There is a strong perception out there that people who have bariatric surgery will often regain the weight they lost. It seems that individuals that I talk to about my experience have stories of friends or acquaintances who had the surgery and then regained the weight. I have several of those stories myself. It seems like there are fewer stories about long term successes. A nurse friend said that while the surgery works for some, most people will regain weight and that is why insurance doesn’t often cover the procedures. I would like to discuss in this entry the possible reasons for weight loss failure including the surgical procedure itself, pre- and post –surgical counseling and support, and the emotional side of eating.
The surgical procedures
There are generally four basic surgical procedures available for bariatric patients. There are some significant variations between the surgical procedures, and are based upon individual surgeon’s preferences. The general procedures are all are based upon one basic principle. That is the restriction of food input. How that is accomplished varies with the procedure selected by the surgeon.
The general procedures are the Lap Band, vertical gastrectomy, Roux en Y gastric bypass, and the duodenal switch. The procedures are either mechanical (Lap Band and the vertical gastrectomy) or what I call mechanical/physiological (Roux en Y gastric bypass, and the duodenal switch). Mechanical surgery rather simply reduces the physical capacity of the stomach and restricts the volume of food that can be ingested at one time. The Roux en Y gastric bypass and the duodenal switch are more complex procedures that reroute the movement of food from the esophagus directly into the intestinal tract, and while providing restricted eating also alter the actual physiological processing of the food in the digestive tract where almost all digestion actually takes place.
For the insertion of the Lap Band a small tunnel is made behind the top of the stomach to let the device through and allow it to be wrapped around the upper part of the stomach, like a wristwatch. It is then locked securely in a ring around the stomach. This creates your new, smaller stomach pouch. The rest of the lower stomach will stay in its normal position. A small access port, which is used for band adjustments, is fixed just underneath the skin. The access port is used by the surgeon to inject saline (sterile salt water) into the band when you have an adjustment.
The Duodenal Switch procedure is also called the vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) and by limiting the amount of food that is absorbed into the body (intestinal bypass or duodenal switch). It is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to augment and help maintain long-term weight loss. Of the procedures that are currently performed for the treatment of obesity, it seems to be the most powerful and effective, but may also have more complications associated with it. Most surgeons do not perform this procedure because of the overall concerns about the long term effects of malabsorption.
In the Vertical Gastrectomy (VG) the stomach is divided vertically and more than 85% of it is removed through the small incision in the abdominal wall. This procedure is not reversible. The stomach that remains is shaped like a banana and measures from about 4-7 ounces (120-250cc) in volume depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. In the Roux-en-Y gastric bypass, the stomach is divided, but not removed, and the pylorus is excluded. The esophagus and a portion of the stomach muscle are then connected to the lower part of the duodenum (first section of the small intestines). The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary as can the Lap Band.
The Roux-en-Y gastric bypass has minimal malabsorption compared to the Duodenal Switch. The design of the duodenal switch was done to reduce the adsorption of nutrients through the intestinal wall and into the body. It was part of the procedure and drives a significant part of the weight loss regimen.
As with any surgery, bariatric surgery does carry some inherent risks and potential complications. These can include: Deep vein thrombophlebitis 0.7%; Non-fatal pulmonary embolus 0.5%; Pneumonia 0.5%; Acute respiratory distress syndrome 0.25%; Splenectomy 0.9%; Gastric leak and fistula 2.0%; Duodenal leak 1.5%; Distal Roux-en-Y leak 0.25%; Postoperative bleeding 0.5%; Duodenal stomal obstruction 0.75%; Small bowel obstruction 2.0%; and possibly death 1.0%. (Surgical risk data from Laparoscopy Associates of San Francisco website LAPSF.com)
Pre-surgical evaluation and support
As part of the pre-operative workup, most patients are required to have a psychological evaluation with a counselor. I believe the need for this evaluation is relatively evident and very significant. The discussion should revolve around the reasons for the weight gain, the time frames, factors influencing it, thinking about the surgery as an option, alternatives to surgery, and the question of what happens next. Frankly the most important part was the analysis of the factors influencing the weight gain. These include emotional eating, compulsive over-eating or other eating disorders, lack of self-esteem or social factors, genetic tendencies, and hormonal imbalances. It is very important to be very honest with the analyst in evaluating the potential for surgery. This is not a frivolous venture and in general is a one way ticket. Do not think of bariatric surgery as just a stop gap procedure to help you lose weight and then you can have it reversed and go back to a normal eating habit. You really can’t go back. The habits and mechanisms that got you to gain weight are likely still there.
