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Surgery for Weight Loss

Updated on July 20, 2013

Obesity

According to the CDC (Center for Disease Control and Prevention) more than a third (35.7%) of United States adults were found to be obese in an examination survey conducted in 2010. Obesity increases the risk for cardiovascular illness, endocrine diseases such as diabetes, and even to certain types of cancer and is the second leading cause of death in the United States alone.

The National Institute of Health has issued guidelines on the identification, evaluation, and treatment of obesity in adults. These guidelines suggest dietary changes with lower calorie or lower fat diets, increasing physical activity, behavioral therapy, pharmacotherapy, surgery, or combination of these techniques.

Bariatric Surgery Indications

1. Severe Obesity BMI ≥ 40 or

2. BMI ≥ 35 with comorbid conditions

3. Failed pharmacological therapy with complications of morbid obesity

Bariatric Surgery

Bariatric surgery or surgery for the obese refers to surgical procedures to the gastrointestinal tract (usually to the stomach) that aim in achieving a post-operative weight loss. The term bariatric is derived from the Greek word baros that means weight. Not everyone though that is overweight is eligible for bariatric surgery.

Eligibility for surgery is determined only by the health care provider taking into account the patient’s Body Mass Index (weight (kg) /height2 (m)), comorbidities such as Diabetes, but also a psychiatric evaluation of the patients is conducted in order to determine post-operative success.

Bariatric Surgery categories

Restrictive Procedures

Sleeve gastrectomy

Adjustable gastric band

Intra gastric balloon

Vertical banded gastroplasty

Gastric plastation

Malabsorptive Procedures

Biliopancreatic diversion

Jejunoileal Bypass

Endoluminal Sleeve

Mixed Procedures

Gastric Bypass surgery

Sleeve Gastrectomy and Duodenal Switch

Obesity Procedures

According to the National Health Service (NHS) in the United Kingdom bariatric surgery procedures have increased during the past couple of years from around 470 in 2003/04 to over 6,500 in 2009/10.

There are a large number of procedures to the gastrointestinal tract that lead to post-operative weight loss. Bariatric procedures are performed predominantly laparoscopically (small incisions for the insertion of laparoscope –sort of camera and instruments) rather than open due to the fewer complications of laparoscopy.

Bariatric procedures are divided into three major categories:

  1. Restrictive procedures: the stomach size is restricted or made smaller so that less food can be consumed.
  2. Malabsorptive procedures: bypass surgeries that bypass part of the gastrointestinal tract so less food is absorbed.
  3. Mixed procedure: both restrictive and malapsoptive

Adjustable Gastric Banding

Source

Sleeve Gastrectomy (with Duodenal Switch)

Source

Roux-en-Y Gastric Bypass

Source

Common Bariatric Procedures

Discussed in more detail will be 2 restrictive procedures (adjustable gastric banding and sleeve gastrectomy) and one mixed procedure (gastric bypass surgery) since according to the National Obesity Observatory (NOO) in the UK these three procedures are the most common bariatric procedures in the UK.

Restrictive Procedures

1. Adjustable Gastric Banding

The stomach size is reduced by placing a silicone band around the upper stomach that can be adjusted by inserting saline through a port under the skin to ‘squeeze’ or ‘un squeeze’ the stomach. A small pouch is created and a narrow outlet so food uptake is restricted. If the method does not work the band can be removed. It is considered the safest procedure.

2. Sleeve Gastrectomy

The stomach size is reduced by surgically removal to around 75% and therefore the process cannot be reversed. The stomach is not only reduced in size but also the part that is removed is responsible for the production of a hormone that regulates appetite. This procedure offers many advantages in comparison to malapsorptive procesures since less ulcers occur, less dumping syndrome, and anemia, protein and vitamin deficiency, and gastrointestinal obstruction are reduced.

3. Alternative Restrictive Procedure

A relatively new bariatric procedure (that is not yet FDA approved) is that intragastric balloon that is less invasive than surgery because it is placed endoscopicaly (by gastroscopy) and is considered as a weight loss possibility before elective surgery.

Mixed Procedures

1. Laparoscopic or Open Roux-en-Y Gastric Bypass Procedure

In 2005 this procedure was the most commonly performed procedure in the United States. It involves attaching the small intestine to the upper part of the stomach by forming a small pouch and the end of the stomach with another part of small intestine so a Y is formed. This procedure therefore bypasses most of the stomach and has the disadvantage of malabsorption since a Vitamin B12 deficiency leading to anemia may arise as well as other vitamin or nutrient deficiencies.

Bariatric Surgery Complications

The National Institute of Health reports effective weight loss after surgery for well informed and motivated patients with BMIs≥ 40 and ≥35 with comorbid conditions. The National Obesity Observatory reports effective long term weight loss after bariatric surgery with improvements in co-morbidities such as Diabetes and hypertension. So if bariatric surgery reduces both long-term mortality and morbidities why is it not available as an option to all obese patients?

Obese patients are considered high risk patients since they often suffer from serious comorbidities such as cardiovascular diseases such as hypertension or coronary heart disease, diabetes or metabolic syndrome. These patients are therefore at a higher risk for intra and post-operative complications.

Complications may include anesthesia complications since obese patients have a greater chance of aspiration of stomach content, are more difficult to ventilate and have a greater chance of failed intubation. Surgical complications include bleeding, gastrointestinal leaks and conversion of a laparoscopic procedure to an open procedure.

Post-operatively obese patients are at more susceptible to infections and at a greater risk for pulmonary embolism.

Long term complications may include bowel obstruction, gallstones, ulcer, stricture, protein and vitamin deficiencies, kidney problems and depression. It must also be stressed that the risk of death is higher for these patients mainly due to comorbidities.

The information provided in this article is intended for informational purposes only and is not advise also provided without any representations and no warranties whatsoever. The provided information should never substitute the consultation, opinion , diagnosis, and treatment options provided by a professional healthcare provider.

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