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Bariatric Surgery

Morbid obesity means that a person is so overweight that his or her well-being and health are actually in jeopardy. It is defined in several different ways:

Weighing more than 100 pounds over your ideal body weight. The ideal body weight is determined by the Metropolitan Life Insurance table, has been in existence for many years (since 1959) and is based on mathematical formulas that the Metropolitan Life Insurance Company used to determine insurance risks. Most doctors have gotten away from using this table because it is very difficult to use (with separate categories for "frame size" and for men and women) and can be inaccurate.
A Body Mass Index (BMI) equal to or greater than 35 Kg/M2 in a person who has associated medical problems such as high blood pressure, sleep apnea, or diabetes. The BMI relates one’s weight to his or her height in an attempt to generate a common denominator for all individuals. (See the Glossary of Terms to find out how to figure out your BMI.)
A Body Mass Index (BMI) equal to or greater than 40 Kg/M2 in a person who either does or does not have any other medical problems. (See the Glossary of Terms to find out how to figure out your BMI, or click here to go to a BMI calculator )

Patients who are considered morbidly obese have a significantly higher chance of the following (as compared to individuals who are not overweight):

Dying prematurely – morbidly obese individuals have a 300-500% greater chance of dying before the age of 76.
Developing medical problems including diabetes (1200% higher), high blood pressure (500-600% higher) and heart disease (200-400% higher).
Developing certain types of cancers such as colon, breast and uterine.
Developing premature degenerative arthritis and joint pain causing limited mobility and activity.
Developing Sleep Apnea and Pulmonary Hypertension (which leads to heart failure).

Possible Complications after Surgery

Although Gastric Bypass is relatively safe it is a major abdominal operation and there are many important and potentially lethal complications known to be associated with this operation.

