Getting the Skinny on Weight Loss Surgery

by Scott A. Cunneen, MD, FACS, FASMBS, Director of Bariatric Surgery, Cedars-Sinai Medical Center, Los Angeles

and Nancy Sayles Kaneshiro


What are the basic types of weight loss surgeries?


A wide spectrum of surgeries exists in the weight loss arena today, running the gamut from what they call restrictive operations to those that are malabsorptive. The restrictive surgery takes your stomach and makes it smaller, so that food sits in a new golf ball- sized stomach and empties into your normal stomach to get digested. Everything is processed normally after it goes through your system in a restrictive operation since we donít rearrange the intestines.


On the other extreme, in the malabsorptive category, your mouth is hooked up to your colonÖfood goes virtually from your mouth straight into the toilet, bypassing almost the full length of the intestines so you that canít absorb most of the nutrients or the calories in the food.  Most surgeons donít do those operations anymore because theyíre too extreme and the risk is too great for the benefit.


The good news is that today, somewhere in the middle are the restrictive operations like the gastric band (or lap band) and the Roux-en-Y gastric bypass (named for a 19th century pioneer in surgery and the configuration the surgery accomplishes), the latter combining a little bit of hormonal manipulation with the restriction to get the desired results. This means weíve made your stomach smaller, so you have to eat differently, slow down and chew your food well. These are the operations that have proven to have the best risk-benefit ratio.


With bypass, the small intestine is cut about 1 Ĺ to 2 feet below the stomach and is attached to the new, small stomach pouch weíve created.  The other part of the intestine is reattached so that the bile and other digestive juices can flow easily.  Food moves from the new stomach pouch directly to the lower part of your small intestine.  While bypass definitely offers more guaranteed weight loss than the band, because weíre cutting and rearranging things, thereís a little more risk with that procedure, and taking vitamins becomes non-negotiable after surgery and for the rest of your life.


Whereas early restrictive surgeries relied on fixed-sized rings to accomplish their goal, in recent years the restriction has become adjustable with the use of the gastric band. One risk of banding is the possibility of not losing all the weight you want because you can cheat it easier.  If you choose to drink primarily high-calorie liquids, I can never make a band tight enough to stop the liquid since I have to leave enough room for you to drink water and stay hydrated. So if ice cream is your weakness, you can actually prevent weight loss with the band, and if your brain wonít let you voluntarily stop overeating, then a bypass would be a better operation for you. With bypass, eating certain types of food will make you sick and youíre sort of forced into weight loss by default. While some people need that extra help, most people donít, which is why banding is very popular. It allows for less manipulation with the surgery and is less invasive. That means it requires less surgery to get to your goal, which is to get the weight off so that your diabetes is better controlled, your hypertension, your sleep apnea, all those things we call co-morbidities or illnesses that are related to your being overweight, all those things reverse, and you donít have to have the maximum amount of weight loss in order to accomplish that. You can lose 40% or 50% of your excess body weight and get those health benefits. 


A third choice added relatively recently to the mix Ė one with achievable weight loss somewhere in between bypass and band -- is the sleeve gastrectomy, which is basically the removal of about 90 percent of your stomach, meaning you wind up with a long tube that connects the esophagus to your small intestine that is about the same diameter as the esophagus. What you lose is the reservoir function of the stomach. The size of your new stomach is about 60cc, or about the size of a banana or a quarter of a can of Coke, so it fills up fast. Also, it has become clear that our intestines are not just hollow tubes that absorb things and carry things in transit; there are hormones that are released in the intestines that affect hunger and how we process foods and sugars, so hunger is regulated by more than just the amount of food we eat. Different kinds of food trigger those hormones, and what remains of the stomach after surgery affects hormone levels which allow you to eat less, with a little bit less manipulation of the intestines than gastric bypass.  The sleeve gastrectomy is being widely used and has become a staple (pardon the pun) in the bariatric arena.


The risk factors of a sleeve are about the same as with a bypass. When you cut away the majority of the stomach you have a big, long staple line in the stomach, and if that doesnít heal well, leaks can occur and thatís when you have the potential for infection. And, if you happen to be a diabetic, you might not heal as quickly as you should.  So, while people do like the certainty of the weight loss, if youíre diabetic, if youíre older, if youíre severely overweight, all those things contribute to the risk.


