If you are a patient with New Dimensions, your surgeon will not recommend that you undergo a bariatric surgical procedure unless he or she believes that the risk/benefit ratio weighs in favor of surgery in your particular case. Here are some additional things to be aware of:
The Roux-en-Y Gastric Bypass is a major surgical procedure in the true sense of the word. It is done under general anesthesia, and it involves manipulation and repositioning of the stomach and intestine in ways that are both anatomically and physiologically significant. If one thinks of a heart bypass operation as a "10" on a scale of 1 to 10, then a Roux-en-Y GBP has a magnitude of about a 5-6 on that scale.
The GBP rises to this magnitude because of the complexity of the bowel manipulation and because the procedure has intentional long-term effects on the function of the GI tract. The key risks for Gastric Bypass surgery are:
Implantation of an Adjustable Gastric Band is also a very serious procedure. If things go according to plan, then the physiologic impact on the day of surgery is less than the Gastric Bypass, and is comparable to the laparoscopic removal of the gallbladder (Lap choley). However, the gastric band does not start and end with the implantation procedure. The Band is intended to create a calibrated lifetime change in the function of the previously normal stomach. This is a physiologically important effect. It is also important to remember that the gastric band is a piece of synthetic material that will be present internally for life. The key risks for Gastric Band surgery are:
We believe that the risk of the Gastric Sleeve operation is intermediate between the Gastric Bypass and the Gastric Band. The key risks for the Gastric Sleeve are:
Another important thing to remember is that the bariatric surgical procedure - whichever is chosen, is being done in a patient who is heavy enough to suffer illness from their weight. That means the body comes into surgery already under stress, and may be less able to tolerate even the planned impact of the surgical procedure.
Many complications can occur as a result of bariatric surgery. It is useful to divide the complications into problems that are physically related to the surgical procedure, and those that arise from the stress on the system of major surgery.
One point that deserves to be made up front is that patients do sometimes die as a result of Weight Loss Surgery. Nationwide, the risk of death after bariatric surgery for all types of patients undergoing all types of procedures by all surgeons is about 1 out of 500 or 0.2 percent.
In our practice the risk of death for all patients of all weight and all disease states is about 1 out of 800 or 0.13 percent. For patients who do not have any of the particular risk factors in the list below, the risk of death from bariatric surgery in our practice is less than 1 in 1,000 or less than 0.1 percent. Thus the risk is not "huge" but it is very real. All patients should have their affairs in order before undergoing this elective procedure!
Factors that we find result in some degree of increased risk include the following:
All potential patients should understand that the risk story is not all about life and death. We have outlined a number of other risks and considerations for your review.
We strongly advise you to involve your loved ones in the decision and education process about bariatric surgery. In the end, the decision for surgery falls to the patient alone, but the process is definitely better for everyone if family support is strong.
The spleen and the liver are large solid organs that share space with the upper stomach where the Gastric Bypass or Gastric Band placement is done. It is necessary to retract these organs out of the way, with occasional tears in the substance of the liver or spleen. On rare occasions, it is necessary to remove the spleen because of bleeding. The spleen is more "at risk" for patients who have had prior surgery in the upper abdomen. The spleen is less likely to be injured when we are able to do the surgery laparoscopically.
We will also be working around the upper stomach and the esophagus, attempting to use our surgical instruments to properly handle these delicate structures. Some maneuvers during bariatric surgery must be accomplished by "feel." All of these issues put the esophagus, stomach and the rest of the intestine at some risk.
If it is necessary to remove the gallbladder, injury to the common bile duct (to which the gallbladder is attached) also must be carefully avoided. On rare occasions, the duct stump may leak, or gallstones may be trapped in the main bile duct. If these problems occur they are usually identified and addressed during the primary procedure.
One of the most serious surgical complications that can occur is a leak from the connection between the new stomach pouch and the small intestine, or from the stomach pouch itself. A leak can be caused either by surgical factors (tension on the anastomosis, or inadequate blood supply) or by poor patient healing. We routinely test for leak at the end of the GBP procedure to try to absolutely minimize the rate of leak. The occurrence of a leak is quite rare (much less than one percent in our practice), but we test for it fairly frequently after surgery because it can be so devastating if diagnosed after too much delay. If a leak occurs it will show itself during the hospitalization following surgery, and it will be repaired by return to the operating room or handled by draining the leak fluid to the outside.
A number of blood vessels must be divided and secured in the natural course of the GBP. The spleen or liver can also bleed if injured. Nevertheless it is quite uncommon in our practice for patients to require blood transfusion. If bleeding occurs after surgery it will do so within the first 24 hours, and sometimes requires return to the operating room. Bleeding is rare after implantation of the gastric band, but always possible.
The "rerouting" of the intestine and the scar left in the abdomen by the operation may cause the intestine to become blocked at some point after the operation. This can occur from weeks to more commonly months or years after the surgery and frequently requires re-operation. Bowel obstruction is rare but always possible after Adjustable Gastric Band because the intestines are not handled.
