Is Weight Loss Surgery an Easy Way Out?

In the spirit of Healthy Weight Week, the topic of this piece is weight loss surgery. An array of bariatric surgeries are available to those who have a significant amount of weight to lose, and some of these procedures will be discussed. Nurses Announcements Archive Article

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Is Weight Loss Surgery an Easy Way Out?

Rita McMillan, age 41, reports to her place of employment, a large community hospital located in an upscale suburb of a large Midwestern city. She has been employed at the same hospital as an RN house supervisor in the pediatric intensive care unit for the past 12 years, but was recently promoted to a position as unit manager over the PICU and general pediatric floors. She's become accustomed to the plethora of complimentary comments from coworkers that started approximately six months ago: "You look so great!" "You must feel better." "What have you been doing to lose all that extra weight?"

According to the Centers for Disease Control and Prevention (CDC), 69 percent of all Americans were overweight or obese during the year 2012. When broken down further, 35 percent of these overweight adults were also considered clinically obese, which essentially means they had body mass indexes (BMIs) of 30 or greater. An assortment of techniques to produce weight loss are available, including diets that involve reduced caloric consumption, exercise, commercial meal plans, Weight Watchers, and HCG injections, to name a few. However, without permanent lifestyle changes, any significant amount of weight loss is typically regained. In fact, about 80 percent of dieters regain all their lost weight, plus more.

Rita's body weight has cycled up and down wildly since her prepubescent years; this phenomenon is informally known as yo-yo dieting. Her highest adult weight of 267 pounds occurred in her mid-20s during a prolonged bout of depression, whereas her lowest weight of 130 pounds was achieved in her early thirties after exclusively breastfeeding her twin sons for 14 months while training for a half-marathon. 12 months ago, at 40 years of age, she became dispirited and disgusted at the number that flashed on her electronic scale: 220 pounds. That same afternoon she telephoned the clinic of a prominent bariatric surgeon to set up a consultative appointment. Rita had made up her mind: after losing and regaining the same 100+ pounds at least five times during her adult life, she was seriously exploring the option of weight loss surgery.

Bariatric surgery, also known as weight loss surgery, has exploded in popularity over the past three decades. The National Institutes of Health has deemed bariatric surgery the only effectual treatment for severe obesity and long-term weight loss. In addition, the American Society for Metabolic and Bariatric Surgery (2015) agrees that bariatric surgery leads to long-term weight loss success for most patients. Although a wide range of weight loss surgical procedures are available, the four most common ones are laparoscopic adjustable gastric banding (a.k.a. Lap-Band), sleeve gastrectomy (a.k.a. gastric sleeve), gastric bypass, and the biliopancreatic diversion with duodenal switch (a.k.a. duodenal switch).

Laparoscopic Adjustable Gastric Banding

Commonly called a Lap-Band, laparoscopic adjustable gastric banding is a restrictive procedure that entails placement of an inflatable silicone band around the upper portion of the stomach (ASMBS, n.d.). The newly created pouch is intended to induce a feeling of fullness when only a small quantity of food is consumed. The Lap-Band is reversible and typically yields 40 to 50 percent loss of excess body weight. Patients must routinely visit their surgeons' office or clinic to ensure the Lap-Band receives periodic 'fills' and 'unfills' of normal saline that produce enough restriction to maintain weight loss.

Laparoscopic Sleeve Gastrectomy

Informally known as the gastric sleeve, the laparoscopic sleeve gastrectomy entails removal of the stomach's greater curvature. In this procedure, approximately 80 percent of the stomach is removed, and the remaining stomach pouch is stapled into a banana-shaped 'sleeve' that produces fullness after eating only a few ounces of food. The gastric sleeve is irreversible and normally generates 50 to 60 percent loss of excess body weight.

Roux-en-Y Gastric Bypass

The Roux-en-Y gastric bypass starts with the creation of a golf ball-shaped stomach pouch and ends with the connection to the upper section of the newly divided small intestine to the small intestine further down so that stomach acids and digestive enzymes from the bypassed stomach and upper section of small intestine will eventually mix with the food (ASMBS, n.d.). This procedure typically leads to a loss of up to 80 percent of excess body weight, but also carries the risk of nutritional deficiencies.

