Chapter One
The Authors
WLS Illustrations
WLS Links
How to Order the Book


What is bariatric or weight loss surgery?
Bariatric surgery is the area of surgery that focuses on operations to reduce weight and treat obesity. The name comes from the Greek words baros, meaning weight, and iatrike, meaning treatment.
How is bariatric surgery different than liposuction?
Bariatric surgery is major surgery involving the gastrointestinal tract. The stomach and intestines are modified so that less food can be consumed or absorbed, which leads to a substantial loss of weight that can be maintained for years. Liposuction is a form of cosmetic surgery in which areas of the body are reshaped or resculpted by removing excess amounts of fat in those areas. The purpose of liposuction is not to produce weight loss. 
How do I know if I'm a candidate for this surgery?
You must have clinically severe obesity, also known as morbid obesity. This means your BMI must be higher than 40, or you must be at least 100 lbs above your ideal body weight. You may be a candidate if you're less than 100 pounds overweight, if you also have significant health problems due to your weight, such as Type 2 diabetes. Most people with clinically severe obesity are good candidates for surgical treatment-as long as you understand the procedure, don't have a severe, pathological eating disorder and are willing to come back for life long follow-up. 
What is BMI? 
It stands for Body Mass Index and it determines someone's health risk related to their weight. A BMI greater than 40 or greater than 35 with associated medical problems means you have clinically severe obesity which is associated with diabetes, heart disease, high blood pressure, high cholesterol, heartburn, gallstones, arthritis, urinary stress incontinence, infertility, and some types of cancer.

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How do I calculate my BMI and Ideal Body Weight? 
Ideal Body Weight is equal to 100 lbs for the first 5 ft + 5 lbs for each additional inch for women, and 106 lbs for the first 5 ft + 6 lbs for each additional inch for men. BMI can be calculated using the following formula: Multiply your weight in pounds by 704, then divide by the square of your height in inches. For example, if you weigh 130 pounds and are 5'4" (64") tall, your BMI is (130 * 703)/(64 * 64) = 22.3. (If you use the metric system, divide your weight in kilograms by the square of your height in meters.) There are also height and weight tables that tell you your BMI. 
Does my weight alone justify such extreme measures?
Yes. Morbid obesity is an independent risk factor for premature death, with the risk rising as the BMI increases. People with a BMI of 30 have a relative risk of dying early that is 1.3 times greater than normal weight individuals. By the time the BMI is 40, the risk is close to 3 times as great.
I feel so guilty about being obese. . . is it all my fault?
No, obesity tends to run in families. Identification of several genes and their corresponding hormones (leptin) have been found to be at least partially responsible for obesity. Therefore, there is evidence that obesity is at least partially biological, helping to reduce the misconception that it is a behavioral or psychological disorder. I consider obesity a disease which needs a cure, rather than a moral failing which is the fault of the individual.
Why should I consider WLS? 
Because it works! Surgical treatment for obesity is the ONLY treatment that reliably produces significant and sustained weight loss. People with clinically severe obesity are at great risk for developing many associated medical conditions. Research has shown that surgical treatment results in significant weight loss and improvement in most problems associated with obesity. Surgical treatment for clinically severe obesity has been endorsed by the National Institutes of Health, the World Health Organization, Shape-Up America, the American Heart Association, the American Dietetic Association, and the American Obesity Association.
Why not just lose the weight through diet and exercise and skip the serious complications that could result from surgery?
If you can lose the necessary amount of weight (and keep it off) though diet and exercise-more power to you! Ninety five percent of the people considering WLS have tried (sometimes numerous times) and failed. I like to use this analogy. If someone asks, "If I can buy a lottery ticket and win the lottery, why do I have to work for a living"? My answer would be, "You don't. If it is easier and less painful to win the lottery and if you can do it, then go for it". For a morbidly obese individual, losing a significant amount of weight is comparable to winning the lottery.
Why not take drugs to combat obesity?
Drug treatment does produce limited success (usually weight loss of about 35 to 40 pounds). However, concerns about safety of long-term treatment have limited the drugs available and the length of time people can take them. This in turn, limits their effectiveness because, as with any chronic disease, such as diabetes or high blood pressure, the drug is only effective as long as it is taken.
How this WLS promote weight loss?
Operations for the treatment of obesity usually induce weight loss by limiting the amount of food consumed, altering the normal absorption of nutrients, and/or altering the way the body utilizes energy. A Roux-En-Y Gastric bypass does all three. It actually boosts your metabolism for the first 18 months, which is one reason patients lose weight so quickly.
Is it unhealthy to lose weight rapidly after WLS?
I like to answer this question by asking another question: "Is it healthy to be 100 pounds overweight?" The rapid weight loss experienced after WLS is extremely gratifying psychologically and physically. If you eat properly, making sure you get enough protein, there should be no ill effects from it. 
How do I find a doctor who performs WLS?
Ask your primary care physician for a referral or contact the American Society of Bariatric surgery and ask for a surgeon in your area. Go to the surgeon's support groups and talk to his patients to find out what their experiences have been. Ask for patients you can call for references. If there is a teaching hospital in your area, see if they have a Bariatric surgery program. If you have access to the Web, visit the websites listed at the back of this book and you can find links to many bariatric surgical practices. 
Selecting a physician is a difficult decision. What qualities should I look for in a surgeon?
