Bariatric Surgery - Surgery for Weight Loss

Current numbers indicate that in North America, more than half of adults and nearly one-fifth of children and teenagers are overweight. Approximately 8 percent of adults are morbidly obese, meaning they weigh at least 100 pounds over their recommended body weight. The dangers of obesity are real. Morbid obesity is a harbinger of early hypertension, type 2 diabetes, obstructive sleep apnea, depression, urinary incontinence and osteoarthritis.

It is predicted that obesity will soon overtake smoking as the most common cause of preventable deaths. Despite the awareness of obesity and its associated complications, the treatment/prevention of obesity is very complex and there is no ideal drug or surgery available today. The majority of treatments available have all failed in achieving long term success and the surgery is fraught with potential complication. However, in the past decade numerous new surgical procedures have become available to help combat the obesity epidemic. There is no doubt that some individuals do benefit from surgery and surgery is more likely to be successful than drugs in the long term.

With increasing social isolation and moribund with numerous medical illnesses, many individuals are turning to bariatric surgery.

It is reported that 2.3% (about 7 million) of the US population has a body mass index (BMI) greater than 40 kg/m2, which makes them potential candidates for bariatric surgery. Even though the surgery has complications that should not be a deterrent because the chance of success is reasonable. Medically speaking, a person is morbidly obese when he or she is so heavy that the fat tissue load affects health.  Surgery for obesity is usually considered appropriate if the risk of the excess weight is greater than the risk of surgery. 

Morbid obesity occurs when the individuals’ weighs more than 100 lbs in excess of what his ideal weight should be.  A more exact way to define morbid obesity is to use the Body Mass Index (BMI).  The BMI is calculated as follows:

                                                BMI = weight (kg)/height (m2)

Bariatric surgery is often not the first choice but is definitely the best choice treatment in morbid obesity. Even though the surgery does have risks, for some, there is no choice. If they do not undergo surgery, premature death is a very possible outcome.

Medical complications associated with obesity include:

Cardiovascular           

• Hypertension
• Premature coronary disease
• Peripheral vascular disease
• Unexplained cardiac arrest
• Venous stasis
• Varicose veins

Gastrointestinal           

• Gallbladder disease
• Gastroesophageal reflux disease
• Nonalcoholic steatohepati
• Fatty liver disease

Gynecology           

• Dysmenorrhea
• Infertility
• Stress incontinence

Metabolic           

• Hyperlipidemia
• Type 2 diabetes mellitus

Musculoskeletal

• hernias
• Degenerative joint disease
• Vertebral spine disease

Neoplastic           

• Breast adenocarcinoma
• Colon adenocarcinoma
• Endometrial adenocarcinoma
• Prostate adenocarcinoma

Neurologic and psychologic

• Pseudotumor cerebri
• Psychosocial impairment
• Socioeconomic impairment

Pulmonary           

• Obesity hypoventilation syndrome
•  Obstructive sleep apnea

Surgery vs drugs

Bariatric surgery offers some advantages over drugs for treatment of obesity. Surgery can cause rapid weight loss and therefore rapidly improves the symptoms of obesity. The majority of individuals who undergo surgery claim that the weight loss is much greater than with the use of drugs. In addition, there is no guarantee of weight loss with drugs and over time the drugs are expensive and have significant side effects.

All physicians agree that clinical features alone are not adequate regarding the decision to undergo surgery. Over the years, a few guidelines have been offered in the selection of patient and these include:

• Patients who have failed drug therapy
• Patients who have tried other non surgical methods to lose weight and failed
• Patients who have a BMI in excess of 40 kg/m2
• Patients with a BMI between 35 and 40 kg/m2 along with more than one high-risk co-morbid condition, such as severe diabetes, or poor function.

For those patients who have medical coverage, the criteria for weight loss surgery are more stringent and include:

• a body weight more than 100% above ideal body weight
• weight-related co-morbidities
• Failed attempts at nonoperative, medically supervised weight-loss programs.

These criteria are guidelines only, however, and physicians need to evaluate the expected health benefits and acceptable risks of bariatric surgery for the individual patient. All individuals have to have realistic goals and must have a commitment towards weight reduction.

