Bariatric Surgery Information
Bariatric surgery, or weight loss surgery, is a type of procedure performed on people who are dangerously fat, for the purpose of losing weight. This weight loss is usually 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).
Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%.[1]
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.[1] 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.[2]
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Indications
A medical guideline by the American College of Physicians concluded[3][4]:
- "Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption."
- "Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery."
When determining eligibility for bariatric surgery for extremely obese patients, psychiatric screening is critical; it is also critical for determining postoperative success. In patients with a body mass index of 40 kg/m2 or greater, there is a 5-fold risk of depression, and half of bariatric surgery candidates are depressed.[5]
Classification of surgical procedures
Procedures can be grouped in three main categories:[6] Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.
Predominantly malabsorptive procedures
Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.
Diagram of a biliopancreatic diversion.Biliopancreatic diversion
This complex operation is also known as biliopancreatic diversion (BPD), or Scopinaro procedure. This surgery is rare now because of problems with malnourishment. It has been replaced with the Duodenal switch, also known as the BPD/DS. Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.
In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.[citation needed]
Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventative measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones.[citation needed]
Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.[citation needed]
Jejunoileal bypass
Main article: Jejunoileal bypassThis procedure is no longer performed.
Endoluminal sleeve
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No longer only performed on mice, this surgery involved placing a 10 cm long impermeable sleeve into the mouse's intestine to block absorption of food in the duodenum and upper jejunum. A study at Massachusetts General Hospital Weight Center and Gastrointestinal Unit found that mice who had the surgery ate 30% less food and lost 20% more weight than counterpart mice, while blood glucose levels returned to normal levels in all mice who had the surgery.[7]
Clinical trials began in South America and Europe in 2009. GI Dynamics inc, is testing a new surgery-free medical device called the EndoBarrier Gastrointestinal Liner. It may offer the effective surgery free weight loss. Lining part of the small intestines from the duodenum and into the first part of the jejunum. This mechanical bypass may alter hormonal responses in the body. Resulting in metabolic changes that lead to weight loss and a potential solution for type 2 diabetes.
Clinical studies show losses 20 percent of excess weight within three months, and 30 percent of excess weight within six months. The exact nature of the link between an Endoluminal sleeve and diabetes is unknown. One theory is it may change the hormone levels originating in the intestines.[8]
Since the preceding paragraphs, the procedure's won the European CE Mark of Approval, and is available there now. At this time no information is available about clinical trials or approval in the United States.[9]
Predominantly restrictive procedures
Predominantly restrictive procedures primarily reduce stomach size.[citation needed]
Diagram of a vertical banded gastroplasty.Vertical Banded Gastroplasty
Main article: Vertical banded gastroplasty surgeryIn the vertical banded gastroplasty, also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.[citation needed]
Diagram of an adjustable gastric banding.Adjustable gastric band
Main article: Adjustable Gastric BandThe restriction of the stomach also can be 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 can be performed laparoscopically, and is commonly referred to as a "lap band." The first non-adjustable gastric band was patented in 1979[10] and successfully applied in animal experiments. An American company, INAMED Health, later designed the BioEnterics LAP-BAND Adjustable Gastric Banding System (based on the design by Kuzmak in 1986), which was introduced in Europe in 1993. Neither of these bands was initially designed for use with laparoscopic surgery. The LAP-BAND System received U.S. Food and Drug Administration (FDA) approval in June 2001. In 2000, a lower pressure, wider, one-piece adjustable gastric band called the MIDband was introduced by Medical Innovation Development of Lyon France.[11] In 2002, a lower pressure, wider, one-piece adjustable gastric band called the Bioring designed specifically for laparoscopic insertion was introduced in France by Cousin-Biotech,[12] and swiftly become one of the leading bands in that country. There are now a number of band manufacturers including Ethicon (Realize Band), A.M.I. (Soft Band) and Bariatric Solutions (Mini Mizer Extra).http://www.hospimedical.com/wDeutsch/for-surgeons/minimizer-extra.php?navid=2 [2]
Sleeve gastrectomy
Main article: Sleeve gastrectomySleeve gastrectomy 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. The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.[3]
Main article: Expected Weight LossThis combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6 - 12 month period with the sleeve gastrectomy alone. The timing of the second procedure 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 [4]. - No dumping syndrome because the pylorus is preserved. - 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). - Limited results appear promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m2). - Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
Intragastric balloon
This surgery involves endoscopic placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months[14] and results in an average weight loss of 5-9BMI over half a year.[15] While not yet approved by the FDA the Intragastric balloon is approved in Australia, Canada, Mexico, India and several European and South American countries.[16][17]
Mixed procedures
Mixed procedures apply both techniques simultaneously.