During the psychological evaluation the counselor will be assessing a number of elements and trying to determine the answers to these questions:
What is your drug use?
What is your alcohol use?
Do you have untreated depression?
Do you have suicidal tendencies?
Do you have any eating disorders?
Do you understand the surgery and the needed lifestyle changes?
What is your ability to make lifestyle changes?
Can you follow and comply with the dietary demands?
Will you follow the exercise regimen?
Do you understand the importance for post-operative follow-up?
Can the surgeon rely on you to follow their directions?
Do you understand that not following the directions puts you at risk?
Do you have unrealistic expectations about what will happen?
Do you have adequate support in your social circle and at home?
Post Surgery follow-up and support
Many successful gastric bypass weight loss surgery patients say that their support network helped them immensely in maintaining their new healthy lifestyle changes. From family and friends to bariatric program support groups, there are options available for people interested in gastric bypass surgery and for dealing with the rapid weight loss that follows.
Talking to your family and friends about weight loss surgery and your interest in it is very important. They are most often highly supportive; however there are times when they may not be supportive of your decision. They are likely concerned that you might have unrealistic expectations about the outcome, or you will regain the weight lost, or there are risks that they fear. Speak frankly about your feelings, show them the data, and help them understand that while the process is designed to promote better health for you, they will reap the benefits of you being around with them for a longer time. They may also have preconceived notions about weight loss surgery.
If you find that they are unsupportive, it doesn’t mean you are alone. It is important that you follow the path that you decide upon. Many people have had weight loss surgery and have been very successful with the care they received from those outside their normal circle of family and friends. This is your decision and your life. You need to feel comfortable with the decision, understand the potential outcomes, and be willing to work toward a successful outcome.
Weight loss surgery support groups are an excellent resource of weight loss information and support. You’ll find people who share your goals of health and wellness. A support group is a forum for celebrating successes, such as the your weight loss and resolution of health issues. The support group is for people who have common experiences, who can share their feelings in a safe environment, and develop relationships that can contribute to improved physical and emotional health after their weight loss surgeries.
If you are thinking about weight loss surgery, and you want to learn more about the patient’s perspective or help reluctant family and friends to understand, attending a support group meeting can be invaluable.
Reasons for regaining weight
The most significant issue for post surgical patients is to maintain their weight loss, maintain their health and maintain their sense of “why I did this in the first place”. Regaining weight can be due to emotional eating, compulsions, or the simple fact that if you can eat a bit more after awhile (the stomach stretches a bit and accommodates more food), you will. Be careful and keep in mind that while you can stretch the pocket or the pouch to accomodate more food, should you?
People who snack or eat without thinking because they feel depressed, anxious, or afraid are more likely to regain weight than people who may occasionally overeat because of external factors. External factors include the holiday eating season (such as Thanksgiving and Christmas) and celebrations with family and friends. If you concentrate on the dietary requirements for your continued weight loss and then its maintenance the potential to regain is lessened.
Celebrations and parties, spending time with the family watching a favorite show, cook outs on warm summer evenings are social activities that have long been tied together, and you shouldn’t have to give them up. Eating and events are tied together. However after bariatric surgery and with your new healthy habits, you won’t want to eat as much as you used to and, most likely, you won’t be able to. These social occasions and situations can present challenges.
