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There are several complications that can occur with weight loss surgery. The typical complications that we talk about (and this relates to any type of operation) would be bleeding, infection, injury to other organs, and the risks of general anesthesia. Specifically with weight loss surgery, there are some things that we get concerned about. When talking about either the sleeve gastrectomy or the gastric bypass – because both of those operations use stapling devices to both cut the stomach and to seal it, there is a risk that a patient can develop a leak where fluid actually leaks out of that staple line. That’s really concerning because a leak is the most common cause of death from either a sleeve gastrectomy or a gastric bypass. The leak rate nationwide is somewhere around 2-3%. However, the leak rate at well established and experienced practices such as ours is generally about 0.5%.
Other complications that we worry about would be: developing an intestinal obstruction and that’s something that you might see in a gastric bypass but would very rarely see in a sleeve gastrectomy or a lap band. With a gastric bypass, that would occur at a pretty low rate of about 1%. Other things that we worry about would be developing a blood clot in the legs and that blood clot can break off and travel to the lungs. Now this can happen in anyone who has any operation. However, patients that are morbidly obese have a much higher risk of developing blood clots. What we do is we administer a blood thinner to every patient that is having weight loss surgery and we give this right before the operation and we also give it after the operation until the patient leaves and goes home. This significantly reduces the risk of developing blood clots. However, because we are giving the patient a blood thinner, it does slightly increase their risk of bleeding. However, this risk of bleeding is very small and generally does not pose a problem for us or for the patients.
During the first 2-3 weeks after having weight loss surgery, most patients will experience some degree of discomfort from their incisions. They may also feel fatigued or tired because of the dramatically decreased calorie intake. However, that improves gradually with time and usually by the end of 2 or 3 weeks, most patients feel fairly well.
Patients are often are very eager to start exercising after they have weight loss surgery and that’s great – I encourage that. However, it’s important for them to remember that they cannot perform any strenuous exercises (meaning lifting weights greater than 20 pounds or running or doing sit-ups) for a period of 6 weeks. Once they’ve reached 6 weeks after surgery, they can go ahead and do any type of exercise that they want.
Having surgery is the most effective way to lose weight and to maintain that for the rest of your life. The success rate for weight loss surgery can be as high as 90%, but that really depends on the patient and how well they continue following this lifestyle change. The most important thing for the patient to remember is to remain engaged with either their physician or the weight loss surgeon that performed their operation. By that we mean that the patient should continue to come to the office for support groups and nutritional groups and for routine follow ups with their weight loss surgeon. Patients that remain engaged with the practice that performed their operation are definitely the most successful in terms of long term weight loss.
When an individual loses a significant amount of weight, it’s inevitable that their body changes in the way it looks. Sometimes, patients will feel like they’re concerned that they will lose too much weight. As a matter of fact, most people don’t lose too much weight, but it may look like a patient has lost too much weight to someone who hasn’t seen them for a long time and the last time they saw them, that person was 80 or 100 pounds heavier. One thing we do expect, though, is that patients will have some degree of laxity (or looseness) of their skin. Some patients will have very elastic skin that snaps right back and they really don’t have any excess skin to worry about. However, other patients (and I should say most patients) who lose a significant amount of weight will have some degree of saggy skin. Sometimes it’s not that much and sometimes there’s a large amount of skin that can be removed. Once it’s removed, an individual looks fairly normal.
When it comes to medications, there aren’t any particular medications that an individual needs to take before surgery. After surgery, we do give patients several prescriptions which may include pain medication, anti-nausea medication, and also medication to reduce the amount of acid that your stomach produces, which just helps with the healing process. Some patients are already taking multiple medications to treat their conditions, which might be for high blood pressure or high cholesterol. In general, we will have them continue taking those medications after surgery. However, we also monitor those patients very closely and most of the time we end up gradually weaning them off of his medications, which ultimately is the goal.
There is a genetic component when it comes to obesity. We don’t have a clearcut gene that we’ve identified, but it’s obvious that obesity runs in families where there are certain families (or even countries) where large populations of people and families are all morbidly obese.
Exercise and dieting – while very popular – are actually very unsuccessful in the morbidly obese population. Greater than 95% of people that are morbidly obese fail with diet and exercise, which means that surgery really is the only option.
After surgery, one of the main concerns that patients have is regaining weight. Although that can occur, as long as the patient continues to eat relatively healthy food, they eat small portions, and they continue to exercise, it’s very unlikely that that patient would regain weight. When you hear stories of patients regaining significant amounts of weight, it’s usually the scenario that that patient has stopped following all of the recommendations that we’ve given them and they are now eating junk food, eating a lot of carbs, eating a high volume of food, eating a lot of sweets, and generally eating foods that are unhealthy for them. If you follow our guidelines and adopt a healthy lifestyle, it will be possible for you to maintain a significant amount of weight loss for the rest of your life and probably be much healthier as well.
