One of the things to be considered is that every surgery has risks. All surgical procedures carry risks, and even more so when a patient is obese. Different procedures involve different risks, and depending upon your individual circumstances, your risks may be higher or lower than average. Keep in mind that the more experience a surgeon has performing bariatric surgery, the lower the complication and mortality rates will be.
As obesity rates continue to increase, so do their serious health implications. An estimated one-third of all Americans today are overweight or obese, increasing the risk of weight-related health conditions that include:
- Coronary artery disease
- Diabetes mellitus
- Obstructive sleep apnea
- Gastro-esophageal reflux disease
- Degenerative joint disease
Recent studies have shown that bariatric surgery is the only effective treatment which substantially reduces obesity related disease and mortality in the long term. Bariatric surgery is a major operation and should be reserved for those who have been unable to achieve long-term weight loss after non-surgical weight-loss methods (diet and exercise). For many, it may offer the only remaining hope to improve health, a longer lifespan and a better quality of life. In order to know if you are eligible for bariatric surgery, the patient selection process is based on the National Institutes of Health (NIH) criteria, as follows:
- 100 pounds or more above ideal body weight or a body mass index (BMI) of 40 or greater
- BMI of 35 or greater with one or more obesity-related health conditions
As you may know, obesity contributes to numerous other medical conditions, including: osteoarthritis and gout, gallbladder disease and gallstones, high-risk pregnancy, hypoventilation (breathing disorders), infertility, psychological disorders/social impairments, incontinence, polycystic ovary syndrome, lower back pain and degenerative disc disease. Six months after surgery, patients often find they no longer need medications for many of these conditions. Also, many women struggling with infertility before surgery find that conception is possible after weight loss.
In the same way, life quality undergoes significant positive changes as a result of bariatric surgery. Many patients are thrilled to be able to do ordinary things again, like going to the store, playing with their children, getting in and out of a car easily, riding a bike and activities things that were limited because of obesity.
Since morbid obesity is often associated with other medical conditions, and in order to get the better results, an institution with a multidisciplinary team is an ideal setting for your bariatric surgery. The team must include, or have access to, physicians in the following specialties: bariatric surgery, nutrition/dietary, psychology/psychiatry, endocrinology, cardiology, pulmonary medicine (Sleep Apnea), gastroenterology, critical care, physical therapy/exercise therapy and plastic and reconstructive surgery.
BARIATRIC SURGERY OVERVIEW
More than 95 percent of all procedures performed at the Bariatric and Metabolic institutes are performed using minimally invasive (laparoscopic) techniques. Using this method, several tiny (1/4-1/2 inch) incisions are made. A small camera is used to view the inside of the abdomen on a TV monitor, and special small instruments are used for the surgery. The advantages of this minimally invasive approach to surgery means less pain, faster operations, less anesthesia, much smaller incisions, fewer post-operative complications (such as hernia and wound infection), and less scarring with a better cosmetic result. All of which contribute to faster healing and recovery.
In order to better understand how weight loss surgery works, it is helpful to know how the normal digestive process works. As food moves along the digestive tract, special digestive juices and enzymes arrive at the right place at the right time to digest food and absorb calories and nutrients. After we chew and swallow our food, it moves down the esophagus to the stomach, where a strong acid and powerful enzymes continue the digestive process. Food is slowly released into the small intestine where absorption of the nutrients, vitamins and minerals takes place.
Surgical procedures for weight loss restrict the volume of food intake and/or cause some of the food to be less digested and less absorbed so it is eliminated in the stool.
ROUX-EN-Y GASTRIC BYPASS SURGERY (RYGB)
RYGB is the most common type of bariatric surgery. The surgeon creates a small pouch by dividing the upper end of the stomach. This restricts the food intake. Next, a section of the small intestine is attached to the pouch allowing food to bypass the duodenum, as well as the first portion of the jejunum. The advantages of Roux-en-Y gastric bypass include superior weight loss, with excellent long-term weight reduction and resolution or elimination of co-morbidities (80 percent resolution of Type II diabetes after surgery). Early and late complication rates are reasonably low, and operative mortality ranges from 0.2 percent to 1 percent. Depending on their pre-operative weight, patients can expect to lose between 60 percent to 70 percent of their excess body weight in the first year after surgery.
Disadvantages of Roux-en-Y gastric bypass include the potential for anastomotic leaks and strictures, severe dumping syndrome symptoms and procedure-specific complications, including distension of the excluded stomach and internal hernias. Roux-en-Y gastric bypass is technically more challenging to perform than the restrictive procedures, particularly when using the laparoscopic approach. In experienced hands, the conversion rate of laparoscopic Roux-en-Y gastric bypass to open is 5 percent.
LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB)
The LAGB creates a new, tiny pouch that limits and controls the amount of food consumed. The band also creates a small outlet that slows the emptying process into the stomach and the intestines, allowing the patient to experience an earlier sensation of fullness and increased satisfaction with smaller amounts of food. The band is also adjustable and can be modified by inflating or deflating the inner surface with saline solution.
The adherence to monthly appointments for band adjustments the first 6-12 months after surgery is very important to achieve optimal results, and depending on their pre-operative weight, patients can expect to lose between 50 percent and 60 percent of their excess body weight in the first year after surgery.
