Bariatric Surgery Deciding if surgery is right for you, as well as choosing which surgical option is best for you is a decision to be made by you and your doctor. Weight-Loss Surgery Treatment Options
Introduction
Weight-loss surgery, also commonly known as bariatric surgery, is a safe and effective treatment option for those affected by morbid obesity. Morbid obesity is defined as having a body mass index (BMI) greater than 40, or weighing more than 100 pounds over ideal body weight. In addition, a patient with a BMI greater than 35 with one or more obesity-related diseases is classified as morbidly obese. There is a great amount of importance and responsibility associated with choosing a weight-loss treatment option. Weight-loss surgery is one of the most commonly chosen and performed treatment options for morbid obesity; however, choosing which surgery is right for you can be a difficult task. This article will provide you with the education needed for you and your physician to make the appropriate treatment selection. Consult your physician and insurance provider to see if you are a candidate. Remember, weight-loss surgery is not the “easy way out.” This treatment option is a tool that you will continually use to lose weight. Surgery is a resource to help you reduce your weight. Behavioral, physical and psychological changes are required for you to maintain a healthy quality of life. Continued positive weight-loss relies upon your desire and dedication to change your lifestyle with a proactive approach. You may see terms, such as “Malabsorptive” and “Open,” that you may not be familiar with. Prior to reading about the different surgeries, we have provided you with a brief description of some of the most commonly used terms. Open vs. Laparoscopic In each section, you will see the surgeries described as being performed “Open” or “Laparoscopic.” Although laparoscopic has increasingly gained in popularity and frequency, “Open” is also still commonly used in practice today. “Open” – The open approach procedure involves a long incision that opens the abdomen, which provides the surgeon access. “Laparoscopic” – In laparoscopic surgery, a small video camera is inserted into the abdomen allowing the surgeon to conduct and view the process on a video monitor. Both camera and surgical instruments are inserted through small incisions made in the abdominal wall. Malabsorptive vs. Restrictive “Malabsorptive” – Malabsorptive procedures alter digestion, thus causing the food to be poorly digested and incompletely absorbed. “Restrictive” – Restrictive procedures decrease food intake by creating a small upper stomach pouch to limit food intake. In addition to these terms, there may be other words, topics or descriptions that you might not understand. If so, make sure to speak with your physician further to gain a better understanding. Weight-Loss Treatment Options Gastric Bypass Roux-en-Y It is unique in that it is the first of the gastric procedures for morbid obesity to combine restriction with malabsorption. Also, there is an element of intolerance for many patients. These three elements are what make the gastric bypass Roux-en-Y so popular and effective in creating a tool for successful, long-term weight-loss, and resolution of the co-morbidities associated with morbid obesity. The gastric bypass Roux-en-Y can be performed by both open and laparoscopic techniques. It has been argued that there are advantages to both approaches, but these advantages seem to be related to the surgeon’s capabilities and skill sets, and not the patient’s recovery, surgical outcomes or resolution of co-morbidities. In the U.S., the laparoscopic technique has become the more popular approach by patients and competent surgeons, as recovery is quicker and post-operative wound healing complications are significantly reduced. The gastric bypass Roux-en-Y surgery itself can be described in three significant steps. Each of these steps can be related directly to either restriction, malabsorption or intolerance.
Often, the first step in the gastric bypass Roux-en-Y is the creation of the pouch. Restriction is produced because of the pouch. Restriction is one of the most significant outcomes of the surgery and is only related to volume of food able to be ingested at one sitting. This is what is achieved after the creation of a small gastric pouch with a small outlet that, with distention from eating food, causes the sensation of fullness. The pouch can be created either horizontally or vertically, and is generally an average of 15 ml (one half of a shot glass) in capacity. This 15 ml is the size of the pouch initially, but because of the nature of stomach tissue, will eventually stretch to approximately the size of a small egg. Also, this is the size of the pouch at rest, which means that it is not the only amount of food that can be eaten at one time. The nature and texture of the food eaten at the time will determine volume of food eaten at each sitting. Although this initial small size of the pouch can create some challenges for the newly recovered gastric bypass patient, it’s creation is necessary in order to avoid a pouch that is later too large, preventing a patient from either reaching goal weight or being able to maintain long-term weight-loss. The next step is the creation of jejunostomy, causing malabsorption. The malabsorptive element is created from the bypassing of the distal stomach, the entire duodenum and a distance of approximately 100 to 150 cm of the jejunum. A connection and opening are also made so that that food can be passed through the intestine and still receive the same digestive enzymes from the pancreas and liver. This connection is called the jejuno-jejunostomy. The malabsorptive element is significant to the bariatric patient, requiring vitamin supplementation; however, this element does not seem to be as significant in regard to long term weight-loss as the element of restriction. The third step in the gastric bypass Roux-en-Y is the creation of the gastro-jejunostomy. During this step, the second part of the small intestine, the jejunum, is connected to the pouch. This connection is called the gastro-jejunostomy, and it is because of this connection between the pouch and the jejunum that a patient can experience intolerance. This intolerance is in relation to certain foods, and is often referred to as “dumping” or “dumping syndrome.” This intolerance is a direct result of the food, usually higher in sugars and starches, entering directly into the jejunum having only mixed with saliva and not stomach acid. The symptoms of dumping syndrome may vary from person to person, but can include the following:
