Bariatric surgery

Bariatric surgery is a real window of hope and a key to a new life for millions of people around the world who suffer from the burden of morbid obesity and its devastating health and psychological consequences. This surgery is no longer just a cosmetic procedure for weight loss, but has become a comprehensive and globally recognized medical treatment for its superior ability to change the course of patients’ lives, save them from the clutches of chronic diseases associated with obesity, and restore their self-confidence. It is a transformative journey that requires courage and commitment, but it promises results that radically change lives.

In this comprehensive and integrated article, we will delve into the depths of the world of bariatric surgery, exploring all its aspects with precision and detail, starting with its history and development, through its different types and the strict criteria for selecting candidates, the precise psychological and physical preparations that precede it, and down to the details of the new life after surgery, including challenges and achievements. We will also address the latest innovative technologies in this field, potential risks and complications and how to deal with them, available alternatives, and the vital role of the multidisciplinary medical team in supporting the patient throughout their journey.

A Historical Overview of the Development of Bariatric Surgery

Understanding the history of bariatric surgery reveals the long path of trials and innovations that have brought us to the advanced and safe techniques used today, which emphasizes the importance of this medical intervention:

The first surgical attempts to treat obesity began in the mid-twentieth century, and were mainly based on causing malabsorption of nutrients. The “jejunoileal bypass” was one of the first procedures developed in the 1950s, and despite its effectiveness in weight loss, it was accompanied by serious and long-term complications as a result of severe malabsorption, such as severe vitamin deficiency and liver problems. These challenges prompted surgeons and researchers to search for safer and more effective methods, which led to the great development of the concept of bariatric surgery.

• The 1960s and 1970s: This period witnessed a remarkable development with the emergence of operations such as the “gastric bypass,” developed by Dr. Edward Mason, who is considered the “father of bariatric surgery.” These operations focused on reducing the size of the stomach in addition to a calculated degree of malabsorption, which reduced severe complications.
• The 1980s and 1990s: The “adjustable gastric banding” technique was introduced, which offered a less invasive and reversible option. This period also saw the rise of laparoscopic surgery, which revolutionized the field of bariatric surgery by reducing the size of surgical incisions, alleviating pain, and speeding up the recovery period.
• The New Millennium: The “sleeve gastrectomy” operation emerged and became the most common procedure worldwide, due to its high effectiveness and acceptable safety level. More complex procedures were also developed, such as the “biliopancreatic diversion with duodenal switch” (BPD/DS) for severe cases of obesity.

Who is the Ideal Candidate for Bariatric Surgery?

Determining suitable candidates is a crucial step to ensure the success of bariatric surgery and achieve the best possible results, while minimizing risks as much as possible. Bariatric surgery is not a suitable solution for everyone who is overweight. There are precise criteria and conditions that the patient must meet to be considered a good candidate, and each case is evaluated individually by an integrated medical team. The main criterion is the Body Mass Index (BMI), a measure that relates weight to height:

• BMI of 40 or higher: People in this category are considered morbidly obese, which makes them strong candidates for bariatric surgery.
• BMI between 35 and 39.9 with comorbidities: If the patient suffers from serious obesity-related diseases such as type 2 diabetes, severe high blood pressure, sleep apnea, or heart disease, they are considered a suitable candidate.
• BMI between 30 and 34.9 in special cases: In some cases, bariatric surgery may be considered for this category if the patient has obesity-related diseases that are difficult to control with traditional treatments.
• Failure of non-surgical methods: The patient must have seriously tried to lose weight through diet, exercise, and lifestyle changes under medical supervision but without achieving sustainable results.
• Psychological readiness and commitment: The patient must be fully aware of the radical changes that will occur in their life after surgery, and be willing to commit to a new healthy lifestyle for life, including diet and medical follow-up.

The Most Common Types of Bariatric Surgeries

There are several types of bariatric surgery to suit different cases, with each type working through a specific mechanism to achieve the goal of weight loss. The most suitable type is chosen in consultation between the surgeon and the patient. The basic mechanism of most types of bariatric surgery is based on one or both of two principles: restricting the amount of food the stomach can hold (Restrictive), or reducing the absorption of calories and nutrients (Malabsorptive).

