Choosing the right operation
Having decided that weight loss surgery is for you, one of the next decisions is what operation would be best? This is a decision that is made jointly between you and your surgeon and we strongly urge you to do your research to understand which operation would be best suited to your particular circumstances. Here are some pointers to help guide you through the process.
Consider your current health state
|What is your BMI?
||If you don't know what your BMI is now, take a look at our BMI calculator and work it out. Some surgeons relate BMI to the choice of operation; e.g. if your BMI is 35–50, you have a band, if it is 40–60, a bypass and if higher, a two stage operation. However this is not necessarily the case, patients with a BMI over 60 have been shown to do well with a band and if you have unstable diabetes and a BMI of 38, you may be better with a bypass.
|What is your age?
||Some doctors say that increased age is related to a smaller improvement in obesity related illnesses after surgery but recent papers from the USA show that patients in their 60s and 70s derive great benefit from surgery. Physically mature adolescents and teenagers can now also be considered for surgery but this should be handled by only the most skilled bariatric multidisciplinary teams providing proper support services specific to the needs of teenage patients.
|What obesity–related illnesses do you have?
||If you have diabetes, you have more chance of it resolving completely with operations that achieve a greater weight loss or exclude some of the hormone release in the stomach. High blood pressure and sleep apnoea will almost certainly improve with a lesser degree of weight loss. The length of time and the severity of your obesity–related illnesses will also determine how likely they are to resolve and will be something to discuss with a physician in a multidisciplinary team.
Consider your goals
|What degree of weight loss are you looking for?
||If you now weigh 150kg, and your height is 168cm, your BMI is 53.8kg/m². If you lose 50% of your excess weight, your weight will come down to 109.9kg and your BMI down to 39.4, (you would still be severely obese). If you lose 70% of your excess weight, your weight would come down to 93.8kg and your BMI would drop to 33.6 (obese). Look at the different published weight loss amounts for each type of operation and work out your anticipated success.
|What is a reasonable goal to set yourself?
||Although the range of ideal BMI is 18–25, it is above a level of 30 that your risks of developing obesity related diseases and your risk of dying early increase hugely. We recommend that a sensible goal to aim for is a BMI of 30. Many doctors also recommend that it is better to be slightly overweight and fit, than to be of normal weight but unfit.
|How quickly do you need to lose weight?
||All of us would like to wake up slim tomorrow but it will take you at least a couple of years after surgery to lose most of your excess weight. With a bypass, your weight loss will be more rapid initially, and then slow down after the first 6 months. With a band, it will be a steady progression of losing 0.5 - 1kg/week once your band is adjusted to the 'sweet spot'. A study in Australia of patients 10 years after banding show that they continued to lose weight after the initial 2–year period and other studies showed that the differences in weight loss achieved by band and bypass patients narrowed in subsequent years to become almost equal.
Consider your eating behaviours
|Are you a sweet eater?
||If so, then a bypass may be better for you than a band because dumping syndrome, an unpleasant side effect of high sugar intake, is a built in aversion therapy.
|Are you prepared to reduce the amount of food you eat after surgery?
||This is a tough one to envisage until you actually experience it post–op because the big difference will come when the feeling of satiety (fullness) stays with you, even though you have only eaten a small meal. However, if you want to be able to eat larger meals than this and are prepared to put up with offensive wind and stools (are your family too?), maybe you should be considering a BPD or DS operation.
|Do you race through your meals and not chew thoroughly?
||This is something else you will have to learn to change after most obesity surgery operations otherwise you will just regurgitate your meals and that's no fun. Practice cutting up meat into tiny cubes the size of a pencil eraser and chew until totally soft and mushy before swallowing. You will find you are not the first finished your meal any longer!
|Are you prepared to improve the nutritional value of your meals?
||This is something that everyone who has surgery should be prepared to do. If you are only eating a small amount of food, you should ensure that it has a high nutritional value and you need to work with the dietitian on this.
Consider your personality
|Do you have the 'stickability' to stay on track with a surgery treatment programme?
||You will be in this for the long haul if you want to succeed. In most cases the surgery is a tool to limit what happens internally but you are still in control of what you put into your mouth. If you have previously attended a slimming club for 6 months or more and lost more than 10kg doing so, you are probably more likely to do well with surgery than if you haven't.
|Are you prepared to face your altered body image after surgery?
||The NHS does not routinely fund plastic surgery to remove excess skin after you have lost weight. Some people find their body more repulsive than when they were fat. If you are having surgery privately, are you prepared to pay for plastic surgery as well? (expect to pay and extra £4–5,000 per procedure for this).
|Are you willing to learn from other patients?
||This may seem a silly question but if you are willing to participate in a patient support group (whether online or locally) you will do better because you will learn lots of tips from other patients that you won't generally find out from your surgeon or any printed materials.
|Are you prepared to increase your exercise?
||You will automatically gain more energy as your weight falls but there will come a point where your input of calories equals your expenditure of energy and your weight loss stops. Developing and sticking to an exercise programme will help ensure your weight loss keeps going and will also help your muscle tone too.
|Do you suffer from depression?
||It is a mistake if you believe that your depression will disappear if you lose weight – most people who suffer from depression, still suffer it after they have lost weight. If you suffer from depression you need specialist medical help specifically for that condition.
