a higher risk of colon cancer and prostate cancers.
  • Metabolic syndrome – the National Cholesterol Education Program has identified metabolic syndrome as a complex risk factor for cardiovascular disease. Metabolic syndrome consists of six major components: abdominal obesity, elevated blood cholesterol, elevated blood pressure, insulin resistance with or without glucose intolerance, elevation of certain blood components that indicate inflammation, and elevation of certain clotting factors in the blood. In the US, approximately one-third of overweight or obese persons exhibit metabolic syndrome.
  • Psychosocial effects – in a culture where often the ideal of physical attractiveness is to be overly thin, people who are overweight or obese frequently suffer disadvantages. Overweight and obese persons are often blamed for their condition and may be considered to be lazy or weak-willed.

It is not uncommon for overweight or obese conditions to result in persons having lower incomes or having fewer or no romantic relationships. Disapproval of overweight persons expressed by some individuals may progress to bias, discrimination, and even torment.

What is bariatric surgery all about?

Commonly referred to as weight loss surgery, bariatric surgery is one of the few weight loss treatments that has a history of proven results. The term bariatric surgery refers to any surgical procedure on the stomach or intestines to induce weight loss.


The most widely performed surgeries for weight loss are:

  • Gastric bypass
  • Sleeve gastrectomy

Before making a decision about bariatric surgery, the first step is to explore your options. This may start with online research and then attending information sessions or visiting doctors in person. Part of the process is learning whether you qualify for surgery and what to do to be approved. It’s important to consider the pros and cons before deciding whether surgery is right for you.

Most bariatric surgery procedures are now done laparoscopically. This is also called “minimally invasive surgery.” 3 to 6 smaller incisions are made and small instruments and a camera are inserted into the patient’s body. Recovery is quicker and patients experience less pain

What is the history of bariatric surgery

Below is a brief history of bariatric surgery, in pictorial representation for easy understanding

What are the steps of bariatric surgery?

The below infographic provides an overview of all the steps needed, before deciding to go ahead with the bariatric surgery.

Surgery Steps

What are the complications from the bariatric surgery?

In the preoperative and early postoperative periods (usually the first 30 to 90 days after surgery), it is very crucial for the patient to be monitored closely for surgical complications.

Some of the potential medical and nutritional complications of bariatric surgery are:

  • Micronutrient deficiencies
  • Dumping syndrome
  • Post-gastric bypass hypoglycaemia
  • Cholelithiasis
  • Nephrolithiasis
  • Bone loss and fracture

What are the post-operative management of nutrition & exercise?

Given the dietary changes, re-routing of nutrient flow, and gut anatomy/physiology alterations that occur after bariatric surgery, patients who undergo these procedures are at risk for micronutrient deficiencies. Some of these deficiencies can result in severe consequences, such as neuropathy, heart failure, and encephalopathy. Therefore, it is essential that patients comprehend the importance of compliance and the need for lifelong supplementation. Patients who have mal-absorptive procedures, such as RYGB or BPD/DS, are at highest risk for micronutrient deficiencies and require a more extensive preoperative nutritional evaluation and postoperative monitoring and supplementation. But even with restrictive procedures, decreased oral intake and poor tolerance to certain food groups may also increase the risk for micronutrient deficiencies.

Recommended postoperative supplementation of vitamins and minerals

Micronutrient Supplementation
Within a multivitamin with minerals product
Thiamine 12 mg/day
Vitamin B12 (cobalamin) Oral or sublingual: 350-500 mcg/day
Intranasal: 1000 mcg/week*
Intramuscular: 1000 mcg/month
Folate (folic acid) 400-800 mcg/day
Women of childbearing age: 800-1000 mcg/day
Iron 18 mg/day elemental iron
RYGB, SG, BPD/DS or menstruating women: 45-60 mg/day
Take separately from calcium supplements
Vitamin D D3 3000 IU/day
Vitamin A LAGB: vitamin A 5000 IU/day
RYGB or SG: vitamin A 5,000-10,000 IU/day
BPD/DS: vitamin A 10,000 IU/day
Vitamin E 15 mg/day
Vitamin K LAGB, SG or RYGB: 90-120 mcg/day
BPD/DS: 300 mcg/day
Zinc SG or LAGB: 8-11 mg/day
RYGB: 8-22 mg/day
BPD/DS: 16-22 mg/day
Copper SG or LAGB: 1 mg/day
RYGB or BPD/DS: 2 mg/day
As separate supplementation
Calcium LAGB, SG, RYGB: calcium 1200-1500 mg/day (diet + supplements)
BPD/DS: calcium 1800-2400 mg/day (diet + supplements)
(as calcium citrate, in divided doses)

