Weight loss surgery is major surgery requiring a general anaesthetic, therefore it carries a risk of complications. If you are considering weight loss surgery and want to be more aware of the potential risks involved, then this is the article for you. We have categorised the risks into 5 categories:
Anaesthetic Risks
Anaesthesia is very safe in Australia. Despite people’s fears, patients do not die on the operating table, except in extremely unusual circumstances. The risk is so low it is very hard to measure, but is about 1 in 40,000 operations.
General Risks
There are always risks involved during and after surgery, please see below:
- Operations involve incisions, which may become infected or heal poorly.
- Hernias and other wound complications are the most common problems after gastric surgery.
- Operations also involve changes in bodily functions that put people at risk of chest infections (pneumonia), urine infections and blood clots.
These are the risks that pose the greatest threat to life after major surgery. There is also a risk of bleeding during the operation or immediately following it, so occasionally patients may require blood transfusions or even re-operation.
Specific Risks
These risks differ according to which operation you have. They may occur early or late following the procedure. For example, the most feared complication in operations that involve the bowel is a leak from the place where the bowel has been divided or joined. Although these joins are all made in a standard way that is repeated again and again from operation to operation, in about 0.2 per cent (1 in 500) people they fail to heal, allowing the contents of the gut to “spill out”. This causes infection and almost always requires another operation and significantly longer recovery time.
Other risks may be higher for some patients than others, so part of the process prior to surgery is to discuss these with your doctor. The list of rare complications is so long it would be almost impossible to tell you them all, but we can discuss the most common risks and those that are most relevant to you. These issues are best discussed at an individual doctor-to-patient level before you make a decision on having an operation.
Death
Just as driving to work involves the remote risk of a fatal car accident, any operation carries a small risk. Most people decide to undergo an operation with this expectation and accept the possibility that things may not go as planned. The risks depend on the type of surgery you are having and your age, weight and health, so your overall risk of death may vary from one in 200 to one in 3000.
Disability
While recovering from an operation a person is, in effect, disabled. If they have complications the duration of their disability can be prolonged. Some disabilities may be permanent and some permanent disabilities occur even if no obvious complications have arisen. This is because the effects of any operation vary from person to person. As these operations affect the way your body functions, if a complication affects your quality of life it may be difficult to remedy.
Disability may take the form of prolonged tiredness, abdominal pain, difficulty eating, vomiting, or nutritional deficiencies. Most of the operations for obesity are to some extent reversible or modifiable, but attempting to fix or reverse the operation may not fix an established problem. What makes these risks acceptable is the fact that obesity causes disability, psychological distress and risk to life.
If you are considering weight loss surgery as an option and would like to discuss your personal potential risks, please book an appointment online or call our clinic to have a consultation with one of our specialists who will be able to give you more information relating to you specifically. You can call us on 02 9553 1120 or use the Hotdoc link.
We are often asked if somebody is too young or too old for bariatric surgery because of concerns about fairly major surgery for themselves or their family members if they are they are below 20 or above age 65. When somebody presents with obesity at the extremes of age it is very important to individualise their care and make very considered decisions. Below we will discuss some of the issues we examine while making management decisions for these patients.
Bariatric Surgery for patients under the age of 20
There are very few topics that create more controversy than the prospect of bariatric surgery in young people. In general, in order to make decisions easier, we break young people into 3 different groups because each of these groups has their own issues.
Group 1 – Young adults
These are young people who have left childhood and adolescence behind and have often taken on a lot of adult achievements including having left school, going to University or getting a job. While they have entered adulthood they still may not have achieved their full growth and body development. There are also concerns about future potential problems such as vitamin deficiencies or the effect of pregnancy on somebody who has had bariatric surgery that need to be taken into consideration.
The total number of people in this age group seeking bariatric surgery is fairly small, mainly because the majority of young people with excess weight are too young to have suffered irreversible musculoskeletal injuries that come with many years of carrying excess kilograms. There are some young people whoever, who are badly affected by adult diseases such as sleep apnoea, arthritis and diabetes who will seek surgery and, in these situations, we treat them in the same way that we would any other patient.
