Derek Burnett
Derek Burnett is a Contributing Writer at Bottom Line Personal, where he writes frequently on health and wellness. He is also a contributing editor with Reader’s Digest magazine.
We all know that weight loss isn’t easy. People who put in lots of effort sometimes fail to see sufficient results, and others who manage to drop serious weight through hard work and self-discipline sometimes gain back the pounds, leaving them to wonder if it was all worthwhile…or if there’s a better way. If you fall into one of those categories, you may have begun to entertain the idea of weight-loss surgery as an option.
The good news is, surgeons have made great advances in this field in recent decades. What used to be a high-risk, somewhat uncommon procedure is now much safer and effective than it used to be, with several different options available to patients today.
Surgery should always be carefully discussed with your doctor. Specialists will want evidence that you have tried and failed to lose weight by other means, and that you’re healthy enough to undergo surgery. They’ll also want to be sure you understand the risks and that you’re prepared to undertake significant lifestyle changes after surgery, including lifelong follow-up care, possible nutritional supplementation, and avoiding certain foods to prevent side effects. Out of those conversations, if you and your doctors agree that surgery makes sense, you will discuss which type of surgery is most appropriate. That decision will largely be driven by the severity of your obesity and your other health factors.
To understand how these surgeries work, it’s first important to know a bit of the latest science about obesity. This condition is no longer considered a personal failing, but rather a disease. Nor is its description limited to the carrying of excess body fat. Instead, it has several key characteristics, one of which is dysregulation of certain hormones.
Our hormones travel back and forth from our digestive systems to our brains in a constant conversation about food. The hormone ghrelin tells us that we’re hungry and should eat. Two other hormones, leptin and GLP-1, tell us that we’ve had enough and should stop eating. In people with obesity, the body’s internal conversation about hunger and fullness is impaired. Surgery can help correct it.
This fact surprises many people who think of weight-loss surgery more mechanistically, as a way of reducing the size of the stomach so it will hold less food and people won’t eat as much. Today’s surgeries may indeed remove portions of the digestive tract, but they do so not simply to reduce the organs’ size, they remove cells that produce ghrelin, the hunger hormone. Once the stomach stops sending constant hunger signals to the brain, the patient is better able to regulate their fullness.
These days, there are three main “workhorses” of the world of bariatric surgery. While a few other options do exist, the vast majority of patients who sit down with a bariatric surgeon to discuss their choices will be talking about these three. Unlike in days of old, they are all endoscopic and minimally invasive procedures.
Sleeve gastrectomy. In this operation, the surgeon removes 85% of the patient’s stomach, leaving an organ about the size and shape of a banana. Again, the purpose is not to punish the patient for their inability to put down the fork, nor to make their stomach so small that the patient is incapable of overeating. Instead, the surgeon is targeting the portion of the stomach containing its greater curve and its fundus, regions that are home to the majority of ghrelin-producing cells. The physical removal of these tissues results in a correction to the hormonal signaling. Weight loss after this surgery often amounts to 25% to 40% of body weight. Sleeve gastrectomy is often recommended to younger, healthier patients whose obesity is not as severe.
Roux-en-Y gastric bypass. Often considered the gold standard of bariatric surgery, the Roux-en-Y (pronounced “Roo N-Y”) is a two-step procedure involving both the stomach and the small intestine. The surgeon creates a small pouch in the stomach which is connected directly to the small intestine. It’s called a “bypass” because food that the patient eats goes from that stomach pouch straight to a relatively distant point along the small intestine without ever encountering other parts of the stomach or intestine. Because food is absorbed into the body during its time in the intestine, skipping over large parts of the intestine means more food will pass through your digestive tract without being absorbed. And just as with the sleeve, bypassing those sections of digestive anatomy brings about profound hormonal changes that, in some patients, result in up to 50% loss of body weight. Roux-en-Y bypass is reserved for severely obese patients with comorbidities, including type 2 diabetes.
Duodenal switch. This is both the most complex and the most effective of the weight-loss surgeries. It combines a gastrectomy with a bypass. In other words, just as with the sleeve gastrectomy, a portion of the stomach is removed, and just as with a Roux-en-Y gastric bypass, the path from the reduced stomach is rerouted to skip over a portion of the intestine (but even more of the intestine is bypassed with the switch than the with Roux-en-Y). Sometimes these two components of the surgery are done in one operation, or they may be performed separately. Patients undergoing the duodenal switch may lose 70% to 80% of their weight. Switch procedures are performed on patients with clinically severe obesity, typically with a body mass index of 50 or greater. Because the procedure is more involved than a simple sleeve or bypass, it has a higher rate of complications.
Patients often ask doctors, “How much does weight loss surgery cost?” Unfortunately, medical billing is so complex that the answer can vary quite widely depending on the facility, the physician, and the insurance company. Some patients end up paying as little as $7,000 and others as much as $30,000. Insurance can drastically reduce out-of-pocket costs. Unfortunately, only 1% of patients are covered for these procedures.
All surgeries carry risks, and in this case the operations are performed on crucial organs. However, the safety profiles of these procedures have steadily improved, and today these surgeries are statistically as safe as a minimally invasive gallbladder removal. Acute post-surgical risks include wound infection, blood clots, bowel blockages and a leaking small intestine. Fortunately, these are rare.
Almost all patients spend one night in the hospital and go home the next day. They’re discouraged from heavy lifting and strenuous activity for six weeks. For the same six weeks, they’ll eat a modified diet under doctor’s orders, gradually working their way up to normal foods.
Patients who have undergone duodenal switch must forever afterward be careful not to take in an excessive serving of fat or sugar, such as scooping a fingerful of icing off a cake. This can trigger a condition known as dumping syndrome which, while unpleasant (it involves cramps and diarrhea) is not life-threatening. And because so much of the intestine is bypassed in these patients, some might have trouble absorbing enough nutrition from their food and will therefore need to take daily nutritional supplements and undergo periodic testing for deficiencies.
The short answer is, “It’s up to you.” A 2023 analysis led by Ohio State University researchers found that between 37% and 76% of bariatric-surgery patients experience significant weight regain in the years following their operations…which is largely due to the resumption of old habits, a sedentary lifestyle, “grazing” behavior, and overeating.
Therefore, weight-loss surgery should not be thought of as a one-shot, permanent fix, but rather as a jump-start to a new lifestyle. If you opt for surgery, go into it thinking that it will help you make permanent changes to your shopping, cooking, and eating habits, as well as your exercise regime, and will set you on a new path toward a lifetime of healthy living.
