Weight Loss: With or Without Surgery?

by Leah Frankel, MS, RD

Americans are always looking for the newest and fastest thing on the market. From fast food to express car service, Americans can’t get enough quick fixes. If you listen to ads on the radio or read the billboards on the freeway, you may have noticed an increase in advertisements for the lap band, a weight loss procedure promising quick results. Aside from the fact that the lap band procedure aids in weight loss, most people don’t know much about how this procedure works or whether they’re an appropriate candidate. While media has recently focused on the lap band procedure, there are several other surgeries available for people trying to lose weight. At the same time, realize that these are surgeries and should not be taken lightly.  Every operation, no matter how technologically advanced, carries with it the risk of serious complications.  We’ll discuss each type of procedure, which individuals are candidates for these procedures as well as some of the risks and benefits of each of these procedures.

Types of Procedures

There are a variety of surgeries that are used to aid in weight loss; these are collectively classified as bariatric surgery. While each surgery works differently, the primary goal of each is to decrease the volume of food someone eats and/or decrease the amount of food that is absorbed. We’ll explain briefly how each of these procedures works.

1. Roux-en Y Gastric Bypass: The roux-en Y is considered the “gold standard” in bariatric surgery. It involves an invasive operation where a small portion of the stomach is separated either through stapling or vertical banding into a small pouch. Since the stomach is now a small pouch, the person can only consume small amounts of food or beverages at a time before feeling full. After the small pouch is formed, a Y-shaped section of the small intestine is attached to pouch; when the intestine is attached it bypasses the rest of the stomach and part of the small intestine which reduces the amount of nutrients absorbed.  This procedure thus reduces the amount of food you can eat and decreases the amount of nutrients you absorb.  Two birds, one stone.

2. Laparoscopic Adjustable Gastric Banding (Lap Band): While this procedure has only been approved in the US since 2001, it has been used for a significant amount of time in Europe. The procedure involves placing an adjustable silicone band around the stomach reducing the size of the stomach. Much like the roux-en Y procedure, this smaller stomach forces the person to consume small amounts of food. The adjustable band contains a saline reservoir that is placed beneath the skin.  This reservoir can be used to adjust the size of the stomach pouch to either increase or decrease the functional volume of the stomach.  One of the reasons for the popularity of this surgery is that the procedure can be reversed, if necessary, and the gastrointestinal tract is not surgically altered.

3. Vertical Banded Gastroplasty: This procedure has lost some popularity recently but is still used in situations where the roux-en Y or lap band is not appropriate. As with the other surgeries we’ve discussed, the vertical banded gastroplasty creates a small pouch out of the stomach, in this case by applying staples to a portion of the stomach. A mesh band is then placed at the stomach opening (in the space between the esophagus and the connected stomach which you can see in the picture to the right) to prevent the remaining region of the stomach from growing larger during the years after surgery.

Random Fact: Between 1998 and 2002, there has been a 450% increase in the number of bariatric surgeries performed in the United States (6).

Bariatric Surgery Recommendations and Complications

Regardless of the type of bariatric surgery someone undergoes, there are some standard criteria that candidates must meet to qualify for these procedures. In 1991, a National Institute of Health consensus development panel endorsed bariatric surgery as appropriate treatment for patients with extreme obesity (1).  Criteria for bariatric surgery include:

  • BMI (Body Mass Index) = 40 kg/m² or higher
  • BMI = 35-39.9 kg/m² in an individual with life threatening or disabling obesity-related conditions (Diabetes mellitus, musculoskeletal issues, weight interfering with employment, difficulty with ambulation).

The following conditions also may be required:

  • Obesity that has been present for at least 5 years
  • No history of alcohol abuse
  • No depression or other major emotional disorder

  • Age = 18 – 65 years old

The billboards and commercials smattered across the country don’t explain these criteria (surprised?) so keep in mind that these procedures are not intended for slightly overweight individuals looking for a quick and easy weight loss plan.  If your weight isn’t impairing your daily function, surgery probably isn’t for you.

Before you undergo surgery, you should always try lifestyle modifications including diet and exercise changes. Dieting and exercising aren’t easy fixes but they are a much safer and healthier approach to weight loss.  In addition, it is critical that the individual who is planning on undergoing surgery receive a complete medical evaluation to make sure they are physically capable of going through a surgical procedure.  Just because you’re sleeping through the surgery doesn’t mean that it’s a walk in the park for your body.

What happens after surgery?

