All about

Bariatric Surgery
What is bariatric surgery
Bariatric surgery produces significant and sustainable weight loss result
for improving one’s health.
It is not a cosmetic surgery.
This booklet will provide information on the health issues related to
obesity, surgical options for weight loss and the multidisciplinary care
involved in the peri-operative period.

Introduction
Obesity has become a global epidemic, and is on the rise in Singapore.
This is contributed by an increasingly sedentary lifestyle and easy access
to calorie-dense processed foods.
The World Health Organization (WHO) estimates that globally, half a billion
people are obese and at least 2.8 million deaths per year are attributable
to obesity and consequent health issues.
Obesity is a condition where a person has accumulated so much body fat
that it has a negative impact on their health.
This is associated with many major chronic diseases including
cardiovascular disease, Type 2 diabetes and cancer.
Body Mass Index (BMI) is a calculation used to determine a person’s weight
in relation to their height.

Weight (kg)
BMI = Height (m2)

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Definitions
WHO Classification BMI (kg/m2)
Normal 18.5 – 24.9
Overweight 25.0 – 29.9
Obese ≥ 30.0

Health Risk (for Asians)* BMI (kg/m2)

Average 18.5 – 22.9
Moderate 23.0 – 27.4
High ≥ 27.5

* The WHO has revised the BMI risk categories for cardiovascular disease and
diabetes in the Asian population in 2004 due to a higher body fat composition for
a given BMI.
BMI of 23 kg/m2 and 27.5 kg/m2, respectively, have been recommended as the
cut-off points for public health action in Asians.

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Health problems related to obesity

1
1 Neurological
• Headache
• Stroke
• Dementia, including Alzheimer’s
• Vision loss from diabetes complications
• Raised intracranial pressure
• Diabetic neuropathy

4
3
2 Psychological 3 Respiratory
• Depression • Asthma
• Anxiety • Sleep apnea
• Eating disorders • Pulmonary embolism
• Pulmonary hypertension
5

4 Circulatory 6
• High blood pressure • Poor circulation
• High cholesterol • Leg and ankle swelling
• Atherosclerosis • Blood clots
• Irregular heartbeat • Peripheral artery disease
• Heart attack • Lymphoma
• Heart failure (lymph node cancer)
7

5 Gastrointestinal
• Reflux disease • Liver cirrhosis
• Esophageal cancer • Liver cancer
• Colon polyps • Gallstones
• Colon cancer • Gallbladder cancer
• Fatty liver disease

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 6 Reproductive
Women Men
• Irregular menses • Prostate cancer
2 • Infertility • Infertility
• Polycystic ovarian • Erectile dysfunction
syndrome
• Ovarian cancer
• Endometrial cancer
• Cervical cancer
• Breast cancer

4
7 Musculoskeletal
• Arthritis (hips, knees and
ankles)
Nutritional • Lower back pain
• Vitamin D • Vertebral disc disease
and calcium
deficiency Urological
• Other vitamin • Diabetic kidney failure
and mineral • Kidney cancer
6 deficiencies
Pancreas
• Diabetes mellitus
• Pancreatitis
• Pancreatic cancer

Non-medical problems
• Limited social activities and public access
• Limited clothing choices
• Limitations in sexual activity
• Limited employment opportunities
• Increased costs of daily living
• Increased costs of medical treatment
• Lack of insurance coverage or increased in premiums

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Managing obesity
Obesity management is tailored to the BMI of the patient. Non-surgical
measures can be effective for those with a lower BMI, and lower
accompanying health risks.
Non-surgical means of weight loss include:
– Behaviour modification
– Diet modification
– Exercise therapy
– Medications
However, for the morbidly obese, surgery has been shown to be the most
reliable, effective and durable way for patients to lose enough weight to
treat their medical problems.
Dietary compliance, regular exercise and behavioural modifications are
still essential peri-operative strategies to maintaining healthy weight loss
following surgery.

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 Multi-disciplinary approach
At Changi General Hospital (CGH), our multidisciplinary care team will work
with you to achieve healthy weight loss and better health.

Bariatric
Endocrinologist
surgeon

Dietitian Bariatric
nurse

Clinical Medical social

psychologists worker

ENT surgeon/
Sports
respiratory
physician
physician

After bariatric surgery, regular

exercise and a balanced diet are
still the key fundamentals of
ensuring sustainable weight loss.