	Complications	Description
1	Allergic Reactions	All kinds of allergic reactions are possible, from minor reactions such as a rash to sudden overwhelming reactions that can cause death.
2	Anesthetic Complications	Anesthesia used to put you to sleep for the operation can be associated with a variety of different complications up to and including death.
3	Bleeding	Surgery involves incisions and cutting that can result in bleeding complications, from minor to massive, that can lead to the need for emergency surgery, transfusion or death.
4	Blood Clots	Also called Deep Vein Thrombosis (DVT) and Pulmonary Embolus can sometimes cause death. In the people that have had the Mini-Gastric Bypass 0.08% have developed clots in their legs (Deep Vein Thrombosis) and 0.16% have had a pulmonary embolus. This is 10 times lower than seen in other series of gastric bypass but it can still happen. I understand that I need to get out of bed the evening after surgery and move and flex my feet and legs to try to help prevent clots from forming in my legs
5	Infection	Including wound infections, bladder infections, pneumonia, skin infections and deep abdominal infections that can sometimes lead to death.
6	Leak	After operation to bypass the stomach the new connections can leak stomach acid, bacteria and digestive enzymes causing a severe abscess and infection. This can require repeated surgery, and intensive care and even death. In the patients that have had the Mini-Gastric Bypass 1.6% have developed a leak.
7	Narrowing (stricture)	Narrowing (stricture) or ulceration of the connection between the stomach and the small bowel can occur after the operation this can require emergency operation, intensive care and can sometimes lead to death. To protect your new stomach from ulcers you must never again take aspirin, or aspirin like drugs such as Motrin, Ibuprofen, Naprox, Relafen or other similar drugs.
8	Indigestion, Reflux or Ulcers	The operation can sometimes lead to severe nausea, vomiting, indigestion, abdominal pain, gastritis or ulcers. This can be severe and can last for days, weeks and possibly even longer. This is especially likely if you have had previous problems with nausea, abdominal pain or ulcers. Nausea is much more common in women than men. Women that have been treated with any type of hormone therapy (Premarin, Estrogen or Birth Control Pills) are much more likely to have nausea and vomiting after surgery.
9	Dumping Syndrome	Dumping Syndrome (Symptoms of the dumping syndrome include cardiovascular problems with weakness, sweating, nausea, diarrhea and dizziness) can occur in some patients after gastric bypass. This can be so severe that the surgery may have to be reversed.
10	Bowel Obstruction	Any operation in the abdomen can leave behind scar that can put the patient at risk for later bowel blockage or obstruction. The bowel can twist, obstruct and even perforate leading to serious complications and even death.
11	Laparoscopic Surgery Risks	Laparoscopic Surgery uses punctures to enter the abdomen and this can to lead to abdominal injury, bleeding and even death.
12	Side Effects of Drugs	All drugs have inherent risks and complications and in some cases can cause a wide variety of side effects, reactions and in some cases including death.
13	Loss of Bodily Function	The performance of surgery and anesthesia can stress the body’s systems leading to a variety of complications including stroke, heart attack, limb loss and other problems related to operation and anesthesia.
14	Risks of Transfusion	Including Hepatitis and Acquired Immune Deficiency Syndrome (AIDS), from the administration of blood and/or blood components. These illnesses are serious and can be fatal.
15	Hernia	Cuts and incisions in the abdominal wall can lead to hernias after surgery. Hernias can lead to pain, bowel blockage, obstruction and even perforation and death in some cases. Treatment of hernias usually requires another operation.
16	Hair Loss	Many patients develop hair loss for a period after operation. When this occurs it usually starts around 3-4 months after surgery and resolves at 7-9 months after operation. This usually responds to increased oral intake of protein and vitamins but it may be permanent.
17	Vitamin and Mineral Deficiencies	After gastric bypass there is a malabsorption of many vitamins and minerals. Patients must take vitamin and mineral supplements forever to protect themselves for these problems. You also need to have yearly blood tests to measure the blood levels of these vitamins and minerals. Common deficiencies that can occur after gastric bypass include iron and calcium deficiency, B12 and Folate deficiencies. This is very important: Patients must take vitamin and mineral supplements forever. In some cases the deficiencies are so severe that they can lead to nerve and brain damage and the operation must be reversed.
18	Inadequate Weight Loss	WARNING: Remember that you might not lose weight after the operation. There are patients that will fail any type of surgery. Inadequate weight loss is a risk of all types of weight loss surgery and indeed of all types of weight loss treatment. I recognize that the Gastric Bypass is not by any means a perfect treatment and that one of the risks that I face is a real possibility of inadequate weight loss following my Gastric Bypass surgery.
19	Excessive Weight Loss	Some patients sustain excessive weight loss after operation and may require reversal of the bypass to prevent severe malnutrition, nausea or vitamin and mineral deficiencies or death.
20	Complications of Pregnancy	Vitamin and mineral deficiencies can put the newborn babies of gastric bypass mothers at risk. No pregnancy should occur for the first one to two years after operation. Gastric Bypass has been shown to cause multiple types of vitamin and mineral deficiencies including: iron, B12, Folate, calcium and many others. Many of these deficiencies have been shown to cause birth defects or are suspected that they could cause birth defects. We also know that many patients who lose weight feel that they are well after surgery and forget to take their vitamins. Patients must be certain not to miss any of their vitamins if they decide to go ahead with pregnancy later.
21	Unplanned Pregnancy	Warning to women using Oral Contraceptives (Birth Control Pills): More than 80 million women worldwide take "the pill" to prevent pregnancy. Typical failure rates among pill users are as high as 12% to 20% in some surveys. Other factors have been shown to increase the risk of pill failure: smoking, diarrhea and/or vomiting drug interactions, systemic illness, psychological stress, and menstrual disturbances. So it is important to recognize that Birth Control Pills may not be an effective method of birth control after the Mini-Gastric Bypass until those factors have resolved. We have found on several occasions that in many cases the hormonal methods of birth control fail after Gastric Bypass. Couples need to plan another form of nonhormal birth control for 6-12 months after surgery. Depo-Provera has also been associated with marked cases of nausea in post MGB patients. An unplanned pregnancy can be one of life's most difficult experiences.
22	Other	Major abdominal surgery, including the Gastric Bypass, is associated with a large variety of other risks and complications, both recognized and unrecognized that occur both soon after and long after the operation.
23	Depression	Depression and anxiety are common medical illnesses and have been found to be particularly common after operation.
24	Cancer	Cancer can occur in anyone. Many cancers are more common in obese as compared to thin patients. Overweight men have a significantly higher rate of prostate cancer. Obese women have higher risks of developing breast cancer and cancer of the uterus and ovaries. It is expected, but not certain, that with weight loss you will have an overall decrease in your risk of cancer.
25	Death	This is a major and serious operation. It may lead to death from complications. There has been a death in the first week after this surgery in one patient.

