Jennifer*, only five feet four inches, weighs 346 lbs. She has tried dieting for more than 20 years, each time with limited success, eventually regaining all of her weight and then some. Previous attempts at exercise have been embarrassing. “Everybody just stares at me, and one gym even canceled my membership for fear that I would hurt myself and take legal action against them,” she recounts.

“I literally ate myself out of my job,” former policeman Richard* reports. First, he was forced out of motorcycle duty and placed on desk assignment. Then his supervisor fired him six months ago when his weight reached 400 lbs, and he could no longer get to work. Inactivity combined with depression contributed to Richard’s current weight of 462 lbs, supported by a six-foot one-inch frame.

Melissa* has had a 10-year struggle with her weight, trying pills, diets, and even liposuction. Nothing seems to keep the weight off for long. Although she needs to lose only about 85 pounds, serious health conditions are affecting her quality of life, putting her at risk for developing hypertension, type 2 diabetes, and obstructive sleep apnea.

Each of these people satisfies established criteria as so severely obese or affected by moderate obesity that consideration of a surgical weight loss intervention is appropriate. These life-altering interventions offer a viable option for many who have failed at more traditional weight loss methods.

A Serious Problem

More than two-thirds of adults in the United States are overweight, and of those, one-third is obese. Shockingly, the inability to maintain a healthy weight is rapidly becoming an epidemic of youth. Approximately 17.5% of children (age 6 to 11) and 17% of adolescents (age 12 to 19) are overweight.¹ The National Institutes of Health (NIH) uses the body mass index (BMI) to categorize overweight and obesity in three grades. Grade-1 obesity is moderately overweight people with a BMI of 25 kg/m² to 29.9 kg/m². A BMI between 30 kg/m² and 39.9 kg/m² constitutes grade 2 obesity, and people with a BMI greater than 40 kg/m² are grade 3, massively or morbidly obese.¹

Americans spend more than $117 billion every year to treat obesity-related conditions and avoidable healthcare expenses, such as knee replacements from wear, medications for type 2 diabetes, and other complications less frequently seen in nonobese people.¹ Clinical morbid obesity is a disease of excess energy stores in the form of fat. It is an independent risk factor for diabetes mellitus, coronary heart disease, and hypertension.

The NIH suggests consideration of surgical weight loss procedures for clinically severe obese individuals with a BMI greater than 40 kg/m², and those with a BMI greater than 35 kg/m² who have medical conditions, such as cardiovascular problems, obstructive sleep apnea, cardiomyopathy, hyperlipidemia, degenerative joint disease, and diabetes, when other interventions have failed.² The NIH has recognized weight loss surgery, also known as bariatric surgery, as a surgical specialty since 1992; both the American College of Surgeons and the American Medical Association consider it a subspecialty. Weight loss surgery is not considered experimental or cosmetic.

When candidates for weight loss surgery are identified, the screening procedure must be intense and realistic. Morbidly obese individuals can expect to be thinner after the procedure, but they need to know that surgery is only a tool that needs to be accompanied by lifelong lifestyle modifications. Postoperative weight loss usually reaches its maximum between 18 and 24 months.³

Surgical Options

Surgeons currently perform three types of weight loss surgery procedures — restrictive, malabsorptive, or a combination of both. Restrictive procedures involve the stomach only, reducing its volume with adjustable gastric banding or vertical-banded gastroplasty, so-called “stomach stapling.” The procedure helps patients lose weight by reducing their food intake. On the other hand, malabsorptive procedures facilitate weight loss through a reduction in calorie absorption.

Gastric-banding procedures involve wrapping a device around the stomach to create upper and lower pouches. A small upper pouch restricts food intake by limiting the amount of food that can be ingested at a sitting. Early banding devices, placed by open surgical technique, were not adjustable. Now, surgeons laparoscopically insert devices, such as the LAP-BAND^®, which can be adjusted by changing the volume of the subcutaneous reservoir to control the degree of gastric constriction.⁴

With restrictive procedures, such as gastric banding or vertical-banded gastroplasty, weight loss is lower and the failure rate is higher than with malabsorptive procedures.^5,6 The typical gastric volume after vertical-banded gastroplasty is initially two ounces and may increase over time to approximately six ounces. At first, patients can consume only liquids and food particles no larger in diameter than a drinking straw. Unpleasant adverse effects, which usually result from not chewing well, overeating, or eating too quickly, may include vomiting and choking. Consequently, patients may alter their food choices to include high-calorie liquids, which may impede weight loss.⁷

The human body has about 20 feet (seven meters) of small intestine. The earliest malabsorptive weight-loss procedure, the jejunoileal bypass, left about 12 inches of small intestine for digestion. This procedure, which resulted in many late complications, has not been performed for about 20 years. However, early surgical failures led to the recognition of obesity as a chronic disease that requires longer-lasting procedures, rather than temporary measures that can be reversed after desired weight loss.

