The extent of risk from bariatric weight-loss surgery may depend on the skill of the surgeon.
The Complications of Bariatric Weight-Loss Surgery
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Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
After sleeve gastrectomy and Roux-en-Y gastric bypass, the third most common bariatric procedure is a revision to fix a previous bariatric procedure. Up to 25 percent of bariatric patients have to go back into the operating room for problems caused by their first bariatric surgery. And re-operations are riskier, carrying around 10 times the mortality rate, and offer no guarantee of success. Complications include leaks, fistulas, ulcers, strictures, erosions, obstructions, and severe acid reflux.
The extent of risk may depend on the skill of the surgeon. In a study published in the New England Journal of Medicine, bariatric surgeons voluntarily submitted videos of themselves performing surgery to a panel of their peers for evaluation. Technical proficiency varied widely, and was related to the rates of complications, hospital readmissions, re-operations, and death. Patients operated on by the less competent surgeons suffered nearly three times the complications, and five times the risk of death.
As with athletes and musicians, some surgeons may simply be more talented than others, but practice may help make perfect. Gastric bypass is such a complicated procedure that the learning curve may require 500 cases for a surgeon to master the procedure. Complications risk plateaus after about 500 cases, with the lowest risk found among surgeons who’ve performed more than 600 bypasses. The risk of not making it out alive may be double under the knife of those who’ve done less than 75, compared to more than 450. So, if you do choose to undergo the operation, I’d recommend asking your surgeon how many procedures they’ve done, as well as choosing an accredited bariatric “Center of Excellence,” where surgical mortality appears to be two to three times lower than non-accredited institutions.
It’s not always the surgeon’s fault, though. In a report entitled “The Dangers of Broccoli,” a surgeon described a case in which a woman went to an all-you-can-eat buffet three months after a gastric bypass operation. She chose really healthy foods (good for her!). She just evidently forgot to chew. Her staples blew, and she ended up in the ER, and then the OR. They opened her up, and found “full chunks of broccoli, whole lima beans, and other green leafy vegetables” inside her abdominal cavity. A cautionary tale to be sure, but perhaps less about chewing food better after surgery than about chewing better foods before surgery, so you can keep all your internal organs intact in the first place.
Even if the surgical procedure goes perfectly, lifelong nutritional replacement and monitoring are required to avoid vitamin and mineral deficits. This includes more than a little anemia, osteoporosis, or hair loss, but full-blown cases of life-threatening deficiencies, such as beriberi, pellagra, kwashiorkor, and nerve damage that can manifest as vision loss years or even decades after surgery in the case of copper deficiency. Tragically, in cases of severe deficiency of a B vitamin called thiamine, nearly one in three patients progressed to permanent brain damage before the condition was caught.
The malabsorption of nutrients is on purpose for procedures like gastric bypass. By cutting out segments of the intestines, you can successfully impair the absorption of calories, but at the expense of impairing the absorption of necessary nutrition. Even people who just undergo restrictive procedures like stomach stapling can be at risk for life-threatening nutrient deficiencies because of persistent vomiting. Indeed, vomiting is reported by up to 60 percent of patients after bariatric surgery due to “inappropriate” eating behaviors (in other words, trying to eat normally). The vomiting helps with weight loss similar to the way a drug for alcoholics called Antabuse can be used to make them so violently ill after a drink that they eventually learn their lesson.
“Dumping syndrome” can work the same way. A large percentage of gastric bypass patients can suffer from abdominal pain, diarrhea, nausea, bloating, fatigue, or palpitations after eating calorie-rich foods as they bypass your stomach and dump straight into your intestines. As surgeons describe it, this is a feature, not a bug: “Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food.”
Please consider volunteering to help out on the site.
- English WJ, Demaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259-63.
- Pinto-Bastos A, Conceição EM, Machado PPP. Reoperative bariatric surgery: a systematic review of the reasons for surgery, medical and weight loss outcomes, relevant behavioral factors. Obes Surg. 2017;27(10):2707-15.
- Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-56.
- Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434-42.
- Doumouras AG, Saleh F, Anvari S, Gmora S, Anvari M, Hong D. Mastery in bariatric surgery: the long-term surgeon learning curve of Roux-en-Y gastric bypass. Ann Surg. 2018;267(3):489-94.