Most micronutrients are provided in multivitamins, and chewable multivitamins are recommended postoperatively. Multivitamins for the general population can be used, provided that attention is paid to the product’s micronutrient contents. The ASMBS recommends one general multivitamin tablet daily for patients who have had LAGB, or 2 general multivitamin tablets daily for those undergoing SG, RYGB or BPD/DS. As an alternative to general multivitamins, bariatric surgery-specific, high-potency multivitamins are available and often contain the recommended doses of micronutrients in one tablet daily.

Multivitamins do not contain the recommended doses of calcium, as calcium can impede the absorption of other micronutrients. Therefore, separate calcium supplementation is usually required. Calcium citrate is the preferred form of supplemental calcium, as it is better absorbed than calcium carbonate in the state of impaired gastric acid production. A patient’s dietary calcium intake should be considered when determining the dose of a calcium supplement, as the recommended intakes are generally total daily intakes (diet plus supplements). Iron absorption may be enhanced by co-administration of vitamin C (500-1000 mg) to create an acidic environment or when taken with meat. If inadequate absorption or intolerance occurs, parenteral iron replacement may be necessary.

A suggested schedule for postoperative biochemical monitoring is listed in below table. Patients who develop micronutrient deficiencies may need more frequent monitoring.

Schedule for postoperative micronutrient monitoring

6 months 12 months 18 months 24 months Annually
Vitamin B12 X X X X X
Folate X X X X X
Iron, ferritin X X X X X
25-hydroxyvitamin D X X X X X
Calcium X X X X X
Intact PTH X X X X X
24-hour urinary calcium X† X† X† X†
Thiamine Optional Optional Optional Optional Optional
Vitamin A Optional Optional

Oral repletion is often sufficient for correcting micronutrient deficiencies, although parenteral therapy may be required in severe disease. After a repletion course, biochemical testing should be performed and a maintenance dose should be established. Micronutrient deficiencies may co-exist; for example, malabsorptive procedures may result in deficiencies of the fat-soluble vitamins A, E and K.

How to maintain weight loss, after surgery?

Here are five vital steps to prevent gaining weight back after undergoing bariatric surgery.

  • Get post-op support for long-term success – Bariatric surgery is an emotional roller coaster and developing a support network is key. Having an opportunity to freely discuss concerns, expectations, and challenges with others who have been through the same experience can be invaluable.

    “Support groups provide the answers to many questions and can guide you in ways that surgeons do not address. The support groups provide information on managing plateaus and food alternatives for the different stages of recovery. These groups also offer key moral support and encouragement pre- and post-surgery.”

  • Assemble a health team – An important addition to every support system is a team of experts to guide you through the process, including a therapist specializing in emotional eating and a nutritionist.

    Bariatric surgery is only one tool in the toolbox for long-term success. Commitment to a permanent lifestyle change is a must and working alongside a team of experts can help a patient to commit to and maintain these changes. Registered dieticians provide support and answer vital questions, while holding you accountable in preventing old eating habits from creeping back, she adds.

  • Rethink your relationship with food – For many patients who undergo bariatric surgery, the relationship with food is a complicated one. Rewiring yourself to think of food as fuel, instead of as an emotional comfort, is an essential part of the process.

    Work on creating a healthy relationship with food so that the emotional baggage that led to your weight gain initially is controlled or even squelched. With the help of your healthcare team, identify the emotional connections you have with food and work to change those patterns before and after surgery for the best chance at success.

