Chapter 1

Welcome to the ultimate guide to bariatric surgery for beginners!

This document has been prepared by Dr. Ceyhun Aydoğan in 5 sections in order to help obese patients, who are considering excess weight loss surgery, gain accurate insights on the types of surgery, their risks, diet before and after surgery, and the average cost of each surgical procedure

You might feel depressed, isolated, and be suffering both mentally and physically. You might find yourself alone in this process and feel like no one else understands what you’re going through. To be honest, you’re not the only person feeling disappointed because of obesity-related difficulties. 

Just take a look at the map below to see how many people are dealing with the same challenges as yours. 

Obesity Statistics

According to WHO, in 2016, there were about 1.9 billion obese people in the world. See? You are absolutely not alone!

Weight loss surgery has raised in popularity over the last decades due to the increase of severe obesity in different parts of the world because when exercise and diet can’t eliminate extreme obesity, surgical options are the final solution to enhance obese patients’ health conditions.

The variety in surgical procedures and methods used in these operations has led to the invention of different types of weight loss surgery including gastric bypass, gastric sleeve, biliopancreatic diversion, and so on. 

This variety acts as a double-aged sword since having more options brings about more confusion as well. But no worries at all! After reading this beginner-level series you will have more than enough information about bariatric surgery and will be able to easily determine the most suitable type of weight-loss operation for your situation.

To evaluate your knowledge of bariatric surgery and find on which topics you need more information, just take a look at these questions and see if you have the answers:

1- Do I know weight loss surgery pros and cons?

2- Am I aware of the changes I have to make after the procedure?

3- Do I know the qualifications for weight loss surgery? Is bariatric surgery right for me?

4- Is bariatric surgery covered by medicare?

5- Am I ready to make a lifelong commitment to change my lifestyle?

6- Do I know how to prepare for this journey?

So, have you got sufficient information on this topic? If not, no worries at all. By the end of this guide, you’ll have more than enough information to make the best decision. 

What Is Bariatric Surgery and How Does It Work?

Bariatric or metabolism surgery are the names generally given to all types of weight loss surgery, mainly because they directly affect surgical patients’ weight and metabolism to enhance the quality of their lives. 

These types of surgery are performed when excessive weight cannot be lost through changes in lifestyle and exercise. 

Most of the patients who have decided to have an obesity operation are under the impression that gastric reduction operations are only tube stomach (vertical sleeve gastrectomy) operations. However, this is not the case.

Does Bariatric Surgery Work?

Morbid obesity creates serious health problems that can be solved to a high extent, in some cases completely, by choosing the right type of surgical treatment for adolescent obesity. These problems include:

– High blood pressure

– Type 2 diabetes

– Obstructive Sleep Apnea 

– Depression, anxiety, and other psychological challenges

– Snoring

– High cholesterol

– Fatty liver disease 

– Kidney diseases

– Gestational diabetes

– Cancer

– PCOS and other pregnancy problems 

– Heart disease

Unfortunately, the list does not end here. But, having to deal with even one of them can turn your life into a nonstop nightmare. 

You might have tried tons of diets and plans to get rid of the excess weight, but not have been successful till this moment. Luckily, there is one solution that almost all obesity specialists have recognised as the most effective solution for sustained, long-term weight loss with a notably high success rate.

Cancer

The reason for devoting one section to cancer is that even though most people are aware of some problems related to obesity, especially cardiovascular, liver, and kidney diseases, but unfortunately, not a lot of people are aware that obesity raises the possibility for different types of cancer.

Obesity and Cancer

Bariatric Surgery Requirements

Before moving forward, you must know who qualifies for bariatric surgery. Let’s overview the features of the best candidates for bariatric surgery.

  • Psychiatric Evaluation

First of all, it is necessary for patients to pass a psychological evaluation so that a specialist can find out whether they’re mentally ready or not. 

The purpose of this evaluation is to determine the patient’s psychological readiness for the operation and gather information about their behaviors such as motivation about the operation and self-preparation.

  • BMI > 40

Candidates for bariatric surgery must tick some other boxes as well. Except for passing the psychiatric evaluation, you must have a body mass index (BMI) of 40 and above. 