 Look for a person who is committed to caring for severely obese patients. Obesity is a chronic disease and it requires specialized pre-operative care and post-operative follow-up. The surgeon should not delegate these to other individuals.
What is a bariatric surgeon? 
The field of obesity surgery is also known as bariatric surgery. Bariatric surgeons are general surgeons who perform surgical procedures in the abdominal cavity. 
Can you explain exactly what you do, in terms that I can understand, when you perform a Roux-en-Y Gastric Bypass?
The Roux-en-Y Gastric Bypass (RYGB) is a combination of a restrictive (inhibiting the amount of food that can be eaten), and malabsorptive (limiting the amount of food that is absorbed into the system) procedure. The restrictive component consists of creating a small pouch at the top of the stomach with a surgical stapler. The malabsorptive portion is created by dividing the small intestine and re-routing it so that one portion is connected to the small stomach pouch (Roux limb) and the remaining portion, which delivers the bile and pancreatic juice, is reconnected to the small intestine at a predetermined distance from the stomach. 
What is a VBG? 
Vertical banded gastroplasty (VGB), which is only restrictive, is another common form of WLS. This operation is performed by creating a 1 ounce pouch near the junction of the stomach and esophagus using a vertically placed staple line. 
Which operation do you prefer and why? 
I prefer the Roux-en-Y gastric bypass (RYGB) because it produces greater weight loss more reliably than the vertical banded gastroplasty (VBG) and the weight lost is more likely to stay off.
At last weigh-in, I was 450 pounds. Is there any limit on how heavy one can be to have obesity surgery?
No. I have successfully operated on a patient who weighed 750lbs., who had a BMI of 100. The operative risks are higher the more you weigh, but they still don't approach the risk of remaining at such a high weight. 
How much weight can one expect to lose after surgery? 
Most patients lose between 50 and 70% of their excess body weight over about 1-1 years. Some reach their ideal weight, but most don't. 
Can you gain the weight back?
Long-term results after Roux-en-Y gastric bypass have shown that patients usually regain less than15% of the weight they lost after 10 years. However, if you go back to your old eating habits, and don't exercise at all, you might gain more than that. 
How long does it take to perform the operation? 
The open Roux-en-Y gastric bypass usually takes between 1 and 2 hours, depending on the surgeon. The VBG should take less time and the BPD or DS, which is more complex, should take longer. 
Does it matter how long takes? I'd be asleep anyway.
The length of the operating procedure may make a difference. Many studies have documented an increase in the incidence of infectious complications, such as pneumonia and wound infection, after prolonged surgical procedures. Longer operations result in a fall in body temperature that interferes with the immune system. In addition, longer operative times mean increased exposure to general anesthesia, which often results in the collapse of portions of the lung and can lead to pneumonia. In general, shorter operations are safer.
How long will I be in the hospital? How long does it take to recuperate?
Most patients are admitted to the hospital on the morning of surgery, remain in the hospital for 2 or 3 days, and require between 2 and 6 weeks to recuperate before returning to work, depending upon the type of job they have.
I'm concerned about my future. Does anyone know what the adverse long terms affects of Roux-en-Y surgery will have on me?
The only long term adverse affects of Roux-en-Y surgery are vitamin and iron deficiencies. These can be treated with vitamins, iron and B12 supplements. 
When I tell people that I'm considering this operation, they all have something negative to say. Why does WLS seem to have such a bad reputation?
The operations that were performed thirty years ago achieved weight loss but carried a high complication and mortality rate. That's when the surgery acquired a bad reputation, and rightly so. We no longer perform those operations. The ones done currently achieve comparable weight loss and are safe.
I really like to eat. What's going to stop me from overeating after the surgery? 
Because your stomach will be smaller, it will fill up with food sooner. When the food touches the walls of the stomach, it sends a message to the brain that you don't want any more to eat. The brain will receive this signal after eating much less food and consequently, you'll eat less. Most people just don't feel hungry. When you do overeat, or eat too quickly, you may experience what's called "dumping syndrome."
A year after the surgery, are most people generally happier with their lives?
Yes. Much happier. Most patients say they would do it again "in a heartbeat." Studies show that this kind of patient satisfaction is a true test of the surgery.
When it's over, will there be things I need to do after surgery?
Regular, long-term follow-up is needed to monitor weight loss, provide dietary counseling, and to monitor for the occurrence of nutritional deficiencies or complications.
I'm sixteen years old. Can someone be too young to be a candidate for this surgery?
Yes. People can be too young. You need to have stopped growing and you need to have a mature bone age. In addition, you must understand the surgery and want it. You can't have an operation because your friends or your parents want you to. You need to be able to give "informed consent", which means you make an educated decision and then give your permission for the procedure. It is also necessary that your parents are supportive of your decision and understand the role they will need to play in your care and recovery. 
I'm well over fifty. Can you be too old for this surgery?
Age is one factor that needs to be considered together with all other aspects of a person's health. I would not give an arbitrary or absolute cut off. I have done gastric bypasses on several patients in their late 60s and early 70s, with excellent results.
I am severely overweight, have diabetes, hypertension, and congestive heart failure. My internist tells me that I am "too sick" to be a candidate for WLS.
If you are overweight with associated problems due to obesity, you are not too sick not to have this operation! You are too sick NOT to have it. The only chance you have for improvement in your medical conditions is through weight loss.