Today, the majority of weight-loss procedures combine gastric restriction and malabsorption measures, accounting for the volume of food consumed as well as how much intestinal mucosa is available for digestion and caloric absorption. The most common weight loss surgery procedure is the Roux-en-Y gastric bypass. One variation includes closing off the unused stomach portion with an incision; another detaches the stomach completely, so that it remains free-floating. The length of bypassed small intestine varies from 10 inches to 10 feet, averaging two to five feet.³ Surgeons perform the Roux-en-Y gastric bypass by both traditional open and laparoscopic techniques; a newer laparoscopic technique produces shorter recovery times and fewer postoperative complications.⁵ When performed by surgeons adept at laparoscopy, operative time and blood loss are less, critical care and entire hospitalization times are significantly shorter, and weight loss is not significantly different than when traditional open techniques are used.⁶

The most drastic weight loss surgery performed today is the biliopancreatic diversion (BPD). So far, it is the most effective procedure for prolonged weight management, with 72% of recipients maintaining healthy weight for 18 years.³ This procedure removes a portion of the stomach and reroutes food into a short segment of the ileum, known as the “common channel,” reducing the mixing of pancreatic secretions and bile with food. Malabsorptive procedures may cause adverse effects different from those incurred with restrictive surgery; patients may experience chronic diarrhea and “dumping syndrome,” a combination of symptoms after eating sweets that includes nausea, weakness, faintness, diaphoresis, and diarrhea immediately after eating. Fruits, often necessary sources of nutrients, can be particularly problematic for these patients because of their high sugar content.⁸

A variation of the biliopancreatic diversion, the duodenal switch, preserves the pyloric valve and some of the proximal duodenum. The small segment of the retained duodenum protects against ulcer formation and perforation. With biliopancreatic diversion-duodenal switch, most of the acid-producing fundus of the stomach is not simply stapled off and left behind, but removed. Biliopancreatic diversion-duodenal switch has the lowest incidence of dumping syndrome and produces the most weight loss of all procedures.⁸ Some surgeons have begun performing the procedure laparoscopically with a subsequent reduction in short-term postoperative complications.

To view an evidenced-based clinical guideline on bariatric surgery for adults, go to http://www.guideline.gov/summary/summary.aspx?doc_id=10714&nbr=005577&string="VA%2fDoD+clinical+practice+guideline+for+screening"+and+"management+of+overweight"+and+obesity.9 A guideline has also been formulated for bariatric surgery for severely overweight adolescents and can be viewed at http://pediatrics.aappublications.org/cgi/content/full/114/1/217.10

What Can Go Wrong?

Following purely restrictive procedures that reduce gastric volume, patients will quickly know their intake limit at one sitting; if they overeat, they will feel pain or vomit. They will need to chew foods thoroughly to avoid plugging up their stoma or vomiting.

Nutritional deficits related to the reduction in food intake can occur if oral supplements are not taken. Anemia is less common with purely restrictive procedures, but it may occur if patients make poor nutritional choices and do not take recommended supplements. This is particularly true among women who are still menstruating.²

Complications of weight loss surgery are associated with the general surgical risk and the type of procedure. For example, complications after gastric restrictive procedures include increased incidence of gastroesophageal reflux disease and heartburn after nonadjustable gastric banding; mucosal swelling at site and gastric perforation shortly after surgery; and esophagitis, gastritis, a dilated small upper pouch, or the stomach slipping above the band. The most common complications after malabsorptive procedures are gastric or duodenal leaks, although distal anastomosis site leaks leading to abscess, fistula formation, peritonitis, sepsis, adult respiratory distress syndrome, and even death may occur; however, the overall mortality rate following weight loss surgery is less than 1%.⁶ Strictures may also develop, further increasing the risk for vomiting. Often endoscopic dilation is successful in correcting this complication on an outpatient basis.¹¹ Deep vein thrombosis and pulmonary emboli are also possible; however, anticoagulant prophylaxis and early mobilization have decreased the risk for these complications.¹²

Long-term complications after malabsorptive or combination procedures include diarrhea, flatulence, or lactose intolerance. The development of Crohn’s disease has also been on the increase after malabsorptive or combination procedures.¹³ Patients may develop elevated liver enzymes or uric acid levels. Gallstones and calcium oxalate renal stones may occur. Patients are also at risk for neuropathy related to vitamin B-12 deficiency, night blindness from vitamin A deficiency, and elevated alkaline phosphotase levels, which occurs when calcium and vitamin D intake are low. Because iron and calcium are primarily absorbed in the duodenum and jejunum (segments typically bypassed in most procedures), these patients are at risk for anemia and osteoporosis.

