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Weight loss surgery

Initiated by Dr. Praveen Raj

WHAT IS BARATRIC SURGERY?

Bariatric surgery (weight-loss surgery) includes a variety of procedures performed on people who are obese. Weight loss is achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).

Several recent studies reported decrease in mortality and severity of medical conditions after bariatric surgery. In the Swedish prospective matched controlled trial, patients with a body mass index (BMI) of 34 or more for men and 38 or more for women underwent various types of bariatric surgery and were followed for an average of 11 years. Surgery patients had a 23.7% reduction in mortality (5.0% vs. 6.3% control, adjusted hazard ratio 0.71). This means 75 patients must be treated to avoid one death after 11 years (number needed to treat is 77).

The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes. However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities.

But recent studies have shown that the Asian population especially Indians have on average more visceral fat than normal and hence more predisposition to diabetes and other metabolic disorders. Hence at a same BMI, Indians are more prone to development of obesity related T2DM than our western counterparts.

Hence accordingly the Asian specific guidelines for Bariatric surgery was formed in 2005 and is as follows

  • BMI>37 kg/m²
  • BMI>32 kg/m² + DM or any 2 Obesity related comorbidities
  • + unable to lose or maintain weight through conventional means
  • + ages between 18-65 yrs

This criterion has now been accepted as the standard for selection of patients in Asia.

Bariatric surgeries work by two mechanisms. One is restriction i.e. reduced capacity to eat at one particular point of time and 2.Malabsorption .All the procedures combine one or both the mechanisms in a variable manner and accordingly the procedures are classified as follows.

  • PURELY RESTRICTIVE
    • Intragastric balloon
    • Vertical-banded gastroplasty
    • Gastric adjustable banding
    • Sleeve Gastrectomy
    • Gastric plication
  • RESTRICTIVE > MALABSORPTIVE
    • Roux-en-Y gastric bypass
    • Duodeno Jejunal Bypass with Sleeve
  • MALABSORPTIVE > RESTRICTIVE
    • BPD with duodenal switch
  • PURELY MALABSORPTIVE
    • Jejunoilieal bypass
    • Jejunocolonic bypass
    • Duodenojejunal bypass

RESTRICTIVE PROCEDURES

They work by reducing the volume of the stomach hence by the patient achieves satiety much earlier. Vertical banded gastroplasty has been abandoned due to inadequate results and the more accepted procedures have been Lap banding and Sleeve gastrectomy.

In Lap banding the restriction of the stomach is created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation is performed laparoscopically and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today with a mortality rate of 0.05%.

SLEEVE GASTRECTOMY

Sleeve Gsatrectomy

It is one of the most commonly done procedures. It is a surgical weight-loss procedure in which the stomach is reduced to about 25% of its original size, by surgical removal of a large portion of the stomach, following the greater curvature. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

Most patients can expect to lose 70-80% of their excess body weight over a 6–12 month period with the sleeve gastrectomy alone. The timing of the second procedure, if required will vary according to the degree of weight loss, typically 6 – 18 months.

  • Stomach volume is reduced, but it tends to function normally, so most food items can be consumed in small amounts.
  • Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed.
  • Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur anytime stomach surgery takes place).
  • Minimizes the chance of an ulcer occurring.
  • By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.
  • Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).

MALABSORPTIVE PROCEDURES:

These procedure are now abandoned either because they are ineffective (Literature has shown that duodenojejunal bypass alone may not be effective without sleeve) or they cause secondary liver disorders (jejunoileal and jejunocolonic bypass) and have been abandoned.

RESTRICTIVE - MALABSORPTIVE PROCEDURES:

Long term data has shown that this combination of procedures have been most effective in weight loss remission and also in resolution of T2DM, in fact all components of metabolic syndrome. The gold standard has been Roux en Y gastric bypass which has stood the test of time with T2DM resolution of >85% after a mean follow up of 14 years.

The gastric bypass procedure consists of:

Sleeve Gsatrectomy
  • Creation of a small, (15–30 mL/1–2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach (about 400 mL and variable). This restricts the volume of food which can be eaten. The stomach will be totally divided into two parts with staples
  • Re-construction of the GI tract to enable drainage of both segments of the stomach. The particular technique used for this reconstruction produces several variants of the operation, differing in the lengths of small intestine used, the degree to which food absorption is affected, and the likelihood of adverse nutritional effects.
  • Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur anytime stomach surgery takes place).
  • Minimizes the chance of an ulcer occurring.
  • By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.
  • Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).

BILIOPANCREATIC DIVERSION:

Biliopancreatic diversion (BPD) or popularly called the Scopinaro procedure is a quite complex operation. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach. The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.

The results in terms of weight loss and resolution of diabetes has been best compared to all other procedures but with a possible malnutrition rate of 20% especially more common in vegetarians and in those with reduced protein intake and hence not preferred in most centers of Asia.

What you need to know before surgery?

Watch the single incision laparoscopic gastric bypass surgery:
Single incision laparoscopic gastric bypass surgery
© 2017 GEM Obesity & Diabetes Surgery Centre - Updated by GEM Hospital IT Department