Biliopancreatic Diversion with Duodenal Switch

Most commonly referred to as the duodenal switch, this procedure is usually reserved for the most severely obese patients because it leads to greater excess weight loss than all other types of bariatric surgeries. This procedure involves two integral steps: firstly, a small stomach pouch is surgically created, then a large section of the small intestine is bypassed to ensure food doesn't mix with biliary and pancreatic enzymes until far down into the small intestine, resulting in a remarkable decrease in absorption of calories, fats, and other nutrients (ASMBS, n.d.).

At 5'6" and 220 pounds, Rita's BMI of 35.5 placed her into the grade 2 obesity category. However, since she had less than 100 pounds to lose, the bariatric surgeon with whom she consulted was unwilling to perform a Roux-en-Y gastric bypass or duodenal switch. With a goal weight of 135 pounds and a goal BMI of 22, this meant she had about 85 pounds to lose. She opted for the sleeve gastrectomy, reached her goal weight in less than 8 months, and is successfully maintaining through a regimen that involves a high-protein diet combined with three days of strength training per week. Her type 2 diabetes and elevated cholesterol resolved within three months of the surgery.

Is weight loss surgery the easy way out? Some would say "yes," but many of those who have had bariatric surgery would say no. Finally, we must remember that weight loss surgery is merely a tool to a healthier life. It is up to the patient to execute the lifestyle changes that are required to maintain whatever weight has been lost, or else weight regain is a possibility. Celebrities such as Carnie Wilson are anecdotal evidence that a significant quantity of weight can be regained after bariatric surgery if adherence to lifelong changes does not occur.

RESOURCES

Long-term weight loss maintenance

FastStats - Overweight Prevalence

American Society for Metabolic and Bariatric Surgery. (n.d.). Bariatric Surgery Procedures. Retrieved from Bariatric Surgery Procedures – ASMBS | American Society for Metabolic and Bariatric Surgery

American Society for Metabolic and Bariatric Surgery. (n.d.). Benefits of Bariatric Surgery. Retrieved from Benefits of Bariatric Surgery | American Society for Metabolic and Bariatric Surgery

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TheCommuter

About TheCommuter, BSN, RN

TheCommuter, BSN, RN, CRRN is a longtime physical rehabilitation nurse who has varied experiences upon which to draw for her articles. She was an LPN/LVN for more than four years prior to becoming a Registered Nurse.

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Specializes in Medical-Surgical/Float Pool/Stepdown.

I actually wrote a paper on this during my RN to BSN (and work at a Bariatric center of excellence as well) and most, if not all, of the research papers I found and used for my paper stated that Bariatric surgeries are almost the only way for severely obese Pt's to lose and keep off any significant amount of weight loss.

The papers often discussed that this is just what we have evolved to over a century of ever increasing inactivity (compared to having to go out and spend hours daily hunting for food, etc) and having less and less really natural food products to consume...and I think it's fair to say our portion sizes have increased.

What most don't realize unfortunately is just how many hoops and the time invested into getting a reputable Bariatric surgeon to operate on a Pt. It is often a years worth of losing a certain amount of weight and passing psychological evals as well!

Excellent article Commuter! This is a hard topic to discuss and stay objective with maintaining empathy when so many of us struggle to lift and care for more and more morbidly obese Pt's every shift we work.

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Specializes in Dialysis.

As someone who's had bariatric surgery, I can say it's not an easy way out. I had gastric sleeve in 2009. I had to jump through hoops to get the surgeon to do it, and for my PCP to sign off on the necessaries. I can't give any details, d/t it would identify me immediately (and I may have done so by just saying that!), but I will say that I wasn't always heavy. I exercised (in fact PCP was my gym partner!) and ate ultra healthy (I'm known for that among my friends), but the weight would not leave. I paid out of pocket for my surgery (had inherited a decent amount when my dad passed), because I was not the typical bariatric patient in the eyes of the insurance company. I got very sick after surgery, had TPN for 2 weeks, because I couldn't eat without becoming violently ill. I've lost all the weight, gained some back (due to a stressful working situation-no time to make lunch before work, another story), but am currently on the downturn on the scale again, as I'm not stressed (cortisol is BAD, not our friend!), and actually have the time to make healthy choices again. I pack my lunch for work, eat out 1x week with my sweetheart if that often, and try to stay active outside of work. To have someone say I took the easy way out, my reply would be to come walk in my shoes, learn my history, then think about your comment. Not everything is always as it seems, as it meets the eye. Would I do it again? In a heartbeat. Is it for everyone? No. Are there some that use it as a shortcut? You bet, but in the end, it will fail and they will gain all the weight back. It's about enhancing a lifestyle change that must be embraced. It's not a solution to life's problems

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Very interesting. At the end of the day, does it matter if it's the "easy way" or not? The goal is health. If surgery helps a patient become healthier, that's great: goal met.

