Bariatric Surgery

Shared Decision Making and Dialogue Tool

for the Patient and Physician

Bariatric surgery is used in morbidly obese adult patients for significant long-term
weight loss and other comorbidities. Results following bariatric surgery may vary.
Bariatric surgery may be appropriate for some patients, and not for others depending
on their specific weight, age, and medical history. Patients and doctors should review
all available information on non-surgical and surgical options in order to make an
informed treatment decision. This brochure was developed by Ethicon, a device
manufacturer that markets general surgical instruments used in bariatric surgery.
Overview
What is bariatric surgery? Bariatric surgery
Bariatric surgery—also known as weight loss • Limits the amount of food you eat, causing your body to stop storing excess calories
surgery—makes surgical changes to your and start using its fat supply for energy
stomach and/or digestive system. These • Causes changes in gut hormones which may impact hunger, satisfaction,
changes limit how much food you can eat and blood sugar control4
and how many nutrients you absorb, leading
• Allows the body to adjust to its new, healthier set point, which enables sustained
to weight loss. By making these changes,
weight loss, may reduce appetite, and may improve obesity-related conditions
bariatric surgery may also reset your body’s
“set point,” or weight regulation system, – Your body’s metabolic set point is the weight range that your body is programmed
by affecting hormonal signals, resulting in to function at its best. As your body adapts to a higher-than-normal weight,
it establishes and attempts to maintain a higher set point. Bariatric surgery
decreased appetite, increased feelings of
intervenes in this cycle
fullness, increased metabolism, and healthier
food preferences.
There are four main types of bariatric surgery
• Sleeve Gastrectomy • Gastric Bypass
• Biliopancreatic Diversion • Gastric Banding

Most bariatric surgeries today are performed using minimally invasive techniques,
called laparoscopic surgery.5 Laparoscopic surgery is done with video cameras
and thin instruments inserted through small incisions in the abdomen.

Depending on the type of

bariatric surgery, the average
patient loses between

55–75%
of excess body weight by
3 years post-surgery.1-3
Health benefits of bariatric surgery
Many patients with severe obesity continue to struggle with managing their weight
and related health conditions. Bariatric surgery has been shown to be an effective
means of achieving lasting weight loss, and can improve many obesity-related health
conditions. People who have bariatric surgery also experience improvements in many
areas of their life, including physical functioning and appearance and social and
economic opportunities.

Potential risks of bariatric surgery

With more bariatric procedures being performed in recent years, safety has improved
significantly. The overall death rate is 0.1%—less than gallbladder (0.7%) and hip
replacement (0.93%) surgery. The overall likelihood of major complications is 4%.6

The risk for serious complications depends on the type of surgery, your medical
condition, and your age, as well as the surgeon’s and anesthesiologist’s experience.

The long-term commitment to weight loss, and the decision

to have bariatric surgery
The decision to have bariatric surgery is an important one. It shouldn’t be made quickly
or without weighing the health risks and benefits.

It is important to recognize that bariatric surgery is a complement, not an alternative,

to lifestyle changes. The modifications made to your gastrointestinal tract will require
permanent changes to your eating habits that must be adhered to for successful
weight loss.

Having bariatric surgery entails a lifetime commitment to following dietary restrictions,

adhering to an exercise program, taking dietary supplements, and complying with
follow-up recommendations. The surgery is one step in a lifelong journey towards
better overall health.

In order to reach a decision that both you and your doctor feel good about, you should
have an open conversation about the surgery you are considering, and make sure your
doctor has answered any questions you may have.

Having bariatric surgery

entails a lifetime commitment
Outcomes for obesity-related health conditions based on data for sleeve gastrectomy, gastric bypass, and gastric banding.
* Figure is for hyperlipidemia. Hyperlipidemia is a general term for high fats in blood, which may include cholesterol and/or triglycerides.
IMPORTANT SAFETY INFORMATION: This procedure is for the treatment of patients suffering from severe obesity only. Patients should consult
their physicians to determine if this procedure is appropriate for their condition. All surgery presents risk. Risk of bariatric surgery are generally
low and similar to other commonly performed procedures like gallbladder surgery. Risks include adverse reactions to medications, problems with
anesthesia, problems with breathing, bleeding, blood clots, inadvertent injury to nearby organs and blood vessels, nutritional deficiency, even death.
 Understand Your Surgical Options This section provides an overview of the different surgical weight loss procedures. Discuss these
options with your doctor so you can come to an informed agreement about which is right for you.

