TORG-MAG Vol 1 Issue 1, PP. 21-24
By Olasunkanmi Idris Olalekan (Member, TORG Education & Training Committee)

Recently, Metabolic and bariatric surgery are performed with small incisions using minimally invasive surgical techniques such as laparoscopic and robotic surgery. These advancements allow patients to have a better overall experience with less pain, fewer complications, shorter hospital stays and a faster recovery. These operations are extremely safe, with complication rates that are lower than common operations such as gallbladder removal, hysterectomy, and hip replacement.

The goal of these operations is to modify the stomach and intestines to treat obesity and related diseases. The operations make the stomach smaller and also bypass a portion of the intestine. This results in less food intake and changes how the body absorbs food for energy resulting in decreased hunger and increased fullness. These procedures improve the body’s ability to achieve a healthy weight.

Early interventions for managing excess weight may include diets, structured exercise programs, and intensive behavioral therapies to target and change unhealthy eating habits. It is when these non-surgical strategies are not effective that bariatric surgery may be considered. People that will benefits from the surgery are body mass index (BMI) greater than or equal to 40, more than 100 pounds overweight and a BMI of 35 or more with complications of obesity. Bariatric surgery achieves weight loss through restriction and malabsorption mechanisms.

Restriction: Surgery physically reduce the amount of food the stomach can hold, which in turn restricts the number of calories a person can eat.

Malabsorption: Surgery shortens or bypasses part of the small intestine, reducing the absorption of calories and nutrients by the body.

Purpose of Bariatric Surgery

Bariatric surgery is intended to reduce the number of calories absorbed by the body to promote weight loss and reverse/prevent high blood cholesterol and improve type 2 diabetes. RYGB can improve diabetes within days, even before weight loss occurs. Some patients with type 2 diabetes, especially those with diabetes for a short time, can have a reduction in glucose which allows reduction or elimination in diabetes medication use. It helps to bring blood fat levels back to normal—lowering LDL (bad) cholesterol and triglycerides, and raising HDL (good) cholesterol. It improves fertility in women who are obese, especially women with polycystic ovary syndrome (PCOS). PCOS is a common condition in women of reproductive age. It can result in diabetes, high blood pressure, and unhealthy blood fat levels. It increases testosterone levels in men who are very obese and also improves or eliminates high blood pressure. Some studies show that individuals who decide to have bariatric surgery have a reduction in cardiovascular disease, such as heart attack and stroke, and improvements in fatty liver disease.

Types of Weight Loss Surgery

Gastric balloon: This involves the insertion of a deflated balloon through the mouth and into the stomach using a flexible scope called gastroscope. Once positioned, the balloon is inflated with product specification solution to reduce the space within the stomach and this can remain in the stomach for last up to six months. There are currently 2 types of gastric balloons available the single balloon and dual-balloon. Also types of gastric balloons product but the most common ones are Orbera, ReShape, Obalon and Spatz.

Adjustable gastric banding (lap band): It involves the placement of a permanent silicone band around the stomach. The band reduces the size of the stomach without cutting away any portion of it. This procedure is usually performed laparoscopically. A small port is placed directly underneath the skin so the band can be adjusted.

Advantages

1. Lowest rate of complications early after surgery.
2. No division of the stomach or intestines.
3. Patients can go home on the day of surgery.
4. The band can be removed if needed.
5. Has the lowest risk for vitamin and mineral deficiencies.

Disadvantages

1. The band may need several adjustments and monthly office visits during the first year.
2. Slower and less weight loss than with other surgical procedures.
3. There is a risk of band movement (slippage) or damage to the stomach over time (erosion).
4. Requires a foreign implant to remain in the body
5. Has a high rate of re-operation.
6. Can result in swallowing problems and enlargement of the esophagus.

Sleeve Gastrectomy

The Laparoscopic Sleeve Gastrectomy, often called the “sleeve”, is performed by removing approximately 80% of the stomach. The remaining stomach is the size and shape of a banana. The part of the stomach is separated and removed from the body. This smaller stomach cannot hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen desire to eat. However, sleeve gastrectomy does not affect the absorption of calories and nutrients in the intestines.

Advantages

• Technically simple and shorter surgery time.
• Can be performed in certain patients with high risk medical conditions.
• May be performed as the first step for patients with severe obesity.
• May be used as a bridge to gastric bypass or SADI-S procedures.
• Effective weight loss and improvement of obesity related conditions.

Disadvantages

• Non-reversible procedure.
• May worsen or cause new onset reflux and heart burn.
• Less impact on metabolism compared to bypass procedures

Gastric Bypass

It is the detachment of the opening of the small intestine from the lower part of the stomach and its reattachment to the upper part of the stomach. This decreases the amount of food the stomach can hold, and more importantly, decreases the time that the food spends in the small intestine, limiting how much is absorbed. The most common gastric bypass procedure, called the Roux-en-Y bypass, is typically performed laparoscopically and involves the cutting away of a portion of the stomach in addition to the bypass.

Advantages

• Reliable and long-lasting weight loss
• Effective for remission of obesity-associated conditions
• Refined and standardized technique

Disadvantages

• Technically more complex when compared to sleeve gastrectomy or gastric band.
• More vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding.
• There is a risk for small bowel complications and obstruction.
• There is a risk of developing ulcers, especially with NSAID or tobacco use.
• May cause “dumping syndrome”, a feeling of sickness after eating or drinking, especially sweets.

