Weight loss surgery, or bariatric surgery is the surgical management of obesity and it has come a long way from the procedures people commonly refer to as stomach stapling. The most common bariatric surgeries performed in Canada are the roux-en-y gastric bypass and the vertical sleeve gastrectomy. Some private clinics may offer laparoscopic gastric banding or intragastric balloons but these procedures’ lesser average outcomes have led most provinces to not include them as covered procedures.
Depending on your province, the procedures offered and covered almost certainly include the roux-en-y gastric bypass and the vertical sleeve gastrectomy. Some provinces may also cover laparoscopic gastric banding and/or duodenal switch.
If you have a BMI between 35 and 40 with weight responsive medical conditions such as high blood pressure, diabetes, sleep apnea and more (check with your family MD for your province’s requirements), or a BMI > 40 with or without weight responsive medical conditions unless there are contraindications to surgery in your case, you would qualify.
It's worth noting that In Canada private insurance does not cover weight loss surgeries as they are covered by provincial health care.
Weight loss surgery’s benefits are wide ranging. Decades long studies of patients who have had gastric bypass surgeries have demonstrated that those who have it live longer and with a higher quality of life than those who don’t. Bariatric surgeries have also been shown to markedly reduce the burden of weight responsive medical conditions, often pushing them into remission, and lowers the risk of developing other weight associated conditions including common cancers such as breast, colon, and uterine.
Every abdominal surgery carries risks of infections and blood clots, some of which can be very serious or even fatal, but these surgeries do not carry more risk than other abdominal surgeries. All abdominal surgeries also carry the risk of abdominal wall hernias.
Weight loss surgery can cause a range of gastrointestinal problems, including with the gastric bypass a condition called dumping syndrome, which often is experienced as diarrhea, nausea, and abdominal discomfort. People can also develop ulcers in the stomach or small intestine. There is also the risk of leaks or bleeds from the internal anastomosis in the early days post operatively.
Weight loss surgery can lead to nutritional deficiencies consequent due to reduced absorption and intake of vitamins and minerals.
As with any intervention that leads to rapid weight loss, gallstone formation risk and gallbladder disease risk is increased.
Medical interventions are all about weighing the risks of the intervention versus the risks of doing nothing. When it comes to weight loss surgery, statistically speaking, intervening is less risky than not. That said, individuals aren’t statistics, and lifestyle and emotions need to be considered by each person exploring weight loss surgery in their determination of whether or not to pursue it.
Every surgical centre will have their own guidelines and requirements as will each patient. All patients will need to be cleared by a medical team whose job it is to ensure their surgical safety, by a dietetic team whose job it is to ensure they understand their postoperative nutritional needs, and many centres will also require visits with a behaviouralist or a psychologist.
Blood work and an electrocardiogram will likely be required for all patients and some may need additional testing such as sleep studies (to rule in or rule out sleep apnea) or endoscopies (to look in a person’s stomach to ensure there are no existing ulcers or hiatal hernias).
Once patients are cleared by their teams and a surgical date is set many centres will require patients to undertake an all liquid diet for two or more weeks so as to shrink their livers prior to surgery and in so doing make the operation safer to perform.
On average, depending on the procedure, weight loss surgeries lead to losses of between 20-40 percent of a person’s presurgical weight. That said, people don’t have direct control over how much they lose. An analogy for this is school. You can go to class, do your homework and study, but whatever grade you get, you get. And not everyone who studies the same amount gets the same grade, nor does everyone who studies their best get an A+.
Regarding weight responsive medical conditions - many do improve or even go into remission leading to the cessation of medications and treatments such as CPAP. Pain and mobility also regularly improve. Unfortunately, this is not the case with everyone and it’s worth remembering that there are people who have never had any excess weight who have weight responsive medical conditions and chronic pain or mobility issues.
Smaller meals consequent to rapid fullness is the most obvious change. Some people will also find that palates change leading to new dietary choices. People will also need to take multivitamins and supplements and undergo at least annual blood testing to review. As to impact on lifestyle as a whole, many people consequent to their weight losses will see their activity levels change as mobility and pain improve with decreased mechanical loads.
Different surgical centres provide slightly different advice. Some will recommend maintaining a food diary long term as a means to provide ongoing feedback and reminder of behaviour changes. You may be advised to avoid alcohol, caffeine, and carbonated beverages altogether. You may be encouraged not to drink beverages with your meals. You may be encouraged to utilize protein supplements to meet your daily protein recommendations.