Sleeve Gastrectomy The procedure

The surgeon creates a small stomach
Gastric Bypass The procedure
The surgeon creates a small stomach pouch
“sleeve” using a stapling device.
Also referred to as Roux-en-Y using a stapling device that significantly
gastric bypass (RYGP) surgery reduces the overall stomach size.
The sleeve is about the size of a banana.
Esophagus The remaining stomach area is stapled shut
Esophagus
The rest of the stomach is removed. and divided from the smaller pouch.
Removed portion Gastric pouch
of stomach
An estimated 58% of bariatric procedures The pouch is surgically attached to the middle
in 2016 were sleeve gastrectomies.24 Excluded portion of the small intestine, thereby bypassing the
of stomach rest of the stomach and the upper portion of
How it works the small intestine (duodenum).

Gastric Permanently reduces the size of your stomach, An estimated 19% of bariatric procedures
sleeve which limits how much food you can eat. in 2016 were gastric bypasses.24
Alimentary
Food passes normally through your digestive or roux limb
tract, allowing vitamins and nutrients to be How it works
fully absorbed. Pylorus
Pylorus
Creating a smaller stomach pouch limits the
Duodenum amount of food you can eat, so you feel full
Potential complications sooner and stay full longer.
You may develop stomach ulcers. Bypassing part of the intestine limits calorie
Small Stomach staples may cause complications absorption.
intestine
such as leaks from staple lines or separation
Small
of tissue that was stapled or stitched together. intestine Potential complications
Stomach-related discomfort may occur, such Because the duodenum is bypassed, poor
as heartburn, nausea or belching. absorption of iron and calcium can lead to
vitamin deficiencies and anemia.
Irregular contractions of your esophagus
may cause complications with swallowing To combat this, you’ll need to take dietary
(also known as esophageal dysmotility). supplements (including daily multivitamin,
calcium, and sometimes vitamin B12
and/or iron).
Average surgery time Average surgery time
1.5 to 2 hours 21,22
2 to 4.5 hours 10,25
You may experience discomfort as food
moves rapidly through your small intestine.
This is called “dumping syndrome” and is
Average length of hospital stay Average length of hospital stay a warning sign that you’re consuming too
2 to 3 days 21-23
2 to 8 days 10,25-27 much sugar or food.

66% Total % of excess

weight lost at 3 years1 71% Total % of excess
weight lost at 3 years2
 Understand Your Surgical Options

Biliopancreatic Diversion/ The procedure

The surgeon removes part of the stomach, leaving
Gastric Banding The procedure
A silicon band is placed at the top of your
Duodenal Switch (BPD/DS) a sleeve with the beginning of the duodenum intact. stomach dividing it into two parts: a small
upper pouch and a lower stomach.
The small intestine is then divided with one end
Esophagus Gastric pouch attached to the stomach pouch to create what Saline is added to the band to restrict food
is called an “alimentary limb.” passage. The saline is delivered through
Gastric pouch
Removed portion a port that is connected to the band and
All the food moves through this segment; attached to the abdominal wall.
of stomach
however not much is absorbed. The digestive
juices move through the alimentary limb. This The surgery can be reversed. No part of
separates digestive juices until they join at a the stomach or digestive system is stapled,
common channel. cut or removed.

BPD/DS is the least common bariatric surgery, An estimated 3% of bariatric procedures

with less than 1% performed in 2016.24 in 2016 were gastric banding procedures.24