- Azagury D, Morton JM. Bariatric surgery outcomes in US accredited vs non-accredited centers: a systematic review. J Am Coll Surg. 2016;223(3):469-77.
- Gibbs KE. The dangers of broccoli. Surg Obes Relat Dis. 2010;6(4):439-40.
- Trilk JL, Kennedy AB. Using lifestyle medicine in U.S. health care to treat obesity: too many bariatric surgeries? Curr Sports Med Rep. 2015;14(2):96-9.
- Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S89-96.
- Rapoport Y, Lavin PJ. Nutritional optic neuropathy caused by copper deficiency after bariatric surgery. J Neuroophthalmol. 2016;36(2):178-81.
- Oudman E, Wijnia JW, van Dam M, Biter LU, Postma A. Preventing Wernicke encephalopathy after bariatric surgery. Obes Surg. 2018;28(7):2060-8.
- Bohan PK, Yonge J, Connelly C, Watson JJ, Friedman E, Fielding G. Wernicke encephalopathy after restrictive bariatric surgery. Am Surg. 2016;82(4):E73-5.
- Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional recommendations for adult bariatric surgery patients: clinical practice. Adv Nutr. 2017;8(2):382-94.
- Skinner MD, Lahmek P, Pham H, Aubin H-J. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One. 2014;9(2):e87366.
- Banerjee A, Ding Y, Mikami DJ, Needleman BJ. The role of dumping syndrome in weight loss after gastric bypass surgery. Surg Endosc. 2013;27(5):1573-8.
Video production by Glass Entertainment
Motion graphics by Avo Media
Below is an approximation of this video’s audio content. To see any graphs, charts, graphics, images, and quotes to which Dr. Greger may be referring, watch the above video.
After sleeve gastrectomy and Roux-en-Y gastric bypass, the third most common bariatric procedure is a revision to fix a previous bariatric procedure. Up to 25 percent of bariatric patients have to go back into the operating room for problems caused by their first bariatric surgery. And re-operations are riskier, carrying around 10 times the mortality rate, and offer no guarantee of success. Complications include leaks, fistulas, ulcers, strictures, erosions, obstructions, and severe acid reflux.
The extent of risk may depend on the skill of the surgeon. In a study published in the New England Journal of Medicine, bariatric surgeons voluntarily submitted videos of themselves performing surgery to a panel of their peers for evaluation. Technical proficiency varied widely, and was related to the rates of complications, hospital readmissions, re-operations, and death. Patients operated on by the less competent surgeons suffered nearly three times the complications, and five times the risk of death.
As with athletes and musicians, some surgeons may simply be more talented than others, but practice may help make perfect. Gastric bypass is such a complicated procedure that the learning curve may require 500 cases for a surgeon to master the procedure. Complications risk plateaus after about 500 cases, with the lowest risk found among surgeons who’ve performed more than 600 bypasses. The risk of not making it out alive may be double under the knife of those who’ve done less than 75, compared to more than 450. So, if you do choose to undergo the operation, I’d recommend asking your surgeon how many procedures they’ve done, as well as choosing an accredited bariatric “Center of Excellence,” where surgical mortality appears to be two to three times lower than non-accredited institutions.
It’s not always the surgeon’s fault, though. In a report entitled “The Dangers of Broccoli,” a surgeon described a case in which a woman went to an all-you-can-eat buffet three months after a gastric bypass operation. She chose really healthy foods (good for her!). She just evidently forgot to chew. Her staples blew, and she ended up in the ER, and then the OR. They opened her up, and found “full chunks of broccoli, whole lima beans, and other green leafy vegetables” inside her abdominal cavity. A cautionary tale to be sure, but perhaps less about chewing food better after surgery than about chewing better foods before surgery, so you can keep all your internal organs intact in the first place.
Even if the surgical procedure goes perfectly, lifelong nutritional replacement and monitoring are required to avoid vitamin and mineral deficits. This includes more than a little anemia, osteoporosis, or hair loss, but full-blown cases of life-threatening deficiencies, such as beriberi, pellagra, kwashiorkor, and nerve damage that can manifest as vision loss years or even decades after surgery in the case of copper deficiency. Tragically, in cases of severe deficiency of a B vitamin called thiamine, nearly one in three patients progressed to permanent brain damage before the condition was caught.