Sometimes even the most well-meaning family and friends may try to push food on you or may have difficulty supporting you. They may be unaware that certain comments they make or things they do are not supportive. You may get frustrated because a family member continues to bring home high-calorie foods, even though you are trying to avoid them. My advice is to take a bite, it won’t kill you and then explain why you can’t eat more. Ask them to bring other types of foods and offer suggestions. You may be upset because a friend who only knows the myths of bariatric surgery thinks it is the easy way out. That is a hard one to get people to understand. It is not an easy way out, it is a lifestyle change and it is for you, your health and well-being. You may never convince them (particularly if they are slender and have never experienced weight issues). Remember why you did what you did.
So with regard to the potential for regaining weight there are a number of things you need to do or understand:
1. Be sure you fully evaluate the reasons for your weight gain and why you are looking at bariatric surgery as an answer. If a single session with the counselor does not resolve your questions or their questions, do another session or more. Get to the bottom of the issues. Be forthright and honest.
2. Select a surgeon you are comfortable with and discuss all of the positive and negative aspects of the surgery, the weight loss potential, other health effects AND the potential to regain the weight. They have the most current data on the successes of the different surgeries and you need to be sure they discuss the known and potentially unknown outcomes and issues with you. Do not be frightened by the risks. Going out to the car and driving to work carries risks. But you need to know the risks.
3. Follow the post operative “rules” to ensure that your weight loss gets off to a good start. It will be amazingly fast at first and you will marvel at the rapid results. But be patient and things actually will get even better. Do not overeat. You need to relearn how to eat and how you feel as the stomach fills and empties. Try to eat to within one bite of full and then stop.
4. Go to group sessions if you feel the need to get that additional support. Your doctor will provide you with locations and times. If you need help with questions ask them, either to your doctor or in the group. If you are still a bit conflicted about the psychological component go seek additional counsel. This is for you and you alone. You have set yourself on this path and you need to be disciplined in its journey.
5. As you move along on your weight loss, add bits of new tastes or maybe old ones you would like to try again. Do not be afraid to taste, just don’t overeat.
And oh yes, do drink plenty of water. Mangia!!!
The surgical procedures
There are generally four basic surgical procedures available for bariatric patients. There are some significant variations between the surgical procedures, and are based upon individual surgeon’s preferences. The general procedures are all are based upon one basic principle. That is the restriction of food input. How that is accomplished varies with the procedure selected by the surgeon.
The general procedures are the Lap Band, vertical gastrectomy, Roux en Y gastric bypass, and the duodenal switch. The procedures are either mechanical (Lap Band and the vertical gastrectomy) or what I call mechanical/physiological (Roux en Y gastric bypass, and the duodenal switch). Mechanical surgery rather simply reduces the physical capacity of the stomach and restricts the volume of food that can be ingested at one time. The Roux en Y gastric bypass and the duodenal switch are more complex procedures that reroute the movement of food from the esophagus directly into the intestinal tract, and while providing restricted eating also alter the actual physiological processing of the food in the digestive tract where almost all digestion actually takes place.
For the insertion of the Lap Band a small tunnel is made behind the top of the stomach to let the device through and allow it to be wrapped around the upper part of the stomach, like a wristwatch. It is then locked securely in a ring around the stomach. This creates your new, smaller stomach pouch. The rest of the lower stomach will stay in its normal position. A small access port, which is used for band adjustments, is fixed just underneath the skin. The access port is used by the surgeon to inject saline (sterile salt water) into the band when you have an adjustment.
The Duodenal Switch procedure is also called the vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) and by limiting the amount of food that is absorbed into the body (intestinal bypass or duodenal switch). It is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to augment and help maintain long-term weight loss. Of the procedures that are currently performed for the treatment of obesity, it seems to be the most powerful and effective, but may also have more complications associated with it. Most surgeons do not perform this procedure because of the overall concerns about the long term effects of malabsorption.