Sleeve Gastrectomy

The sleeve gastrectomy is one of the most famous and widespread types of bariatric surgery at the present time, in which a large part of the stomach is removed. In this procedure, the surgeon removes approximately 75-80% of the stomach’s volume longitudinally, leaving a small part in the shape of a tube or “sleeve.” This reduction in the size of the stomach greatly limits the amount of food the patient can eat, and it also removes the part of the stomach responsible for producing the hormone ghrelin, known as the “hunger hormone,” which significantly reduces appetite.

• Mechanism: Primarily restrictive, with a hormonal effect.
• Advantages: High effectiveness in weight loss, does not involve re-routing the intestines, and reduces the risk of vitamin deficiencies compared to other operations.
• Disadvantages: An irreversible procedure, and may cause or worsen GERD in some patients.

Roux-en-Y Gastric Bypass

The gastric bypass is one of the oldest and most successful types of bariatric surgery, combining food restriction with reduced calorie absorption. In this operation, the surgeon creates a small pouch in the upper part of the stomach, and then this pouch is connected directly to the middle part of the small intestine (the jejunum), thus bypassing the rest of the stomach and the first part of the small intestine (the duodenum). This new path for food reduces the amount of food consumed and reduces the absorption of calories and fats.

• Mechanism: Restrictive and malabsorptive.
• Advantages: Excellent and sustainable results in weight loss, and is considered very effective in treating type 2 diabetes and GERD.
• Disadvantages: More complex than sleeve gastrectomy, and requires a strict commitment to taking nutritional supplements for life to avoid vitamin and mineral deficiencies.

Adjustable Gastric Banding

The gastric band was a popular option in the past within bariatric surgery because it was the least invasive, but its popularity has declined in recent years. In this procedure, an inflatable silicone ring is placed around the upper part of the stomach, creating a small pouch above the band. The tightness of the band can be adjusted by injecting or withdrawing a saline solution through a port implanted under the skin. This procedure limits the amount of food that can be eaten and slows down the digestion process.

• Mechanism: Restrictive only.
• Advantages: Reversible and adjustable, and does not involve cutting or stapling the stomach or intestines.
• Disadvantages: Its results in weight loss are less than other operations, and the rate of long-term complications (such as band slippage or erosion) is relatively high.

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

This is one of the most complex and effective types of bariatric surgery, and is usually reserved for patients with severe morbid obesity (BMI > 50). This surgery involves two main steps: the first is performing a sleeve gastrectomy, and the second is a significant re-routing of the small intestine, which leads to a significant reduction in the absorption of calories and fats.

• Mechanism: Restrictive and significantly malabsorptive.
• Advantages: Achieves the highest percentage of weight loss, and is very effective in treating obesity-related comorbidities.
• Disadvantages: It has the highest surgical risks and malabsorption complications, and requires careful lifelong follow-up and a strict commitment to nutritional supplements.

Preparing for the Bariatric Surgery Journey

Good preparation before undergoing bariatric surgery is no less important than the surgery itself, as it paves the way for the success of the operation and helps the patient adapt to the upcoming changes. The bariatric surgery journey begins long before the day of the operation. This stage includes comprehensive evaluations and precise examinations to ensure that the patient is physically and psychologically ready for this major change in their life.

Comprehensive Medical Evaluation

The patient undergoes a series of medical examinations to ensure that the bariatric surgery procedure is safe for them and to identify any health problems that may need special attention:

• Comprehensive blood tests: To evaluate liver and kidney function, vitamin and mineral levels, and a complete blood count.
• Heart and respiratory system examinations: Such as an electrocardiogram (ECG), a chest X-ray, lung function tests, and a sleep study to diagnose sleep apnea.
• Upper gastrointestinal endoscopy: To examine the esophagus, stomach, and duodenum and to ensure there are no ulcers or other problems.
• Consultations with specialists: The patient may need to consult doctors in other specialties such as cardiology or endocrinology.

