More than every second Swede is nowadays overweight. The most common trick you try to do something about your overweight or obesity is dieting. Dieting regimes all have in common that you eat fewer calories than the body needs -you end up in slight starvation and then lose weight. This works as long as you are still on your diet. The problems come instead when the dieting is finished and you will try to keep this new, lower weight.

The reason why it is now extremely difficult to keep the new lower weight is that the body has begun to defend itself against the weight loss: substances in the body that signal hunger have increased (including the starvation hormone ghrelin). However, substances that will signal saturation when we have eaten (including the hormone leptin) have been decreased. These different hormones control how the brain acts-we eat more, but do not get fed as we should be once we have eaten. Add to this that the body has also reduced its basic metabolism greatly, and you will understand why it is so difficult to keep your body weight down after a diet.

So here is one piece of bad and two pieces of better news; the bad one first-if you have lost weight by dieting seriously once in life, but then regained all the kilos again, then your body’s defense system is activated. Then you should never again try to lose weight-it will just result the same way again.

The first piece of good news is that bariatric surgery (such as gastric bypass or sleeve gastrectomy) works, as the operation neutralizes the body’s weight loss defences. You will thus be much less hungry, even though you are losing weight effectively.

The other piece of good news is that the body’s defense systems against weight loss are purely biological – this has absolutely nothing to do with neither discipline, intelligence, morals nor “bad habits”!

You are therefore completely normal.

A gastric bypass surgery procedure is performed laparoscopically, thus with keyhole surgery. Surgery is done in full anesthesia-you sleep and notice nothing. The operation time with us is on average 35 minutes.

A gastric bypass has basically three different mechanisms:

-the stomach is made much smaller. This leads to the need to change how you eat-you should eat a little but often, chew properly and eat slowly.

-You become much less hungry. This is because the majority of the stomach and the beginning of the small intestine are disconnected. The body’s production of the starvation hormone ghrelin is then reduced greatly.

-the small intestine is partially bypassed. The mechanisms here are more complicated. You get, among other things, increased metabolism in the body, as well as other taste preferences. You will spontaneously want to eat healthier food than before.

Advantages with the operation include it being the most effective procedure and also the most proven one. We therefore have long-term data on the results after the procedure. Potential disadvantage is approximately one percent risk of ileus (bowel obstruction) after surgery. This complication requires a reoperation where the problem is corrected.

Another disadvantage may be that you can become more “punished” (with discomfort, dumping, etc.) if you do not establish good routines with food and drink afterwards.

A sleeve gastrectomy operation is performed laparoscopically, thus with keyhole surgery. Surgery is done in full anesthesia-you sleep and notice nothing. The operation time with us is on average 35 minutes.

A gastric sleeve has basically two different mechanisms:

-the stomach is made much smaller. Most of the stomach is surgically removed, the remaining part gets the shape of a long, narrow tube. The space in this sleeve stomach is limited. This leads to the need to change how you eat-you should eat a little but often, chew properly and eat slowly.

-You become much less hungry. This is because the majority of the stomach is surgically removed. This also removes a large part of the body’s starvation hormone cells – the ghrelin producing cells.

This operation is newer than gastric bypass, it came into use around 2005 and received increasing volumes in Sweden from 2012.

This is a very effective operation. “Everything else equal” is it a little less effective than a gastric bypass. This means that a sleeve gastrectomy often becomes an option at a slightly lower BMI, and if intestinal bypassing (as in the case of a gastric bypass) is less appropriate.

The disadvantage of the gastric sleeve is that we do not have such strong long-term data on the results after the procedure. There is therefore a risk that you can gain some weight back again over a longer period of time. A potential adverse side effect of the sleeve gastrectomy is an increased risk of reflux problems, i.e. heartburn and acid reflux, which may then be handled separately.

An SASI-operation (single anastomosis sleeve ileal bypass) is a kind of hybrid or intermediate between a sleeve gastrectomy and a gastric bypass surgery procedure. The operation is performed laparoscopically, i.e. with keyhole surgery. Surgery is done in full anesthesia-you sleep and notice nothing.

You make a sleeve stomach, and then a limb of small intestine is connected to it. This means that two exit openings from the sleeve stomach are available for the ingested food to pass through: the normal one into the duodenum, and the new one into the connected intestine. About 20% of the food will follow the normal route, the remaining 80% will go via the anastomosis to the connected small intestine.

The method began experimentally, but has now become more widespread in several countries also in clinical practice.

SASI may be suitable for patients suffering from very high BMI, as well as if one has had a sleeve gastrectomy operation already, but begins to lose effect from it (with weight regain).

What is special about this operation, because it is so new (long-term data is missing), is that we want to be able to help you ensure that everything works even in the long term. If we together with you decide on a SASI operation, we would like you to commit yourself to five years follow-up with us afterwards.

The first period after the actual operation is always a little special: you live on Liquid diet first two weeks, then eat puree meals a period after that. You take blood-thinning syringes, start taking vitamins, and more. Here it is important to take one day at a time; some things will be easy to learn, others a little harder.

At Week 5 after surgery you will start to try eating regular foods again, you are back at your job, and now everything will gradually go easier and easier.

The goal is to finally learn five things, and these are then valid life-long:

1-try to eat 5-6 meals every day, evenly distributed over the day.

2-do not drink liquid with the food, only between meals. (At least in everyday situations!).

3-drink fluid properly, between meals. The rule of thumb is 1.5 liters of water per day. This may sound easy, but in the beginning it is a challenge. You can only drink small, small amounts at a time when you are recently operated. Get a water bottle, always have it with you and take advantage of the time you have between meals to drink. This will make it easier for you to keep up adequate fluid intake every day.

4-start with the vitamin supplements Week 3 after surgery. GB Obesitas Skåne recommends primarily Baricol Complete Powder, which you subscribe to yourself through the company Baricol Bariatrics Website. There are also other arrangements for vitamins and we will go through it with you, and make sure you find something that works for you. Then you should take these vitamins every day, life-long -even though you probably feel subjectively great “anyway”. It is important after bariatric surgery to look upon the vitamin supplements as medicines.

5-try doing everyday exercise. Be active in your everyday life! All activity is good. If there is any type of training or exercise you like so go for that, preferably fixed days in the week so that you get a structure going. Please aim “high” with your training -but not higher than you can see in front of you that you continue liking in 1, 2 or 5 years. It is the long-term routine that makes a difference.

These five rules can be a bit hard to learn all at once at the beginning, but it’s a one time effort you put in to do it. Once you start mastering the rules, they will become a routine that works increasingly automatic. Getting to the spot where everything just “cruises on” takes 3-6 months for most people. We will of course help you along the way.