A few patients have long term nausea or intolerance to food, in the absence of a physically identifiable problem. This is a rare but very difficult problem, and is one of the few reasons that "reversal" of the weight loss procedure might be recommended.
If the surgery is done using a traditional open incision, then approximately 20 percent of patients will develop an incisional hernia. This is usually manifested three months or more after the surgery, with patient complaints of midline abdominal pain and a bulge under the incision. Repair of these hernias is necessary, but if possible, repair should be delayed until the patient’s weight and nutritional status have stabilized. The patient needs to be directly evaluated to establish that there is no incarceration (entrapment) of the bowel, or other complication that would indicate that early/urgent repair should be done. Surgical mesh is frequently used in the process of repair. Ventral hernia is very rare (less than one percent) after laparoscopic WLS. If a ventral hernia is present before the weight loss operation, then the chance of need for future repair is quite common because it is difficult or impossible to perform a definitive repair at the same time as the weight loss operation.
Bacteria sometimes colonize the fat tissue just under the skin during the operation, and subsequently grow to create an infection. This is very uncommon, but when it occurs it shows up as a tender red bulge in the incision, usually between four and seven days after surgery. The therapy is release of the contained pus by opening the wound, most commonly done on the ward or in the office. An infection can also occur within the abdomen after surgery, but this is uncommon.
We almost never see wound infection or wound seroma (see below) after surgery done laparoscopically, and the smaller laparoscopic incisions heal much better.
In all patients, some of the fat tissue under the skin liquefies. In most cases, the body reabsorbs this fluid over a period of weeks and the patient never becomes aware of it. In a few patients this fluid finds its way to the outside through a weak spot in the incision, usually a week or two after the skin staples are removed. The drainage can be a large (scary) amount of yellow/orange fluid. Usually nothing needs to be done other than to cover the open spot to protect the clothes, but your surgeon should still be contacted because similar fluid can come out of the wound in the setting of a rare but more serious wound complication.
Obesity increases stress on the body systems, so the chance of systemic complications after bariatric surgery is much greater than systemic risks of major surgery in a thin person. This effect is seen because the patient comes into the surgical procedure with the body’s many organ systems "working overtime" to support the extra weight. Furthermore, some organs may have pre-existing damage related to the excess weight. Thus the body of the obese patient has less ability to withstand and compensate for the stress of the surgical "injury." Some specific risks are divided below by organ system.
Low ventilation, pneumonia and fluid on the lungs (pulmonary edema) are some complications that can focus specifically on the lungs. These complications show up within the first 72 hours after surgery or (in the case of pneumonia) within the first week. Usually they can be managed by medications and getting the patient walking. Sometimes the patient must keep the breathing tube for a while or have it re-placed. Our best defense against this set of complications is for the patient to be up and walking as soon as possible after surgery.
Low mobility around the time of surgery can allow blood clots to form in the large leg veins called a Deep Venous Thrombosis (DVT), which can float up into the blood vessels of the lungs - then called a Pulmonary Embolus (PE). This is a serious and even life threatening event, usually but not always manifested by sudden shortness of breath, rapid heartbeat, and a feeling of weakness. It is by far most likely to occur during hospitalization, but the risk of PE persists at steadily-decreasing levels until four to six weeks after surgery. It is our practice to use both of the established means for reducing the incidence of DVT/PE (leg compression stockings, and Heparin shots) and to help the patient be up and walking as soon as possible following the surgery. Over the last several years our rate of DVT and PE has been substantially lower than nationally published reports.
The heart is required to do extra work around the time of any surgery or stress, and because bariatric surgery is a major stress it is no surprise that it will impose significant extra demands on the heart. This can be a problem if the patient’s heart is already working at maximum capacity due to the excess weight and the patient is in or near congestive heart failure. In addition, patients who are very overweight are more likely than average to have narrowing or blockages in the arteries of the heart called coronary artery disease. These conditions may predispose the bariatric surgery patient to worsened heart failure or a heart attack in the recovery time after surgery. The good news is that these problems either occur or don’t within about 72 hours following the surgery, so that close monitoring can be done in patients who are more at risk.
Kidney function normally weakens over time, and diabetes damages the kidneys, so that many of our patients come into bariatric surgery with a decent chance of having kidney weakness or damage. We see transient kidney problems in a patient of ours every two to three months, but we have not had any patient with permanent kidney failure in the last several years.
About 85% of our patients reach the medically accepted standard of successful weight loss after Gastric Bypass. This means that they lose and keep off more than 50% of the excess weight. Obviously then, 15% or so of our patients fail to lose sufficient weight. The more complex truth is that some patients who succeed by medical criteria are unhappy with the amount of weight they lose and some who fail still achieve substantial medical benefit and are very happy. See Results of Surgery. The available data suggests that gastric band patients don’t lose as much weight on average, but they seem to have comparable rates of improvement in medical problems.
Almost all patients achieve weight loss measured in the tens of pounds. There are two categories of problems for those who stop losing after only 30 to 50 pounds of weight loss. Sometimes there is a failure of the surgical procedure, where the pouch is too large or connects to the lower (large capacity) stomach. This kind of problem can be corrected surgically, though revision surgery in this area is a very significant undertaking. Unfortunately most patients with inadequate weight loss are experiencing a behavioral problem, where they "eat around" the surgical procedure. These patients usually cannot benefit from further surgery, and need to go back to "square one" on control of food intake.