The absolute contraindications to bariatric surgery are:

• psychotic illness
• active substance abuse
• defined noncompliance with previous medical care
• Other psychiatric conditions, including borderline personality disorder
• uncontrolled depression
• patients who are at high risk of heart disease

Bariatric surgery requires a strong commitment and can interfere with various aspects of one’s social life and eating habits. A commitment towards weight loss means having to sacrifice friends, family, food and adopt a rigid life style.

There are three general types of bariatric surgery for obesity: restrictive, malabsorptive, and combined restrictive and malabsorptive.

Restrictive (Limiting intake or altering digestion)

The restrictive procedures limit food intake by decreasing the size of the stomach so that there is a sensation of "fullness" (or pain) occurs after ingestion of small amount of food.

Gastric banding

Gastric banding involves no suturing, stapling or cutting of the stomach; rather a strip of plastic band is placed around the upper part of the stomach to limit entry of food into the stomach. The new stomach pouch formed usually fills quickly with food but emptied very slowly, giving a sensation of food in the stomach at all times. Over eating can cause pain or vomiting.

Individuals who undergo gastric banding can expect to lose up to 60 pounds or more in one year. The duration of weight loss and number of pounds lost, however, is variable.

Malabsorptive procedures

Malabsorptive procedures alter and divert the digestion process, thus causing food to be poorly digested, incompletely absorbed and the majority is excreted in the stool. There are numerous variations for creation of malabsorption. The stomach is not removed but is bypassed using various surgical techniques. The principle behind restrictive surgery is to create a small gastric reservoir that forces the patient to eat less at any one time. The surgery is done to reduce the stomach size and leave only a small chanell to allow for food to pass through.

Malabsorptive bypass procedures in general produce more weight loss than restrictive operations and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally can lose > 75-150 pounds within 1-2 years. The weight loss generally continues for 1½ years before stabilizing.

Unlike older bypass procedures that involve removal of the stomach, current procedures pose fewer operative risks.

New approaches help reduce pain, shorten recuperation

Older bariatric surgery procedures required a long midline abdominal incision and the post operative recovery was about 4-6 weeks long. Today, minimally invasive surgical techniques are available that enable the doctors to perform both restrictive and malabsorptive bariatric procedures without making big incisions in the abdomen. The minimally invasive approach achieves results comparable to those associated with open surgery, but with less post-operative pain and rapid recovery. Patients who undergo minimally invasive bariatric surgery can expect to return to work 1-2 weeks after undergoing surgery.

Specific Risks of surgery

Despite many hospitals and surgeons claiming that the risks of bariatric surgery are rare, this is false. Patient data are not always available and anecdotal data suggest that complications are frequent and occasionally serious.

 Complications of gastric banding include:

• kinking of the stomach
• leaking from the site of banding or band breakage

Both the above require surgery to fix the complications.

Side effects of gastric bypass surgery include:

• internal bleeding
• pulmonary embolism
• unidentified leakage
• organ injury (esp. spleen)
• breathing problems
• leaks from suture lines
• infections
• blood clots in legs

Results of Surgery

One certain thing is that complications of obesity resolve after weight loss. The majority of individuals report better control of their type 2 diabetes, less requirement for BP medications, and resolving of sleep apnea. Most individuals complain that with the weight loss there is less joint and muscle pain and over time, osteoarthritis is significantly decreased. The effects of surgery are more effective than any combination of medications.

What is successful bariatric surgery?

The definition of successful bariatric surgery is a loss of 50% of the patient's excess body weight. Most restrictive procedures have generally shown a mean loss of 50-60% of excess body weight at 1 year and a slow weight gain thereafter. At 5 years, only 50% of patients manage to keep the weight off, and at 10 years, the success rate is less than 20%.  Complications of restrictive procedures are generally infrequent. It is highly recommended that the surgeon remove the gall bladder during the weight loss surgery because gallbladder disease develops in about 30% of patients as a result of rapid weight loss. .