Younger patients do need to be aware of the requirement for longer-term follow-up especially to reduce the risks of weight regain which would clearly be a disappointment for anyone but especially so in a younger person.
Group 2 – Adolescents
An adolescent is a young person who is not a child but is also not an adult. Their issues need to be taken into consideration given this is a time of rapid development with hormonal changes and the individual becoming more affected by their interactions with their friends and peers and less under the direct day-to-day control of their parents and very close family.
The number of adolescents with obesity severe enough to benefit from consideration of surgery or other fairly aggressive weight management treatments is very low. If, however, somebody is overweight enough so that they are disabled and unable to function or they have particularly aggressive diabetes or sleep apnoea then occasionally these types of procedures will be considered. In reality surgery in the 12 to 17 age group is very uncommon but we do know for patients afflicted with severe obesity in this age their quality of life is worse than the quality of life of adolescents undergoing chemotherapy for cancer.
The teenage years are tough on all of us and they are especially tough on very overweight kids who feel discrimination and social isolation far more acutely than adults do because they haven’t yet developed the life skills to manage themselves in difficult social circumstances. While the number of people in this situation is thankfully small it is very good to know that the published results from this type of surgery are very good as long as the individual is appropriately supported by a range of specialists before and after the procedure including paediatricians, endocrinologists, psychologists and dietitians. In general patients of this age having surgery should be under the care of a paediatrician before considering this option.
Group 3 – Childhood obesity surgery
It seems that there is nothing media likes more than the spectre of children having obesity surgery. This type of option is very uncommonly considered and only as part of a multidisciplinary specialist management plan. The rare children who do end up being considered for this surgery usually have marked biologically based abnormalities in their growth, sometimes with genetic conditions that predispose them to obesity. While the numbers of surgery in this age group worldwide are very low the results once again seem sufficiently safe to be a valid option for this rare group of patients.
Bariatric Surgery for patients over the age of 65
People tend to accumulate weight problems and medical conditions associated with their weight as they get older. Unfortunately, as people get older their mobility and general health can become pretty poor if they’ve been carrying extra weight for many years. For this reason, older Australians who feel their mobility, quality of life and overall health are very compromised will sometimes elect to consider weight loss surgery as a treatment option.
There are a couple of extra issues when considering bariatric surgery in people over the age of 65 compared with younger patients. One issue is that many of the diseases associated with severe obesity in younger patients will reverse with surgical treatment and this will lead to a significant prolongation of that individual’s life expectancy. If, however, you treat somebody after many years of suffering diabetes or other diseases a degree of damage has already been done so life expectancy increases are not as likely to occur. Older patients will still find that uncontrollable conditions can be brought under control with a 20 to 40 kg weight loss.
In general people over the age of 65 who seek weight loss surgery have very specific goals they wish to achieve, usually involving increasing their ability to undertake normal day-to-day tasks and maintain their independence as they get older.
Safety of Bariatric Surgery for older patients
There are always concerns about medical fitness for surgery in people over the age of 65. Cardiology and lung assessments will usually determine if an individual is a high risk or not.
Putting things in perspective our weight loss operations are less likely to lead to a complication leading to either death or a major injury than knee or hip replacement, hysterectomy or other reasonably routine procedures such as angiography. Because weight loss surgery is elective surgery, we are able to take the time to identify and correct any risk factors that might be at increased risk of harm in somebody having surgery.
At St George Hospital we’ve looked at the safety profile of over 400 patients who have had bariatric surgery aged over 65 and haven’t had an increase in complication or re-admission compared with the younger patients.
The weight loss goals we have for older patients are a little different than younger patients, in this group we are not aiming to get people down to an ideal body weight of BMI 25 but prefer them to get down closer to a BMI of 30 so they have a couple of extra kilograms in reserve. There is a concern that excessive weight loss in older people can lead to loss of bone and muscle tissue which is very important for maintaining mobility, day-to-day activities and immunity.
Surgery between the ages of 65 and 70 is reasonably common however it is uncommon for patients over the age of 70 to consider this as an option however there is no doubt that the rare individual may consider this as a reasonable option even out up to the age of 80.