Although dumping syndrome may not seem desirable, it can be. For the gastric bypass patient, it can be a strong motivator to eat healthier, protein-dense foods and to avoid junk food. This has been referred to as “forced behavior modification.” Many patients wonder what happens to their old stomach or if the rest of it was removed. What they are referring to is the distal portion of the stomach, or the part of the stomach tissue that was separated from the tissue used to create the pouch. The “old” or “distal” stomach is not removed, as this would not be in a patient’s best interest. First of all, it is still well connected to other organs in the body, and separating or removing it would provide an added risk. Secondly, although the distal stomach will no longer receive food, it does continue to serve an important function. After gastric bypass, it still continues to receive digestive enzymes from the pancreas and liver, which are very necessary for digestion and absorption of nutrients. These enzymes continue to drain into the distal stomach, and flow through the duodenum, later mixing with food at the point where the food drains from the pouch and flows through the jejunum (jejuno-jejunostomy). Weight-loss Complications Long term complications can include stricture (generally the gastro-jejunostomy), ulcers, staple line disruption and internal hernia. Nutritional complications are few, and can generally be avoided with life-long supplementation of a multivitamin, iron, calcium and B12. Peripheral neuropathy is also a rare complication, and can mostly be avoided with vitamin supplementation and adequate protein intake. Also, ventral hernia rates are significant with open gastric bypass Roux-en-Y, just as for any open abdominal procedure. Conclusion Laparoscopic Adjustable Gastric Banding How It Works Weight-loss and Health Benefit Band patients often see a significant improvement in their weight related medical problems. Most patients will see a reduction in their need for medications to treat diabetes, high blood pressure, and high cholesterol and in fact many will come off of their medicines completely. Many patients will see resolution of their sleep apnea and will no longer have to sleep with a CPAP machine. Most patients also report a significant improvement in the quality of their life, as they are able to do activities they haven’t been able to do for years. Advantages Recovery from surgery is usually quick and most people return to work a week or so after surgery. The risk of death from band surgery is 0.1 percent, although many centers report even lower rates. The adjustability of the band makes it unique among weight-loss operations. This feature makes it possible to make band adjustments based on the individual weight-loss goals and needs of the patient. The stomach and intestines aren’t bypassed, so vitamin, mineral and nutrition problems after banding are unusual, but still possible. Many programs still recommend vitamin supplementation after banding. The adjustable gastric band can be easily removed if necessary. Clearly we are learning more and more about obesity every day and there may come a time when medical management proves to be very effective in controlling weight. Band patients could have their band removed at that point and their gastrointestinal tract returned to normal. Considerations before Choosing A Band After banding, patients need to be available for regular follow-up, especially in the first year after surgery when the band is being “tightened”. If you live several hours from your surgery center this can be difficult. Filling the band involves sticking the patient with a needle, so if you “hate shots,” a band may not be the right choice. Band patients do not suffer adverse effects from eating sugars (dumping syndrome) so they need to be more disciplined in their food choices. Things like sodas, ice cream, cakes and cookies slide through the band easily, but obviously these choices will not lead to the desired goal of significant weight-loss. Although the band has an excellent safety profile, there are complications that can occur with any weight-loss operation, and the band is no different. About 10 percent of patients will require a second operation to address a problem with their band. Conclusion Biliopancreatic Diversion with Duodenal Switch How is the Biliopancreatic Diversion with Duodenal Switch Performed? A portion of the stomach is then left with the pylorus still attached and the duodenum beginning at its end. The duodenum is then divided, allowing for the pancreatic and bile drainage to be bypassed. It is a pyloric saving procedure, which eliminates the “dumping syndrome” that is inherent to gastric bypass. Weight-Loss In all weight-loss surgery options, emphasis is placed on nutritionally beneficial and nutrient dense foods. BPD/DS patients enjoy “normal” sized food portions at meals. The BPD/DS allows patients to increase portion size over time, allowing for greater diversity in food consumption at each meal. Complications There are minimal iron deficiencies and B-12 deficiencies are not created by the Duodenal Switch. Of course, all patients are monitored for iron and B-12 as well as other water soluble vitamin deficiencies. Patients who undergo BPD/DS are able to enjoy nutritional foods and eat more normally without the restriction of a small pouch (one to two ounces) as in a gastric bypass. The BPD/DS is a more invasive operation. According to a recent analysis, BPD/DS carries a mortality rate of 1.1 percent within 30 days after surgery. Conclusion: Patients are always encouraged to maintain the commitment to lifestyle and food changes associated with weight-loss. BPD/DS patients are asked to first increase protein intake; then vegetables; and lastly, if able at all, breads, pastas or rice in very limited amounts. Laparoscopic Sleeve Gastrectomy What is a Laparoscopic Sleeve Gastrectomy? How is the Sleeve Gastrectomy Performed? Weight-Loss Complications This is primarily because the small intestine is not divided and reconnected during LSG as compared to the bypass procedures. This lower risk and shorter operative time is the main reason we use it as a staging procedure for high-risk patients. Complications that can occur after LSG include: a leak from the sleeve which results in an infection or abscess, deep venous thrombosis or pulmonary embolism, narrowing of the sleeve (stricture) requiring endoscopic dilation and bleeding. Major complications requiring re-operation are uncommon after sleeve gastrectomy and occur in less than 5 percent of patients. Conclusion Patients with lower BMIs who undergo LSG will lose a larger proportion of their excess weight (60 – 80 percent) within three years of the surgery. More than 75 percent of patients will have significant improvement or resolution of major obesity-related co-morbidities such as diabetes, hypertension, sleep apnea and hyperlipidemia following sleeve gastrectomy. Note: Individuals affected by morbid obesity rely on their insurance provider to assist them in the process of seeking access to safe and effective medical treatment. Many times they experience difficulty when working with their insurance providers, such as repeated denials of claims. In addition, the process often times seems complicated, and physically and emotionally draining. For more information on working with your insurance provider, please visit the OAC Web site and view the OAC’s Insurance Guide, titled Working with Your Insurance Provider: A Guide to Seeking Weight-loss Surgery. |