How it works Adjustable How it works

gastric band
This surgery permanently alters the normal Port The degree of band tightness affects how
Small
intestine digestive process. much food you can eat and the length of
Alimentary
limb time it takes for food to leave the smaller
Food bypasses most of the small intestine where stomach pouch.
calories and nutrients are normally absorbed.
Common Your health care team will determine when
Biliopancreatic It also limits the amount of food that can be adjustments to your band are needed.
channel limb eaten by reducing the size of the stomach.
Does not significantly alter normal digestion
and absorption. Food passes through the
Potential complications
digestive tract in the usual order, allowing
There is a period of intestinal adaptation when it to be fully absorbed in the body.
bowel movements can be very liquid and frequent.
This condition may lesson over time, but may be
a permanent condition. You may also experience Potential complications
bloating, gas, and malodorous stool. There are risks of band erosion, leakage,
Average surgery time Average surgery time
migration/slippage, or displacement from
2 to 6 hours 28-30
Lifelong vitamin supplementation is required, 1 to 2.5 hours 10
the port.
and close lifelong monitoring for protein
malnutrition, anemia and bone disease There could also be tubing-related complications,
Average length of hospital stay is recommended. Average length of hospital stay such as kinking of disconnection from the port.
4 to 5 days 28-30
Changes to the intestinal structure can result in 1 to 3 days 10,23
There is also the risk of port-site infection.
the increased risk of gallstone formation and the
need for removal of the gallstone.
75% Total % of excess
weight lost at 3 years3 You may experience “dumping syndrome” as food 55% Total % of excess
weight lost at 3 years2
moves rapidly through your small intestine.
Understand Your Surgical Options — Estimates of Bariatric Surgery Benefits

Sleeve Gastric Biliopancreatic Gastric

Gastrectomy Bypass Diversion Banding

Total %
of excess
weight lost
at 3 years
66% 71% 75% 55%
1 2 3 2

Resolution
of Type 2
diabetes (%) 45% 68% 99% 59%
17* 17* 13 10

Resolution of
high blood
pressure
(%) 56% 66% 81% 42%
11 10 13 12

Improvements
in high
cholesterol
(%) 77% 94% 99% 71%
31 13 13 13

Resolution of
obstructive
sleep apnea
(%) 54% 76% 95% 45%
11 10 13 10

*Results achieved with combination of bariatric surgery and intensive medical therapy as defined by American Diabetes
Association guidelines. Intensive medical therapy included frequent glucose monitoring, lifestyle counseling, weight management,
and treatment with antidiabetic, lipid-lowering and antihypertensive medications.
Preparing for surgery Recovery after surgery
Your bariatric healthcare team will be there for you as you After surgery, you will remain in the hospital for a few days, where you will consume a clear
undertake this life-changing event. Your healthcare team liquid diet and be monitored for any immediate complications. Upon discharge, you will be
includes not only your surgeon and nurses, but also other health given strict dietary instructions. Depending on the type of surgery you have, about 10 to 14
professionals, such as a dietitian, psychologist or counselor, days after surgery, you will be allowed to add soft or pureed protein sources to your liquid diet
exercise physiologist, and your primary care physician. This and will then gradually build up to a solid food diet at 5 to 6 weeks after your surgery.
team will help you prepare you for surgery, and guide you
throughout your recovery and for the long term. In addition to the health benefits of bariatric surgery, keep in mind that you may experience
some unwanted changes to your body after surgery, such as scarring or loose skin. Your
Since bariatric surgery is a complement to lifestyle changes scars can be various sizes or shapes, depending on the type of surgery you have. Talk to your
such as diet and exercise, it’s important that you are mentally healthcare team if you are worried about scarring, and they may be able to recommend tips to
and behaviorally prepared. Your healthcare team may work limit scarring.
with you prior to surgery to start healthy lifestyle changes that
will help you succeed in the long term. Often, patients are Most patients who have bariatric surgery experience loose skin as they lose weight. For some,
required to be on a diet prior to their surgery.32 The length of this may be temporary. The amount of loose skin depends on many factors, including how
the diet depends on your surgeon’s suggestions as well as the much weight you lose, your genetics, age, smoking history, and whether you exercise. Clothing
requirements of your insurance provider. or compression garments can often hide loose skin. But, if the extra skin bothers you, discuss
options with your healthcare team to see if plastic surgery may be an option for you.

As you begin to lose weight and gain strength, members of your team will help you take the next
steps to full health and recovery. They may refer you to support groups or exercise facilities
in your community. Studies have shown that patients who have frequent, face-to-face contact
with their healthcare team are most successful in achieving and maintaining their goals.33

You will most likely need to see your healthcare team for follow-up appointments every 3 to
6 months, and then every 1 to 2 years after that. It’s important to remember that the decision
to have bariatric surgery is the first step in a lifelong commitment to your health, so follow-up
care is recommended for life.

Throughout preparation and recovery,

you’ll be supported by a dedicated
Insurance coverage
healthcare team Insurance plans differ in their coverage requirements. In addition to being medically
fit for surgery, you may need documentation that you have tried other weight loss
methods, are mentally healthy and able to understand what is involved and are
free of drug and alcohol dependencies.