Malabsorptive procedures

The goal of malabsorptive procedures is to bypass a major part of the absorptive surface of the small intestine. These initial surgeries performed for weight loss dominated the bariatric field in the 70s and 80s. Their advantage was a rapid, sustained weight loss and no need for a change in dietary habits or need for physical activity. However, these procedures were associated with severe metabolic complications and death was not uncommon. The complications included multiple nutritional deficiencies, steatorrhea, oxalate-induced nephropathy, and late-onset liver failure with cirrhosis. These procedures are best assigned to the history books today.

Combined restrictive and malabsorptive procedures

The aim of combined restrictive and malabsorptive procedures is to balance the benefits and reduce the risks of the two approaches. The advantages of the combined procedures are improved success and fewer complications compared with either purely restrictive or malabsorptive procedures.

The disadvantages of the combined procedures are the increased technical difficulty compared with restrictive procedures and the real possibility of long-term nutritional deficiencies. With conventional gastric bypass procedures, deficiencies of iron, calcium and vitamin B12 are common. These deficiencies can be prevented with regular monthly vitamin B12 injections and supplemental vitamins, calcium, and iron. Iron deficiency is more of an issue in premenopausal females. With more complex and longer gastric bypass procedures, folate, magnesium and fat-soluble vitamin deficiencies can occur as well. In some individuals, there can be associated protein malabsorption resulting in severe malnutrition.

Complications of the combined procedures are decreasing but definitely not zero. Morbid complications are potentially serious and include several very complex complications including bowel obstruction, herniation and leaks from suture lines.

Laparoscopic gastric bypass

The laparoscopic procedure is growing in popularity because it decreases the hospital stay, pain, and the incidence of incisional hernias. It is more technically difficult than the open gastric bypass procedure, and most surgeons initially have a fair number of operative complications. With more experience, the technical risks decrease but never approach zero.

Nutritional deficiencies can cause significant morbidity and long-term complications can occur if patients do not receive regular vitamin and mineral supplementation. Lifelong vitamin B12 injection therapy and a daily multivitamins are mandatory. Calcium and iron supplementation are often needed as well. A number of patients have required multiple surgeries to correct the complications.

Patients also need continued support and counseling on lifestyle modifications, especially physical activity. Finally, as weight loss is achieved, medication dosages need to be adjusted.

Today, there are several options available in the treatment of obesity. Too often, physicians are often frustrated and disappointed by the lack of success that patients have had with weight loss treatments, or they are too focused on the treatment of individual complications and ignore the underlying problem of obesity. In all overweight patients, it is essential to make it mandatory to adopt a lifestyle changes, and behavior counseling is an essential part of treatment.

IF bariatric surgery is deemed to be a valuable treatment for selected obese patients, the individual should be assessed and evaluated about the procedures for weight loss and one should discuss expectations, risks and benefits, and the challenges of dietary limitation, lifestyle and behavioral modifications. A physical activity program and preoperative dietary improvement can help with postoperative function and recovery.

Patients must realize that the definition of success for these procedures is the loss of 50% of their excess weight. Although a surgically based approach will likely result in a healthy weight, it seldom results in the patient achieving his or her ideal weight.

Conclusion 

So far there is no magic bullet for morbid obesity and there is no ideal surgery. Despite the best surgeon and the latest technology, the surgery is still considered high risk and complications are unpredictable. In the last decade, numerous deaths have occurred after surgery and various state agencies have assessed quality control in some hospitals. Deaths have occurred all over the country and this has become more of a concern because of the numbers of individuals seeking this surgery is increasing.

Recent statistics reveals that about one in every 100 to 300 patients dies from complications from obesity surgery, and another 10 to 20 percent experience surgery-related infections and other problems

There has been a bandwagon of surgeons and hospitals all clamoring for the bariatric surgery business. Not all hospitals are adhering to the highest standards of care or decent surgeons and excellent postoperative care is doubtful in a number of cases. Many states are now in the process of adopting regulations that will monitor the surgery and publish morbidity and mortality data.

The only way to decrease the surgery complications is to get the surgery from an accomplished surgeon who is well versed into the various surgical techniques. The weight loss program should offer a postoperative recovery program, nutritional consultation, support groups and mental health counseling. This will help achieve an optimal outcome. There is no easy solution to weight loss and more than anything else, it requires a lot of hard work.