Weight loss and metabolic surgery in younger and older Australians are appropriately less commonly performed than in patients in the middle years of their life. By carefully selecting patients who are heavy enough to benefit but well enough and supported enough to have the procedure safely we can ensure that benefits from surgery outweigh any risks.
A question we are often asked by our patients is whether or not they need to go on a diet before they have bariatric surgery. So today we thought we would explain the pre-surgery diet that we recommend to our patients and why.
Why do I need a special diet pre-bariatric surgery?
Although bariatric surgery is a very safe procedure, it is still major surgery and with all surgery, there are risks involved. The pre-bariatric surgery diet is designed to assist in making your surgery as safe as possible by increasing the amount of space in your abdomen to allow easier laparoscopic surgery.
When someone goes on a high protein Very Low Energy Diet (VLED) ½ the weight they lose comes from their abdomen. A 6kg weight loss will lead to an increase of 3 litres of intra-abdominal space for surgery to occur for example. This leads to less pain and faster recovery for you as internal cuts and bruising is less.
Other benefits;
- Patients with bad diabetes will get a reduction in their blood sugars which significantly reduces their risk of post-operative infections.
- Patients with sleep apnoea will reduce their risk of post-op breathing complications by over 50%
- Weight loss improves overall immunity
- Weight loss softens the abdominal wall, so if other issues such as hernias are found during surgery, they can be fixed without needing further surgery down the track.
- This diet allows people to try different formulations of VLED that they can use for the post-op diet.
How much weight someone “needs” to lose before surgery is different from person to person, however for many, 2 weeks on a VLED pre-op is sufficient to do the job. This equates to 4-8 kg for most people.
Special Cases
People with a BMI over 50 or weighing over 160-200 kg, those with significant and poorly controlled medical problems, and people who have had complex abdominal surgery before may need to lose a greater amount of weight before they can safely have surgery. In these circumstances we may set a specific weight target before surgery, with a plan to delay the procedure until the goals are met.
These goals may include, for example, achieving a 10% bodyweight reduction or getting to a certain nominated weight. In these circumstances the pre-op diet may need to be extended out to 4-12 weeks, depending on the goal.
What is the pre-bariatric surgery diet?
Our patients are asked to follow an intensive phase of VLED (very-low-energy-diet) or VLCD (very-low-calorie-diet), of three meal replacements and two cups of vegetables (sometimes an additional protein serve to ensure protein requirements are met if BMI is too high) for 2 weeks. Additional fibre and plenty of water are also advised during this VLED period.
The meal replacement that we often recommend to our patients is Optifast. It is a low carbohydrate, total diet replacement consisting of three Optifast products (meal replacement shakes or bars) that total 600-800 calories per day. Another really good product that we also recommend is Formulite, however any commercially available VLED will be OK as long as it has the protein and nutrients you need.
This diet puts patients into mild ketosis to help them lose weight rapidly, yet safely (on average 1.5 – 2.5kg per week). The low-carb nature is critical to success. Being in Ketosis forces us to burn glycogen and fat, but also suppresses hunger. Most other low energy diets promote hunger which isn’t very tolerated by most of us for more than a day or two.
It is important before you start on any diet to ensure that you have the approval of your doctor or dietitian, to avoid any nutritional deficits and to make sure you are losing weight safely.
Pre-op Diet Troubleshooting.
VLED’s or “diet shakes” are formulated foods. This means they have a number of natural and synthetic ingredients, and not everyone tolerates them or likes the flavours. It’s worthwhile for people to try different varieties before committing to the diet, not just to make the pre-op diet easier but also to make the post-op diet easier as well.
Common issues include
- Lactose intolerance which leads to wind and diarrhea in some people. There are lactose-free variants available (Tony Ferguson and some Vegan Shakes) however Lacteze tablets taken with the VLED will sort out most symptoms.
- Optifast Bars are an alternate for people who want a solid VLED or are lactose intolerant.
- Soy intolerance and artificial sweetener intolerance is an issue for some patients, in which case an individualised pre-op high-protein and low carb diet can be worked out with our dietician.
- Headaches/crankiness/hunger. The most difficult time of the diet is the first 24-48 hours when ketosis is “switching on”. Taking regular Panadol and avoiding stressful work over this time will help.
