This blog provides free general information for anyone who is seeking to understand more about the different procedures or options available for weight loss, not intended as a medical consult. Please seek proper medical advice for individual assessment and management.

The crucial learning points are:

• Recognize that there are currently different endoscopic and surgical procedures to achieve weight loss.
• Recognize that there will always be new innovations and ideas to improve on the current forms of bariatric surgeries. However a lot of these newer operations are still in their infancy stage and considered experimental at this stage.
• Each of these procedures have their distinctive advantages and disadvantages and careful consideration is needed before it can be recommended to the patients.

Please refer to the section on “Roux Y gastric bypass” for further information on the malabsorption side effects.

The need for bariatric surgery

Morbid obesity (like Type 2 diabetes mellitus) is now considered to be a chronic disease. In other words with central obesity there is ongoing chronic inflammation and metabolic damage to various organ systems, which lead to development of obesity related medical problems (such as glucose intolerance/insulin resistance, Type 2 diabetes, hypertension, dyslipidaemia, accelerated atherosclerosis, endocrine dysfunction, etc.), which leads to further accumulation of central/visceral body fat, which in turn leads to the development of metabolic syndrome and cardiovascular complications, more weight gain and more visceral fat, a perpetual negative vicious cycle.

It has been established that bariatric surgery is the only proven effective therapeutic measure for those with morbid obesity (BMI>40) or severe obesity (BMI>35) with associated medical problems in the Caucasian population.

The understanding of the science of obesity and its related adverse health consequences helps us to understand the need for bariatric surgery. Today there are many bariatric procedures or variations available and each has its own individual merits. However it is sometimes easier to determine who would be a good candidate for surgery than to determine which procedure is best for the individual patient or how to assign patients to a specific bariatric procedure, especially when it comes to revisional bariatric operations.

The current accepted bariatric operations include:

• Laparoscopic gastric band
• Laparoscopic sleeve gastrectomy
• Laparoscopic Roux Y gastric bypass
• ? Laparoscopic duodenal switch procedure

Naturally with the passage of time, ongoing research and the development of new medical technology, a lot of innovative procedures have emerged on the market recently and even being promoted. Some has raised a lot of concerns amongst the medical communities.

Amongst some of the newer weight loss options available are:

• Endoscopic intragastric balloon
• Endoscopic duodenal-ileal barrier
• Laparoscopic gastric greater curve plication
• Laparoscopic gastric band with gastric greater curve plication
• Laparoscopic minigastric bypass or omega loop gastric bypass
• Laparoscopic sleeve gastrectomy with duodenal jejunal bypass
• Laparoscopic sleeve gastrectomy with duodenal ileal bypass

Needless to say that the bariatric surgeon’s experience and explanation of the different types of operations during the consultation is invaluable in providing the patient with an unbiased and balanced perspective, in order to help them make an informed decision about the correct choice of bariatric surgery.

In the end the decision about which intervention is better and which one to recommend to patients often comes down to whether foregut bypass is necessary or not, the long term metabolic consequences, potential complications and intensity of follow care (that is needed with the more radical surgeries).

The choice of bariatric surgery

The independent metabolic effect of surgical procedures such as the laparoscopic sleeve gastrectomy has been extremely beneficial for long term sustained weight loss and resolution of obesity related medical co-morbidities compared to a purely restrictive operation such as the gastric band.

The concern amongst some surgeons (especially those who favours a form of foregut bypass procedure) is that a sleeve gastrectomy alone does not provide adequate weight loss results and there is a potential for weight regain (recidivism) in the long-term compared to Roux Y gastric bypass. This has led to the development of innovative surgical bypass procedures (as listed above) but it is emphasized that many are still considered experimental and controversial.

However it is safe to say that the laparoscopic sleeve gastrectomy is still the preferred primary bariatric procedure in many countries outside North America and especially in Asia. This is due to a high incidence of gastric ulcer and malignancies in the remnant stomach in Japan and South Korea, where the Roux Y gastric bypass or omega loop gastric bypass has its disadvantages.

For our local community in Australia, the many advantages of a sleeve gastrectomy in terms of its effective excess weight loss results, resolution of medical co-morbidities, the patient’s satisfaction, meal tolerance, quality of life, less long term metabolic consequences (dumping syndrome, nutritional deficiencies, marginal ulcers and internal hernias) and the ease of post op follow up, is still very hard to beat.

For now the sleeve gastrectomy with intestinal bypass is only done in a trial setting where the long-term consequences need to be studied closely before it can be recommended either as a primary or revisional bariatric procedure.

However being aware that there are other endoscopic or laparoscopic (operative) procedures available is important in order for physicians, surgeons and patients to appreciate the advantages and disadvantages of each.

Non-operative interventions

The endoscopic intragastric balloon

With a gastroscope a silicone balloon is inserted into the stomach fundus and usually inflated to over 500-600mls to induce a fullness sensation or early satiety to cause a reduction in food/calorie intake. From some research studies, ghrelin is reduced as well.