Follow up visits after having weight loss surgery are extremely important. In fact, it’s as important as having the operation itself. The importance of these visits stems from multiple factors: one, you want to go back and make sure that you are healing properly from the operation. Aside from that, it’s important to go back because visiting with your weight loss surgeon on multiple frequent visits also holds you accountable and helps to make sure that you adopt this healthy lifestyle and that you maintain this healthy lifestyle. The follow up visits that we expect patients to come for after surgery are the 1-week post-op visit, we then see our patients at 1 month, and then at 3-month intervals at 3, 6, 9, and 12 months. After 12 months, we see our patients 6 months later (at 18 months) and at 2 years. After 2 years, we continue to see our patients every year for the rest of their lives.
Having a thorough and robust aftercare program is important because that is the component that ensures the greatest amount of success for the patient. It is well documented that patients who are very well engaged with the office that they had their operation at that tend to be the most successful in terms of losing weight and keeping weight off for the rest of their lives.
The latest research on weight loss surgery is centered around diabetes and the ability of a weight loss operation to cure an individual with type 2 diabetes. A statement was recently released by the American Diabetes Association that strongly supported weight loss surgery as the primary source of cure for an individual with type 2 diabetes. For instance, if somebody has fairly significant type 2 diabetes, we may suggest the gastric bypass to them. Why? Because the gastric bypass is the most effective operation in treating type 2 diabetes.
Most insurance companies cover weight loss surgery. However, it varies from plan to plan, so it’s important for you to contact your insurance company to ask if the plan that you have covers weight loss surgery.
Weight loss surgery can be performed in an outpatient setting, which means that the patient would go home after spending a night in a recovery facility. The recovery from the actual operation is fairly quick in that most patients can go back to work at about 2-3 weeks.
The basic philosophy of weight loss surgery (and especially our philosophy on weight loss surgery) is that surgery is really just a tool to help you lose weight. It is not the answer. It’s not the magic pill. It’s not going to make you lose weight if you don’t participate and do your part in this process. The idea behind surgery is that we make your stomach smaller so that you eat less food and you’re not nearly as hungry anymore. After that it’s the patient’s job to make the right food choices and eat healthy food and all sorts of exercise and without those two other components that the patient has to participate in, that patient won’t be successful when it comes to weight loss surgery. It is just a piece of the puzzle, but patients definitely have to participate in what we call a lifestyle change and they have to maintain this lifestyle change for the rest of their life.
Body image is a very important concept and I think in the modern era we are trying to teach people that you have to be comfortable with your own body and you shouldn’t let people tell you what you should look like. The flip side of that is that there are patients out there who are morbidly obese who are comfortable in their skin and they ask: “Why should I have weight loss surgery?” The answer to that is: Yes, it is important to be comfortable with your body. On the other hand, it’s not safe to be morbidly obese for the rest of your life because most people that are morbidly obese will develop complications of obesity and those complications include things like: type 2 diabetes, high blood pressure, high cholesterol, heart disease, sleep apnea. All of these things can be potentially fatal to an individual if left unchecked. Weight loss surgery is a really important for anyone that is morbidly obese.
The main qualification to have weight loss surgery is based on an individual’s body mass index (or BMI.) This is something that’s easy to calculate and is really just a formula that takes your height and weight into consideration and it spits out a number. In order to have weight loss surgery and to have your insurance company cover it, a patient needs to have a body mass index of 40 or greater if they have no medical problems. Or it can be as low as 35 and greater if they do have some medical problems that are related to their weight – things like diabetes, high blood pressure, high cholesterol, and sleep apnea, for example.
The medical problems that you can develop from being morbidly obese are things like: type 2 diabetes, high blood pressure, high cholesterol, sleep apnea, heartburn and reflux, problems with your bones and joints, and the list goes on and on.
People often wonder: “how much weight am I going to lose?” It really depends on multiple factors: the first of which would be: “which operation did you have?” With the lap band, the weight loss that a patient can experience afterwards is quite variable. On average, we somewhere around 45% excess body weight loss, which means 45% of however much a patient weighs is what what they will lose. So if an individual weighs 100 pounds over their ideal body weight, they would typically lose about 45 pounds with a lap band. With a sleeve gastrectomy, we see about 60% excess body weight loss, meaning an individual that is 100 pounds overweight will lose about 60 pounds. With the gastric bypass we typically see about 65-70% excess body weight loss.