Duodenal Switch

The Biliopancreatic Diversion with Duodenal Switch, abbreviated BPD-DS, begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. It resembles the gastric bypass, where more of the small intestine is not used. The food stream bypasses roughly 75% of the small intestine, the most of any commonly performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients.

Advantages

• Among the best results for improving obesity.
• Affects bowel hormones to cause less hunger and more fullness after eating.
• It is the most effective procedure for treatment of type 2 diabetes.

Disadvantages

• Has slightly higher complication rates than other procedures.
• Highest malabsorption and greater possibility of vitamins and micro-nutrient deficiencies.
• Reflux and heart burn can develop or get worse.
• Risk of looser and more frequent bowel movements.
• More complex surgery requiring more operative time.

Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy (SADI-S)

The Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, referred to as the SADI-S is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. While similar to the BPD-DS, the SADI-S is simpler and takes less time to perform as there is only one surgical bowel connection.

Advantages

• Highly effective for long-term weight loss and remission of type 2 diabetes.
• Simpler and faster to perform (one intestinal connection) than gastric bypass or BPD-DS.
• Excellent option for a patient who already had a sleeve gastrectomy and is seeking further weight loss.

Disadvantages

• Vitamins and minerals are not absorbed as well as in the sleeve gastrectomy or gastric band.
• Newer operation with only short-term outcome data.
• Potential to worsen or develop new-onset reflux.
• Risk of looser and more frequent bowel movement.

Risk Factors

As with any major procedure, bariatric surgery poses potential health risks, both in the short term and the long term which can include:

• Excessive bleeding.
• Infection.
• Reactions to anesthesia.
• Blood clots.
• Lung or breathing problems.
• Leaks in your gastrointestinal system.
• Rarely, death.

Complications

Endocrine-related and other complications can occur with any type of bariatric surgery. Most complications are often linked to the surgery which changes how food is routed through the intestine or how the stomach empties. Surgical complications of weight-loss surgery vary depending on the type of surgery. They can include:

• Bowel obstruction.
• Dumping syndrome, a condition that leads to diarrhea, flushing, light-headedness, nausea or vomiting.
• Gallstones.
• Hernias.
• Low blood sugar, called hypoglycemia.

• Malnutrition: Macronutrient deficiency—a lack of protein and calories caused by reduced absorption, in severe cases, can cause swelling, diarrhoea, dehydration, and heart problems. Micronutrient deficiency—a lack of vitamins and minerals which are essential for many functions in the body. Bone loss leading to weak bones (osteoporosis). Low blood sugar (glucose) levels after eating, also called hypoglycaemia. Peripheral neuropathy—a form of nerve damage to feet, legs, or hands, causing pain, numbness, or tingling.

• Ulcers
• Vomiting
• Acid reflux
• Bleeding
• Infections
• Leakage
• Block gut/ narrow of the intestine.
• The need for a second surgery or procedure, called a revision
• Rarely, death.

Some of these surgical effects take a long time to develop, and symptoms may only occur many years after surgery. You can prevent some of these complications by getting enough protein in your diet, taking daily vitamin and mineral supplements for life as recommended. You should also follow up with your primary physician and surgeon for lifelong monitoring. The effects on other hormonal systems are still unknown and are areas of active research.

References

• Arterburn D, Wellman R, Emiliano A, et al. Comparative effectiveness and safety of bariatric procedures for weight loss: A PCORnet cohort study. Annals of Internal Medicine 2018;169:741–750. doi:10.7326/M17-2786
• Arterburn DE, Olsen MK, Smith VA, et al. Association between bariatric surgery and long-term survival. JAMA. 2015;313(1):62–70. doi:10.1001/jama.2014.16968
• Bariatric Surgery and the Risk of Cancer in a Large Multisite Cohort. September 2017. Available at: https://insights.ovid.com/pubmed?pmid=28938270
• Bariatric surgery procedures. American Society for Metabolic and Bariatric Surgery. https://asmbs.org/patients/bariatric-surgery-procedures.Accessed Nov 21, 2023.
• Feldman M, et al., eds. Surgical and endoscopic treatment of obesity. In: Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Nov 24, 2023
• Li, Jian-Fang MDSurgical Laparoscopy, Endoscopy & Percutaneous Techniques:
• February 2014 – Volume 24 – Issue 1 – p 1-11
• McTigue KM, Wellman R, Nauman E, et al. Comparing the 5-year diabetes outcomes of sleeve gastrectomy and gastric bypass: The National Patient-Centered Clinical Research Network (PCORNet) Bariatric Study. JAMA Surgery. 2020;e200087. doi:10.1001/jamasurg.2020.0087
• Morton JM, Ponce J, Malangone-Monaco E, Nguyen N. Association of Bariatric Surgery and national medication use. Journal of the American College of Surgeons. 2019;228(2):171–179. doi:10.1016/j.jamcollsurg.2018.10.021
• Obesity, surgical management. Clinical overview. Elsevier; 2022. https://www.clinicalkey.com. Accessed Nov 24, 2023.
• Hetye B, et al. Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022. Obesity Pillars. 2022; doi:10.1016/j.obpill.2022.100015
• Weight loss surgery – Risks – NHS (www.nhs.uk)

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Maiden Edition: Surgical Symphony, Issue 1 Vol 1 Aug 2024
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