If you are considering bariatric surgery and would like to know more then contact our practice on (02) 9553 1120 or you can
A counterpoint to the argument for denying effective anti-obesity therapy during a time of medication shortage.
In response to criticism about previous statements that were directly stigmatising of persons with a lived experience of severe obesity, the Therapeutics Goods Association (TGA) and others have appropriately altered their language regarding the use of GLP-1 agonists which have clinical effectiveness for the management of Type II Diabetes as well as clinically significant obesity. They have now asked clinicians prescribing these medications to consider delaying prescription unless other suitable alternatives are not available, rather than seeking to deny patients with severe obesity the opportunity to receive treatment.
While the best of these agents are only approved for use in Australia for the treatment of Type II Diabetes, ample research data and clinical experience are showing excellent results when used for severe obesity, which has subsequently led to widespread “off-label” prescription by Obesity Practitioners in Australia. Some versions of these drugs which are approved as obesity therapies are clinically inferior and more expensive than the newer and potentially scarcer agents.
The widespread success stories of people living with severe obesity who have lost weight with these medications have subsequently been shared on social media support groups set up by patients, which has then led regulatory agencies and the press to be aware of the potential contribution of these prescriptions to medication shortages. Unfortunately, this has potentially trivialised the importance of providing effective anti-obesity therapy to those in need, and it denies the validity of their experiences and health as being important.
While it is obvious that a poorly available therapy should not be used for frivolous purposes, appropriate consideration should be given to the needs of people living with severe obesity before denying them the opportunity to receive appropriate care. Overweight and obesity have skyrocketed in prevalence over the last 40 years and is Australia’s second largest cause of fatal disease and the largest contributor to non-fatal disease.
While substantial increases in the prescription of diabetic and cardiovascular therapies over this time have blunted the effects of obesity on mortality rates, little has been done with regard to managing obesity itself. No one is going to argue about the importance of lifestyle changes in obesity prevention as part of the suite of interventions for those living with obesity-related diseases. However, we have overwhelming evidence that lifestyle change as sole therapy is universally inadequate for those with severe disease, even though its effects in so-called multi-modality or combined therapies are important.
We know enough about obesity to predict, before treatment, the likely outcomes for an individual depending on the treatment prescribed. Patients requiring health improvement and weight stability should therefore be prescribed differing obesity therapies than those presenting with poorly controlled medical conditions, disabilities or diseases likely to become life-threatening soon.
While offering obesity therapies to patients has been made more difficult by the relative scarcity and complexity of treatments until reasonably recently, those treatments that are suitable, successful and cost-effective are rarely offered. The cost of therapy is often cited as a reason, but there appears to be a double standard applied to those seeking or who are eligible for obesity treatment. Therapies for obesity that are known to be more cost-effective than what we currently offer other patients with chronic disease (such as renal failure, osteoarthritis etc) or which are even potentially health-cost neutral, are consistently denied to patients by Federal and State healthcare systems.
Clinically severe obesity is the only major health condition where all healthcare costs are expected to be covered by the person with the disease. Most successful medical therapies for obesity are not approved for use by the TGA and are prescribed “off-label”, and even those that are TGA approved receive no government subsidies, which somewhat negates the point of seeking TGA approval in the first place. Patients presenting for treatment in public hospitals with life-threatening or disabling obesity-related conditions will have their condition treated but are virtually guaranteed to receive no obesity directed care other than documentation of their body mass index (BMI).
It is beyond the scope of this opinion piece to discuss the many complexities of obesity stigma, but for those who are interested, The Obesity Collective provides succinct and easily readable information for the public and lay-press, and the Weight Issues Network, a person-centred support group created by those with a lived experience of obesity, for those with a lived experience of obesity, have created an excellent position statement detailing the experiences of seeking health care when one has obesity. It’s unlikely that anyone reading these documents would come away without increasing their understanding and empathy for those negotiating their lives and the healthcare system with obesity as a front and centre issue.
