Obesity & weight loss / Surgical Management

Surgical Management

Bariatric (weight-loss) surgery is the only option today that effectively treats morbid obesity in people for whom more conservative measures such as diet, exercise and medication have failed. Bariatric Surgery also contributes significantly to resolving co-morbidities and regaining your quality - and quantity - of life.

Potential candidates include:

  • people with a BMI greater than 40.
  • men who are about 45 Kgs over their ideal body weight or women who are 35 Kgs over their ideal body weight.
  • persons with a BMI between 35 and 40 who have another condition such as obesity-related Type 2 diabetes, sleep apnea or heart disease.

Bariatric Surgery does help many people reduce or eliminate some health-related obesity problems. It may help to:

  • lower blood sugar
  • lower blood pressure
  • reduce or eliminate sleep apnea
  • decrease the workload of the heart
  • lower cholesterol levels

Surgery for weight loss is not a universal remedy, but it can be highly effective if you're motivated after surgery to follow guidelines for nutrition and exercise and to take nutritional supplements.

Bariatric Surgery - Types

There are several approaches to Bariatric Surgery, but all procedures are either malabsorptive, restrictive or a combination of the two. Malabsorptive procedures typically result in more weight loss than restrictive procedures.

Malabsorptive procedures change the way your digestive system works. Food is re-routed past a large portion of the stomach and part of the small intestine that absorbs some calories and nutrients. With some procedures, a portion of the stomach is removed. These procedures are commonly referred to as “gastric bypass” procedures.

Restrictive procedures severely reduce the size of the stomach to hold less food, but the digestive functions remain intact. This type of procedure may be referred to as a “gastric stapling” procedure.

Gastric bypass surgery is a surgical procedure that alters the process of digestion. There are several types of gastric bypass procedures, but they all involve bypassing part of the small intestine by varying degrees. For this reason, procedures of this type are referred to as malabsorptive procedures, because they involve bypassing a portion of the small intestine that absorbs nutrients.

Some of these procedures also involve stapling the stomach to create a small pouch that serves as the “new” stomach, or surgically removing part of the stomach.

Although a gastric bypass procedure is malabsorptive, it can also be restrictive because it reduces the size of the stomach so that the amount of food you can eat is restricted due to the smaller stomach. While malabsorptive procedures are more effective in contributing to weight loss than those that are solely restrictive, they also carry more risk for nutritional deficiencies.

Types of Gastric Bypass Procedures

Roux-en-Y Gastric Bypass Surgery (RGB):
Roux-en-Y gastric bypass, the most commonly performed bariatric procedure, is both malabsorptive and restrictive. This surgery can result in two-thirds of extra weight loss within two years. The procedure involves stapling the stomach to create a small pouch that holds less food, and then shaping a portion of the small intestine into a “Y.” The “Y” portion of intestine is then connected to the stomach pouch so that when food is being digested it travels directly into the lower part of the small intestine, bypassing the first part of the small intestine (called the duodenum) and the first part of the second section of the small intestine (called the jejunum). Bypassing these sections of the intestine restricts the amount of calories and nutrients that are absorbed into the body.

The Digestive System and Malabsorptive Surgery:
During digestion, food and liquid are broken down into smaller parts so that the body can absorb and use them for nourishment. Digestion starts in the mouth and continues downward into the stomach, where the three mechanical tasks of storing, mixing and emptying of food occur. The food is then digested in the small intestine and dissolved by the juices from the pancreas, liver and intestine, and the contents of the intestine are mixed and pushed forward to allow further digestion. Malabsorptive procedures alter this process in different ways depending on the type of procedure.

Risks of Gastric Bypass Surgery:
With the gastric bypass procedure, malabsorptive symptoms may be more serious, with an increased risk of anemia. Your body may not adequate amounts of iron, calcium and vitamin B12, potentially causing metabolic bone disease and osteoporosis.

Stomal stenosis occurs when there is a stricture (tightening) of the opening between the stomach and intestine after a Roux-en-Y procedure. When this occurs, vomiting after eating and sometimes after drinking may occur. Stomal stenosis can be treated easily but should be treated immediately.