Psychological Evaluation

The psychological aspect plays a pivotal role in the success of bariatric surgery, so a psychological evaluation is an essential step to ensure the patient’s readiness for the psychological and emotional challenges:

• Mental health assessment: The patient is evaluated to detect any untreated mental disorders such as depression, anxiety, or eating disorders, which could affect their ability to adhere to lifestyle changes.
• Understanding motivations and expectations: The evaluation helps to ensure that the patient has realistic motivations for undergoing the surgery and that their expectations for the results are logical.
• Assessing the ability to adapt: The patient’s ability to cope with stress and adapt to major changes in diet and the relationship with food is assessed.

Dietary and Lifestyle Preparations before Bariatric Surgery

Weeks before the date of the bariatric surgery, the patient is asked to start making important changes in their diet and lifestyle to prepare for the operation:

• Pre-operative diet: The patient is usually put on a low-calorie, low-sugar, high-protein diet in the weeks leading up to the surgery. The goal of this diet is to reduce the size of the liver and the fat in the abdominal area, which makes the surgery safer and easier.
• Quitting smoking: Smokers are asked to stop smoking several weeks or months before the surgery, because smoking significantly increases the risk of surgical and respiratory complications.
• Starting an exercise program: Patients are encouraged to start regular, moderate physical activity, such as walking, to improve their overall fitness.

Risks and Complications of Bariatric Surgery

Despite the great development in bariatric surgery techniques and the increase in safety rates, like any major surgical procedure, it is not without potential risks and complications:

Short-term risks (related to the surgery)

These risks usually occur in the period close to the time of the surgery:

• Anesthesia risks: Adverse reactions to anesthetic drugs.
• Infection: Inflammation at the wound site or inside the abdomen.
• Blood clots: The formation of blood clots in the legs (DVT) which can travel to the lungs (Pulmonary embolism), a serious condition.
• Bleeding: Severe bleeding during or after surgery.
• Leak: Leakage of stomach or intestinal contents from the staple lines or surgical connections, which is considered one of the most serious early complications.

Long-term complications

These complications may appear months or years after the bariatric surgery:

• Vitamin and mineral deficiencies: As a result of the change in nutrient absorption, the patient may suffer from a deficiency in iron, calcium, vitamin B12, and other vitamins, which requires taking nutritional supplements for life.
• Dumping Syndrome: Occurs after eating foods rich in sugar or fat, and causes symptoms such as nausea, vomiting, diarrhea, dizziness, and severe sweating.
• Gallstones: Rapid weight loss increases the risk of forming gallstones.
• Hernia: A hernia may occur at the site of the surgical incisions.
• Bowel obstruction: A narrowing or blockage of the intestines may occur due to the formation of scar tissue.
• Weight regain: Some patients may regain some of the lost weight if they do not adhere to the new healthy lifestyle.
• Loose skin: Significant weight loss often leads to loose skin in different parts of the body, which may require cosmetic surgery later on.

Benefits of Bariatric Surgery

The benefits of bariatric surgery go far beyond the external appearance, as it offers a radical improvement in general health and quality of life, making it a real investment in the future:

Physical Health Benefits

Bariatric surgery leads to a significant improvement or complete remission of many chronic diseases associated with obesity:

• Treatment of type 2 diabetes: A large percentage of patients can go into remission from diabetes, and may stop using medications or insulin.
• Improved cardiovascular health: Lower blood pressure, improved cholesterol and triglyceride levels, and a reduced risk of heart attacks and strokes.
• Treatment of sleep apnea: Most patients experience a complete recovery from this condition, which improves sleep quality and energy during the day.
• Relief of joint pain: Weight loss reduces the burden on weight-bearing joints such as the knees and hips, which relieves pain and improves mobility.
• Improved fertility: Bariatric surgery may help improve fertility in women who suffer from Polycystic Ovary Syndrome (PCOS) and other obesity-related problems.
• Reduced risk of cancer: Obesity increases the risk of certain types of cancer, and weight loss reduces this risk.