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Indication for bariatric surgery
According to Ministry of Health’s Clinical Practice Guidelines, bariatric
surgery is recommended for the following patients:
– morbidly obese patients with *BMI > 37.5 kg/m2
– obese patients with *BMI > 32.5 kg/m2 with medical conditions**
or complications as a result of obesity
– failure of significant lifestyle and medical therapy attempts at
weight loss

* As Asians have a higher body fat composition, the BMI action point is 2.5kg/m2 less
than Caucasians.
**Medical conditions include type 2 diabetes, high blood pressure, high cholesterol,
obstructive sleep apnea, musculoskeletal problems etc.

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Benefits of bariatric surgery
Durable weight reduction
Studies have found that bariatric surgery consistently
results in greater and longer lasting weight loss
compared to exercising, dieting and taking medications
only. These results are more pronounced in obese
patients with higher BMI.
Most studies demonstrate that more than 90% of severely obese patients
are successful in maintaining 30% of total weight loss following bariatric
surgery.

Reduction in mortality (death) due to obesity related medical conditions

Several large population studies have found that severely obese individuals
who have had bariatric surgery are at 30% lower risk of death by obesity
related conditions, than those who did not undergo the surgery.

Improvement and cure of obesity related medical conditions

Weight loss and hormonal changes can result in improvement or even
remission of type 2 diabetes, high blood pressure, obstructive sleep apnea
(OSA), high cholesterol, musculoskeletal problems and more.
Based on recent studies, bariatric surgery is recommended as the treatment
of choice for patients suffering from severe obesity and poorly controlled
type 2 diabetes.

Improvement in quality of life

The weight loss and improvement in medical conditions
brought about by bariatric surgery can enhance quality
of life and psychological well-being, by increased
mobility, self-esteem, ability to work, and social
interactions.

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Types of surgery
Surgery will be tailored to the needs, expectations and medical conditions
of every individual patient.
These procedures are performed via laparoscopy (“key-hole”) under
general anaesthesia.
This offers smaller scars, faster recovery, less pain and better cosmetic
outcome compared to conventional surgery methods.
The two common procedures performed in CGH are the ‘sleeve gastrectomy’
and the ‘gastric bypass’.

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 Sleeve Gastrectomy Gastric Bypass
Laparoscopic Laparoscopic
Surgical approach
(“key-hole”) (“key-hole”)
Operation duration 2 - 3 hours 3 - 4 hours
Hospital stay 3 - 4 days 3 - 4 days
Estimated total
25 - 30%* 30 - 35%*
weight loss
Resolution of diabetes 40 - 50%* 60 - 70% *
Heartburn/reflux Anastomotic stricture
Sleeve stricture Anastomotic leak
Significant Staple line leak Intestinal obstruction
complications Bleeding Bleeding
Nutritional/vitamin Nutritional/vitamin
deficiencies deficiencies
Re-operation rates 0.4 - 0.6% 2 - 2.5%
Post-surgery 30 days
2 in 1000 patients 5 in 1000 patients
mortality (death) rate

*Weight loss and resolution of diabetes outcomes are obtained from the data of
international studies and guidelines. Results may vary between patients. Extent of
weight loss and diabetes resolution is also closely linked to compliance with post-
surgery dietary, lifestyle modifications and exercise.

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Laparoscopic sleeve gastrectomy
The stomach is stapled and excised along its outer edge, leaving a narrow
tube-like (“sleeve”) remnant. This reduces the size of the stomach and
controls the amount of food the patient can consume.
The reduction in food (as well as calorie) intake results in weight loss.
This surgery involves removing part of the stomach (the fundus) that
produces an appetite-stimulating hormone, ghrelin. In addition to the
restriction of the narrow sleeve, this helps patients to reduce their calorie
intake.
Sleeve gastrectomy also results in more rapid emptying of food from the
stomach. This leads to changes in intestinal hormones, resulting in weight
loss and improved diabetes control.

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 Before surgery

After surgery

2
1

1 Gastric sleeve (new

narrow stomach)
2 Portion of stomach
removed

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Laparoscopic gastric bypass
In this procedure, the size of the stomach is reduced by trimming it into a
small pouch. This reduces the size of the functional stomach and restricts
the amount of food patients can consume. The small bowel will also be
“rewired” and connected to the stomach pouch.
This procedure may result in greater long-term weight loss compared
to the laparoscopic sleeve gastrectomy. Due to the changes in intestinal
hormones from rewiring of the small bowel to the stomach pouch,
there is better blood sugar control and decreased reliance on diabetic
medications. This operation is also suitable for patients with gastric reflux
disease.
As this is a more complicated procedure, risks are slightly higher than that
of laparoscopic sleeve gastrectomy.