BMI Chart

In case of complications such as type 2 diabetes, high blood pressure, or sleep apnea, the necessary amount of BMI is between 35 and 40.

  • Not Being a High-risk Patient

Pre-surgery check-ups should prove you’ve got no medical conditions that put you in the group of high-risk patients. Also, you should be mentally ready so that post-surgery depression is avoided as much as possible. 

If you have these requirements, make sure to check out the next section, Chapter 2, where you will be provided with information about the types of stomach reduction surgery.

How Old You Have to Be to Get Bariatric Surgery

Regarding the age of patient characteristics and age, there are two groups that are not advised to undergo weight loss surgery.

– The first group is children, basically, anyone under 14 who has not undergone puberty yet.

Even though childhood obesity causes serious problems that jeopardize their health, surgical solutions will also affect children’s health. Therefore, most doctors tend to control these complications using nonsurgical methods until they grow up.

Moreover, for obese patients under 18 doctors do the examinations very carefully and make the final decision according to their overall physical and mental circumstances. 

– The second group are people above the age of 65 who have weaker mobility and general health.

Before undergoing bariatric surgery, an experienced surgeon will make sure the obese patient is not a high-risk one. This determination is mostly done through cardiology and lung assessments

Who Is Not a Good Candidate for Bariatric Surgery?

If you have at least one of the below-mentioned conditions, then you should reconsider your decision on surgical options: 

– Being medically fragile

In case you have a serious chronic illness, cardiovascular complications, or spent more than one month in the hospital during the last month, you are considered as medically fragile. This term includes other conditions as well. That’s why you should provide your doctor with all your medical history. 

Psychiatric disorders, significant eating disorders in particular 

Not willing to change your lifestyle, for instance, quitting smoking and doing exercise

Alcohol addiction

In case you want to know who qualifies for bariatric surgery and all the characteristics of good candidates, in a nutshell, take a brief look at the table below.

Bariatric Patients

Bariatric Surgery Statistics

As one of the types of invasive surgery, weight loss surgical options mostly bring about some concerns related to life after surgery its success rates, and complications. 

This is a very sensitive matter and cannot be covered in a few paragraphs. So, to complete this puzzle, you’d better read the third chapter, which is about all the risks after the operation. 

But for now, you should know the failure rate of bariatric surgery has decreased in the last decade and is getting even lower with all the study and research done in this field alongside the improved proficiency of bariatric surgeons. 

Also, these risks are not the same for all people and differ from person to person depending on each individual’s overall situation. 

Weight Loss Surgery Options

Gastric reduction surgeries performed with laparoscopic (closed) methods are basically divided into two groups known as restrictive and malabsorptive (absorption preventer) operations.

However, some types of procedures are considered as combinations of the two as some features of both of these methods are mixed during their processes. 

1- Restrictive Surgery

Any surgical procedure performed on the shape of the stomach to restrict food coming into the stomach is called restrictive weight loss surgery. For example; sleeve gastrectomy is such an operation. During this operation, only the shape of the stomach is manipulated.

During restrictive procedures, the stomach size will be decreased by at least one quarter. 

2- Malabsorptive Surgery

On the other hand, malabsorptive stomach reduction operations aim to reduce the amount of food absorbed by the small intestine by performing operations related to the size and position of the intestine. Gastric bypass surgery is an example of such an operation.

Detailed descriptions plus photos of these procedures are provided in the next chapter.

What Is the Process of Bariatric Surgery?

All types of bariatric surgery generally go through three main stages:

1- An intravenous line will be started using IV pain medication. 

2- General anesthesia is required in order to put the patients to sleep. 

3- Finally a breathing tube will be inserted into the patients’ windpipe to streamline breathing through the operation and the operation begins.

Bariatric Surgery Effectiveness

According to the University of Iowa Hospitals & Clinics, during the first six months after the surgery, on average most patients with obesity lose 40 percent of their excess weight. This number will add up to 77% one year after the operation. 