In short, most of the weight loss operations today combine a little bit of restriction and hormonal manipulation in order to get you there, rather than go to one extreme or the other.


All of these surgeries are currently done laparoscopically, that is, using instruments through very small incisions rather than the necessity of stem-to-stern incisions associated with abdominal surgery years ago. Recovery time has been shortened and risk has been significantly reduced with the use of these minimally-invasive procedures.


Another procedure weíre beginning to see more often is gastric plication, which involves not cutting the stomach, but folding it in on itself so that you reduce the size of the stomach, just like pleating a dress. Itís like taking in the waistband, rolling it in and clipping it down with staples.  Some people are doing it as a stand-alone procedure and some are adding it to the band.  The thought is to make this procedure available to more people because, as of this writing, less than one percent of the people who qualify for surgery actually access care. We know that many people who choose not to go the surgical route do so because of the expense, and with these plication procedures, because you donít have a device which costs money and you donít have expensive stapling machines, they can be done at lower cost than bypass or band.  Plus, gone are the band adjustments, which can add significantly to the cost of the band.  In addition, this surgery is said to have less risk -- and quicker recovery Ė than bypass or the sleeve, which is especially significant to people who have jobs they need to get back to or who canít take a lot of time off.  


Because there is no device required that is regulated by the FDA, this procedure, often referred to as ďthe wrap,Ē (catchy, huh?) can be done in surgical centers, and thatís what is happening.  Doctors at several of the major medical centers are looking at why these operations work, and then sort of engineering backwards to find out what this operation is doing to create satiety or satisfaction with less food and seeing how can we design a better way to achieve that less invasively.  If everything pans out, if the data supports the anecdotal evidence, this could be a real option for many people.  The ease of reversibility because of the lack of cutting, as well as the possibility of achieving the same weight loss or near the same weight loss as the sleeve without removing tissue, will be more comfortable for people with reservations about the other operations.  Plus, you usually donít suffer a most unpleasant reaction called dumping that occurs after gastric bypass when you eat high fat and high sugar foods.


If a band alone gives you 40%-50% excess weight loss and you and you plicate below it (add the wrap), you might be able to get 60%-70% or even greater weight loss with less risk than the gastric bypass or sleeve.



What do you want your new patients to know when they walk out of your office for the first time?


Most people already have an idea of what weight loss surgery is, so what I want them to know is that there is help for them, even though theyíve failed at every other past attempt at weight loss. I want them to know that itís not the easy fix, and I want them to not feel guilty about taking this route thatís going to give them better health. I want them to realize that weíre there to help and weíre committed to being there for the long term, that they donít have to go through this alone. So I think they need to walk out feeling that their concerns are legitimate, that theyíre not crazy for seeking surgery to help fix this, that improving their health is a worthwhile endeavor and that they shouldnít feel guilty about using this option to help them get there.



How do I decide which surgery I need? 


A lot of times, if patients know someone who has had a particular surgery and had success, theyíll gravitate toward that procedure. If they know someone who has struggled with a procedure, theyíll tend to stay away from it. I think that in general we want to find the simplest way to get us there, and thatís why the band is so seductive. Its popularity lies in the fact that itís a very safe procedure that will result in the weight loss needed to get the co-morbidity resolution Ė the obesity-related health issues --  and itís a fast recovery.  Itís hard for a lot of people with   busy lives to take three weeks off from work to recover from major surgery.  With a band, theoretically you can have surgery on Friday and,  if you have a desk job, you can be back to work on Monday and do it safely. And thatís what everyone wants.


On the other hand, while roughly half of what we do are banding procedures, bypass comprises the other half, because so many people say if I Ďm going to do something as drastic as have surgery, it had better work, so just give me the gold standard, give me the biggest gun you have to attack this problem. If I fail with surgery, even though I know thereís another potential surgery out there, Iíll never be able to live with myself.  Thereís a lot of embarrassment in having to come to a surgeon.  People are not just asking for help, they often think theyíve failed in what everyone thinks should work for them, which is an endless cycle of dieting and trying hard. They may think if I fail with the surgery, that makes me an even worse person. They tell me, just give me the biggest thing youíre willing to try.  Letís get this done. Give me the biggest gun.  I have to lose weight.  I canít fail. They just want the biggest, baddest one.



What do you think patients should learn about how to manage after surgery -- how to eat, how to get back to health, increase their health and maintain their health?