“Dumping syndrome” is also more likely to occur with these procedures because the food in the stomach moves to the intestines quickly. Symptoms include nausea, sweating, fainting, weakness and diarrhea.

There is a risk that you may require additional surgery because of complications. One of the most serious complications of gastric bypass is a stomach leak that can cause peritonitis to develop. Peritonitis is an inflammation of the peritoneum, the smooth membrane that lines the cavity of the abdomen. There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.

Sleeve Gastrectomy
Sleeve Gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve with surgical staples, to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible. Most patients can expect to lose 60 to 70% of their excess body weight over a 6–12 month period with the sleeve gastrectomy.

  • Size of stomach is reduced, but it tends to function normally, so most food items can be consumed in small amounts.
  • Dumping syndrome is less likely due to the preservation of the pylorus.
  • 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).
  • Limited results appear promising as a single stage procedure for low BMI patients
    (BMI 35–45 kg/m2).

Surgical Management
Surgical Management

Gastric Banding
Adjustable Gastric Banding works by placing a band around the upper most part of the stomach, separating the stomach into one large and one small portion, which can hold about 30 grams of food. The food from small pouch in the stomach empties into the closed-off portion of the stomach and then resumes the normal digestive process.

No staples are used in this procedure, and your Doctor can adjust the diameter of the band around the stomach by adding or removing saline (salt water). Over time, the pouch can expand to hold 60-80 grams of food. Since no part of the stomach is removed, digestion remains normal.

This type of procedure is classified as restrictive because the size of the stomach is reduced so dramatically. Despite the lack of malabsorption, we still encourage daily vitamin intake as part of your healthy lifestyle.

Weight loss is slower and lesser with the lap band. You can expect to lose 50 percent of your excess weight at two years. Potentially, with continued adjustments of the band and better eating and exercise habits, you may lose more weight. Like gastric bypass, your effort will be critical to producing significant weight loss. Even with this operation, it’s possible for you to eat enough to maintain your pre-operative weight or to regain any weight you lose.

It will be critical that you begin and continue an exercise program for the rest of your life. This should include at least 30 minutes of exercise five to seven days a week. In addition, it’s critical that you maintain a diet for the rest of your life that consists of no sweets, very small amounts of carbohydrates, small volumes of food and high protein intake. You’ll need to eat 40-60 grams of protein a day and it’ll be very important for you to pay attention to food labels to make sure you get enough.

After the procedure, you’ll only be able to eat about three-quarters to one cup of food, and you have to chew the food thoroughly. Eating more than the stomach pouch can hold may result in nausea and vomiting. Restrictive procedures pose fewer risks than gastric bypass procedures, but they’re also less successful because continuous overeating can stretch the pouch so that it accommodates more food.

Because the surgery can have serious side effects, the long-term health benefits must be considered and found greater than the risk. Despite the fact that some surgical techniques can be done laparoscopically with reduced risk, all bariatric surgery is considered to be major surgery.

Although not all risks with each procedure are fully known, bariatric surgery does help many people to reduce or eliminate some health-related obesity problems. It may help to:

  • Lower blood sugar
  • Lower blood pressure
  • Reduce or eliminate sleep apnea
  • Decrease the workload of the heart
  • Lower cholesterol levels

Surgery for weight loss is not a universal remedy, but these procedures can be highly effective if you're motivated after surgery to follow your physician's guidelines for nutrition and exercise and to take nutritional supplements. There may be other reasons for your physician to recommend a gastric banding procedure

Risks of the Procedure
As with any surgical procedure, complications may occur. Risks specific to vertical gastric banding include breakdown of the line of staples and erosion of the band. Rarely, stomach juices may leak into the abdomen and emergency surgery may be needed.

The most common complication that may develop with adjustable gastric band surgery is that the stomach pouch enlarges. Band slippage and saline leaks are also risks specific to adjustable gastric band surgery.

A laparoscopic banding procedure can reduce risk because there’s no incision in the stomach wall. There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your Doctor prior to the procedure.

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