The malabsorption of nutrients is on purpose for procedures like gastric bypass. By cutting out segments of the intestines, you can successfully impair the absorption of calories, but at the expense of impairing the absorption of necessary nutrition. Even people who just undergo restrictive procedures like stomach stapling can be at risk for life-threatening nutrient deficiencies because of persistent vomiting. Indeed, vomiting is reported by up to 60 percent of patients after bariatric surgery due to “inappropriate” eating behaviors (in other words, trying to eat normally). The vomiting helps with weight loss similar to the way a drug for alcoholics called Antabuse can be used to make them so violently ill after a drink that they eventually learn their lesson.
“Dumping syndrome” can work the same way. A large percentage of gastric bypass patients can suffer from abdominal pain, diarrhea, nausea, bloating, fatigue, or palpitations after eating calorie-rich foods as they bypass your stomach and dump straight into your intestines. As surgeons describe it, this is a feature, not a bug: “Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food.”
Please consider volunteering to help out on the site.
- English WJ, Demaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259-63.
- Pinto-Bastos A, Conceição EM, Machado PPP. Reoperative bariatric surgery: a systematic review of the reasons for surgery, medical and weight loss outcomes, relevant behavioral factors. Obes Surg. 2017;27(10):2707-15.
- Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet. 2016;387(10031):1947-56.
- Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369(15):1434-42.
- Doumouras AG, Saleh F, Anvari S, Gmora S, Anvari M, Hong D. Mastery in bariatric surgery: the long-term surgeon learning curve of Roux-en-Y gastric bypass. Ann Surg. 2018;267(3):489-94.
- Azagury D, Morton JM. Bariatric surgery outcomes in US accredited vs non-accredited centers: a systematic review. J Am Coll Surg. 2016;223(3):469-77.
- Gibbs KE. The dangers of broccoli. Surg Obes Relat Dis. 2010;6(4):439-40.
- Trilk JL, Kennedy AB. Using lifestyle medicine in U.S. health care to treat obesity: too many bariatric surgeries? Curr Sports Med Rep. 2015;14(2):96-9.
- Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab. 2008;93(11 Suppl 1):S89-96.
- Rapoport Y, Lavin PJ. Nutritional optic neuropathy caused by copper deficiency after bariatric surgery. J Neuroophthalmol. 2016;36(2):178-81.
- Oudman E, Wijnia JW, van Dam M, Biter LU, Postma A. Preventing Wernicke encephalopathy after bariatric surgery. Obes Surg. 2018;28(7):2060-8.
- Bohan PK, Yonge J, Connelly C, Watson JJ, Friedman E, Fielding G. Wernicke encephalopathy after restrictive bariatric surgery. Am Surg. 2016;82(4):E73-5.
- Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional recommendations for adult bariatric surgery patients: clinical practice. Adv Nutr. 2017;8(2):382-94.
- Skinner MD, Lahmek P, Pham H, Aubin H-J. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One. 2014;9(2):e87366.
- Banerjee A, Ding Y, Mikami DJ, Needleman BJ. The role of dumping syndrome in weight loss after gastric bypass surgery. Surg Endosc. 2013;27(5):1573-8.
Video production by Glass Entertainment
Motion graphics by Avo Media
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Title
The Complications of Bariatric Weight-Loss Surgery
LicenseCreative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)
Content URLDoctor's Note
This is the second video in a four-part series on bariatric surgery. If you missed the first one, see The Mortality Rate of Bariatric Weight-Loss Surgery.
Stay tuned for Bariatric Surgery vs. Diet to Reverse Diabetes and How Sustainable Is the Weight Loss After Bariatric Surgery?.
My book How Not to Diet is focused exclusively on sustainable weight loss. Check it out from your library, or pick it up from wherever you get your books. (All proceeds from my books are donated to charity.)
I also have two videos on extreme weight loss interventions: Is Gastric Balloon Surgery Safe and Effective for Weight Loss? and Extreme Weight-Loss Devices.
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