Bariatric surgery has evolved over time

Dr. Gustavo E. Bello, is a bariatric surgeon for the Greater Baltimore Medical Center Comprehensive Obesity Management Program.

Obesity is a growing problem in the United States and Americans have increasingly turned to surgery to help them lose weight. Nearly 200,000 people now get bariatric surgery each year. The procedures have improved and evolved over the last decade. Dr. Gustavo E. Bello, a bariatric surgeon for the GBMC Comprehensive Obesity Management Program, discusses the latest in bariatric surgery.

In general, how has bariatric surgery changed in the last decade?


The field of metabolic and bariatric surgery has evolved significantly and continues to do so. Basic science and clinical research, along with new technology, have made weight loss surgery not only a safer strategy to fight obesity, but one that is overwhelmingly better and more efficient than any other. The field continues to expand globally and surgeons now have the ability to complete a much more thorough and specialized training process.

What are the main Bariatric surgeries now performed?


Laparoscopic sleeve gastrectomy and gastric bypass are the most commonly performed weight loss surgeries across the board. Together, they account for more than 90 percent of all bariatric surgical procedures. Laparoscopic sleeve gastrectomy, which sits comfortably in first place, has been around for nearly 14 years. It is a procedure that alters the capacity of the stomach by actually removing around 75 percent of its reservoir and leaving the rest of the anatomy intact. It also reduces the levels of Ghrelin, the so-called "hunger hormone," causing a profound and positive change in the relationship between patients and food. The Roux-en-Y gastric bypass, the second most popular, has been performed for more than 40 years now. It is a well-studied, researched and reliable procedure. It helps patients lose weight and get healthier by reducing the capacity of the stomach, by rearranging the intestinal transit that interferes with the different mechanisms involved with how food gets digested and absorbed and by altering and improving patient's metabolisms. A less used procedure is the the biliopancreatic diversion with duodenal switch, where part of the stomach is removed and the remaining portion is connected to the lower part of the small intestine. Doctors also have cut back on the use of gastric bands, or lap bands, when a surgeon places a band around the upper part of your stomach to create a small pouch to hold food. The band limits the amount of food you can eat by making you feel full after eating small amounts of food

Why is the once popular lap band rarely used anymore?

The adjustable gastric bands that were so popular about a decade ago, have fallen out of favor and are very rapidly fading away. In my opinion, there are actually many reasons why this is happening but the perception that bands are "less invasive" has kept them alive for many years. Compared to other options, a gastric band simply isn't a good and efficient enough procedure to help patients lose weight and get healthier. Also, the majority of patients struggle with poor quality of life and lack of long-term success which has become increasingly notorious lately with the rise and acceptance of sleeve gastrectomy.

Has bariatric surgery become more affordable and are more insurance companies covering it?

No doubt weight loss surgery is now covered widely by virtually every insurance with very few rare and disappointing exceptions. This has given almost every patient affected by obesity access to this great tool and treatment modality. The better understanding of the obesity epidemic and its detrimental effects on overall health have increased awareness and made us more proactive on addressing and treating it. Simplified pathways, better outcomes and shorter hospital stays have significantly lowered the overall cost of surgery and that is not counting all the health care cost savings that come with eliminating obesity.

Who qualifies for bariatric surgery?

For many years now, the overwhelming majority of insurance companies, including Medicare and Medicaid, have provided coverage for weight loss surgery to those patients with a Body Mass Index (BMI) of 35 Kg/m2 or higher and who can demonstrate that they suffer from an obesity-related medical problem, such as hypertension, diabetes, sleep apnea, liver disease, among others. This is often waived if the patient's BMI exceeds 40 Kg/m2.

What are the risks and potential complications of bariatric surgery?


Fortunately, bariatric surgery has become extraordinarily safe with extremely low mortality rates that are now comparable to much more commonly performed operations such as gallbladder removal and hip replacement. Of course it is not completely free of possible complications, including bleeding, infection and the exceedingly uncommon, but troublesome, leakage.

What do people have to do to prepare for bariatric surgery?

As good and as efficient weight loss surgery can be in helping patients lose weight and become healthier, it should not be forgotten that, in the end, it is just a great tool that must be used wisely and decisively by the patient to obtain desired results. Preparing well for this life-changing event is of utmost importance. It includes becoming more knowledgeable about nutrition, getting mentally prepared, committing to adopting new and better habits, and finding creative ways to increase physical activity.

What protocols do patients have to follow after surgery for long-term success?

It has been said that long-term success following weight loss surgery occurs in more than 85 percent of cases. Success on definitively eliminating obesity relies first on being well-prepared ahead of time by better understanding the impact that nutrition has in our overall health and being mentally ready to adopt new lifestyle changes. This allows patients to more easily adhere to any post-surgery guidelines and key principles that are necessary to achieve adequate and sustainable weight loss. This begins with following a postoperative diet for a few weeks to allow stomach healing, to then monitoring protein intake to secure adequate nutrition as well as proper hydration, compliance with vitamin intake and the increase of physical activity, among other lifestyle and behavioral changes.