So many of the popular diet programs find someone else planning all your meals and giving you pre-measured portions, asking you to pick one from column A, one from column B, eat them three times a day, and youíre probably not learning what the nutritional content of the food is or what the proper choices are. So I think part of what you learn from a good program is a basic nutritional education, even so simplistic as saying what is a carbohydrate, what is a fat, what is a protein. These are examples of foods that have those things in them.  Having sample diets is great, but in our society you still have to make choices. People need to learn to read labels -- we stress that -- so they actually know whatís in the food. Theyíre not just being handed a box and told to eat this.   I also think that taking away hunger for a lot of people encourages them to read the labels. I mean, if youíre not starving all the time and are just putting something in your mouth because you need to, youíll read the label a little more carefully and say you know, thatís not a great choice. So I think the surgery allows you to actually think about it, whereas before you werenít thinking, you were on autopilot and just consuming.


So much eating is done on autopilot. Because itís 7 oíclock and time to eat.  Because Iím watching American Idol.  Because the gameís on and thereís that Doritos commercial again. Unfortunately, we do have a lot of social expectations that have been developed or culturally passed down to us. So someone may be telling you when you should eat breakfast, lunch and dinner,  or someone says you should be hungry at 6 oíclock because thatís when Iím making dinner, and you need to eat a full plate, youíre wasting food, people are starving in Ethiopia.    And I think that weíre also eating out a lot.  In restaurants, weíre given portions that are meant to feed multiple people rather than a single person, and weíve come to think thatís what weíre supposed to eat.  When people get serious about this process, I think they learn that the portion sizes needed to maintain their weight are much smaller than they ever imagined. 


We sometimes run into family members who say sheís not eating enough! We say well, we checked her labs and sheís nutritionally replete, meaning her protein levels are all great, her vitamin levels are all great, sheís maintaining a healthy weight so sheís eating enough, you just THINK she needs to eat more. And thatís their problem.  It may be a cultural thing since in a lot of cultures, food is love. If you donít eat my food, you donít love me. If somebody comes over, itís welcoming, and you canít let anyone go hungry, so you make enough for the Fifth Army.


I think for a lot of people satisfying hunger is different from feeling stuffed, but a lot of people think they should feel stuffed after every meal and theyíre not going to get that feeling unless they overeat greatly. While some people think itís not Thanksgiving unless they have to unbutton their pants afterwards, some people are doing that after every meal. 

So, how much do you have to know about proper nutrition?  A lot! The more you know, the better choices you will make, the more variety you will discover and the greater your success following surgery. (My own patients report that their newfound knowledge of nutrition has made their entire families better eaters.  They may be surprisedÖbut Iím not!)



How important do you think it is to have realistic expectations?          

I think thatís the most important thing.  If you donít have realistic expectations about how youíre going to have to eat or how youíre going to have to change your life, you probably wonít succeed.  If you think the only thing thatís important is to be as thin as a Vogue model, then youíre setting yourself up for disappointment. If youíre only going to be satisfied with 100 percent excess weight loss and you get 50 percent, you may tend to view that as a failure and youíre more likely to quit your good behavior. If you think the operationís going to do all the work and you have to do nothing, then you probably wonít stick to an exercise regimen. Unless youíre already an exercise fanatic, itís tough to adopt an exercise lifestyle, especially if you believe it isnít needed.  So setting up the expectation of what surgery will do for you is the important thing.  First of all, you have to work with it, itís a lot of hard work, and itís not a perfect solution. Success requires a lot of effort on your part, and everyoneís a little bit different, so you shouldnít give up if you donít get 100 percent of the results that you want. Just because the guy next to you is doing well, that doesnít mean that he is working somehow harder than you are.


Dr. Cunneen, if thereís one thing youíd like us to take away from these conversations with you, what would it be?

You may have noticed by now that Iím not the kind of guy who can limit my thoughts to one thing, but Iíll give it a try. Your health is at stake.  Being severely overweight threatens your life every day, maybe a little bit at a time, maybe bam, the big one. Youíve got to make the decision to determine the quality of your own life. Youíve got to make the commitment to change your attitude, your lifestyle, your relationship with foodÖforever. If that decision includes weight loss surgery, we hope we have contributed in some small way to the information you need to make these important choices. We wish you good health.