Obesity, a disorder involving an excessive amount of body fat, has become a global problem. The obesity epidemic can be contributed to modern environmental factors such as poor diet, stress, lack of exercise, sleeping habits, and pharmaceuticals. Pharmacotherapy and Diet & exercise are not an effective, durable solution to weight loss. (See recent study for low-carb, low-fat diet).
Research studies have discovered two factors pointing to the reduced efficacy of diet. First is the body’s natural resistance to weight loss and the second, is the body’s tendency to put the weight back on after you’ve lost it.
The body sees calorie reduction diet (Calories In less than Calories Out) as a starvation threat. And body’s natural resistance to weight loss can be described as the increased feelings of cravings and hunger while simultaneously decreasing the metabolism and satiety. These two mechanisms will keep most individuals from losing any considerable weight. This is most aptly explained by body’s metabolic thermostat, i.e. ‘Set Point Theory.’ Body fat setpoint is affected by Genetic Predisposition, Environmental Exposure, and Developmental History.
Even after you succeed to lose the weight, your body will typically try to go back to your previous ‘set point,’ meaning the body may encourage excess weight to regain. As if your body will remember the initial ‘set point.’ This could cause a vicious cycle and it is known as weight cycling or yo-yo diet
Surgical treatment of obesity or bariatric surgery is a proven solution to fight obesity by shifting the neuro-hormonal axis to renew patient’s life. Bariatrics can cure numerous medical diseases including diabetes, hypertension, high cholesterol, sleep apnea, liver disease, and arthritis among others. Obesity surgery works so well because it changes the physiology and creates a new ‘set point,’ in patients. Causing them to keep the weight off for the long-term.
There are a lot of options to lose weight via surgery because there isn’t one bariatric surgery that is ideal for everyone. Each patient has their characteristics that will dictate which surgery is best for them.
Jump to Section of Page:
- Types of Weight Loss Surgeries
- Open vs Laparoscopic vs Endoscopic Procedures
- Stomach Stapling vs. Stomach Banding
- Weight Loss Surgeries Being Operated Today
- Compare Similar Surgeries Side-by-Side
- Outdated Procedures (No Longer Performed)
- New Procedures (Experimental, No Meaningful Data)
Types of Bariatric Surgeries
Weight loss surgeries can be classified into three broad categories, depended on their primary method of action. In other words, the way the operation achieves weight loss. Currently, there are three types restrictive, malabsorptive and a combination of restrictive & malabsorptive.
Restrictive bariatric procedures are procedures which ‘restrict’ the stomach’s capacity, thereby reducing caloric intake. The smaller stomach capacity will induce the feeling of fullness quicker than normal, prompting the patients to eat less, while still being satisfied. This method is seen in procedures such as adjustable gastric banding, vertical sleeve gastrectomy (gastric sleeve), and intragastric balloon .
Malabsorptive bariatric procedures reroute, rearrange or remove part of the digestive system to reduce the body’s absorption of calories from food. Malabsorptive produces more weight loss (typically), then restrictive, but also produces higher unwanted complications and side effects. There are no stand-alone malabsorptive procedures currently being performed today, they’ve all graduated to a combination of restrictive and malabsorptive.
Combination bariatric procedures provide individuals the best chance to reduce morbid obesity. Combination procedures use both techniques (restrictive and malabsorptive) to produce high amounts of ‘excess weight loss’ (amount of weight, determined to be in excess). Some bariatric surgeons describe combination and malabsorptive the same. Current combination surgeries still in operation are gastric bypass and duodenal switch.
Open vs. Laparoscopic vs. Single Incision vs. Endoscopic
In the past, bariatric procedures were performed openly. Now, most bariatric surgeries are performed laparoscopically with excellent results. Qualified bariatric surgeons are very experienced with laparoscopic surgery, producing surgeries with lower recovery time, lower surgical complications, and aesthetically pleasing results.
Open surgery was done without any medical technologies, meaning there would be a large incision in the abdomen for the entire surgery to perform. Now, open surgeries are rarely performed, due to longer recovery periods and higher risks of infection and adhesions.
Open surgery requires patients to recovery in the hospital longer than laparoscopy and has less cosmetic scarring than laparoscopic surgery.
Laparoscopic surgery is performed with medical instruments that have built-in cameras allowing surgeons to view the abdomen on nearby screens. The result is that there are five to six small incisions, rather than one large incision in the abdomen with open surgery.
Laparoscopic requires less recovery time in the hospital, typically two or three days and has more cosmetic appearance post-surgery.
Single Incision bariatric surgery allows patients to undergo bariatric surgery with fewer scars. This allows patients to heal more aesthetically while speeding up the healing time.
Single Incision bariatric surgery is only available on more simplistic surgeries such as the gastric sleeve surgery. Learn more about single incision weight-loss surgery.