LAPAROSCOPIC SLEEVE GASTRECTOMY
During the Laparoscopic Sleeve Gastrectomy, about 75 percent of the stomach is removed, leaving a narrow gastric “tube” or “sleeve”. It does not cause decreased absorption of nutrients or bypass your intestines. Sleeve Gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, Sleeve Gastrectomy may reduce the amount of “hunger hormone” produced by the stomach which may contribute to weight loss after this procedure, and is primarily used as part of a staged approach to surgical weight loss.
Patients who have a very high body mass index (BMI) may benefit from this staged approach. In patients who undergo LSG as a first stage procedure, the second stage (gastric bypass) is performed 12 to 18 months later after significant weight loss has occurred. Laparoscopic Sleeve Gastrectomy can also be used as a primary procedure. Overall, the operative risks associated with LSG are slightly higher than those seen with the laparoscopic adjustable band, but lower than the risks associated with gastric bypass. Depending on their pre-operative weight, patients can expect to lose between 40 percent to 70 percent of their excess body weight in the first year after surgery.
This malabsorptive procedure is less commonly performed and involves a distal gastrectomy and the creation of a long Roux-en-Y limb. A modification of biliopancreatic diversion (BPD) with a duodenal switch (BPD-DS) consists of a sleeve gastrectomy. The advantages of BPD include substantial, durable weight loss (over 70 percent beyond 10 years) and the resolution of many obesity-related co-morbidities.
BPD and BPD-DS, particularly if done laparoscopically, are technically challenging operations, and they have higher postoperative complications and operative mortality rates than other bariatric procedures. Metabolic complications occasionally require re-operation to lengthen the common channel.
WHAT TO EXPECT AFTER GASTRIC BYPASS SURGERY
The operation usually lasts between 2-5 hours depending on prior operations, and the usual uncomplicated hospital stay is between 2 and 4 days. The first office visit after hospital discharge is usually 7-20 days after the operation. Subsequent visits occur at approximately 3 months, 6 months, 9 months and 12 months after the operation. You will go home on a diet of pureed foods and liquids until the first visit.
After that visit you will expand your diet gradually to normal foods based on your individual tolerance. After the first visit you will be asked to start multivitamins with additional iron and calcium supplements. After the second visit you will be started on vitamin B12 replacement which you must continue for the remainder of your life.
WHAT TO EXPECT AFTER ADJUSTABLE GASTRIC BAND (LAPBAND) SURGERY
The operation usually lasts between 1-2 hours, depending on prior operations and your weight. It may be done as an outpatient or with an overnight stay. You will go home on a liquid diet for 2 weeks and will be on a soft diet for an additional 2 weeks.
Your first follow-up will be an appointment 6 weeks after banding. After this you will have a follow-up appointment every month for 6 months, every other month for 6 months, and every 3 months thereafter.
Weight loss is determined solely by the amount of food you eat and the amount of exercise you pursue after your operation. The operation does not ensure weight loss; it only makes it more likely for you to be successful in your efforts. After massive weight loss, one problem often remains: large amounts of excess skin around the abdomen, arms, legs, breasts and face. Because the skin has lost its elasticity, it fails to shrink back to its former shape and size. The only solution is plastic surgery. Many centers offer body-contouring procedures designed specifically for patients who have lost substantial weight.
WHICH OPERATION IS RIGHT FOR ME?
In general, the gastric bypass operation is a longer and more difficult procedure with a higher risk of complications. Late complications after the gastric bypass include bowel obstruction and stenosis, or narrowing of the bowel. Nutritional problems, such as vitamin deficiencies may occur after the bypass operation.
The adjustable band operation, in comparison, takes about 90 minutes and may be done as an outpatient or with an overnight stay in the hospital. Early complications include bleeding and infection.
Late complications may include band slippage requiring re-operation, erosion of the band into the stomach, impaired motility (squeeze) of the esophagus, and dilation (or stretching) of the pouch. Minor complications may be more common with the band than with the bypass. This might include pouch enlargement requiring temporary deflation of the balloon or problems with the port requiring replacement.
To get the best results with the band, frequent adjustments are necessary. This means that weight loss after banding requires frequent and close follow-up, and a much more active involvement by you and your surgical team.
Weight loss is more rapid after the gastric bypass. Because of this, other health problems such as diabetes tend to improve more quickly after gastric bypass than after the adjustable band.
Young women who wish to have children may prefer the adjustable band, as it can be loosened during pregnancy. On the other hand, those with severe diabetes may wish to have the more rapid weight loss and quicker improvement in diabetes found after gastric bypass. It’s important to take the opportunity to research your options and discuss them with your family and your surgeon.
Bariatric Surgery in Mexico City
About the Author
Dr. Torres-Villalobos is the director of the Obesity Surgery Clinic in the Medica Sur Foundation. He specializes in bariatric surgery including gastric bypass, adjustable gastric banding, gastric sleeve and revisional procedures. He trained at the University of Minnesota Medical Center doing two fellowships, one in Minimally Invasive Bariatric Surgery and another one in Advance Laparoscopic and Bariatric Surgery. He is one of the small numbers of surgeons in Mexico with formal fellowship training in Bariatric Surgery in the USA. Dr. Torres-Villalobos also works at the National Institute of Medical Science and Nutrition “Salvador Zubiran”, a world known institution for research and academics. Dr. Torres-Villalobos is fluent in Spanish and English. Dr. Torres-Villabos may be reached at: email@example.com.