  • Create new eating habits that will last a lifetime – As weight loss begins to slow, it can be easy to return to old habits and focus less on dietary guidelines. “Make sure to prioritize nutrient-dense foods. Lean protein is important immediately after surgery, and continues to be, but don’t forget about fruits and vegetables, too.” In the years following surgery, as the stomach slowly expands and appetite begins to increase, incorporating low-calorie, high-volume foods like vegetables into your diet can be key to preventing weight regain.
  • Make fitness a priority, starting with the recovery process – The body is made to move and the more it does, the better it works. Aim to be physically active most days of the week, and incorporate both cardiovascular and resistance exercises to preserve and build muscle mass, an essential component for a healthy metabolism, she says.

    After surgery, “walking is the foundation of exercise”. Aim for small and attainable goals that you can build from.” Increase the walking distance or time by 10 percent every week, or every 2 weeks if that feels too strenuous. “Once you feel like you have reached a good distance or time, you can start working on speed.”

    Remember that slip ups are inevitable, but they don’t have to become major setbacks. “If you feel yourself slipping towards old eating habits, don’t be afraid to seek help,” says Smith. By building a strong support system, improving your relationship with food, and creating new, healthy habits, bariatric surgery can be a valuable tool in promoting long-term weight-loss success

    The postoperative management of the bariatric surgery patient requires an interdisciplinary team, including the surgeon, dietitian, and endocrinologist and/or primary care provider. It is critical that endocrinologists and primary care providers have the training and tools required to meet the population’s medical needs, which include the management of chronic metabolic conditions and the prevention and treatment of postoperative medical and nutritional complications during lifelong follow-up. The teamwork of informed and experienced clinicians can optimize the long-term benefits of bariatric surgery.

What are the dietary instructions?

The following 6 rules are very important to sticking to your dietary restrictions

  • Only eat small quantities: the capacity of the stomach has changed. Also, the amount of food intake has to change. Nevertheless, it is not always easy to stop eating at the right time. What do we mean, if we say small quantities? For example one slice of bread for breakfast or 2 potatoes and a small piece of fish for lunch.
  • Chew well and swallow food only completely mashed: You need more time for chewing and also not all food is possible to chew well. The list of “unsuitable food” will show you the products which are usually not easy to chew.
  • Never eat and drink at the same time: The reduced capacity of the stomach will no longer permit to take in both: liquid and food at the same time. The usual amount of beverage, 2-3 liter liquid per day, are desirable. It´s better to drink between or before meals.
  • Do not lay down or rest after eating: because in a horizontal position reflux is more likely. The food also remains longer in the pre-stomach and leads to a very uncomfortable accumulation of mucus.
  • Eat five times a day: This is important, because if you only eat 2-3 times a day, it is not possible to have a great variety of food. Consequently, as you can only eat small amounts, you do not get enough proteins, minerals and vitamins. In addition, when eating 5 times daily, it is less likely that you are overpowered by sudden hunger attacks where you probably forget the new eating habits.
  • Watch for beverages rich in calories: In our experience, many people take in a lot of their calories with soft drinks, hot chocolate and milk shakes. This is also possible after the operation, so consider this before drinking high calorie liquids. The type of liquid should be varied and include tea or coffee, diluted fruit- or vegetable juice, light drink with artificial sugar, low fat variants of butter milk, mineral water without gas.

*References:
Medical Management of the Postoperative Bariatric Surgery Patient by Tiffany Y Kim, MD, Sarah Kim, and Anne L Schafer, M.D.
https://www.obesitycoverage.com/before-after/to-do-before-surgery
https://www.everydayhealth.com/news/ways-avoid-weight-gain-after-bariatric-surgery/

Dr. Nanda Rajaneesh has over 18 years of experience in surgical oncology and laparoscopic surgery. She is currently a visiting consultant in both Apollo Spectra Hospitals and Sakra World Hospital. She has operated many film stars & VIPS, both at regional and national level.