Psychological and Social Benefits

The profound impact of bariatric surgery on the patient’s mental health and social quality of life cannot be overlooked:

• Improved self-confidence and body image: With weight loss and the ability to wear new clothes and participate in activities that were previously difficult, the patient’s self-confidence increases significantly.
• Reduced symptoms of depression and anxiety: Obesity is often associated with depression and social isolation, and the success of the surgery leads to a remarkable improvement in mood.
• Increased activity and vitality: The patient becomes more able to move, exercise, and participate in social and family activities.
• Improved quality of life in general: Patients feel a great improvement in their ability to perform their daily tasks and enjoy life better.

Life After Bariatric Surgery

The long-term success of bariatric surgery depends mainly on the patient’s ability to adopt and implement radical and permanent changes in their lifestyle. This is the stage that determines the sustainability of the results achieved:

Graduated Diet After Bariatric Surgery

Adhering to the diet after bariatric surgery is crucial to ensure proper healing, avoid complications, and achieve weight loss goals:

• Phase 1 (Clear liquids): In the first few days after surgery, the diet is limited to clear liquids such as water, broth, and sugar-free juices.
• Phase 2 (Full liquids): After that, the patient moves on to thicker liquids such as skim milk, liquid yogurt, and strained soups.
• Phase 3 (Pureed food): After about two weeks, the patient begins to eat well-pureed foods that resemble baby food.
• Phase 4 (Soft food): Gradually, soft and easy-to-chew foods are introduced, such as scrambled eggs, cooked fish, and well-cooked vegetables.
• Phase 5 (Permanent diet): After about two to three months, the patient can start eating regular solid foods, with a focus on protein, eating small meals, and chewing very slowly.

The Importance of Sports and Physical Activity

Exercise plays a vital role in the journey after bariatric surgery, as it helps to burn calories, build muscle, and improve overall health:

• Gradual start: The patient starts with light walking shortly after the surgery, and then gradually increases the duration and intensity of the exercises based on the recommendations of the medical team.
• Combining exercises: The exercise program should include aerobic exercises (such as brisk walking, swimming, cycling) and strength training to build muscle mass that may be lost with weight.
• Consistency: Exercise must become an integral part of the patient’s daily routine for life to maintain the lost weight.

Psychological Support and Support Groups

Adapting to the new life after bariatric surgery can be a psychological and emotional challenge, so getting the right support is essential:

• Follow-up with a psychologist: The patient may need to attend sessions with a psychologist to deal with changes in the relationship with food, body image, and other emotional challenges.
• Support groups: Support groups, whether face-to-face or online, provide a valuable platform for patients to share their experiences, exchange advice, and get encouragement from their peers who are going through the same journey.

Alternatives to Bariatric Surgery

For patients who do not meet the criteria for bariatric surgery or who do not wish to undergo a surgical procedure, there are other alternatives that can be explored. These alternatives range from non-surgical procedures to modern medications, and offer various solutions to the problem of excess weight:

Non-surgical Alternatives (Endoscopic)

These procedures offer less invasive options than traditional bariatric surgery:

• Gastric Balloon: A silicone balloon is inserted into the stomach through the mouth using an endoscope, and then filled with a saline solution to occupy space in the stomach and help create a feeling of fullness. The balloon remains for 6-12 months and is then removed.
• Smart Capsule: It is an advanced type of gastric balloon, where the patient swallows a capsule that dissolves in the stomach and releases a balloon that is inflated. After about 4 months, a valve in the balloon dissolves and it passes out of the body naturally.
• Gastric Botox: The stomach muscles are injected with Botox via an endoscope to slow down the process of stomach emptying, which increases the feeling of fullness for a longer period.

Pharmacological Treatments

The field of obesity treatment has seen great development in recent years with the emergence of effective weight loss medications:

• Weight loss injections: Medications such as liraglutide, semaglutide, and tirzepatide, which work by mimicking gut hormones to regulate appetite and blood sugar, have proven highly effective in achieving significant weight loss.

Costs of Bariatric Surgery Treatment

The costs of bariatric surgery vary greatly from one country to another, and are affected by multiple factors such as the type of surgical procedure, the hospital, and the experience of the medical team. The following table shows the approximate average costs of the most famous types of bariatric surgeries in a number of countries:

Note: These prices are approximate averages and may vary based on the factors mentioned above.