In the Vertical Gastrectomy (VG) the stomach is divided vertically and more than 85% of it is removed through the small incision in the abdominal wall. This procedure is not reversible. The stomach that remains is shaped like a banana and measures from about 4-7 ounces (120-250cc) in volume depending on the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. In the Roux-en-Y gastric bypass, the stomach is divided, but not removed, and the pylorus is excluded. The esophagus and a portion of the stomach muscle are then connected to the lower part of the duodenum (first section of the small intestines). The Roux-en-Y gastric bypass stomach can be reconnected (reversed) if necessary as can the Lap Band.
The Roux-en-Y gastric bypass has minimal malabsorption compared to the Duodenal Switch. The design of the duodenal switch was done to reduce the adsorption of nutrients through the intestinal wall and into the body. It was part of the procedure and drives a significant part of the weight loss regimen.
As with any surgery, bariatric surgery does carry some inherent risks and potential complications. These can include: Deep vein thrombophlebitis 0.7%; Non-fatal pulmonary embolus 0.5%; Pneumonia 0.5%; Acute respiratory distress syndrome 0.25%; Splenectomy 0.9%; Gastric leak and fistula 2.0%; Duodenal leak 1.5%; Distal Roux-en-Y leak 0.25%; Postoperative bleeding 0.5%; Duodenal stomal obstruction 0.75%; Small bowel obstruction 2.0%; and possibly death 1.0%. (Surgical risk data from Laparoscopy Associates of San Francisco website LAPSF.com)
Pre-surgical evaluation and support
As part of the pre-operative workup, most patients are required to have a psychological evaluation with a counselor. I believe the need for this evaluation is relatively evident and very significant. The discussion should revolve around the reasons for the weight gain, the time frames, factors influencing it, thinking about the surgery as an option, alternatives to surgery, and the question of what happens next. Frankly the most important part was the analysis of the factors influencing the weight gain. These include emotional eating, compulsive over-eating or other eating disorders, lack of self-esteem or social factors, genetic tendencies, and hormonal imbalances. It is very important to be very honest with the analyst in evaluating the potential for surgery. This is not a frivolous venture and in general is a one way ticket. Do not think of bariatric surgery as just a stop gap procedure to help you lose weight and then you can have it reversed and go back to a normal eating habit. You really can’t go back. The habits and mechanisms that got you to gain weight are likely still there.
During the psychological evaluation the counselor will be assessing a number of elements and trying to determine the answers to these questions:
What is your drug use?
What is your alcohol use?
Do you have untreated depression?
Do you have suicidal tendencies?
Do you have any eating disorders?
Do you understand the surgery and the needed lifestyle changes?
What is your ability to make lifestyle changes?
Can you follow and comply with the dietary demands?
Will you follow the exercise regimen?
Do you understand the importance for post-operative follow-up?
Can the surgeon rely on you to follow their directions?
Do you understand that not following the directions puts you at risk?
Do you have unrealistic expectations about what will happen?
Do you have adequate support in your social circle and at home?
Post Surgery follow-up and support
Many successful gastric bypass weight loss surgery patients say that their support network helped them immensely in maintaining their new healthy lifestyle changes. From family and friends to bariatric program support groups, there are options available for people interested in gastric bypass surgery and for dealing with the rapid weight loss that follows.
Talking to your family and friends about weight loss surgery and your interest in it is very important. They are most often highly supportive; however there are times when they may not be supportive of your decision. They are likely concerned that you might have unrealistic expectations about the outcome, or you will regain the weight lost, or there are risks that they fear. Speak frankly about your feelings, show them the data, and help them understand that while the process is designed to promote better health for you, they will reap the benefits of you being around with them for a longer time. They may also have preconceived notions about weight loss surgery.
If you find that they are unsupportive, it doesn’t mean you are alone. It is important that you follow the path that you decide upon. Many people have had weight loss surgery and have been very successful with the care they received from those outside their normal circle of family and friends. This is your decision and your life. You need to feel comfortable with the decision, understand the potential outcomes, and be willing to work toward a successful outcome.