Roux-en-Y gastric bypass.Gastric Bypass Surgery
Main article: Gastric bypass surgeryA common form of gastric bypass surgery is the Roux-en-Y gastric bypass. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.[citation needed]
The gastric bypass had been the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005, dwarfing the number of Lap-Band, duodenal switch and vertical banded gastroplasty procedures. The gastric bypass operation is considered the "gold standard" in the U.S. A factor in the success of any bariatric surgery is strict post-surgical adherence to a gastric bypass diet.[citation needed] healthier pattern of eating.
Diagram of a sleeve gastrectomy with duodenal switch.Sleeve gastrectomy with duodenal switch
A variation of the biliopancreatic diversion includes a Duodenal switch. The part of the stomach along its greater curve is resected. The stomach is "tubulized" with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75–100 cm from the colon.[citation needed]
Implantable Gastric Stimulation
This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of Bariatric Surgery.[citation needed]
Eating after bariatric surgery
Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free gelatin desserts. This diet is continued until the gastrointenstinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of skimmed milk, cream of wheat, a small pat of margarine, protein drinks, cream soup, pureed fruit and mashed potatoes with gravy.[18]
Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients [19]. Because patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and alcohol.[5]
Effectiveness of surgery
Weight loss
In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures however, have a higher risk profile. A meta-analysis from University of California, Los Angeles reports the following weight loss at 36 months:[4]
- Biliopancreatic diversion - 53 kg
- Roux-en-Y gastric bypass (RYGB) - 41 kg
- Open - 42 kg
- Laparoscopic - 38 kg
- Adjustable gastric banding - 35 kg
- Vertical banded gastroplasty - 32 kg
In terms of percentage of excess weight lost, following are aggregated study results for the range of each procedure (number of studies; total patients in all studies):[20]
- Biliopancreatic diversion with duodenal switch – 65% to 75% (4; 3,266)
- Roux-en-Y gastric bypass (RYGB) – 50% to 70% (5, 6,234)
- Adjustable gastric banding – 25% to 80% (9; 2,672)
- Vertical banded gastroplasty – 50% to 60% (4; 1,114)
- Sleeve gastrectomy – short-term results – 65% to 75% (5; 384)
More recent studies have demonstrated that the medium (3–8 years) and long term (>10 years) weight loss results for RYGB and LAGB become very similar [6].However, the range of excess weight loss for LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data (beyond 5 years) for Sleeve Gastrectomy is not yet available (as of 12/09).
Reduced mortality and morbidity
Several recent studies report decrease in mortality and severity of medical conditions after bariatric surgery.[21][22][23] But long term effects are not clear.[24] 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).[21]
In a Utah retrospective cohort study that followed patients for an average of 7 years after various types of gastric bypass, surgery patients had 0.4% mortality while control patients had 0.6% mortality.[22] Death rates were lower in the gastric bypass patients for all diseases combined, as well as for diabetes, heart disease and cancer. Deaths from accident and suicide were 58% higher in the surgery group.
A randomized, controlled trial in Australia compared laparoscopic adjustable gastric banding ("lap banding") with non-surgical therapy in 80 moderately obese adults (BMI 30-35). At 2 years, the surgically-treated group lost more weight (21.6% of initial weight vs. 5.5%) and had statistically significant improvement in blood pressure, measures of diabetic control, and high-density lipoprotein cholesterol.[23] Post surgical complications included 1 patient with an infected surgical site, 4 with lap band malpositioning requiring laparoscopic revision, and 1 patient with cholecystitis. In the non-surgical group, 12 patients declined or did not tolerate orlistat or diet restrictions, and 4 patients developed acute cholecystitis.[citation needed]
Bariatric surgery in older patients has also been a topic of debate, centered on concerns for safety in this population. One study of elderly patients undergoing laparoscopic bariatric surgery at Mount Sinai Medical Center, however, reported 0% conversion to open surgery, 0% 30-day mortality, 7.3% complication rate, and average hospital stay of 2.8 days.[25] post operative mortality from 0.1 - 2 %
Laparoscopic bariatric surgery requires a hospital stay of only one or two days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery.[1][26][27]
Adverse effects
Complications from weight loss surgery are frequent. A study of insurance claims of 2522 who had undergone bariatric surgery showed 21.9% complications during the initial hospital stay and a total of 40% risk of complications in the subsequent six months. This was more common in those over 40 and led to increased health care expenditure. Common problems were gastric dumping syndrome in about 20% (bloatedness and diarrhoea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%). Mortality was 0.2%.[28] As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery is performed in dedicated or experienced units.[3]
See also
- Revision weight loss surgery
- Gastric Bypass Information
References
- ^ a b c Malcolm K. Robinson, Editorial, Surgical treatment of obesity -- weighing the facts, N Engl J Med, 361:520, July 30, 2009
- ^ http://www.soard.org/article/S1550-7289%2808%2900219-0/abstract
- ^ a b Snow V, Barry P, Fitterman N, Qaseem A, Weiss K (2005). "Pharmacologic and surgical management of obesity in primary care: a clinical practice guideline from the American College of Physicians". Ann. Intern. Med. 142 (7): 525–31. PMID 15809464. http://www.annals.org/cgi/content/full/142/7/525.