Bariatric Surgery Prices

The following is a list of the average prices of the most famous bariatric surgeries worldwide:

• Sleeve Gastrectomy: Its cost worldwide ranges between $8,000 and $25,000 USD.
• Gastric Bypass: Its cost worldwide ranges between $15,000 and $35,000 USD.
• Gastric Balloon: Its cost worldwide ranges between $2,000 and $8,000 USD, and the price depends on the type of balloon and the duration of its stay in the stomach.
• Mini Gastric Bypass: Its cost worldwide ranges between $10,000 and $20,000 USD.

The World’s Best Specialists in Bariatric Surgery

There are many distinguished surgeons in the field of bariatric surgery around the world, including:

• Dr. Michel Gagner
  • Location: Montreal, Canada.
  • Bio: Dr. Gagner is considered one of the pioneers of laparoscopic bariatric surgery in the world. He has made great contributions to the development of innovative surgical techniques, including the sleeve gastrectomy. He is known for his extensive experience and his research published in major medical journals.
• Dr. Kelvin Higa
  • Location: Fresno, California, USA.
  • Bio: A world-renowned surgeon in the field of complex and revisional bariatric surgeries. He has served as president of the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO), and is known for his expertise in handling difficult cases.
• Dr. Mathias Fobi
  • Location: Los Angeles, California, USA.
  • Bio: An innovative surgeon known for his development of the “Fobi Pouch” technique in gastric bypass surgery. He has decades of experience in the field of bariatric surgery and has performed thousands of successful operations.
• Dr. Ricardo Cohen
  • Location: São Paulo, Brazil.
  • Bio: One of the pioneers of metabolic surgery for the treatment of type 2 diabetes. He is the director of the Center for Obesity and Diabetes at the German Hospital Oswaldo Cruz, and is known for his pioneering research in this field.
• Dr. Jean-Marc Chevallier
  • Location: Paris, France.
  • Bio: A prominent surgeon in Europe and a former president of the French Society for Bariatric and Metabolic Surgery. He has extensive experience in a variety of bariatric surgery procedures and is an active contributor to research and international conferences.

Best Specialized Centers in Bariatric Surgery

Many medical centers around the world are distinguished by their comprehensive and advanced programs in bariatric surgery, including:

• Cleveland Clinic Bariatric and Metabolic Institute
  • Location: Cleveland, Ohio, USA.
  • Detailed Address: 9500 Euclid Ave, Cleveland, OH 44195, USA.
• NewYork-Presbyterian Hospital Bariatric Surgery Program
  • Location: New York, New York, USA.
  • Detailed Address: 161 Fort Washington Ave, New York, NY 10032, USA.
• Mayo Clinic Bariatric Surgery Program
  • Location: Rochester, Minnesota, USA.
  • Detailed Address: 200 First St. SW, Rochester, MN 55905, USA.
• Johns Hopkins Center for Bariatric Surgery
  • Location: Baltimore, Maryland, USA.
  • Detailed Address: 601 N Caroline St, Baltimore, MD 21287, USA.
• Duke Center for Metabolic and Weight Loss Surgery
  • Location: Durham, North Carolina, USA.
  • Detailed Address: 407 Crutchfield St, Durham, NC 27704, USA.

Frequently Asked Questions

Conclusion

In conclusion, bariatric surgery can only be seen as a powerful and effective tool that has the ability to change the lives of individuals who have long suffered from the burden of morbid obesity. It is not just an operation to lose kilograms, but the beginning of a new chapter of health, wellness, and self-satisfaction. However, it is of utmost importance to emphasize that this surgery is not a magic wand. Its true and sustainable success lies in the full commitment of the patient to changing their lifestyle, adopting healthy eating habits, and making physical activity an integral part of their day. The decision to undergo bariatric surgery is a fateful one that must be made after deep consideration and comprehensive medical advice, and when it is made correctly, it opens the door to a brighter, healthier, and happier future.