Weight loss surgery support groups are an excellent resource of weight loss information and support. You’ll find people who share your goals of health and wellness. A support group is a forum for celebrating successes, such as the your weight loss and resolution of health issues. The support group is for people who have common experiences, who can share their feelings in a safe environment, and develop relationships that can contribute to improved physical and emotional health after their weight loss surgeries.
If you are thinking about weight loss surgery, and you want to learn more about the patient’s perspective or help reluctant family and friends to understand, attending a support group meeting can be invaluable.
Reasons for regaining weight
The most significant issue for post surgical patients is to maintain their weight loss, maintain their health and maintain their sense of “why I did this in the first place”. Regaining weight can be due to emotional eating, compulsions, or the simple fact that if you can eat a bit more after awhile (the stomach stretches a bit and accommodates more food), you will. Be careful and keep in mind that while you can stretch the pocket or the pouch to accomodate more food, should you?
People who snack or eat without thinking because they feel depressed, anxious, or afraid are more likely to regain weight than people who may occasionally overeat because of external factors. External factors include the holiday eating season (such as Thanksgiving and Christmas) and celebrations with family and friends. If you concentrate on the dietary requirements for your continued weight loss and then its maintenance the potential to regain is lessened.
Celebrations and parties, spending time with the family watching a favorite show, cook outs on warm summer evenings are social activities that have long been tied together, and you shouldn’t have to give them up. Eating and events are tied together. However after bariatric surgery and with your new healthy habits, you won’t want to eat as much as you used to and, most likely, you won’t be able to. These social occasions and situations can present challenges.
Sometimes even the most well-meaning family and friends may try to push food on you or may have difficulty supporting you. They may be unaware that certain comments they make or things they do are not supportive. You may get frustrated because a family member continues to bring home high-calorie foods, even though you are trying to avoid them. My advice is to take a bite, it won’t kill you and then explain why you can’t eat more. Ask them to bring other types of foods and offer suggestions. You may be upset because a friend who only knows the myths of bariatric surgery thinks it is the easy way out. That is a hard one to get people to understand. It is not an easy way out, it is a lifestyle change and it is for you, your health and well-being. You may never convince them (particularly if they are slender and have never experienced weight issues). Remember why you did what you did.
So with regard to the potential for regaining weight there are a number of things you need to do or understand:
1. Be sure you fully evaluate the reasons for your weight gain and why you are looking at bariatric surgery as an answer. If a single session with the counselor does not resolve your questions or their questions, do another session or more. Get to the bottom of the issues. Be forthright and honest.
2. Select a surgeon you are comfortable with and discuss all of the positive and negative aspects of the surgery, the weight loss potential, other health effects AND the potential to regain the weight. They have the most current data on the successes of the different surgeries and you need to be sure they discuss the known and potentially unknown outcomes and issues with you. Do not be frightened by the risks. Going out to the car and driving to work carries risks. But you need to know the risks.
3. Follow the post operative “rules” to ensure that your weight loss gets off to a good start. It will be amazingly fast at first and you will marvel at the rapid results. But be patient and things actually will get even better. Do not overeat. You need to relearn how to eat and how you feel as the stomach fills and empties. Try to eat to within one bite of full and then stop.
4. Go to group sessions if you feel the need to get that additional support. Your doctor will provide you with locations and times. If you need help with questions ask them, either to your doctor or in the group. If you are still a bit conflicted about the psychological component go seek additional counsel. This is for you and you alone. You have set yourself on this path and you need to be disciplined in its journey.
5. As you move along on your weight loss, add bits of new tastes or maybe old ones you would like to try again. Do not be afraid to taste, just don’t overeat.
And oh yes, do drink plenty of water. Mangia!!!
Thanks for another wonderful article. Where else could anyone get that kind of information in such a perfect way of writing? I’ve a presentation next week, and I’m on the look for such info.
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