To what extent you lose weight and how long you will be able to keep your ideal weight depends highly on yourself. Preventing weight regain is only possible if you manage to keep a healthy lifestyle for the rest of your life, which requires a healthy diet and eating habits alongside regular, appropriate exercise. 
Let’s have an overview of what you’ve learned so far, and what you’ll read in the next sections.
All about bariatric surgery

Pros and Cons of Weight Loss Surgery

Advantages

As you lose weight and become lighter, your ability to move increases, hence becoming more active. Enjoyable activities you found impossible to do in the past will become sweet again. As your new life begins, you’ll be able to walk, swim, do yoga, and do any other physical activities you were unable to do before. Even talking about it is intoxicating, isn’t it?

On top of that, all the previous physical and mental complications you had to live with due to excess obesity will be out of your life. Let’s take a look at some of the life-changing effects of weight loss surgery.

  • Sustained, effective weight loss
  • Improving patients’ body image 
  • Improved fertility in women (the ones with PCOS in particular)
  • Enhanced quality of life
  • Long-lasting resolution of type 2 diabetes 
  • Long term psychological effects (decreased level of anxiety and depression due to excess obesity) 
  • Reduced risk of cardiovascular disease
  • Improvements in dyslipidemia, hypertension, and other metabolic comorbidities related to obesity

Disadvantages

Like all the other medical treatments, bariatric surgery has its own side effects. However, this does not mean that you will necessarily experience all of them. Here’s a list of major complications of bariatric surgery. 

  • Dumping syndrome 
  • Nausea
  • Abdominal cramps
  • Hernias
  • Low blood sugar
  • Vomiting
  • Malnutrition
  • Hair loss
  • Loose skin
  • Psychological side effects (depression, changes in social relationships, etc)

Let’s weigh your life before bariatric procedure against after it.

Life Before and After Bariatric Surgery

Preparing for Bariatric Surgery

First of all, you have to visit an expert in order to understand whether you qualify for surgery or not. After the initial observation, your doctor will provide you with some guidelines on how to prepare for the surgery, which also includes some medical tests to analyze your overall circumstances.

Some of these tests are:

– Chest X-ray 

– Cardiac evaluation 

– Urinalysis 

– Complete blood count

Afterward, your bariatric surgeon will give you advice on the types of operations and together you make the final decision. Your surgeon will let you know which type he finds better for you based on some factors including your history of surgery, eating habits, overall physical and mental situation, and BMI. 

Final Step

Once you’ve set the date for your surgery, it is time to start making changes in your life:

– Quit smoking cigarettes and limit drinking alcohol.

– Inform your doctor of your medications and the history of your previous complications and surgeries. 

– Add simple, yet regular exercise to your daily life.

– Practice eating in accordance with a healthy diet (suggested by your doctor).

– Implement new eating habits; for instance eating slowly and not eating solid food and liquids simultaneously. 

– Educate yourself by reading more about your life before and after bariatric surgery and the changes your body will go through.

– Take multivitamins (consult with your dietitian).

– Clarify your weight loss expectations for your doctor and consult with them in order not to have any unrealistic expectations.

Weight Loss Before Bariatric Surgery

Most patients worry about whether they must lose weight before bariatric surgery procedures or not. First and foremost, you should know that one of the factors that directly increases the failure rate of weight loss surgical options is severe obesity.

Therefore, most doctors ask their patients to lose some weight and provide them with helpful advice in addition to diet and exercise schedules so that they can achieve this goal.

This schedule mostly includes eating healthy food in addition to adding regular activities to your life. 

Life After Bariatric Surgery

There are concerns patients might have that are related to the time right after the surgical procedures. Some of these concerns are:

– How long is the recovery time?

– How much pain one might have to tolerate?

– What to eat and what not to eat?

– What are the complications, right after the surgery?

and so on and so forth.

On the other hand, there are some other worries that although they might happen sometime after the surgery, yet still are important.

– Is life after gastric sleeve different from gastric bypass?

– Will I regain weight? If yes, when and why? 

– Will the limitations in my food intake affect my health? 

– When will I reach my healthy weight?

Each of these questions is so important that one separate article can be devoted to them. However, we’ve tried to give you a brief, yet all-encompassing overview of the answers.