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Before surgery

After surgery

1 2
1 Gastric pouch
2 Portion of
stomach and
duodenum
bypassed
3 Small bowel
joined to allow
mixing of food
and digestive
3 juice

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Peri-operative care
A general timeline of the surgical journey is shown below. You are expected to be
placed under observation for 3 to 4 days after surgery.

1 First clinic visit

• Counselling and assessment
2 Day of surgery
3 4 to 6 weeks before surgery
• Anaesthetist assessment (PAAC)
• Bariatric nurse
• Dietitian
• Otolaryngologist (ENT- ear, nose and throat)
• Endoscopic evaluation (OGD)
• Endocrinologist (if required)
• Psychologist (if required)
• Social worker (if required)
4 1 to 2 weeks before surgery
• Start continuous positive airway pressure (CPAP)
• Start very low calorie diet (VLCD) meal replacement
5 Day of surgery
• Admission and surgery
• Have sips of water
• Sit out of bed
6 Day 1 post-surgery
• 500mL of clear liquids
• Walking physiotherapy
7 Day 2 post-surgery
• Liquids as tolerated
• Continue walking physiotherapy

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8 Day 3 - 4 post-surgery
• Liquids as tolerated
• Discharge when able to tolerate > 1.5L a day
9 Discharge from hospital
10 2 weeks post-surgery
• Clinic review
• Dietitian review for diet progression (blended diet)
• Resume normal daily living activities/work
• Bariatric lesson
11 4 weeks post-surgery
• Clinic review
• Dietitian review for diet progression (soft diet)
• Start simple exercises e.g. brisk walking
• Endocrine review (if needed)
12 6 weeks post-surgery
• Dietitian review for diet progression (normal diet)
• Engage in moderate intensity exercises
• Endocrine review (if needed)
13 3 months post-surgery
• Clinic review with blood tests
• Engage in moderate to high intensity exercises
• Endocrine review (if needed)
14 6 and 12 months post-surgery
• Clinic review with blood tests
• Engage in moderate to high intensity exercises
• Endocrine review (if needed)

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Post-operative care
After bariatric surgery, you will need to make some changes to your lifestyle:
Take only ½ to 1 cup of food per meal.
Take nutritious food as advised by dietitians.
Chew every mouthful of food slowly and carefully.
Strongly encourage you not to take any water while
eating.
Drink water about 30 minutes before or 45 minutes after meals.
Take small sips of water regularly throughout the day to reach
1 - 1.5L of fluid per day.
Take lifelong multivitamins and supplements.
Exercise regularly for 3 times per week for 30 minutes
each time, to facilitate and maintain weight loss while
maintaining muscle mass.
Go for follow-up clinic reviews with blood tests.
These changes will prevent weight regain and avoid nutritional complications
after bariatric surgery.

Summary
Obesity is a serious medical condition with increasing rates, on a global
scale.
Many medical and psychosocial problems resulting from obesity cause
higher mortality and poorer quality of life for patients.
Bariatric surgery, together with healthy eating and increased physical
activity, is the most effective treatment for severe obesity.
A multidisciplinary team approach helps to tailor the pre and postoperative
care for patients undergoing bariatric surgery.
Changes in dietary habits, physical activity levels and lifestyle helps to
prevents weight regain after bariatric surgery.

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For enquires
Email [email protected]
Online resources
– American Society for Metabolic and Bariatric Surgery
https://asmbs.org/patients
– http://www.obesitycoverage.com
– Health Promotion Board website page on weight management
http://www.hpb.gov.sg/HOPPortal/healthtopic/Weight%20Management

For consultation appointment

Obtain referral from outpatient services e.g. government polyclinics
(for subsidised patient)
Please call CGH appointment centre hotline at 6850 3333 to make an
appointment under obesity surgery (for private patients)

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 2 Simei Street 3 Singapore 529889
Tel: 6788 8833 Fax: 6788 0933
Reg No 198904226R

CGH Appointment Centre

For appointments and enquiries,
please call: (65) 6850 3333
Operating hours:
8.30 am to 8.00 pm (Monday to Friday)
8.30 am to 12.30 pm (Saturday & Sunday)
Closed on Public Holidays

For more information, please visit www.cgh.com.sg

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Changi General Hospital

All information is valid at the time of printing (January 2019)

and subject to revision without prior notice.