A more nuanced way of managing the potential conflict between the requirements of those with severe diabetes or obesity is to make decisions based on the clinical needs of the patient. There are multiple drugs known to improve diabetes and prolong survival approved for use in Australia. If a diabetic patient does not require significant weight loss and is being prescribed one of the new GLP-1 agonists that are in short supply, alternatives could be prescribed without sacrificing their care.
Similarly, if a patient is being prescribed a GLP-1 agonist for obesity and is at the weight maintenance part of their therapy, other alternatives are available. Those requiring a lesser degree or slower weight loss have other options as well. This would leave scarce agents available for those patients requiring reliable and consistent weight loss to treat significant illness, and for those diabetics where significant weight loss and lifestyle modification are part of the management of their complicated diabetes associated illnesses.
GLP-1 agonists are part of the first of a suite of anti-obesity medications being released which are effective and well-tolerated when appropriately prescribed. Whether or not these make it into the hands of those in need will depend on our Health system’s re-evaluation of the importance of the needs of those affected by severe obesity, as well as advocacy by patients, clinicians and healthcare institutions.
Dr Talbot is a surgeon working in a multi-disciplinary clinic that provides treatments to patients referred for management of severe obesity. He is a past president of the ANZ Metabolic and Obesity Surgery Society (ANZMOSS) and is on the Board of The Obesity Collective.
The Obesity Collective
The Obesity Collective Australia is a platform for individuals and organisations from across the community to tackle the obesity challenge together. Their collective purpose is “to transform the way society thinks, speaks and acts on obesity”, with a vision to “reduce the impact of obesity in Australia”.
Members come from a range of backgrounds and organisations across Australia, including our own A/Prof Michael Talbot. Here’s a quick video of how Dr Talbot is contributing, or if you want to find out more about other members click here.
Each year World Obesity Day has a theme and this year the theme is ‘Everybody Needs to Act’.
Everybody Needs to Act
The key message for World Obesity Day this year is that obesity is a global problem. That the roots of obesity run deep, and the only way to make progress is by working together to tackle the rising rates of obesity (not just in adults, but children too), reduce the stigma faced by those living with obesity and improve the systems that contribute to obesity around the world. Giving everybody the best chance to live longer, happier, healthier lives.
At Upper GI Surgery our team of bariatric surgeons and practitioners, strongly support World Obesity Day and other initiatives such as WIN (Weight Issues Network), also continuously campaigning for people affected by obesity.
Take Action Today
People living with obesity – call for change
Healthcare professionals – show you care
Employers – end stigma
Policymakers – lead the way
Award-Winning Cause
This year’s World Obesity Day campaign has won the Purpose Award for Best Health Cause Campaign, which is fantastic recognition of the hard work that goes into the campaign each year and the awareness that it is bringing to this increasing issue around people’s health.
Recently, Dr Jennifer Matthei joined Dr Georgia Rigas as a SCOPE Certified bariatric practitioner. The SCOPE Certification is the international standard of obesity management expertise, recognising excellence in obesity. The SCOPE Certification is part of the World Obesity Federation, whose mission is to reduce the global burden of obesity and the understanding of obesity as a multifactorial disease. The WOF is also working hard to combat the stigma associated with obesity.
Who is eligible for the SCOPE Certification? The SCOPE Certification is the only internationally recognised certification in obesity management. If a healthcare professional wishes to become certified, they have to meet the following criteria to
apply:
Evidence of 6 months practical experience related to obesity management within a medical or allied healthcare professional setting.
Completion of the Core Learning Path (4 SCOPE points).
To achieve certification, 12 SCOPE points are required in total. The remaining 8 points can be achieved through e-learning with SCOPE Schools or other SCOPE Accredited courses.
In addition to their busy days as Bariatric Medical Practitioners here at Upper GI Surgery, both Dr Rigas and Dr Matthei have had to complete additional learning and training in their spare time towards achieving this certification.
The certification is renewable annually, by completing two additional SCOPE modules.
Why is this important?
SCOPE certified practitioners have access to an international community of obesity experts and credible and up-to-date obesity education materials developed by leading experts in the field. Obesity and bariatric surgery is a very specialised area of expertise, and at Upper GI Surgery all of our medical team ensure that they are up-to-date with the latest information to use when treating patients.