The endoscopic procedure utilizes an endoscope, a flexible medical instrument inserted through the mouth, rather than making an incision in a traditional surgery. In newer, experimental procedures such as such as Endoscopic Sleeve Gastroplasty, the endoscope is used to place sutures in the stomach and making it smaller. In addition, most patients will require endoscopy before revisional weight loss surgery.
Stomach Banding vs. Stomach Stapling
Many individuals may conflate stomach surgery and stomach stapling as both are bariatric (weight loss) surgery. Both are essential components in weight loss surgery, but are different, and thus, necessary to distinguish.
- Stomach banding is the colloquial term for the vertical banded gastroplasty and gastric banding, which are the same restrictive procedure as Lap-Band surgery. Stomach banding procedure relies on a medical device to wrap around and ‘band’ the stomach, thereby causing restriction. This is typically a stand-alone procedure but has been utilized previously by surgeons in other surgery types.
- Stomach stapling, is the colloquial term to describe a few weight loss surgeries, including gastric sleeve surgery (vertical sleeve), roux-en-y gastric bypass, duodenal switch. This type uses medical staples to recreate permanently and close a smaller stomach for individuals. This requires just one surgery and may result in more predictable weight loss.
Current Weight Loss Surgery Options
Below are the five primary weight loss surgery options that are typically accepted and practiced by bariatric surgeons in the United States, Canada, Mexico, and Europe. In other countries, especially countries in Europe, are quicker to approve more experimental procedures.
Weight Loss Surgeries: Table Comparison
|Gastric Sleeve||RNY Gastric Bypass||Mini Gastric Bypass||Gastric Banding||Duodenal Switch|
Method of Weight Loss
|Restrictive||Restrictive & Malabsorptive||Restrictive & Malabsorptive||Restrictive|
|Restrictive & Malabsorptive|
|Stomach size reduced||New Stomach is Created: Stoma.||New Stomach is Created: Stoma.||Stomach size reduced||Stomach size reduced|
Changes to Intestine
|No Change||Cut and Bypassed||Cut and Bypassed||No Change||Intestines “Switched.”|
Average Hospital Stay
Time off Work
|The average recovery time following a gastric sleeve procedure is 3 weeks. This is a laparoscopic procedure with a short recovery time. You may need pain medication to help get you through the recovery period though you will have a small amount of discomfort compared to other weight loss surgery procedures.||The average recovery time for RNY gastric bypass is typically six to eight weeks. You are not able to drive on your own for at least 10 days and are instructed to follow all post-op instructions, including taking medications and not returning to normal activities until directed by a doctor.||On average, recovery takes a six to eight weeks. You are released from the hospital in just a couple days, but you will need a few months before you can return to all of your normal activities following the procedure.||The gastric banding procedure is minimally invasive and has a short recovery time of 4-6 weeks.||Recovery time for the duodenal switch is about six to eight weeks, though this varies based on the person. It is laparoscopic so only small incisions are made, but the inside takes longer to heal.|
|The gastric sleeve procedure is done by removing part of the stomach and making a tube-shaped sleeve where the food will then be digested. This reduces how much is eaten during each meal, resulting in weight loss. This is a laparoscopic procedure, with very minimal incisions used.||A small stomach pouch attached to the small intestine is created during the RNY gastric bypass procedure. This allows all food to bypass the stomach and go directly to the small pouch, which reduces how much food can be absorbed during each meal. It is preferred for patients with heartburn.||Mini gastric bypass is done by creating a small pouch using a laparoscopic stapler for the stomach. The majority of the stomach isn’t attached to the esophagus, and food bypasses the larger part of the stomach after the procedure.||Gastric banding is done by placing an implanted silicone ring around the upper part of the stomach. This separates the stomach with a smaller pouch on top where the food goes, avoiding the larger part of the stomach.||A vertical pouch is made similar gastric sleeve during the duodenal switch, which is attached to the final 6 feet of the small intestine.|
|60% to 70% EWL|
Patients lose an average of 60 to 70 percent of their excess weight in 1-2 years following surgery.
|70% to 80% EWL|
On average, patients lose between 77 percent and 80 percent of their excess body weight in the first 2 years after the surgery.
|70% to 80% EWL|
Within the first year after surgery, patients can lose up to 70 percent of their excess body weight.
|40% to 50% EWL|
Patients have been known to lose around 50 percent of their excess body weight and keep it off in the long-term.
|75% to 85% EWL|
Patients lose an average of 50 percent to 85 percent of their excess body weight in the first year, keeping it off for three years or longer.
|85% to 95%|
The majority of patients have kept the weight off. Up to 90 percent of patients that had success with the surgery.
|80% to 90%|
The majority of patients have kept the weight off. Up to 85 percent of patients that had success with the surgery.
|85% to 90%|
The majority of patients have kept the weight off. Up to 90 percent of patients that had success with the surgery.
|40% to 50%|
Difficult procedure to manage weight loss (requires diet & exercise) with complications and failure rate > 50%
|85% to 95%|
Up to 95 percent of patients that had success with the surgery. It is possible to lose too much weight after the surgery.