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RNinIN said:
As someone who's had bariatric surgery, I can say it's not an easy way out. I had gastric sleeve in 2009. I had to jump through hoops to get the surgeon to do it, and for my PCP to sign off on the necessaries. I can't give any details, d/t it would identify me immediately (and I may have done so by just saying that!), but I will say that I wasn't always heavy. I exercised (in fact PCP was my gym partner!) and ate ultra healthy (I'm known for that among my friends), but the weight would not leave. I paid out of pocket for my surgery (had inherited a decent amount when my dad passed), because I was not the typical bariatric patient in the eyes of the insurance company. I got very sick after surgery, had TPN for 2 weeks, because I couldn't eat without becoming violently ill. I've lost all the weight, gained some back (due to a stressful working situation-no time to make lunch before work, another story), but am currently on the downturn on the scale again, as I'm not stressed (cortisol is BAD, not our friend!), and actually have the time to make healthy choices again. I pack my lunch for work, eat out 1x week with my sweetheart if that often, and try to stay active outside of work. To have someone say I took the easy way out, my reply would be to come walk in my shoes, learn my history, then think about your comment. Not everything is always as it seems, as it meets the eye. Would I do it again? In a heartbeat. Is it for everyone? No. Are there some that use it as a shortcut? You bet, but in the end, it will fail and they will gain all the weight back. It's about enhancing a lifestyle change that must be embraced. It's not a solution to life's problems

This sounds exactly like my aunt. She would eat nothing but salads and all-natural, home-made smoothies and would work out for a couple hours a day. After one month of this rigorous routine, she lost a mere half pound. Not everyone is able to shed pounds easily, and I think we need to have surgical options for people who still deserve to be healthy, but can't get there on their own.

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

Here are some insightful thoughts from Dr. Berkeley, a weight loss physician at the Cleveland Clinic, on the 'easy keeper' phenomenon.

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While we debate about whether different people store food differently, owners of animals have long been aware of a phenomenon called "the Easy Keeper". Easy Keepers are animals that need very little food to exist, and who gain weight with extreme ease. They are easy to keep because they require so little feed. Let us always bear in mind that we human beings are part of the animal kingdom.
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I believe that people can be Easy Keepers too. In fact, this is exactly the phenomenon that most overweight people experience when they have trouble understanding why weight comes on them so easily.

- See more at: Are You An Easy Keeper? Weight After Menopause (and Before) - Refuse To Regain

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Specializes in ER, Paeds, Gen Surg.

I have been overweight all my life - never able to get any large amount of weight off - no matter what program, diet, medication I tried. I sustained a trimalleolar fracture with ORIF in 2003. Following that - I put on even more weight as I was not able to walk or do the treadmill for a number of months. Then I just didn't get back into an exercise routine. In 2005 - at a highest weight of 295lbs - I'm 5'8" - my younger sister had an MI. My blood pressure and sugars were creeping up. I was working full time in the ER - but finding it increasingly difficult due to pain/arthritis in my operative ankle - as well as arthritis in my hips and knees - due to being overweight for sure. I decided I would have bariatric surgery - I wasn't going to be able to continue work much longer, and family activities were getting difficult for me, and my health was suffering. I really was miserable. I went out of province to another province, as they were not doing bariatric surgery yet in my home province. The wait time was 3 yrs. In the mean time I suffered a Jones fracture in the same foot I had fractured previously. The pain was debilitating - It took me a year of physio and actually transferring to another nursing unit for a year (CCU) - before I got back to work. Had an RNY in 2008 - weight was 280 at that time. I quickly lost 100lbs and felt great. Work and life was a breeze. 16 months after the RNY - I had a post op complication - a Petersens hernia. I was very ill by the time I ended up having an emergency laparotomy. Had a g-tube in for a month after - was off work for 3 months - weight post op was down to 157lbs. I looked and felt awful. But I got better - got back to work full time and life was good. I was 47 when I had my RNY - I only wish I had done it sooner - my hips and knees and ankles remind me all the time of the damage I did to them being overweight all those years. I have put weight back on. My goal was 180 - I would be happy to be 200. Have been slowly losing those extra lbs over the last 6 months. Not too far left to go. I'm 54 now - work approx five 12hr shifts every two weeks. Would I do the RNY again - absolutely - even with the complication. I have been able to continue to work and have a life. I know this comment is lengthy, but if it helps just one person out there - it's all good!

