Which Bariatric Surgery is right for me?
My first visit with patients is usually focused on choosing the right Bariatric Surgery. While there are a number of options, my practice focuses on only two procedures, the Gastric Bypass and the Sleeve Gastrectomy. The reason that I’ve chosen to focus on only these two procedures (this is common, around 90% of all Bariatric Surgeons limit their practice to just these two surgeries) is because these are time tested, predictable procedures with low complication rates, and high success rates.
In my opinion, other options, like the adjustable gastric band, gastric balloon and endoscopic sleeve gastrectomy don’t offer reliable results (most patients fall well short of their goal weight), or, like the duodenal switch or SADI procedure, offer too high of a complication rate with only a slight increase in weight loss results.
Choosing Between a Sleeve Gastrectomy and a Gastric Bypass
There are Five major factors that must be considered in choosing the right bariatric surgery. Often, there are important factors in your medical history that you must consider in order to choose the right Bariatric Surgery. A Sleeve Gastrectomy is the safest weight loss surgery and impacts your future digestive life less, but results in less weight loss and a higher risk of weight regain. A Gastric Bypass offers more weight loss, but has a higher complication rate and can result in difficulties eating fatty or greasy foods in the future.
Five Major Factors in choosing between a Sleeve Gastrectomy and a Gastric Bypass
- Your BMI
- Alcohol Use
- Heartburn or GERD
BMI stands for Body Mass Index and is a measure of the severity of obesity. This number can be used to compare obesity across people of different heights. For instance, if you are 6’2″ and weigh 195 lbs, your BMI is 25 which is considered normal. If you are 5’2″ and weigh 195 lbs, your BMI is 35.7 and you are considered obese.
When choosing between a Sleeve Gastrectomy and a Gastric Bypass, the higher your BMI, the more you should consider a Gastric Bypass. I use 45 as the cut off – if your BMI is less than 45, I steer patients more toward the Sleeve Gastrectomy, higher than 45, more toward the Gastric Bypass. This is not an absolute rule, there are many other factors to consider when choosing the right bariatric surgery, but your BMI is a helpful starting point. Here’s a link to a BMI Calculator if you don’t already know your BMI.
If your BMI is between 30-35, this is outside of the range that most insurance companies will approve for Bariatric surgery. There is excellent evidence that supports the role of Sleeve Gastrectomy in patients in this BMI range, particularly if you have medical conditions like high blood pressure, diabetes, high cholesterol or sleep apnea. Because you are unlikely to get insurance coverage, you would have to opt for a self pay option. This video offers more insight into Sleeve Gastrectomy for low BMI patients.
If your BMI is more than 55, Dr. Weiner typically performs Gastric Bypass procedures in this setting after achieving weight loss prior to surgery. Other surgeons may offer you a Sleeve Gastrectomy with the option to convert it to a Duodenal Switch or SADI procedure down the road if you don’t reach an ideal weight. You should work hard to lose weight before surgery in order to reduce the risk of complications. Dr. Weiner’s nutrition program offers support for people to lose weight prior to surgery.
Smoking can cause major problems after Bariatric Surgery, especially after Gastric Bypass so if you smoke, it’s critically important that you quit immediately! Please speak honestly about smoking with your Bariatric Surgeon – they’re on your side and will support you in your efforts to quit.
If you are not 100% certain that you can quit, you should definitely have a Sleeve Gastrectomy and should definitely NOT choose a Gastric Bypass. Even if you quit before the surgery and then restart smoking a few months, or even years after surgery, you will still be at risk for all of the problems that smoking after Bariatric Surgery causes. Here’s a video (of a much younger me) that covers the dangers of smoking after Bariatric Surgery. In case that didn’t convince you, here’s some information about marginal ulcers after Gastric Bypass that will.
Alcohol use is a critical factor in deciding on the right surgery. After a Gastric Bypass, there is approximately a 4% risk of alcoholism (it is less common after a Sleeve Gastrectomy). The most likely cause of this is due to increased absorption of alcohol. If you do decide to have a Gastric Bypass, Dr. Weiner recommends that you avoid alcohol altogether – this is the only way to eliminate the risk of alcoholism after Bariatric Surgery.
Even if you drink very little, you still have a chance of developing a dependency on alcohol after a Gastric Bypass. At the very least, you should ensure that you do not drink more frequently after surgery than you do right now. If you have concerns about your ability to severely restrict alcohol intake after Bariatric Surgery, a Sleeve Gastrectomy may make a better choice.
Heartburn is a critical factor when choosing between a Sleeve Gastrectomy and a Gastric Bypass. Since a Sleeve Gastrectomy can worsen GERD or heartburn symptoms, existing heartburn symptoms put you at risk for developing severe GERD or heartburn if you opt for a Sleeve Gastrectomy. A preoperative endoscopy to evaluate your esophagus for inflammation or a hiatal hernia is a critical part of your preoperative workup.
It’s also important that you understand that a Gastric Bypass is an excellent treatment for GERD. Approximately 10% of all Sleeve Gastrectomy patients will develop significant heartburn symptoms after surgery that may or not be able to be controlled with medication. Approximately 5% of all Sleeve Gastrectomy patients ultimately will be revised to a Gastric Bypass to treat severe heartburn symptoms.
Diabetes is a devastating disease, and until Bariatric Surgery came along, was looked at as “uncurable.” While we try to avoid using the term “cure” when discussing diabetes after Bariatric Surgery in favor of “remission,” it’s now well accepted that the best treatment for Diabetes is Bariatric Surgery. While both procedures are very effective treatments for diabetes, A Gastric Bypass is a more effective, and more durable. If eliminating Diabetes is your primary reason for having Bariatric Surgery, a Gastric Bypass makes a better procedure choice.
Going through these factors in a systematic way with a Bariatric Surgeon who performs reasonable volumes of both Gastric Bypass and Sleeve Gastrectomy can help you in choosing the right bariatric surgery for you. Our quiz allows you to answer questions about these five factors (as well as less important and personal considertions) and provides detailed feedback about the best surgery for you.