19 Reasons NOT to Have Bariatric Surgery

Reasons not to have bariatric surgery can range from as simple as a person not fulfilling the criteria or indication to have surgery to complicated medical conditions that can lead to serious post-operative issues or the death of the patient.

As the saying goes:

” A good surgeon knows HOW to operate but the best surgeon knows WHEN NOT to operate”

It is important to evaluate the person who wishes to undergo surgery thoroughly so as to minimize post-surgery complications and achieve the best results.

Before a surgeon decides which procedure is the best for his patient, he must first look into any reasons not to have bariatric surgery.

Next, the surgeon must look into any reasons not to have a specific type of bariatric surgery, especially if the patient insists on or wishes to undergo it.

This happens most of the time, especially when people see their friends and relatives undergoing a specific type of surgery with unbelievable results.

The patient then insists to have the same procedure as his friend or relative which might not be suitable for him/ her.

General Reasons NOT to Have Bariatric Surgery:

• You do not fulfill the criteria of class II or III obesity:

It is generally recommended that a person who falls into the criteria of class III obesity or class II obesity but has one or more obesity-related complications is a candidate for bariatric surgery [Ref].

If you are overweight with a BMI of > 25 to 30 kg/m² or have class I obesity with a BMI > 30 to 35 kg/m², you are NOT a candidate for bariatric surgery.

This is one simple and basic reason not to have bariatric surgery.

• Heart failure or advanced lung disease:

Both medical conditions increase the risk of intraoperative complications. As the patient may not tolerate general anesthesia.

Either the patient may have a cardiac event during surgery or may not recover from prolonged anesthesia.

Even if you lose weight with bariatric surgery, your medical condition may not allow you to recover or mobilize.

Going through a surgical procedure, hospitalization, and the risk of complications without expecting any improvement in the quality of life is a logical reason not to have bariatric surgery.

However, the criteria by which a person is denied bariatric surgery are not defined and people may take risks if they think that losing weight may benefit them.

In one study, bariatric surgery in patients who had heart disease or heart failure at baseline reduced the risk of hospitalization due to heart failure, stroke, heart attack, or death by 42% [Ref]

Furthermore, morbid obesity is one contraindication of OHT (orthotopic heart transplantation). A study was conducted on patients with advanced heart failure who were candidates for OHT but because of morbid obesity, were denied a heart transplant.

Of patients who underwent bariatric surgery, 42% achieved the target BMI of <35 kg/m², and 12% underwent OHT [Ref].

• Chronic pancreatitis and pancreatic exocrine insufficiency:

Pancreatic exocrine insufficiency refers to the insufficient release of pancreatic digestive enzymes and bicarbonate to meet the body’s demands.

Most bariatric surgeries result in pancreatic exocrine insufficiency. It is seen more commonly in surgeries involving bypasses of the GI tract.

This is because of reduced stimulation and a reduced amount of hormones entering the gut. In the case of chronic pancreatitis, the pancreas is already weekend.

Bariatric surgery will worsen the exocrine insufficiency of the already compromised pancreas.

Chronic pancreatitis is a reason not to have bariatric surgery as it may worsen your symptoms.

• Psychiatric instability:

Post-bariatric surgery patients had attempted suicide. This was seen especially in patients who didn’t have a psychiatric evaluation before undergoing bariatric surgery.

The risk of suicide is generally < 3% of all patients undergoing bariatric surgery. In one study, patients had a 50% increased risk of death from accidents and suicide.

However, the overall mortality rate was reduced by 40% in the bariatric surgery group vs the control group [Ref].

This included:

• 56% reduction in the rates of deaths due to cardiovascular diseases
• 92% reduction in deaths due to diabetes, and
• 60% reduction in deaths due to cancer.

The risk of suicide is greater in patients who have:

• a mood disorder such as major depression
• a psychotic disorder such as schizophrenia, and
• a personality disorder

A psychiatric evaluation is essential before a person is undergoing any kind of bariatric surgery.

