Is Bariatric Surgery Right for You?
Considering metabolic surgery? Weigh the pros and cons before taking the leap
Medication and lifestyle changes may help people with type 2 diabetes manage their blood glucose and their weight. But that approach does not work for some people, especially those who are obese. For them, weight-loss surgery—also known as bariatric or metabolic surgery—may be the best solution.
The two major types of surgery—Roux-en-Y gastric bypass and sleeve gastrectomy—together account for more than 95 percent of bariatric surgeries performed on people with type 2 diabetes. Studies show that both procedures offer significant benefits, including:
- Dramatic weight loss
- Complete type 2 diabetes remission, or partial remission (defined as having test results lower than the range for diabetes for at least a year)
- Improvements in blood pressure and cholesterol
- Improved quality of life
- Longer life
- Alleviation of obstructive sleep apnea
“With surgery, almost everything points to the positive,” says Samar Hafida, MD, an endocrinologist who specializes in obesity and clinical nutrition at the Joslin Diabetes Center in Boston. The benefits are often lasting. Two studies published in the January 2018 issue of JAMA found that obese people with type 2 diabetes had kept off half to two-thirds of their excess weight five years after either gastric bypass or sleeve gastrectomy. The two studies also showed that bariatric surgery led to partial or complete remission of diabetes in as many as 2 out of 3 participants.
Another study in the same issue of JAMA revealed an additional benefit linked to weight-loss surgery. Though their study was not designed to determine cause and effect, researchers did observe that people who underwent sleeve gastrectomy and gastric bypass surgery had a significantly reduced risk of dying over a nearly five-year period compared with similar people who did not have surgery. These studies all examined fairly long-term outcomes from bariatric surgery, but you don’t have to wait long to see positive results.
“People begin to benefit from bariatric surgery almost immediately,” says Samer Mattar, MD, a bariatric surgeon at Swedish Medical Center in Seattle and president of the American Society for Bariatric and Metabolic Surgery. “It works by normalizing the blood glucose in the system, and it reverses many of the effects of diabetes. It also re-multiplies the beta cells in the pancreas that produce insulin. And most important, it reduces insulin resistance.”
In addition to weight loss and better blood glucose management, bariatric surgery also helps curb your desire to eat. Researchers theorize that weight-loss surgery cuts off the supply of the hormone ghrelin, a chemical messenger that travels from the gut to the brain, where it stimulates the appetite. “After surgery, all patients experience a rapid reduction in appetite,” says Mattar. “You can imagine how helpful this can be for patients to change their behavior and relationship to food.”
Traditionally, gastric bypass has been considered the gold standard procedure. Experts agree that bypass patients typically lose more weight than those who have a sleeve gastrectomy, and they’re more successful at keeping the weight off. Gastric bypass has been shown to provide better improvements to blood glucose levels in people with type 2 diabetes. But more recent research, backed by the clinical experience of bariatric surgeons, attests to the near-comparable benefits of sleeve gastrectomy. “It’s a misperception that the sleeve is less effective than gastric bypass,” says Mattar. “Both operations are equally effective in the treatment of diabetes.”
Find out which—if either—is right for you.
1. How are the surgeries performed?
In what’s known as laparoscopic surgery, surgeons make several small incisions in the abdomen and insert a camera for guidance. They create a stomach pouch the size of a golf ball by separating the top of your stomach from the larger, lower portion. Then they divide the small intestine into two parts, connecting the first part of the small intestine to the newly created stomach pouch. Food then bypasses the larger part of the stomach and part of the small intestine. The result: You can eat only about a cup of food per meal, and your body absorbs fewer calories.
As with gastric bypass, surgeons insert a camera into your belly through small incisions to guide them during the minimally invasive procedure. They remove about 80 percent of your stomach. Using surgical staples, they join together the remaining 20 percent of your stomach into a banana-shaped tube or sleeve. The resulting smaller stomach will permit only small meals. Unlike gastric bypass, however, sleeve gastrectomy is a shorter, less complicated surgery.
Recovery time is about the same for both. Most people return to normal activities after three to four weeks. “For the first couple of weeks after surgery, they’re not able to get in many calories, and they tend to be fatigued and feel washed out,” says Erik Dutson, MD, surgical director of the Center for Obesity and Metabolic Health at the University of California–Los Angeles. “Almost universally, people’s energy levels start to spike back up after three weeks. That’s when people tend to be ready to go back to work.”
2. What considerations should guide the choice of procedure?
“Both surgeries are safe and effective, with minimal differences between them,” says Ali Aminian, MD, a bariatric surgeon at the Cleveland Clinic. “But we consider all factors when deciding on a procedure for an individual patient.”
First, your health care team will evaluate your diabetes status, based on factors such as how long you’ve had the disease, how many medications you require, and how well managed your blood glucose is. The severity of your condition at the time of surgery will help predict which procedure will be more likely to lead to long-term diabetes remission, according to research Aminian published in 2017 in Annals of Surgery.