Since these surgeries lead to a “new” and smaller stomach, your post-operative diet needs to be modified to prevent any complications or intolerances. Typically after surgery, the individual would slowly progress from a liquid diet to solid foods, making sure they consume enough protein during this progression. In addition, it is important to supplement with vitamins and minerals including calcium, folate, iron and vitamin B­12 (we’ll discuss why this is important in the next paragraph). Eating slowly and chewing foods thoroughly is also important since large unchewed pieces of food can clog the pouch opening. Since the stomach is significantly smaller, it is important to eat many small meals throughout the day to get sufficient nutrients and calories.

What can go wrong?

There are a number of postsurgical problems associated with maladaptive behaviors including (2):

  • Nutritional and vitamin deficiencies
  • Severe food restriction
  • Insufficient weight loss
  • Rapid weight regain
  • Emotional eating
  • Body image disturbance
  • Depression
  • Alcohol abuse

A procedure, such as the roux-en Y gastric bypass can cause vitamin or nutrient deficiencies since a portion of the stomach and intestine that traditionally absorbs some of these nutrients is now being bypassed. Protein deficiency occurs by the same mechanism as well as failure to eat enough protein. A number of surgical complications can also occur with bariatric surgeries including anastomotic leaks (leakages in area of the gastrointestinal tract where the surgeon re-connected two pieces of the tract), wound healing problems, internal hernias, blood clotting complications and death (yes, death is always a risk) (3).

Looking at the Research

In order to truly understand the risks and benefits associated with each of these procedures we’ve summarized the results of a few studies looking at bariatric surgery.

A study was conducted with 50 adolescents between the ages of 14 and 18 years, who had a BMI (Body Mass Index) greater than 35 kg/m² to determine whether a gastric banding procedure or a lifestyle intervention would be more effective (4). Two years after the study began, 84% of the participants in the gastric banding group had lost greater than 50% of their excess weight, while only 12% of the participants in the lifestyle group had these results. In addition, all of the participants who had metabolic syndrome at the start of the study and had the gastric bypass procedure no longer exhibited the characteristics of metabolic syndrome at the end of the study. However, approximately half of the participants who underwent the gastric banding procedure experienced adverse advents including several participants who needed a revisional procedure.

Research by Nguyen et al. compared the outcomes of gastric bypass surgery and adjustable gastric banding (lap band) (5). Subjects who had the gastric bypass procedure were in surgery longer, had a longer hospital stay and had a higher rate of complications after 30 days when compared with the group who underwent gastric banding. However, when comparing weight loss between the two groups, those who had the gastric bypass surgery lost significantly more weight than the participants who had the adjustable gastric banding procedure. Notably, 16.7% of participants who underwent gastric banding had a “poor/failure” level of weight loss, while none of those with gastric bypass were in this category. A final consideration is that the gastric bypass procedure is more costly than the adjustable gastric banding procedure.

Are you a Candidate for Bariatric Surgery?

With everything we’ve discussed, you hopefully now understand that bariatric surgeries, including the lap band, carry noteworthy risks and that these procedures are not for everyone.  Ironically, while candidates for bariatric surgery may have struggled with their diet and weight for years, they will need to make significant dietary changes after surgery, including eating very small, frequent meals, in order to be successful after surgery. For most of us, small lifestyle changes can help us lose weight without the risks of surgery.  If you are a candidate for bariatric surgery, be sure to discuss this procedure in detail with your physician before making your final decision.

Take Home Message: While bariatric surgery can be a successful option for obese and morbidly obese individuals, it is not intended for your run-of-the-mill overweight individuals.  If you do decide to proceed with bariatric surgery, remember that you will still be required to make changes to your diet to lose weight while consuming all of your needed protein, vitamins and minerals.

What You Should Do: Before beginning any weight loss program, including bariatric surgery, be sure to research the program and discuss it with your physician.

Questions? E-mail the Author: frankel@myhousecallmd.com


  1. Gastrointestinal Surgery for Severe Obesity. NIH Consens Statement Online 1991;9:1-20.
  2. Rusch MD, Andris D and JR Wallace. Reasons for Failed Weight Loss Surgery. Clinical Nutrition Insight 2009;35:1-4.
  3. Nguyen NT, Paya M and CM Stevens, et al. The relationship between hospital volume and outcome in bariatric surgery at academic medical centers. Annals of Surgery 2004;240:586-593.
  4. O’Brien PE, Sawyer SM and C Laurie, et al. Laparoscopic Adjustable Gastric Banding in Severely Obese Adolescents. JAMA 2010;303:519-526.
  5. Nguyen NT, Slone JA and XMT Nguyen, et al. A Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity. Annals of Surgery 2007;250:633-641.
  6. Nguyen NT, Root J and K Zainabadi, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Archives of Surgery 2005; 140:1198-1202.


10 2010

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