Patients often hear that having weight loss surgery will cause them to lose about 100 pounds and that’s really not true. That’s a generic number that’s often thrown around. The reality is: each one of these operations results in a specific amount of weight loss and that weight loss really is a percentage of how much overweight that patient is. So if a patient is 100 pounds overweight, we might expect them to lose anywhere from 60-70% (or 60 to 70 pounds) for a given operation. The weight loss that a patient experiences after surgery usually peaks at somewhere about a year to a year and a half after surgery. There are some patients that might lose the weight very rapidly and lose all their weight in 6 months, whereas other patients may take an entire year and a half to lose all over their weight. In the end, it really doesn’t matter how quickly you lose the weight, it’s just important that ultimately you lose the amount of weight that we expect to lose.
In the United States, we have an obesity rate of about 30% and that translates to about 20 million Americans who would potentially qualify to have weight loss surgery. Unfortunately, we only perform about 350,000 operations a year in this country, which means that there is a huge population of patients out there that could benefit from weight loss surgery and aren’t taking advantage of it.
Patients come to me to have weight loss surgery for all different reasons. Sometimes it’s the patient themselves who realize that one day they look in the mirror and say, “you know what? I am way too heavy, I have too many medical problems and it’s time for me to lose weight.” Other times it’s that patient’s doctor who tells them that they need to lose weight because of all of their medical problems. Other times, it’s somebody like an orthopedic surgeon or a spine surgeon who tells their patient: “Look: before I can fix your back or I can fix your knees or hip, you need to lose a significant amount of weight and therefore you need to say a weight loss surgeon.”
Because weight loss surgery is a major operation and can be complicated and has significant effects on your health, it is important for you to see multiple specialists when being considered for weight loss surgery. That usually includes seeing the surgeon, a gastroenterologist, a dietician, and a psychologist, to start. These specialists will determine if both your body and your mind are healthy enough to undergo the rigors of weight loss surgery.
When selecting your weight loss surgeon, it’s important to look for a practice that offers a comprehensive and multidisciplinary weight loss program, which includes a robust aftercare program with things like support groups, nutritional groups, and frequent follow ups with the physician.
When you come into our office for a consultation, you generally first see myself or one of my colleagues that are weight loss surgeons. After that evaluation, if we feel that you are an adequate surgical candidate, we then have you see our dietitian for an evaluation. Then we have you see our psychologist for a mental evaluation. Then after that, we also have you see a gastroenterologist who performs and upper endoscopy at some point to look inside of your stomach and make sure that your stomach is healthy enough to undergo an operation. Patients that are old enough will be sent for a stress test to evaluate their heart and if there are any other tests that need to be done to evaluate a patient’s health in regard to being prepared for surgery, we will order those tests as well. Once all of these evaluations are completed, we meet with the various other specialists and if everybody agrees that a patient is a good candidate for surgery, we then go ahead and schedule the patient for surgery.
There are various types of weight loss operations. The most commonly performed weight loss operations in this country would be the gastric bypass, the sleeve gastrectomy, and the lap band. The gastric bypass has been around for over 50 years and is still considered to be the gold standard when it comes to weight loss operations. The sleeve gastrectomy is relatively new in that it has only been around for about 7-8 years but it has now become the most common (or the most popular) weight loss operation. The lap band (otherwise known as the adjustable gastric band) has been around for about 20 years and at one point was the most commonly performed weight loss operation in the United States and in other countries around the world. However, currently it only accounts for about 5% of all of the weight loss operations. Bariatric surgery is a term used to cover all different types of weight loss operations, and that typically includes the sleeve gastrectomy, the gastric bypass, and the lap band.
Weight loss surgery is for anyone that is what we would consider morbidly obese. It’s not for someone that is only 20 or 30 pounds overweight. It’s generally for people that are roughly 100 pounds overweight and those patients definitely need to lose weight because of all the different medical problems that can develop as a result of them being morbidly obese.
After having a consultation with a surgeon, most patients will require anywhere from 6 weeks to several months before they actually have the operation. During that period of time, it allows them to see all the various specialists like the dietician and the psychologist and the gastroenterologist. Sometimes they also need to see a cardiologist or a pulmonologist (which is a lung doctor) to make sure that that patient is optimized for that operation.
There are risk factors for having weight loss surgery and these risk factors can increase your complication rate. However, when it comes to weight loss surgery, it’s often the sickest patient that stands to benefit the most. So take a patient, for instance, that has type 2 diabetes and they have high blood pressure and high cholesterol and heart disease. You might typically think, “well, gee, that’s the type of person that I really don’t want to operate on.” However, that type of patient is really the one who needs it the most. We recognize that they have those risk factors, but if the patient is healthy enough and they undergo a rigorous series of tests to make sure that they are healthy enough, then we will go ahead and perform the operation. The great thing is that many of these medical problems will either improve or completely resolve after the patient does have weight loss surgery.