- If you have gastroesophageal reflux disease (GERD) or related conditions such as Barrett’s esophagus, sleeve gastrectomy may not be right for you. Increased pressure in the stomach following surgery can cause or worsen reflux, says bariatric surgeon Andrea Stroud, MD, of Oregon Health and Science University in Portland.
- If you’ve had an organ transplant, sleeve gastrectomy would likely be the better choice because you’ll be able to more consistently absorb the medications that you need to take to support your transplanted organ, says Stroud. People who have had pelvic surgery or small bowel radiation should also avoid gastric bypass. “Such previous procedures may make bypass surgery less safe and successful,” she says.
- Nonsteroidal anti-inflammatory drugs (NSAIDS), common over-the-counter painkillers that include aspirin and ibuprofen, increase the risk of ulcers following bypass surgery. “Patients with degenerative joint diseases like osteoarthritis who rely on such pain medications would benefit more from the sleeve,” says Mattar.
3. What are the risks and side effects?
No surgery comes without some risk, but both sleeve gastrectomy and gastric bypass appear as safe as or safer than many common surgical procedures. Sleeve gastrectomy is slightly safer than gastric bypass, but gastric bypass is almost 10 times safer than hip replacement surgery, says Dutson. “The complication rate for both bypass and sleeve is low.”
While both procedures offer numerous—and often life-altering—benefits, each has its share of negatives. Gastric bypass has a low but lifelong risk of internal hernias and small bowel obstructions. And gastric bypass patients have a 4 to 5 percent chance of developing a painful ulcer at the newly created connection between the stomach and the small bowel. Such ulcers often can be managed with medications, but on rare occasions, they require surgery.
Sleeve gastrectomy can raise your risk of GERD and, says Stroud, symptoms of GERD can make some people so miserable that they opt to undergo surgery again to convert to a gastric bypass.
“Post-op reflux is the No. 1 reason to reoperate,” Stroud says. Chronic gastritis, or inflammation of the lining of the stomach, also may occur after sleeve gastrectomy.
Other considerations: Although rare, severe low blood glucose (hypoglycemia) is more common after gastric bypass. Patients who undergo the procedure also more frequently experience dumping syndrome, which occurs when food moves too quickly from the stomach to the small intestine. The condition causes cramps and nausea shortly after eating. Making changes to your diet and eating slowly can help prevent it.
Both procedures make it more difficult for your body to absorb all the nutrition it needs. Multivitamins and other over-the-counter supplements can help offset deficiencies, but you will need to be evaluated at least once a year to make sure you’re meeting your nutritional requirements.
4. How do the surgeries compare over time?
While surgeons have been performing gastric bypass surgery for decades, sleeve gastrectomy has been around for only about 15 years. So experts can’t say with certainty how effectively it can help people control their weight and their diabetes 10 to 20 years after surgery. However, says Dutson, “the long-term data that we do have is very similar to gastric bypass.”
Mattar cautions against relying on statistics when evaluating the two surgeries. Instead, consider your individual needs, desires, and circumstances. “We’re moving away from which operation is the gold standard, which operation is superior, to focusing on what’s more appropriate for a particular patient,” says Mattar. “We’re trying to customize and personalize surgery as much as possible.”
Are You A Candidate For Bariatric Surgery?
According to the American Diabetes Association’s 2018 Standards of Medical Care in Diabetes, bariatric surgery is:
- Recommended for people with a body mass index (BMI, a ratio of weight to height used to estimate how close a person is to a healthy weight) of 40 or higher (37.5 for Asian Americans, who often develop diabetes at a lower BMI than other groups), regardless of their A1C.
- Recommended for people whose BMI falls between 35 and 39 (32.5 to 37.4 for Asian Americans) if, despite lifestyle changes and medication, their A1C is still above goal.
- Considered an option for people with a BMI between 30 and 34.9 (27.5 to 32.4 for Asian Americans) if, despite medications (including insulin), their A1C is above goal.
Not all people who match these criteria will be immediately eligible for surgery. The Association’s guidelines recommend delaying surgery until issues such as alcohol and substance abuse, depression, and mental health problems have been addressed.
Life After Surgery
Weight-loss surgery may offer life-altering benefits, but there’s much to keep in mind after it’s over.
- Your appetite may start to return within six months to two years. Learn to eat more healthfully and mindfully before then so you regain a minimal amount of weight.
- Accept that your diabetes may not go into remission or that you may not lose as much weight as you’d hoped. Celebrate the improvements that you do see and your much-reduced need for medication.
- Don’t get distraught when your weight loss begins to slow down. It’s normal to lose a dramatic amount of weight in the first few months after surgery, and it’s also normal for it to taper off.
A Note About Cost
Weight-loss surgery costs an estimated $15,000 to $20,000, and insurance companies typically offer plans that cover its costs.
Your employer, however, might not purchase plans that include such coverage. In general, insurance companies only cover surgery for people whose body mass index (BMI, a ratio of weight to height used to estimate how close a person is to a healthy weight) is at least 35. You will be responsible for any deductible payments and out-of-pocket expenses outlined in your insurance policy.