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Specializes in Case mgmt., rehab, (CRRN), LTC & psych.
MCRNENCC1961 said:
Would I do the RNY again - absolutely - even with the complication.

Thank you for sharing your story.

Would you be willing to do a revision of your gastric bypass? If not, there's a nonsurgical option called the Five Day Pouch Test that noninvasively restores that tight feeling of stomach restriction and kickstarts weight loss in bariatric surgery patients who have regained some of their weight.

Good luck to you. The battle of the bulge is very real and lasts for a lifetime.

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Specializes in ER, Paeds, Gen Surg.

Nope - no revision for this gal. Not having another general anesthetic. Between a cesarean, an open tubal ligation, ankle surgery, RNY and then the laparotomy - I think I have had my share. At 54 - almost 55 - I'm not willing to take a chance of possible problems if I did have a revision. My weight gain is due to making poor choices and not being active enough, as well as having a few glasses of wine here and there - which I didn't do that much years ago. It all adds up. I still have restriction, still eat VERY slowly, don't drink with meals, take my supplements etc. I have heard of the 5 day pouch test. If I don't keep slowly losing - will probably do it. Thanks for your good wishes - and feel free to share my story to anyone - anywhere. :)

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Well, given that I've been conducting my own little n=1 experiment over the past year and a half, with 110.8 lbs. lost to date (281.2 lbs. to 170.4 lbs) without bariatric surgery (this after having been chronically obese since college and overweight since infancy), I'm inclined to question the necessity of resorting to a potentially life-threatening surgical procedure except as an absolute last resort. Part of the problem appears to lie in the concept of what actually constitutes a "healthy diet", and the rest stemming from an unwillingness to examine fundamental biochemical processes going on in the human body. Thankfully, the research community appears to be addressing these issues to attempt to come to a better understanding of exactly why we're becoming obese, and how to address this issue without having to resort to radical surgery to correct it.

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Specializes in Critical Care; Cardiac; Professional Development.

As a bariatric nurse educator, I work daily with those living beneath the physical, mental and social burdens of this disease process. It is true for some that diet and lifestyle changes can be curative, but evidence based studies are proving over and over that for the majority of individuals the best treatment available at this time, in terms of five year outcomes, is bariatric surgery. No other treatment for obesity out there comes anywhere close. This disease affects holistically almost ever body system. Surgical treatment combined with psychological support, dietary and kinetic education within an umbrella of medical management can and does lead not only to near complete resolution of the condition, it also leads to rapid resolution of comorbid conditions that go hand in hand, such as DMII, hypertension, depression/anxiety, DJD, chronic pain and others.

Diet and exercise are great and I am distinctly happy for those whom this treatment path has proven effective. However, there is no denying that for the vast majority it is a failed treatment modality. Surgery IS drastic and should not be entered into lightly, nor without thorough education, preparation and supportive services at the ready. Bariatric surgery remains, at this time in history, the best option out there for a cure when compared scientifically to everything else available.

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Specializes in Med/Surg crit care, coronary care, PACU,.

I just celebrated my 5th "surgiversary" post RNY. Six years ago I was a 285lbs, hypertensive on 3 meds, diabetic taking 3 insulin shots/day emergency responder. Realization hit me that one day running to a code, I too would need this service. My body was so metabolically shot, I feared I was past the point of irreparable damage. The learning curve pre-surgery was immense to learn all the things my new digestive system would do for me, but I did it. I have to say, I would do surgery all over again. I have felt so healthy, and in control post op. My diet is not always perfect, but I have tools in my box to keep on track. I think my experience has helped me be a better nurse in dealing with all of my patients, it is amazing that situational sharing of experiences as nurses (without pointed telling ptd what to do) can be beneficial.

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