Post Surgery Dietary Info:
|After surgery, patients are instructed to follow a phase diet. It has four stages, beginning with clear liquids, followed by full liquids, soft foods, and then regular foods. Calcium supplements, vitamin B12, and multivitamins are recommended.||After surgery, it is important to drink enough water for staying hydrated, taking recommended vitamins and minerals, and eating enough protein. You are advised to eat three small meals a day and avoid high-fat food as they lead to dumping syndrome. Eat and drink slowly, do not drink through a straw, and do not drink during meals. Take vitamin B12, zinc and iron.||Take calcium, vitamin B12, iron, and a multivitamin to avoid vitamin deficiency. Eat three small meals a day that is low in fat and sugar. Start slowly with a liquid diet.||Follow a liquid diet for three weeks then slowly add in solid foods. Eat 3 small meals a day aiming for no more than 1,000 healthy calories a day.||Eat pureed food frequently throughout the day for 2 weeks, then switch to solid foods every 2-3 hours. Take all the required vitamins and supplements, including a protein supplement.|
Compare two Procedures Side-by-Side for Easier Analysis
- Gastric Sleeve vs. Gastric Bypass – Most Common Comparison of Surgeries.
- Gastric Bypass vs. Duodenal Switch – Very common Comparison. Both will contribute to high expected weight loss.
- Gastric Sleeve vs. Gastric Banding – Two restrictive procedures.
- Gastric Bypass vs. Gastric Banding – Both were once the top weight loss surgeries for surgeons to recommend.
- Lap-Band system vs. REALIZE Band – Different Brands that fall under the Gastric Banding category.
- Gastric Balloon vs. Obalon Pill – Both considered Intra-Gastric Balloon Procedures (both Experimental).
- Orbera vs. ReShape Duo vs. Spatz – Compare the three leading Gastric Balloon Implants.
Outdated (No Longer Recommended) Bariatric Surgery Procedures – History of Obesity Surgery
Procedures like Jejunoileal Bypass was performed in late 1960’s after surgeons learned that patients who had lost a portion of their small intestine would lose weight. Many old surgeries such as Jejunocolic Bypass, Jejunoileal Bypass, and Vertical Banded Gastroplasty are no longer performed due to their high complication rates and a slew of health problems including fatality.
Jejunoileal Bypass (JIB)
The jejunoileal bypass is the first surgery designed for weight loss. The Jejunoileal Bypass, was the purely malabsorptive procedure (rare), is a surgery that bypasses most of the intestine. Although weight loss was enough, it caused severe complications due to permanent malabsorption. Patients would encounter diarrhea, night blindness, osteoporosis, liver disease and liver failure. Other serious issues, like fat-soluble vitamin deficiencies, malnutrition and death can occur in patients with JIB.
Overall, the JIB is no longer being performed or recommended as it needs frequent hard-to-do revision surgery. This procedure and Jejunocolic Bypass were a stepping stone to future procedures.
Vertical Banded Gastroplasty (VBG)
Vertical Banded Gastroplasty (VBG) is a combination surgery, devised in between 1970 and 1980 by Dr. Edward Mason (known as the ‘father of obesity surgery‘ and the American Society for Metabolic and Bariatric Surgery). This procedure was designed to be a safer alternative to RYGBP and the JIB. Ultimately, VBG is no longer being recommended with better options including RNY Gastric Bypass.
Experimental & New Weight Loss Procedures, Tools
Below are various experimental procedures that either upcoming FDA approval, experimental or approved in another country other than the United States.
- Gastric Sleeve Plication Surgery
- Intra Gastric Balloon (IGB)
- Endoscopic Sleeve Gastroplasty Procedure (nonsurgical) – Via Endoscopic
- Primary Obesity Surgery Endolumenal (POSETM) Procedure
- Transoral Gastric Volume Reduction (TGVR)
- EndoBarrier Gastrointestinal Liner (on hold due to safety concerns)
Other Latest Bariatric Procedures Today Are:
FDA approves the new device, Vagal Blocking, to curb hunger. Through the leads placed around the trunk of the vagus nerve, the pacemaker-like device sends intermittent electrical pulses. The pulses sent along the vagus nerve reduces hunger and increases feelings of fullness. This is a safe and reversible procedure that is performed minimally invasive.
The company reports 28% excess weight loss over a period of one year for 12 hours of a day. Serious Adverse Events (SAE) related to this procedure includes neuro-regulator malfunction, pain at the neuro-regulator site, vomiting, collapsed lung and gallbladder disease.
AspireAssist is an aspiration therapy system approved by FDA that helps remove about 30% of the ingested food from the stomach before the food enters the small intestine. It is made up of A-tube inserted into the stomach (endoscopically) connected to the reservoir and the drain tube.
Emptying the food after you eat and is ingested from the stomach into the toilet can be gross to some patients. read more
Last revised by Ron Elli, Ph.D. on 10/22/2017