The sleeve gastrectomy is an operation in which we take the stomach (which is about the size of a football) and we remove about 85% of the stomach and take that out and discard it. What you’re left with is a stomach that is in the shape of a tube which kind of looks like a banana. Because of that, patients are able to eat much less food and that in turn causes them to lose a significant amount of weight. This operation is permanent and is a lifelong change for the patient.
Prior to surgery, we do not require patients to go on any specific or special diet to lose weight. However, early on in the process (in fact, right after I have my consultation with a patient) we begin working with them to help them to change their lifestyle and start eating healthier foods and to start exercising. In general, we expect to see patients lose some degree of weight prior to having surgery. If a patient continues to gain weight or gains a tremendous amount of weight prior to having surgery, that really tells us that they’re probably mentally not prepared and not ready to have surgery at that time. We’ll hold off until we are sure that that patient is ready to have surgery.
One of the most common questions I get from patients is: “which operation should I have?” That is actually one of the tougher questions to answer. There’s no one right answer for everybody, but there are guidelines that we go by and suggestions that we may give the patient. For instance, if somebody has fairly significant type 2 diabetes or they have horrendous heartburn and reflux, we may suggest the gastric bypass to them. Why? Because the gastric bypass is the most effective operation in treating type 2 diabetes and it is also an anti-reflux operation and usually cures an individual of their heartburn and reflux. On the other hand, if a patient has a strong family history of stomach cancer, let’s say that their mother or their father or their brother or some other relative has had stomach cancer and they are at an increased risk of that, we may suggest performing a sleeve gastrectomy because we are removing 85% of that patient’s stomach and that in turn reduces their risk of getting stomach cancer. It is also much easier to monitor a patient that has had a sleeve gastrectomy for screening with an upper endoscopy to check and see if they do have stomach cancer. With the lap band, that is generally a choice that the patient makes. Lap bands are the safest operation when it comes to the weight loss operations and it is also reversible. Because of that fact, patients often select the lap band because of those features. However, it’s important to note that the lap band does result in the least amount of weight loss when compared to the sleeve gastrectomy and the gastric bypass. When considering weight loss surgery, it’s important to have a lengthy discussion with your weight loss surgeon to decide which operation fits you best.
The newest procedure that is available to patients in the United States is the intragastric balloon. There are various types of balloons, but this is one of them. This is a saline filled balloon and the outside is made out of silicone. What we do is we place this inside of a patient’s stomach when it’s empty and we begin inflating it with fluid and once it’s fully inflated, we pull on the tube (which gets disconnected from the balloon) and the balloon stays inside of the patient’s stomach. The idea behind this device is that it takes up space within the stomach, so you can’t eat a lot of food. It also has weight to it. 600 cc’s of fluid does have some heft to it, so it also feels like you have eaten a large meal. Therefore most patients have a sense of fullness within their stomach and in the end, you end up eating less and losing weight.
The gastric bypass is an operation in which we take the stomach and we cut off the upper portion of the stomach and create that as your new stomach pouch. So a patient’s stomach goes from the size of a football to being the size of a large egg. We then cut the small intestine lower down and we bring that up and we connect it to the stomach pouch so that the food can go into the stomach pouch and directly into the small intestine. When you do that, you end up bypassing the old stomach and you bypass part of these beginnings of the small intestine. People lose weight for multiple reasons with the gastric bypass: 1. They have a small stomach so they can’t eat very much fruit. 2. We are bypassing part of the old stomach and the small intestine and by doing that, patients absorb a little bit less food than they normally would. The third reason why they lose weight is that by causing the food to go directly into the small intestine, patients generally cannot tolerate eating sweets. By that I mean that they can’t tolerate eating ice cream or cake in any large quantity. If they do, they experience something called Dumping Syndrome, which is a combination of symptoms that include a stomachache, diarrhea, cold sweats, and a racing heartbeat. Obviously, that doesn’t sound very good and it is very uncomfortable, but it’s quite effective in causing patients or restricting patients from eating sweets.
My name is Dr. Kai Nishi. I am a minimally invasive surgeon – which means that I do laparoscopic and robotic surgery. I did all of my training at Cedar Sinai Medical Center and then I was hired by the hospital and I worked there for several years where I gained a lot of valuable experience. After that, I went into private practice with a few of my partners and that is where I had been for the last seven years.
The benefits of weight loss surgery include being able to get rid of your health problems like high blood pressure, high cholesterol, and diabetes. It also allows you to do things that you never thought were possible like running in the park with your children or going on rides at an amusement park. Basically – weight loss surgery can change your life.
Weight loss surgery is probably the healthiest thing that a morbidly obese individual can do for themselves. Most patients that are morbidly obese have some sort of comorbidity or medical problem – whether it’s diabetes or high cholesterol or hypertension. In general, when an individual has weight loss surgery, most of these medical problems get better or they completely disappear and in the process the patient becomes healthier.
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