Recovery Time After Bariatric Operations 

Most bariatric operations are done using laparoscopic surgery procedures. Due to the small cuts that are made during these procedures, the initial recovery process usually does not take more than 2 to 3 days.

In case of further complications, you might need to stay longer in the hospital to have your circumstances checked by your doctor. 

Depending on the type of your surgery you should rest between 3 and 5 weeks after leaving the hospital and then you’ll be able to restart your normal life.

Average Weight Loss After Bariatric Surgery

Even though your weight loss progress differs after each type of surgery, both in terms of pace and quantity, its average amount is somehow the same, especially in the long run. 

You can expect 35 to 45% loss of your excess weight after the simple ones. However, with more complicated procedures like gastric bypass, your body will lose 75% of its excess weight. 

For more details, make sure to carefully read chapter 2 where you’ll learn more about the exact differences in weight loss between various types of bariatric surgery. 

Moreover, the overall expected weight loss after bariatric surgery depends on other factors including genetics, age, sex, etc, which is exactly why you should consult with your doctor and have realistic expectations before you agree to undergo an operation. 

How Long Can You Return to Work After Bariatric Surgery

It mostly takes two to three weeks for gastric sleeve surgery and gastric bypass patients to go back to work. Some patients might feel better and ready to get back to work within at most a month. 

However, the exact recovery duration before going back to work depends on the type of surgery as well as your body’s response to it. 

ّFollow-ups After Bariatric Surgery

If you ask for one definite solution that will minimize post-operation complications it is for sure follow-up sessions. Why?

– First and foremost, you cannot be sure whether your surgery was successful or not at the time of discharge. During follow-up sessions, your weight loss process and overall circumstances will be closely examined and you’ll be certain when your doctor tells you everything has gone well.

– Second of all, malnutrition is the one complication that can be eliminated simply by having the right diet and taking the necessary supplies. With the help of your dietitian, probable nutritional deficiencies will be diagnosed and treated. 

– Last but not least, during follow-up sessions dumping syndrome and the other side effects of bariatric surgery can be diagnosed in the early stages. Therefore, you’ll be able to control and cure them before it gets severe. 

When Can You Take a Shower?

After 48 hours of your surgery, you can take a shower, but you’re not allowed to stay in a bathtub. For that, you should wait about one week. 

How You Should Take Care of Your Wounds After Weight Loss Surgery

Your wounds are not very big and are mostly small incisions because of the laparoscopic surgery. Some bandages that look like white tapes are placed on these small spots. 

If they become a little red or white or yellow liquids come out of them, do not worry, it is very normal; unless it becomes excessive. 

If the bandages don’t fall after 5 to 7 days, you can take them off yourself. 

Check them every day. If you see any signs of infections, or the liquid becomes smelly and more than usual, call your doctor. 

The scars may still stay a bit red or purple depending on the type of your skin. If you don’t have any marks remaining at all, use sunscreen whenever your abdominal skin is exposed to the sun. 

How to Manage Pain

Don’t forget that you have experienced an operation. Of course, you’ll have some pain, especially from your incisions. But it becomes better during the first three days.

Your doctor will prescribe some painkillers before you are discharged. The key point is not to let your pain become intolerable. According to this pain scale, take your pills whenever you feel pain between 3 and 4. 

If you feel like your pain is not decreasing every day, or weeks have passed but it is not completely gone, you should give your doctor a call. 

Also, if your bariatric surgeon gave you other instructions while using the painkillers, make sure to follow them. 

Keep Yourself Motivated

There might be times after the surgery that you’ll feel demotivated to stay committed to the changes you’ve made in your life. Here are some tips that will help you regain your motivation:

Carry on with Your Journey

Believe it or not, you just took the first step of your bariatric surgery journey. But you only have a general image of what it is and there are still essential pieces to complete this puzzle and decide whether you want to have bariatric surgery and if yes, which type suits you best, what its risks are and where to have the surgery to enjoy both the most affordable prices and ultimate expertise. 

Let’s move on to the next chapter to read everything about weight loss surgery types.