Remaining aware and active in maintaining the recommendations provided to you by your surgical team will decrease your risk of weight regain.
Follow up care in the first years post bariatric surgery is crucial as the vast majority of complications and challenges will occur during those first two years. The frequency of your appointments with your care team as well as which members of your team will vary according to the province in which you reside. Generally speaking frequency will decrease with time as will blood work with the first year seeing the most of both. Close monitoring will help to identify issues early and allow for their correction often before they become symptomatic.
The long term effect of weight loss surgery is durable and significant weight loss and all of the impacts that brings - from decreased risk of multiple chronic medical conditions, to the decreased risk of many of our most common cancers, to improvements to endurance, energy, pain, mobility and quality of life.
Success can be measured in a number of different ways, but generally involves the comparison of people with similar weights/ages/medical issues who do and don’t have bariatric surgery to see whether surgery improves various aspects of their lives.
What we know for certain is that on average surgery leads to far more durable and extensive losses than non-surgical approaches, that people who have surgery live longer lives with higher qualities and with reduced risks of developing multiple medical conditions - from diabetes to various types of cancers.
Certainly the most important factor is the type of surgery chosen by the patient and their care team, but putting type of surgery aside factors that influence success rate would include age (younger doing better on average), presurgical weight, comorbid medical conditions, ability to affect post-operative lifestyle changes, job and lifestyle requirements related to eating out, the amount of follow up with the surgical care team, and positive mental health and attitudes.
On average weight loss surgery leads to losses between 20-40% of presurgical weight depending on which procedure is utilized.
While the only guarantee following weight loss is smaller clothing sizes, bariatric surgery leads to clinically meaningful weight loss - meaning an amount that has an impact on a person’s health and quality of life. Many weight responsive medical conditions improve or go into remission. Mobility increases and pain related to mechanical load decreases, and roughly 75% will maintain significant losses long term.
The treatment pyramid of obesity is easy to envision. The base of the pyramid is lifestyle modification, and there are certainly some people for whom lifestyle modification alone is sufficient.
The next level of the pyramid is pharmaceutical management and we finally do have medications that are safe, effective, and well tolerated that can serve to augment and add to lifestyle modification.
The third level of the pyramid is weight loss surgery which when coupled with lifestyle modification leads a large majority of people to durable weight losses.
The final level of the pyramid is weight loss surgery coupled with those same pharmaceuticals to help the minority of people who despite weight loss surgery still struggle to maintain their losses.
Though there are always people who lose more and less than average, the average weight lost through lifestyle means alone would be 5-10% of a person’s weight. With medication that would increase to 15-20%. And with surgery it would increase to 30%.
Pros and cons are highly subjective.
Clearly lifestyle modification alone is the least invasive and likely carries the least amount of treatment risk. Lifestyle modification alone can also be more challenging to sustain long term, especially when not done with proper guidance..
Pharmaceuticals can have side effects, though for the vast majority of those who use them they are extremely well tolerated. Currently used pharmacotherapy for obesity may also have independently beneficial effects on type 2 diabetes and may provide cardioprotective benefits beyond what would be expected from weight loss alone. Just as with any other chronic medical condition’s pharmaceutical treatment, to enjoy their benefits long term, a person needs to remain on them long term.
Surgery of course has surgical risks which would include infections, blood clots, anastomotic leaks, and nutritional deficiencies along with other potential side effects including dumping syndrome or reflux. Surgery has a dramatic effect on type 2 diabetes and often puts patients into long term remission.
Obesity is a chronic disease that confers significant risks to those who have it. Weight loss surgery is offered to people where the risks of having the procedure are lesser than the risks of not having the procedure. Suggesting that weight loss surgery is just about appearances denies the risks of obesity as well as its commonly experienced and often significant impact on quality of life.
Final thoughts and recommendations
If you are considering weight loss surgery in Canada, please speak with your primary care provider about the requirements and process to get you involved. Know too that being enrolled in a provincial weight loss surgical program does not require you to have surgery but will instead afford you and the clinicians involved the ability to determine if it’s a good choice for you.
If you're considering the first two steps of the pyramid or have had bariatric surgery and find that you're still struggling with your weight, our team has the expertise to help.
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