The relationships and life of a morbidly obese person are inextricably linked to the fact of their obesity. One’s relationships with a spouse, parents, other loved ones, co-workers and with casual acquaintances all carry the obesity as an underlying assumption. Thus, in the six to 12 months after surgery, the rapid weight loss will cause a "sea change" in every relationship experienced by the patient. Many of these are positive changes, but their sheer magnitude makes the changes stressful. Some are adverse changes: spouses may become jealous of the patient’s newfound mobility and attractiveness, or a sister may be resentful and angry not to have a "fat buddy" in the family.
Rest assured that the surgeons and hospital staff do everything we can from our end to reduce the occurrence of complications. We have unfortunately seen most of the possible complications in our own patients and we stay abreast of the medical literature to be certain we are up-to-speed on the best preventive measures available. We use prophylactic (preventative) measures such as antibiotics or anticoagulation therapy where they benefit the patient, and remain vigilant for the remainder of potential complications. Patients also frequently ask what they can do to reduce their risk, and there actually are a few important answers:
Smoking has a truly significant influence on your outcome, including the chance of dying around the time of surgery. Everyone knows that smoking creates lung problems, but the unavoidable reality is that a history of smoking also leads to a five to 10 fold increase in the following risks:
Obviously it is best if the patient has never smoked; however if a patient does smoke we insist that they abstain from all tobacco products for at least one month prior to surgery. We feel so strongly about this that we will not set up the individual surgeon consultation until the patient has stopped smoking. Following surgery it is best if the patient never resumes smoking, but that is not a primary issue between the surgeon and the patient.
After tobacco freedom, the most important influence a patient has on outcome is to get moving around the ward as soon as and as much as possible following the surgery. The surgeons will do their best to control the surgical pain, the nursing staff will assist, and we aim for the patient to be walking out in the hallway on the afternoon of surgery. The main important benefit of this plan is to restore normal circulation in the veins of the legs, but it also helps lung function, maybe gut function, probably improves pain control going forward, and definitely boosts overall attitude.
It appears that the body suffers the most from obesity or an obese person is sickest when they are at their maximum weight. Surprisingly significant risk benefit comes from the loss of even 10 or 20 pounds, and more loss is better. We also find that excess weight tends to come out of the abdomen first, so just a few pounds can make it much easier for your surgeon to do their work. There is no such thing as losing too much weight in preparation for the surgery.
Get your heart and lungs in the best possible shape by doing whatever physical exercise you can tolerate. Starting an exercise program before surgery is also the best bet on keeping a regular exercise program following surgery.
Try to approach the surgery as the beginning of a whole new phase in life. The bariatric surgical procedure is a watershed event, and if the patient approaches it with thorough education and determination to make the best of the opportunity, then the chances of success are high. If the patient slides into the operation and aims for it to have minimal impact on his or her life, then the prospects are not as good. One thing a prospective patient can do along these lines is practice the surgical diet prior to surgery. This gives the patient a practical idea of what he or she is committing to, with the benefit of some weight loss. Another practical suggestion for mental prep is to attend our monthly "Staple Mates" gastric bypass support group. Much can be learned from other patients that the surgeons and staff cannot teach.
Taken as a group, patients who undergo bariatric surgery do better than equally heavy people who work hard on non-surgical means of weight loss. Because surgical weight loss tends to be successful and non-surgical weight loss tends not to be, the risks of the bariatric surgery are outweighed by the benefits obtained in terms of improvement/resolution of the many medical problems (considered as a group) affecting patients. This has been statistically demonstrated to be true.
Four recent medical research articles reported that bariatric surgery patients achieve a reduction in risk of death each year, in comparison to overweight patients who do not undergo surgery. One study showed that bariatric had one fourth the annual risk of death, and another study showed that bariatric surgery patients were one ninth as likely to die each year as were similarly obese patients. The remaining two studies showed about a 40% reduction in the risk of death for patients who underwent surgery. All the studies included the complications and the small but real mortality rate from bariatric surgery. All studies also showed profound overall improvement in health, including the changes associated with surgery. These articles support our direct experience, and these. facts are the reason that we have and will continue to offer this surgery.
Some who object to bariatric surgery are concerned that it is too risky. There’s no doubt that surgery carries risk, but the other side of the equation is that morbidly obese people are subject to the ongoing life-threatening risk of weight-induced stress and damage to their body every day. For most people with a BMI of greater than 40, the risk of the weight is greater than the risk of surgery. As surgery becomes safer, many people would say the same is true for most people with a BMI of greater than 35.
For more information on the risks of bariatric surgery, see the medical summary about bariatric surgery on the website of the American Society for Metabolic and Bariatric Surgery.
You may also wish to get our legal perspective about risk by reviewing the consent forms that we use for each surgical procedure. Our goal is that every patient will be so well informed that the risk discussion on the consent forms appears familiar.