Talk to your doctor’s office staff about your health insurance options. They may be
able to help guide and inform your conversations with your healthcare provider.
 Physician and Patient
Conversation Guide
and Checklist The benefits of shared
decision making
The best way for patients and doctors to make a shared decision about surgery is to Today, more studies show that patients
have an open discussion about treatment options and concerns. Your doctor should who are more actively involved in their
help you understand how the latest research can influence recommendations about your healthcare experience have better health
surgery, and you should help the doctor understand what aspects of your surgery and outcomes and incur lower costs.37
recovery are most important to you.

During your conversation, use this checklist to ensure the following

topics have been covered to your and your doctor’s satisfaction:

TOPIC TO DISCUSS: The risks of obesity, including the relationship between other health TOPIC TO DISCUSS: The surgical team’s experience with bariatric surgeries, affiliation with an
conditions and my weight accredited bariatric surgery program, how your surgery will be performed (laparoscopically or open),
and who will be assisting with your surgery (resident, surgical assistant, or another surgeon)
? DID YOU KNOW
•O  besity can increase the risk of medical conditions such as diabetes,
chronic heart disease, stroke and cancer34 ? DID YOU KNOW
• More than 90% of bariatric surgeries are performed laparoscopically5
• Bariatric surgery can help reduce medication use for diabetes and other • In addition to your surgeon, your healthcare team may include psychologists and dietitians
obesity-related diseases35
TOPIC TO DISCUSS: Preparation for surgery, including behavioral and mental readiness;
• In the US, an estimated 112,000 excess deaths per year are associated with obesity36
dietary or lifestyle changes to be made; other special considerations or actions to prepare for
TOPIC TO DISCUSS: The health benefits of bariatric surgery, including reduction or resolution this life-changing event

?
of obesity-related health conditions DID YOU KNOW

? DID YOU KNOW

• Bariatric surgery can cause changes in gut hormones which impact hunger,
• For 2 to 3 weeks prior to bariatric surgery, most surgeons require patients to be on
a special diet in order to help with surgery. But remember, bariatric surgery entails a
satisfaction, and blood sugar control4 lifetime commitment to following dietary restrictions, adhering to an exercise program,
• Bariatric surgery can improve many obesity-related health conditions6 taking dietary supplements, and complying with follow-up recommendations
• The surgery is one step in a lifelong journey towards better overall health
TOPIC TO DISCUSS: The available bariatric surgery options, the differences between the
surgeries, and the risks and benefits of each TOPIC TO DISCUSS: Recovery after surgery, including how long my hospital stay will be,
how often I will have follow-up care, and what to expect during recovery
? DID YOU KNOW
• Bariatric surgery is an accepted treatment option for patients with severe obesity
? DID YOU KNOW
who do not respond to non-surgical treatment • Most patients stay in the hospital for a few days following surgery and then follow-up
•T here are 4 main types of bariatric surgery procedures: sleeve gastrectomy, gastric with their healthcare team every few months as needed, and then every 1-2 years
bypass, biliopancreatic diversion, and gastric banding. There are risks and benefits • A bariatric healthcare team will be there to support you during recovery and for
with each type of surgery the long term

By the end of your discussion, you should feel confident that you understand all the
factors involved and that, together with your doctor, you’ve made the best decision.
Questions and Notes Questions and Notes
Resources
www.thehealthpartners.com
www.asmbs.org/patients
www.cdc.gov/obesity
www.ethicon.com/obesity
www.mbsaqip.org
www.obesity.org/publications/obesity-journal.htm
www.obesityaction.org
www.stopobesityalliance.org
www.win.niddk.nih.gov/publications/gastric.htm

Statements about bariatric surgery from

leading associations
American Association of Clinical Endocrinologists 2015
The beneficial effect of surgery on reversal of existing diabetes and
prevention of its development has been confirmed in a number of studies.38

American College of Physicians 2005

Surgery should be considered as a treatment option for patients with a
BMI of 40kg/m2 or greater who instituted but failed an adequate exercise
and diet program...and who present with obesity-related comorbid
onditions, such as hypertension, impaired glucose tolerance, diabetes
mellitus, hyperlipidemia and obstructive sleep apnea.39

American Diabetes Association 2017

The 2017 ADA recommendations for bariatric surgery and type 2 References

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