- ^ a b Maggard MA, Shugarman LR, Suttorp M, et al. (2005). "Meta-analysis: surgical treatment of obesity". Ann. Intern. Med. 142 (7): 547–59. PMID 15809466. http://www.annals.org/cgi/content/full/142/7/547.
- ^ Chiles C, van Wattum PJ. Psychiatric aspects of the obesity crisis. Psychiatr Times. 2010;27(4):47-51.
- ^ Abell TL, Minocha A (2006). "Gastrointestinal complications of bariatric surgery: diagnosis and therapy". Am. J. Med. Sci. 331 (4): 214–8. doi:10.1097/00000441-200604000-00008. PMID 16617237.
- ^ Intestinal 'Sleeve' Mimics Effects of Gastric Bypass. HealthDay News. December 4, 2008.
- ^ Consumer Guide to Bariatric Surgery.. Keith S. Gersin, MD, FACS, Chief of Bariatric Surgery at Carolinas Medical Center. Review. September 2009.
- ^ [1]. SOURCE GI Dynamics Announcement. December 31, 2009.
- ^ United States Patent Nr. 4,178,915, "Selectively Operatable Blocking Device" by Prof. Dr. Gerhard Szinicz Innsbruck / Austria.
- ^ Medical Innovation Development website (French)
- ^ Cousin Biotech website (French)
- ^ http://www.fitbysurgery.com/SurgicalOptions/SleeveGastrectomy/tabid/488/Default.aspx
- ^ http://dietmotion.com/intragastric-balloon.html
- ^ http://content.karger.com/ProdukteDB/produkte.asp?doi=10.1159/000109385
- ^ http://www.wlshelp.com/news/gastric-balloon-jump-starts-weight-loss/
- ^ Rosenthal, Elisabeth (January 3, 2006). "Europeans Find Extra Options for Staying Slim". The New York Times. http://query.nytimes.com/gst/fullpage.html?res=9400EED61030F930A35752C0A9609C8B63&sec=health&pagewanted=all. Retrieved April 26, 2010.
- ^ Diet After Bariatric {}
- ^ Tucker ON, Szomstein S, Rosenthal RJ (May 2007). "Nutritional consequences of weight-loss surgery". Med. Clin. North Am. 91 (3): 499–514, xii. doi:10.1016/j.mcna.2007.01.006. PMID 17509392.
- ^ http://www.bariatric-surgery-source.com/types-of-bariatric-surgery.html
- ^ a b Sjöström L, Narbro K, Sjöström CD, et al. (2007). "Effects of bariatric surgery on mortality in Swedish obese subjects". N. Engl. J. Med. 357 (8): 741–52. doi:10.1056/NEJMoa066254. PMID 17715408.
- ^ a b Adams TD, Gress RE, Smith SC, et al. (2007). "Long-term mortality after gastric bypass surgery". N. Engl. J. Med. 357 (8): 753–61. doi:10.1056/NEJMoa066603. PMID 17715409.
- ^ a b Paul E. O’Brien, MD; John B. Dixon, MBBS, PhD; Cheryl Laurie, RN, et al. (2006). "Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program". Annals of Internal Medicine 144: 625–43. http://www.annals.org/cgi/reprint/144/9/625.pdf. Retrieved 2008-05-11.
- ^ Colquitt 2009,Surgery for obesity http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003641/frame.html
- ^ Hazzan D, Chin EH, Steinhagen E, et al. Laparoscopic bariatric surgery can be safe for treatment of morbid obesity in patients older than 60 years. Surg Obes Relat Dis. 2006, 2(6):613-6. http://www.ncbi.nlm.nih.gov/pubmed/17138231
- ^ The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Perioperative safety in the longitudinal assessment of bariatric surgery, N Engl J Med, 361:445, July 30, 2009
- ^ Nguyen NT et al. Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project. Arch Surg 2006; 141: 445-9. PMID 16702515
- ^ Encinosa WE, Bernard DM, Chen CC, Steiner CA (2006). "Healthcare utilization and outcomes after bariatric surgery". Medical care 44 (8): 706–12. doi:10.1097/01.mlr.0000220833.89050.ed. PMID 16862031.
Categories: Surgery | Weight loss | Obesity
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