What Is Bariatric Surgery, and How Does It Work?


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Dr. Oliver Varban preforms a laparoscopic gastric bypass procedure.

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Sean Proctor for The New York Times

Bariatric surgery is an option that obesity medicine specialists say is too often ignored or dismissed. Yet it is the only option that almost always works to help very heavy people lose a lot of weight and that also can mysteriously make some chronic conditions vanish. Here are some answers about bariatric surgery and what it does.

HOW MANY AMERICANS ARE ELIGIBLE FOR BARIATRIC SURGERY?

Twenty-four million, according to the American Society for Metabolic and Bariatric Surgery. The criteria are a body mass index above 40, or a B.M.I. of at least 35 along with other medical conditions like diabetes, hypertension, sleep apnea or acid reflux.

HOW MANY HAVE THE SURGERY EACH YEAR?

Fewer than 200,000.

WHAT ARE THE OPERATIONS?

There are four in use today. The two most popular procedures are the Roux-en-Y gastric bypass and the gastric sleeve. Both make the stomach smaller. The bypass also reroutes the small intestine. A simpler procedure, the gastric band, is less effective and has fallen out of favor. And a much more drastic operation, the biliopancreatic diversion with duodenal switch, which bypasses a large part of the small intestine, is rarely used because it has higher mortality and complication rates.

HOW MUCH DO THE OPERATIONS COST?

The average cost of a sleeve gastrectomy is $16,000 to $19,000, and the average cost of a gastric bypass is $20,000 to $25,000. Most insurance plans cover the cost for patients who qualify, though some plans require that patients try dieting for a certain amount of time first.

DOES THE SURGERY SAVE MONEY ON OTHER HEALTH CARE COSTS IN THE END?

Not necessarily, two large studies found. One, comparing nearly 30,000 Blue Cross Blue Shield members who had the surgery with a similar group who did not have it, found no cost savings in the first five years. The other, a study of veterans, also found that the operation did not save money, at least in the first few years.

BUT WHY WOULDN’T MEDICAL COSTS BE LOWER AFTER SURGERY?

Patients often had expensive procedures that they had been ineligible for before the surgery, like hip or knee replacements or kidney transplants, and many had plastic surgery to remove huge flaps of loose skin, an operation that can cost as much as bariatric surgery. Some women who had had trouble becoming pregnant before the surgery succeeded afterward.

Surgery patients used fewer medications after the operation, but the drugs that obese people take tend to be inexpensive generics to treat conditions like high blood pressure, high cholesterol levels and diabetes.

HOW WERE THE OPERATIONS DISCOVERED?

The two most popular treatments were discovered by accident. The Roux-en-Y gastric bypass was intended as a cure for stomach ulcers. It involved cutting out most of the stomach, leaving just a small pouch, and connecting part of the small intestine to the tiny stomach that remained. In 1966, when Dr. Edward Mason of the University of Iowa tried it on a very heavy woman, she lost weight. He began offering the procedure to very fat people for weight loss, but it did not catch on until the late 1990s, when surgeons discovered how to do it laparoscopically, making it much safer.

The other operation, the sleeve gastrectomy, was discovered in 2000 when Dr. Michel Gagner, a surgeon who was then at Mount Sinai in New York, was operating on an extremely obese woman. Suddenly, the anesthesiologist called out to him to stop. Immediately. The woman was not getting enough oxygen. Dr. Gagner had only begun the surgery and all he had accomplished was to cut off most of the patient’s stomach, leaving a pouch. He thought the operation was a failure, but to his surprise, the woman lost a lot of weight.

WHAT HAPPENS TO SOME OF THE HEALTH CONDITIONS RELATED TO OBESITY AFTER BARIATRIC SURGERY?

Sleep apnea often vanishes and, with the bypass operation, so does acid reflux. Blood pressure falls. Diabetes often goes away even before much weight is lost — sometimes before patients leave the hospital. Weight loss can also relieve diabetes, but it turns out that the surgery’s effect is different, and only partly understood. Part of it is because of a marked increase in a hormone, GLP-1, after surgery. The hormone makes the pancreas release more insulin and also makes people — and animals — feel satiated. Patients also become more sensitive to the insulin they make.

But researchers suspect that other changes from surgery contribute to the alleviation of diabetes. They are still trying to figure them out.

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