Osteoporosis risk increases because malabsorptive bariatric procedures augment the patient’s risk of developing calcium and vitamin D deficiencies leading to a number of changes in bone metabolism.¹⁴ Increased rates of vitamin D deficiency, secondary hyperparathyroidism, hypocalcemia, and bone turnover and loss have all been reported with both malabsorptive and restrictive procedures. Typically, the degree of bone changes is dependent on the amount of weight loss achieved by the procedure. The more drastic the procedure, the more significant increases in bone turnover and decreases in bone density.¹⁵

An increasing number of patients have also been found to develop nephrolithiasis postoperatively, even if they had no prior history of stones before surgery. The stones, when analyzed in the lab, are most likely related to calcium and not uric acid abnormalities (90% vs. 10%). Inadequate hydration leading to urine concentration also contributes to stone formation, thus another reason to encourage fluids after malabsorptive procedures have been performed.¹⁶

Some of the complications affecting the nervous system are often disabling and irreversible. The neurologic complications after weight loss surgery include encephalopathy, optic neuropathy, myelopathy, polyradiculoneuropathy, and polyneuropathy. Myelopathy is the most frequently reported and disabling problem with the symptoms beginning about a decade after weight loss surgery. Encephalopathy and polyradiculoneuropathy are typically acute and early complications. Myelopathy can often be traced to vitamin B-12 and copper deficiencies, but the other neurologic complications have not been clearly associated with other nutritional deficiencies.¹⁷

When complications arise, revisions may be required. Bypassed segments of bowel are not permanently removed, but left in place; if weight reduction, protein loss, or diarrhea is excessive, the bowel can be lengthened. When weight loss is poor, the common channel can be shortened. To achieve durable weight loss, patients must adhere to dietary recommendations, suggestions to increase physical activity, close nutritional monitoring during rapid weight loss, and lifelong medical surveillance.¹⁸

Quality of Life and Other Benefits

Sixty-seven percent of individuals with diabetes are overweight, of which 46% are obese. Successful weight loss surgery can help control blood glucose levels in diabetics to the point where oral medications may be no longer necessary.¹⁹ It can also lower blood pressure and reduce triglycerides and total cholesterol. Bad cholesterol, or low-density lipoproteins (LDLs), diminishes, while good cholesterol, or high-density lipoproteins (HDLs), remains the same, improving the LDL/HDL ratio. Other important coexistent conditions, such as asthma and obstructive sleep apnea, may be eliminated or improved after weight loss surgery.^20,21

Obesity results in adipose cells becoming overloaded and unable to adequately serve as storage sites. Fat is then deposited within ectopic sites, such as muscles, the liver, and the pancreas, leading to metabolic derangement, including insulin resistance, central obesity, and chronic inflammation.²² Fat is an abundant storehouse for hormones and proteins that regulate metabolic processes and affect the risk for developing many disorders, including diabetes, hypertension, and atherosclerosis.²³ Changes found in these adipocyte-derived hormone levels, including leptin, adiponectin, and visfatin, may provide an explanation for the observed improvements in numerous metabolic abnormalities associated with obesity after malabsorptive procedures have been performed.²² In fact, research into the endocrine and metabolic effects following malabsorptive bariatric procedures may in time lead to drug therapies that can mimic results of weight loss surgery, without surgery.²⁴

Malabsorptive bariatric procedures result almost universally in reestablishment of more normal patterns of insulin release in response to food intake, improved insulin sensitivity, and improvement of the metabolic syndrome.²² Additional benefits of weight loss surgery have also been discovered, including improvement of nonalcoholic fatty liver disease, improvement of hypertension, and dyslipidemia.^22,25,26

Positive cardiac findings have also been shown after bariatric surgery. One study that included serial Holter monitoring and ECG revealed an improvement in heart rate variation with activity, ventricular size, and function after bariatric surgery.²⁷