• No attempts to reduce weight through lifestyle intervention:

Before you choose surgery, you must try losing weight by changing your diet and start exercising.

Losing weight with a low-calorie diet and exercise leads to healthy weight loss. On the contrary, weight loss pills and surgeries are not without complications.

Lastly, even if you undergo bariatric surgery but are not compliant with a healthy diet and exercise, you may not get the desired results.

If you fail to lose weight with diet and exercise, bariatric surgery is the option. This will not only show motivation but also show that non-invasive techniques will unlikely result in weight loss.

• Poorly Motivated patients:

Proper motivation is an essential part of bariatric surgery.  If the patient is not properly motivated and continues to consume high-calorie foods, this will once again lead to weight regain in the postoperative period.

The whole exercise and resources will go to waste. Plus, you may lose weight but the stress associated with weight loss may be difficult to handle if you are not motivated.

• Medical conditions as reasons for not having bariatric surgery:

Advanced medical conditions such as end-stage renal disease, liver disease, cardiopulmonary disease, stroke, and cancers that are associated with a significant reduction in life expectancy are important reasons not to have bariatric surgery.

Such patients may add more complications to their preexisting medical conditions. Furthermore, they may lose weight but may not mobilize or achieve what they desire after bariatric surgery.

• Affordability and Lack of Insurance:

As it is a known fact that all kinds of bariatric surgeries are costly and some insurance companies do not include these surgeries in their list.

Before undergoing bariatric surgery it is advisable to ask your insurance company. If you don’t want to proceed with insurance then on your first consultations do confirm the total approximate cost of surgery including the number of days in the hospital.

In addition, choose a surgery that you can afford. It is better to be fat and rich than slim and broke!

• Alcoholism and substance abuse:

Alcohol use disorder is a condition when a person drinks alcohol in amounts that he/ she develops social, psychological, and physical side effects. In addition, the person can not limit his/ her alcohol intake despite the fact that it is endangering his health.

A person who abuses recreational drugs or takes excessive alcohol and abuses it is not a candidate for bariatric surgery.

Reasons not to Have a Specific Type of Bariatric Surgery

Each bariatric surgical procedure has specific contraindications. If a person is a candidate for a bariatric surgical procedure and has no contraindications, the next step is to choose which weight loss procedure is best for them.

However, each weight loss intervention has some specific contraindications which are mentioned here.

Reasons not to Opt for Intra Gastric Balloon

• Prior gastric surgeries

Prior gastric surgery is a contraindication for intragastric balloon placement. Because scarring in the stomach wall may lead to gastric perforation.

This system acts as a space-occupying lesion. Over-distension in a previously significant stomach may lead to rupture leading to catastrophic complications.

• Esophageal stricture

Intragastric balloon systems mostly are placed with the help of an endoscope. So in the case of stricture in the esophagus placing this system is difficult.

It may lead to the perforation of the esophagus. That is  why these are not to be placed in case of oesophageal stricture

• Pregnancy or planning to conceive in 6 months

Pregnancy is another contraindication intragastric balloon system because these are inflatable space-occupying systems. They will not allow full distension of the abdomen in late pregnancy.

• Severe liver disease

In cases of severe liver disease, esophageal and gastric varices are formed because of portal hypertension.

The presence of an intragastric balloon system can lead to erosion of these varices leading to massive upper gastrointestinal bleeding.

• Lesion leading to upper Gi bleeding

The presence of a previous ulcer or any other intragastric vascular malformation is a risk factor for bleeding. This is because of the risk of erosion by the presence of long-standing foreign bodies.

Reasons not to Opt for Laparoscopic adjustable gastric banding:

• Esophageal motility disorder

As gastric banding is associated with the development of achalasia of the esophagus.

If the patient is already suffering from motility disorder then there is a high chance of developing esophageal achalasia.

Which may lead to the bursting of the esophagus and the development of fatal mediastinitis.