Consider your surgeon
|What operations does your surgeon do most often?
||Your bariatric surgeon will achieve greatest technical expertise in the operation they perform most often. Beware of the surgeon who says they will "have a go" and if you are one of the first patients to undergo this surgery locally, ask if your surgeon is planning to have a more experienced bariatric surgeon to supervise him/her. If they are new to weight loss surgery, they should be expert in the anatomy of the stomach and oesophagus already as an upper GI surgeon, so you may want to check that.
|What are the weight loss and side effect results of your local surgeon?
||The government requires that a bariatric surgeon maintains a database of patients and he/she should be able to tell you the weight loss results easily and also how many have had side effects etc.
Those seeking surgery privately should also consider the cost elements - these are discussed more fully in the private surgery page.
Although the results of weight loss surgery can be drastic, there are potential risks and complications. Before making your decision, you should be well informed. This is vital as you give "informed consent" for the surgical operation. Informed consent is a legal term meaning that you agree that you have received and understood enough information about the operation's risks and benefits to allow you to make a decision that is right for you. Your bariatric surgeon will require you to sign a consent form before performing your operation.
This table summarises some of the risks and benefits of each operation. This information is collated from the many medical papers published on this subject from around the world. You can see that the lowest risk operation (i.e. it has the lowest death rate associated with it) is the LAGB and the highest risk operations are the BPD or DS. However, conversely the lowest average weight loss is also see with the LAGB and the highest with the BPD or DS.
||DEATH RATE (WITHIN 30 DAYS OF OPERATION)
||SIDE EFFECT RATE++
||AVERAGE EXCESS WEIGHT LOSS AT 2 YRS¹
||DEGREE OF PATIENT DIETARY/NUTRITION COMPLIANCE REQUIRED
||0.05%² (1 in 2000)
||0.31%² (1 in 300)
||0.5%² (1 in 200)
||1.1%¹ (1 in 100)
||1.1%¹ (1 in 100)
* No specific data is available but because of high BMI and co–morbidities in patients having this operation, death rate is expected to be similar to that for RNY gastric bypass. Side effect rates are expected to be quite low due to the relative simplicity of the operation.
++ Here is a list of the commonest side effects and complications of the operations.
||Side effects of operation
||Complications of operation
||Slippage, pouch dilatation, band erosion, infection of port or band, stoma obstruction
|RNY, BPD, DS
||Nausea, vomiting, diarrhoea, dumping, nutritional deficiencies, gall stones
||Leaks, haemorrhage, acute stomach distension, internal hernia, ulcers or strictures of stoma, staple line problems.
The most important thing you can do for yourself is to research, in depth, all of the procedures. You should then discuss them with your surgeon before making a final decision. When you ask a question, make sure you understand the answer. Do not hesitate to ask for a clearer explanation or for your bariatric surgeon to use simpler language.
Your decision to have a weight loss operation may take several consultations with the surgeon, as well as consultations with other doctors. Because of the enormity of this decision, many surgeons will insist on a certain time gap (usually of several months) from the time surgery is agreed to when it is actually performed, even for private patients.
Also ask to be put in touch with other patients who have had similar operations and who are willing to discuss their experiences, good and bad, with you. Meet them individually or at a local patient support group.
Open or laparoscopic surgery
Laparoscopic surgery is a minimally invasive approach to surgery and your surgeon will have undertaken additional training to be able to operate this way. Several small incisions (1/2 – 1 inch long) are made in the abdominal wall, through which are inserted tubes that allow the passage of the surgical instruments needed for the operation. The positioning, number and size of these incisions might vary from surgeon to surgeon. A small camera is inserted into the abdomen, and the surgeon operates by watching his activities on a video monitor. This provides better visualisation and better access to important anatomical structures. To enhance his vision, your abdomen in inflated with gas, and as much as possible of this is expelled again at the end of the operation. However you may feel a bit bloated, or have “wind” pains under your diaphragm or in your shoulder tip for a few days whilst any final gas bubbles are slowly reabsorbed.
Compared to open surgery, benefits of laparoscopic surgery include
- Less post-operative pain
- Better cosmetic results
- Fewer wound infections
- Fewer incisional hernias
- Faster recovery and return to pre-surgical levels of activity
Many UK surgeons ask patients to follow a very restricted eating plan for one week before their surgery to reduce the size of their liver. Information on this can be found on our pre-op eating plan page.
Doing an operation as an open procedure, does not alter the affect of the operation that is being done and may be necessary in patients with certain anatomical characteristics, or who have scarring or adhesions from previous operations, or who have large livers or where other technical difficulties arise when a laparoscopic approach it tried.
- Buchwald H et al, Bariatric surgery: a systematic review and meta–analysis. JAMA 2004 Oct 13:292(14)1724–37
- Chapman AE et al. Laparoscopic adjustable gastric banding in the treatment of obesity: A systematic literature review. Surgery 2004 Mar 135(3):326–51
- Ren CJ, Patterson E, Gagner M. Early results of laparoscopic biliopancreatic diversion with duodenal switch: a case series of 40 consecutive patients. Obes Surg 2000; 10:514 . 523.