Activity tolerance also improves after weight loss surgery as musculoskeletal pain diminishes, especially in the knee and ankle joints. This often facilitates increased physical activity which complements weight loss.²⁸

The major measure of weight loss surgery success often revolves around improvement of medical conditions. However, changes in physical, functional, mental, and social health may uniquely influence how patients perceive their quality of life. One instrument, the Bariatric Analysis and Reporting Outcome System, allows for international comparisons of excess weight loss, medical condition improvement, and quality of life.²⁹ Research has shown that weight loss surgery procedures enhance patients’ quality of life, despite possible gastrointestinal adverse effects and necessary lifestyle modifications.³⁰ Patient satisfaction after weight loss surgery is typically very high, and many obese people have reported better social acceptance, support from others, and easier social adjustment.²⁸ Patients have found jobs more easily than when they were obese and report less absenteeism. Feelings of rejection and shame diminish postoperatively, and patients after WLS report improvement in their self-esteem and body image. Greater ease in performing ADLs also improves quality of life.^28,30

For women, bariatric surgery can have significant impacts on reproduction, requiring both pre- and postoperative considerations. After weight loss surgery, the ability to become pregnant is enhanced, similar to the improvements seen after massive nonsurgical weight loss, because of the normalization of sex hormones.³¹ Bariatric surgery has also been shown to enhance the likelihood of success with fertility treatments among women who still have ovulatory abnormalities after surgery.³¹

There may also be a change in the response to oral contraceptive hormones, making surgical or barrier contraceptive choices more favorable in those wishing not to become pregnant.³²

The obesity epidemic among adolescents has also contributed to a significant increase in weight loss surgery, necessitating specialized programs to prepare them for post weight loss surgery changes that will last them the remainder of their lives. Growth and development considerations both physically and psychologically make bariatric surgery among adolescents both challenging and controversial.^33,34

Body Contouring — The Finishing Touch

Massive weight loss may generate functional and aesthetic deformities. Weight loss after weight loss surgery often produces large amounts of sagging skin that has lost elasticity. Associated physical problems may result, particularly with excess sagging tissue in the abdominal region, known as the panniculus. Many obese individuals have moderate to large panniculuses that compound the physical, social, and emotional problems of obesity. A large panniculus is not simply a cosmetic concern, but poses problems related to hygiene, chronic skin inflammation and/or infection, and back pain.³⁵ The removal of the panniculus can be combined with the initial weight loss surgery procedure or after weight loss has occurred.

Surgeons often perform procedures, such as abdominoplasty (tummy tuck) or a full-circumference removal of truncal skin (sleeve lipectomy), in which two 360-degree cuts are made around the upper and lower abdomen, the in-between skin is removed and discarded, and the skin above and below is reconnected. Other needed surgery may include thigh lifts, arm tucks, and removal of neck skin.³⁵ These procedures may be covered by insurance, if the initial weight loss surgery was covered, but patients need to check with their carriers to be sure. Additional procedures create physiological demands that require patients to be optimally nourished before, during, and following surgery for adequate healing and repair. Properly prepared and nourished patients following weight loss surgery do quite well and pose no greater risk than obese individuals who have not experienced weight loss surgery for body contouring.³⁵ Besides improving patients’ physical disabilities related to excess skin, their overall appearance and sense of well-being are greatly enhanced.³⁶

Psychological Issues

Morbidly obese people often experience discrimination, humiliation, and embarrassment due to weight problems. Others may believe that they lack self-control or have a weak character. However, no specific personality type is associated with obesity. Although image disparity (distorted self-image) and eating disorders (particularly binge eating) are common among the morbidly obese, the incidence of psychological disorders, such as depression, anxiety, or substance abuse, are no greater than among those of healthy weight.³⁷ Situational depression related only to obesity is common, and depressed patients tend to lose more weight postoperatively. These patients may also have other psychiatric disorders that require monitoring not only before surgery, but after as well to increase the chances for successful weight loss and maintenance.³⁸

Psychiatric evaluation and counseling are important in weight loss surgery planning and follow-up. Patients need to know that they will receive both positive and negative responses from others related to their weight loss and the chosen method to achieve it. Serious psychological disorders, such as schizophrenia or substance abuse, contraindicate weight loss surgery because of the necessity for postoperative adherence and follow-up.³⁷ Patients with the best outcomes have strong support systems, although those with less support can also do very well. Patients can benefit from involving spouses and other family members in care planning before surgery. However, weight loss surgery may not help patients with marital problems. Weight loss surgery does not significantly improve marital satisfaction; in fact, when these patients lose weight and improve their self-image and self-esteem, divorce is common.³⁸ For others, weight loss surgery support groups are an option.