Early complications (within the first 2 months after surgery) 5% of patients have some sort of significant complication. About 10% have some sort of minor problem that requires attention.
Anastomotic (staple line) leak	<2%
Anesthetic problem	Severe, rare
Arrythmia (cardiac irregularity)	<1%
Blood clots to lungs (pulmonary embolism)	<1%
Gastrostomy problems	2%
Heart attack (myocardial infarction)	rare
Incision infection, major	2%
Incision infection, minor	3%
Incision opening (fascial dehiscence)	rare
Kidney failure	rare
Pneumonia	1%
Potassium deficiency	rare
Stroke	rare
Thrombophlebitis	<1%
Transfusion	2%

Late complications (after first two months after surgery)
Anastamotic ulcer	<1%
Anastomotic stricture (last 300 patients)	1%
Anemia, iron deficiency	Rare if iron replaced, common if not
B12 deficiency	Rare if B12 replaced, 30% if no B12 supplement
Incision hernia	10%
Potassium deficiency	rare
Psychological challenges (significant)	5-10%
Small bowel obstruction	<1%

The death rate (mortality) from gastric bypass is about 1%. This list is indicated to illustrate the type and frequency of complications following gastric bypass in my practice. The figures are comparable to nationally published figures. Some are a little higher and some are a little lower. Since most of the events are very rare, it is very difficult to tell small differences between one surgeon's series and another's with any statistical certainty. This list does not include all possible complications. The mortality rate for gastric bypass is similar to the mortality rate for other major general surgical procedures done on a group of patients who are obese and have multiple health problems. Risk of dying from any procedure depends on the general health, age, and weight of the individual. Clearly people who are older, have more severe comorbid problems, and are heavier are much higher risk than younger, healthier, less obese counterparts. The most common causes of death after gastric bypass include infection secondary to staple line or suture line leaks, pulmonary embolism, and respiratory problems.

Failure of vertical banded gastroplasty (VBG: old-fashioned "stomach stapling") as a long-term surgical treatment for severe obesity

Ten or more years after VBG as primary operation for morbid obesity

Balsiger BM, Poggio JL, Mai J, Kelly KA, Sarr MG.

J Gastrointest Surg. 2000 Nov-Dec;4(6):598-605.

Long-term follow-up (>10 years) after vertical banded gastroplasty (VBG) is almost nonexistent. The aim of this study was to determine long-term outcome after VBG in a group of 71 patients studied prospectively. Seventy-one consecutive patients with morbid obesity (54 women and 17 men; mean age 40 years [range 22 to 71 years]) underwent VBG from 1985 to 1989 and were followed prospectively. Follow-up was obtained in 70 (99%) of the 71 patients. Weight (mean +/- standard error of the mean) preoperatively was 138 +/- 3 kg and decreased to 108 +/- 2 kg 10 or more years postoperatively. Body mass index decreased from 49 +/-1 to 39 +/- 1. Only 14 (20%) of 70 patients lost and maintained the loss of at least half of their excess body weight with the VBG anatomy. Vomiting one or more times per week continues to occur in 21% and heartburn in 16%. Fourteen patients have undergone conversion from VBG to Roux-en-Y gastric bypass (11 patients) or other procedures (3 patients) because of a combination of inadequate weight loss in 13 patients, gastroesophageal reflux in five, and frequent vomiting in four. Only 26% of patients after VBG have maintained a weight loss of at least 50% of their excess body weight; 17% underwent bariatric reoperation with good results. Thus VBG is not an effective, durable bariatric operation.

Radiologic (x-ray) images of complications after gastric bypass surgery

(1) CT scan showing an intra-abdominal abscess (see arrows) forming next to the stomach pouch 8 days after gastric bypass surgery - most likely related to a staple line leak:

(2) CT scan showing distension of bypassed stomach (see arrows) due to obstruction from an internal small bowel hernia 4 months after gastric bypass surgery:

(3) Barium UGI x-ray showing passage of barium (see arrows) into bypassed part of stomach 2 months after gastric bypass surgery. The staples separating the pouch from the bypassed stomach have "undone". This can lead to acid reflux into the pouch and weight regain: