Weight Loss Surgery: Long-Term Results

Bariatric surgery can help you get past those cravings, get healthier, and be more active.

From the WebMD Archives

After weight loss surgery, success is a long-term project. But if you can stick with a healthy diet and exercise, experts say you’ll enjoy extremely satisfying results.

By most estimates, 80% or more of patients do well after surgery, says Atul Madan, MD, chief of bariatric surgery at the University of Miami School of Medicine. "They have lost the weight they wanted to lose and have kept it off."

Quality of life is vastly improved after bariatric surgery, Madan tells WebMD. "Multiple studies show that patients are healthier. They have fewer obesity-related conditions like sleep apnea, hypertension, diabetes, metabolic syndrome, and other medical problems."

"They get off medications, they can be more active, they're healthier," says Anita Courcoulas, MD, MPH, chief of minimally invasive bariatric surgery at the University of Pittsburgh School of Medicine. "Suddenly, they're able to do things with the family. They have improvements in depression."

Nearly all their patients have lost weight before -- again and again and again.

"Some have lost hundreds of pounds in a year or two, then it's come back," says Madelyn Fernstrom, PhD, a nutrition expert and director of the University of Pittsburgh Medical Center's Weight Management Center. "They have the ability to lose weight, but they can't keep it off. They are unhappy. They don't want to be fat."

Weight Loss Surgery: Beware the Pitfalls

Usually, during the first two years after bariatric surgery, diet and exercise changes come easily, says Courcoulas.

"There is such rapid weight loss, and there's a bit of euphoria with that. They're active and feeling wonderful," she tells WebMD. Once weight loss goals are reached, it's time for maintenance mode. That's a risky stage for some people -- as some slip into bad habits.

"For gastric bypass patients, weight loss can plateau at two years," Courcoulas explains. They're not consistently losing anymore. They're at a steady weight.

If you slack off exercise, start snacking, eat slightly bigger portions -- there's the risk that you will gain weight back. That's where a good support system is critical, to make sure you stick with good habits, she says.

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Regular appointments with your surgeon are critical, Madan adds. "Often, complications occur when patients become complacent. They stop making follow-up visits with their surgeon. Then they develop a problem five years after surgery."

With gastric banding procedures, follow-up is directly related to success because frequent adjustments in bands are necessary for weight loss, he says.

"The band can be consistently adjusted as hunger and fullness change over time," Courcoulas explains. "Gastric bypass patients lose quickly, regain a little, then level out. [Gastric banding] patients lose more slowly, but they don't tend to regain."

Weight Loss Surgery: Tips for Long-Term Success

Don’t look at it as dieting. This is a complete lifestyle change -- exercise and food habits -- that should enhance the rest of your life.

Tune in to satiety. "You have to be really conscious of how your body feels when you're full," says Madan. "Learn when you're full and when you're not full."

Get a hobby. Take the focus off food. "For a lot of my patients, their hobby is eating," he suggests. "They need a hobby that keeps them active. Exercise can become a hobby, painting, guitar lessons, art class, scuba diving. Get pleasure from something other than food."

Make exercise a habit. If you can walk a little bit, that's great. Wear a pedometer to track your steps, so you can challenge yourself. Start by walking five minutes a day, then build on that. Park a little further out in the parking lot. Take a flight of stairs if you can. "It's aboutgetting into the right mindset ... establishing new habits that will stay habits," Fernstrom says.

Get a good support system. Join a weight loss surgery support group. "While friends and family are going be supportive, they haven't gone through the surgery,” Madan says. “It's easier to talk about issues with someone who has walked a mile in your footsteps. People who join support groups lose more weight. The group support reinforces lifestyle changes."

See a psychologist. When people are under stress, eating can happen. Seeing a psychologist can be very helpful in breaking that chain, says Madan. "It's important to learn stress-relieving activities. If after surgery you're engaging in stress-triggered eating, you need to see someone. There's no embarrassment in seeing a psychologist."

Discussions with a nutritionist can also reveal barriers to weight loss -- untreated depression, hostile relationships, stress at work, unhappiness in career, self-esteem issues. "All of those have nothing to do with eating -- but they have everything to do with the drive to eat," says Fernstrom.

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Health Problems After Weight Loss Surgery

Whether you have gastric bypass or gastric banding surgery, specific complications are a risk. It's important that you watch for problems -- and see your surgeon right away.

Gastric Bypass Surgery Problems

Nutrition deficiencies. If you have gastric bypass surgery, monitoring your nutrition intake -- protein, fluids, vitamins, and minerals -- is a critical component in long-term success.

The surgical alterations create a state of malabsorption, which contributes to weight loss. Essentially, it means that the body eliminates calories, fat, vitamins, and minerals in food you eat. To keep the body healthy, those nutrients must be replaced -- with vitamin B12, calcium, and iron supplements as well as a multivitamin.

"Vitamins and minerals are medications," Fernstrom explains. "If you don't take them, you will have significant deficits -- cognitive deficits, anemia, or osteoporosis. There are consequences with not following the lifestyle."

With gastric banding surgery, there is less risk of serious nutrition deficiencies -- as malabsorption is not involved in that surgery. However, there still is the need to eat a healthy, balanced diet. A daily multivitamin is also required.

Malnutrition can be a big problem for some gastric bypass patients. It occurs in rare cases, when the person has lost too much weight, explains Madan. This can be related to surgery, when the connection between the small bowel and the stomach is too small.

"They can only eat very little, even less than the normal four ounces," he says. "They're hungry but they can't eat. They're vomiting all the time."

An outpatient procedure easily relieves the problem. It involves a flexible endoscope into the mouth, then a balloon is used to dilate the connection, which relieves the problem.

However, when patients having this problem don’t go and see their doctor, it can develop into severe nutrition, Madan says.

Regaining Weight -- or Not Losing Weight. For gastric bypass patients, eating too frequently is a typical problem. Since the pouch restricts how much you eat, it's difficult to overeat in any one meal.

"A patient may bring lunch to work, eat only a quarter of it at noon, but eat the rest over the afternoon," says Courcoulas. "They're eating more calories than they should -- just eating them in small amounts."

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Also, the stomach pouch will "give" a little over time, so people can eat a little more several years after surgery -- especially if they're pushing the limit anyway. "Even if they get a fullness sensation pretty quickly, they must learn to tune into it and stop eating," she says.

Another problem: Over time, the body adapts to the surgical changes -- so there is less malabsorption. At that point, lifestyle to maintain your weight loss is key, Courcoulas says.

Madan says there can also be mechanical problems:

  • Food may be going into the old stomach, rather than to transitioning through to the intestine. This indicates that the stomach pouch and the stomach have somehow reconnected themselves -- what's known as a fistula. Surgery can correct this problem.
  • The connection from the stomach pouch to the small bowel may be too large. This can be corrected in an outpatient procedure. Patients who are two years after surgery -- and have lost feeling of satiety after eating -- may be candidates for that procedure.

Gastric Banding Surgery Problems

Regaining weight -- or not losing weight -- also happens with gastric banding surgery. It's likely because of liquid calories (sodas, juices) or easily digestible snack foods.

"The band only restricts portion size, it doesn't affect calories. If you eat chicken, fish, fruits and vegetables at three meals a day, you will be successful with the band," says Courcoulas. "If you're drinking too much soda or juices or snacking on soft snack foods, you won't lose weight."

"After surgery, overeating can cause aggressive vomiting -- which can affect the surgery," says Madan. "It can cause the band to slip. If it slips, another operation is required to fix it."

He outlines other mechanical problems that can occur:

  • Chronic overeating will stretch the stomach pouch (part of the stomach above the band). That may cause a stomach stitch to become torn and the band to slip. Surgery can correct this problem.
  • If the band is too tight, it can erode. "When it erodes, it goes into the stomach layers and becomes infected and needs to be removed," says Madan. "The patient may have to undergo another bariatric surgery or will most likely gain the weight back."

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Time for Skin Reduction After Weight Loss Surgery?

With extreme weight loss, loose skin can be a big problem. Up to 70% of patients have skin reduction surgery (also called body contouring, or panniculectomy when referring to the tummy), says Courcoulas.

With gastric bypass, skin reduction surgery is usually done two years after surgery, she says. With gastric banding, body contouring is usually done three years postsurgery. Insurance typically covers the procedures if they are considered medically necessary, she explains. "That's if loose skin causes hygiene problems, pain, sexual function problems. If the surgery is considered cosmetic, it won't be covered."

It's nothing you can check before having weight loss surgery, she adds, as insurance companies must see after-surgery photographs to make their decision.

In medical centers that do significant numbers of bariatric surgeries, the plastic surgeons are often adept at getting insurance approval, Courcoulas adds. "They are very expert at packaging services. If a bariatric patient needs a hernia repair, for example, they package it with skin removal. We work really hard to service the needs of patients because we know it's tight with insurance."

For many patients, however, plastic surgery isn't really necessary, she says. "The patient who loses 80 to 100 pounds -- if they were shaped well before surgery, are young, their skin is elastic, they exercise -- they may not need it. But someone who loses more weight -- if they are older -- they will need it. It depends on age, size, skin elasticity, and how much tolerance they have for a little loose skin."

WebMD Feature Reviewed by Brunilda Nazario, MD on 2/, 009

Sources

SOURCES: Atul Madan, MD, chief of bariatric surgery, University of Miami School of Medicine. Anita Courcoulas, MD, MPH, chief of minimally invasive bariatric surgery, University of Pittsburgh School of Medicine. Madelyn Fernstrom, PhD, director, University of Pittsburgh Medical Center's Weight Management Center.

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