• Patient with inflammatory bowel disease

Any patient that has inflammatory diseases or bowel is at risk of developing intragastric complications.

This happens because bands are stitched to the stomach wall which can worsen the reaction.

• Patients with severe liver diseases

In the case of severe liver disease patients develop lower oesophageal and gastric varices. As this banding system creates a small pouch for food in the upper stomach.

This will also lead to increased pressure leading to an increased risk of bleeding from the varices.

• Pregnancy

Whenever laparoscopy is done abdomen is insufflated with carbon dioxide. This leads to increased intra-abdominal pressure.

Because of this, the patient can have a miscarriage or other complications related to pregnancy. These kinds of complications are common, especially in late pregnancies.

• Previous trauma or gastric surgery in the upper part of the stomach

Previous surgery or trauma to the upper part of the stomach will have scarring. This scar tissue has a weak tensile strength.

If the band is stitched in this can lead to disruption of the anchoring suture.

• Minors (Ages younger than 18 years):

Patients of age below 18 are in the growing stage. Like other organs are under development same goes for the stomach.

When the band is applied to the upper part of the stomach. This may lead to the migration of the band from the normal site where it has to be.

• Chronic or long-term steroid use:

Steroid use is associated with stomach ulcer formation. If the patient is already on steroids and placement of an adjustable band can lead to erosion of the stomach wall and aggravation of ulcers.

• Pre-existing infection:

Preexisting infection can lead to contamination during surgery which may lead to the development of an intra-abdominal abscess.

• History of autoimmune disease:

Not all autoimmune conditions are contraindications for bariatric surgery. However, autoimmune conditions that involve the gastrointestinal tract such as scleroderma and polymyositis are associated with significant esophageal motility disorders and gastric ulcers.

Patients with these conditions should not opt for bariatric surgery. In addition, patients with other autoimmune conditions in which high doses of steroids are used are not good candidates for bariatric surgery.

Reasons not to have Laparoscopic Sleeve Gastrectomy (Gastric Sleeve Surgery):

Most reasons are the same as an intragastric balloon (see above).

Barret’s esophagus:

This is the condition diagnosed with upper GI endoscopy. This results in chronic exposure of the esophageal lumen to gastric acids that leads to the transformation of epithelium.

This is also a risk factor for developing malignancy. As GERD worsens after this procedure that is why this procedure shall be avoided in such cases.

Reasons not to have Laparoscopic Roux En Y Gastric Bypass:

Most of the reasons for not having Roux En Y gastric bypass are the same same as the rest of the bariatric procedures. There are a few conditions in which this procedure shall be avoided or at least delayed if it is corrected.

• Iron deficiency and other mineral deficiency

As in this procedure, most small gut responsible for the digestion and assimilation of iron is bypassed.

Patients already having iron deficiency will lead to a worsening of their medical condition.  That is why this procedure shall be avoided or corrected.

• Vitamins deficiency

Vitamins especially Vitamin B12 are processed in part of the stock that is bypassed. this bypass will lead to the development or worsening of deficiency.

• Medications:

Most of the medications that are used in the treatment of lifelong disorders like heart failure are absorbed in the small gut.

When this part of the gut is passed it will lead to worsening of medical conditions. That is why in such cases this kind of is to be avoided.

Reasons not to have laparoscopic bilo pancreatic diversion and laparoscopic duodenal switch:

As both procedures are almost the same except length of the common limb of the small gut. Both procedures’ operative time is extensive. It already puts patients at high risk for complications and intraoperative mortality and morbidity.

Most of the reasons are the same as Roux En Y  gastric bypass.

These procedures shall be avoided in patients who have a history of prior abdominal surgery, especially open surgery.

This is because of the risk of adhesion. This may complicate surgery and the risk of post-op obstruction in such patients is high.

• Protein malnutrition:

This is one of the major complications of both procedures. the patient shall be assessed for protein malnutrition. If already present this surgery shall be avoided before correction.

Protein malnutrition not only delays or impair wound healing but also affects the rest of the systems.