Bariatric Surgery in Women

The American Society for Bariatric Surgery estimates that more than 200,000 bariatric, or weight-loss surgery, procedures were performed in the United States in 2007. The typical bariatric surgery patient is a woman, age 25–45, overweight since childhood, having faced a lifetime of discrimination, with multiple attempts at weight loss via diet and exercise. They average 2 years of research into surgery before making the decision that surgery is the choice for them.

Why would a woman turn to surgery for weight loss? It works when all other therapies fail. Once someone has reached the morbidly obese level, diet and exercise alone is only successful in less than 5 percent of the population. Bariatric surgery has a 50 percent success rate at 16 years after surgery. A meta-analysis presented in 2004 that represented 136 studies and over 22,000 patients demonstrated that after bariatric surgery, 86 percent of diabetes was resolved or improved, 70 percent of hyperlipidemia was improved, 78 percent of hypertension was resolved or improved, 83 percent of obstructive sleep apnea was resolved or improved, and perhaps most impressively, there was a 400-percent reduction in the incidence of cancer. The weight loss achieved and maintained after bariatric surgery results in decreased healthcare costs, decreased rates of disability, and a decreased risk of death.

In 1991, the National Institute of Health released a consensus statement on the state of bariatric surgery. The indications for surgery from the NIH are as follows: BMI >40 or BMI 35–39 with comorbid condition; documented ineffective weight-loss attempts; and treatment with a multidisciplinary team approach. At the time of the statement, gastric restrictive (vertical banded gastroplasty), or bypass procedures, were deemed appropriate for motivated patients. They went on to state that surgery is the only approach providing consistent, permanent weight loss for morbidly obese patients. The NIH is expected to release an updated consensus statement in 2008 which will include laparoscopic adjustable gastric banding.

In 2006, the Centers for Medicare and Medicaid Services released a National Coverage Determination for bariatric surgery. The criteria for surgery listed are as follows: BMI >35 with comorbid condition; documented ineffective weight-loss attempts; treatment at a Center of Excellence (American College of Surgeons level 1A–1B and/or SRC full status designation). Specific procedures covered include: Roux-en-Y gastric bypass, Laproscopic Gastric Bypass, and Laparoscopic Bilopancreatic Diversion w/wo duodenal switch. This excludes vertical banded gastroplasty (VBG). Surgery is for the treatment of comorbidities and medical complications related to obesity, and is not considered cosmetic surgery.

Surgical options include restrictive procedures that limit the size of the stomach without changing the basic anatomy (primarily, this is laparoscopic adjustable gastric banding); malabsorptive procedures that change the basic stomach anatomy and bypass a portion of the small intestines (an example is the [Page 75]biliopancreatic diversion with or without duodenal switch; the most frequently performed procedure in the United States and considered to be the gold-standard procedure is a combination of restrictive and malabsorptive procedures, the gastric bypass (Roux-en-Y) open or laparoscopic.

Women should be advised that with malabsorptive procedures, the absorption, and therefore the effectiveness of oral contraceptives, will be diminished. They will need to either change to another form of contraception or utilize a second form in conjunction with oral contraceptives. As weight loss occurs and the amount of hormones secreted by the peripheral adipose tissue decreases, women who were previously thought to be infertile may now find themselves ovulating regularly and now fertile. It is recommended that pregnancy be avoided for the first 12 to 18 months after any bariatric surgery procedure to allow for optimal weight loss prior to conception and to allow the woman to reach a stage where she can take in a more normal amount of nutrition.

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