The PT’s Role

In the inpatient care setting, patients need both education and support. Physical therapy can be very helpful preoperatively by providing education concerning postoperative recovery, as well as designing programs to maintain physical activity and monitor weight. Improving mobility and strength can support and enhance postoperative recovery. Obese individuals may have orthopedic conditions as a result of their weight, such as plantar faciitis or knee complications.  Addressing these problems with a physical therapy evaluation and treatment can also help to improve surgical outcomes.³⁹ 

Postoperative physical therapy intervention for the surgical patient is also very important as part of the multidisciplinary approach. Assessment of bed mobility, transfer status, and gait is imperative as new weakness, decreased functional ability, and decreased endurance can prolong hospitalization and overall outcome. Designing a program to address these areas, as well as cardiovascular and strength issues should be part of the overall team approach.⁴⁰  

Much of the postoperative course is similar to that of other obese individuals who have abdominal surgery, with a few exceptions.⁷ For example, regardless of surgical approach, patients who have had weight loss surgery must be encouraged to splint their abdomen, cough, and deep breathe to avoid atelectasis. Incision lines, laparoscopic insertion sites, and drainage devices need monitoring. If an abdominoplasty is performed at the same time, and the inpatient stay is brief, patients may leave the hospital with drains and require education about their proper care. Patients who still menstruate will be at a much greater risk for anemia, particularly if they have been prescribed anticoagulants to prevent deep vein thrombosis (DVT).³ One way to reduce the risk of DVT for all weight loss surgery patients is to get them up and walking early in their postoperative period and have them wear antiembolic stockings or compression devices.

It is important to note that neurological complications can result from bariatric surgery. The reasons for these complications may vary, but can leave the postsurgical patient with additional problems to address.⁴¹ In this event, PTs may be called upon to evaluate and treat the physical limitations resulting from the surgery.

Surprisingly, patients are not usually hungry during the early postoperative phase, when they are often only permitted liquids. As recovery progresses, so does the diet. At first, patients are able to eat only a few bites of food. Chewing carefully is important to prevent choking or food blockage at narrowed surgical sites. Patients’ diets eventually advance to three small meals a day; they should avoid snacking between meals. Limitations will quickly become apparent, and overeating will cause vomiting. Patients should be instructed to eat slowly and push away from their plate when they feel full, regardless of how much food is left. Patients should learn to make smart nutritional choices to achieve a full feeling. For example, liquids should have low or no caloric value, such as water or diet beverages. Patients should avoid alcohol, which has no nutritional value. Fruits should be consumed as solids, not as juices, to permit both a sense of fullness and nutritional balance.

Patients who do not adhere to nutritional recommendations may experience hair loss from altered protein metabolism, require nutrient injections, or be at greater risk for autoimmune disorders. Selecting complex carbohydrates and proteins is as important as restricting fats and sugars. Patients should first consume protein, such as meats, eggs, fish, dairy products, legumes, or nuts, which can then be followed by carbohydrates, if they are not yet full. If protein intake is inadequate, powdered supplements blended into “smoothies” may be used, particularly during the early recovery period when solids are less tolerated. PTs can reinforce nutritional concepts and promote appropriate food choices that are stressed during in-depth education sessions by dieticians, recommending home modifications and facilitating the development of new habits and routines for the client.⁴²

Patients may need help evaluating financial resources, which may be needed for frequent, complete wardrobe changes, as well as medical office visits, diagnostic studies, and potential lost wages from time off work for recovery. Some balance may be achieved with the reduction in money spent for food offsetting weight loss surgery-related expenses. When resources are limited, weight loss surgery support groups and thrift shops may provide low-cost, short-term clothing.

Weight loss surgery encompasses a total lifestyle change and should not be viewed as an easy or quick weight-loss intervention. Morbidly obese individuals benefit from weight loss surgery procedures physically, psychologically, and socially. Their risk for complications from many diseases is often diminished, if not completely eliminated. However, benefits require lifelong dietary modifications and follow up to prevent complications. Weight loss surgery success depends on a motivated patient, selection of the appropriate procedure, a commitment to follow up, and coordinated collaborative effort of many healthcare professionals, including nurses in inpatient, outpatient, and community settings. For more information, go to www.asbs.org.

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*Name has been changed.