Weight loss is better compared to lifestyle modification and drug therapy alone but less than the results achieved after bariatric surgery. Up to 30% of patients can achieve >25% excess weight loss if they are compliant to diet and behavioural modification.

The advantage is that this is not a surgical procedure and is totally reversible. A second balloon treatment may be possible (a repeatable procedure) or maybe a better indication is for the balloon to be used as a bridge to definitive bariatric surgery.

The disadvantage is that this procedure is recommended for those in the lower BMI range (perhaps BMI>27-30) and the balloon need to be removed after 6 months. Weight regain is common after removal and some (up to half of patients) return to baseline weight within 1 year (especially for those with a starting BMI>35).

The endoscopic duodenal-jejunal bypass liner or barrier

With a gastroscope, a 60cm long impermeable sleeve like device is placed in the duodenum and jejunum for up to 12 months to prevent absorption of calories and fats. Currently this is an experimental procedure for obesity and Type 2 diabetes.

The advantage is that this is an endoscopic procedure, which allows foregut nutrient diversion without requiring the patient to undergo surgery.

But reports indicates that although there may be potential for control of weight and type 2 diabetes in the short term, weight loss seems to be temporary (especially for those with a higher BMI>40) and the benefits for patients with type 2 DM is not sustainable. The patient’s dietary compliance and quality of life is mostly unknown.

Operative interventions

Laparoscopic gastric greater curve plication

This is where a long tubular stomach is created by in folding of the greater curve of the stomach (from fundus to antrum) on itself using two rows of non absorbable sutures instead of transecting the stomach excess. This creates a smaller gastric volume restricting the capacity for food/calorie intake and allows early satiation mimicking the sleeve gastrectomy.

The advantage is in the cost saving in terms of consumables or surgical devices used and that it is potentially a reversible procedure, where the sutures can be removed and the stomach return to its normal size and shape. Plication avoids staple line complications (such as haemorrhage, leaks, strictures, reoperations) that may occur with sleeve gastrectomy.

The weight loss after one year is poor and less than expected compare to the sleeve gastrectomy. The best report is 57% excess weight loss at 3 years.

At the present time, gastric plication is not considered to be superior over the conventional sleeve gastrectomy. Rare complications include gastro-gastric hernia and the sustainable long-term weight loss results are yet to be ascertained and there is possibility of weight regain over time due to gastric dilatation.

Laparoscopic gastric band with gastric greater curve plication

This is a combination of standard laparoscopic adjustable gastric band insertion followed by gastric greater curve plication below the band, over a 36Fr calibration tube. This allows adjustment as well as restriction similar to the greater curve plication described above.

The pioneering surgeon reported better first year and second year results compared to band alone or gastric plication alone.

The disadvantages are mostly related to the gastric band, incurring the cost of inserting the device, multiple follow up visits necessary for band adjustments and the need for revisional surgery for band or port related problems. So far this procedure is considered experimental and is in its infancy stage.

Laparoscopic omega loop gastric bypass

The other name for this procedure is minigastric bypass or the single anastomosis gastric bypass. An elongated gastric pouch is divided (not resected) from the rest of the stomach and anastomosed to the jejunum (the alimentary limb) about 200-250cm from the duodenal-jejunal (DJ) flexure.

The advantage over Roux Y gastric bypass is that the procedure only involves one anastomosis, hence it is technically easier, reduces the operating time, avoiding small bowel anastomotic complications (such as leaks, internal hernia, small bowel obstruction) and has less revision rate in the long term.

The main disadvantage is the potential for bile reflux into the stomach and distal oesophagus with the risk for chemical/bile gastritis or potentially toxic mucosal damage to the oesophagus. The remnant stomach is excluded and can’t be surveyed with a gastroscopy, a concern for patients who have a higher risk to develop gastric stump cancers later in life, especially for those who live in countries such as Japan and South Korea.

The omega loop gastric bypass has the potential for protein calorie malabsorption as well as the micronutrient deficiencies similar to the long limb Roux Y gastric bypass. Lifelong blood tests and multivitamin plus trace mineral supplements are necessary.

Laparoscopic sleeve gastrectomy with duodenal jejunal bypass

After the sleeve gastrectomy is created, the first part of the duodenum is divided and anastomosed to the jejunum (the alimentary limb) 150-200 from the DJ flexure. The patient’s BMI often determine the length of the alimentary limb to tailor the amount of nutrient diversion or malabsorption from the foregut.

The addition of a bypass procedure is postulated to reduce the revision rates for inadequate weight loss, weight regain or recidivism, offering the advantage of foregut diversion similar to the Roux Y gastric bypass or minigastric omega loop bypass.

The advantage is that the remnant stomach is resected to avoid the need for surveillance. The pylorus is preserved, reducing the risk for dumping syndrome and possibly reducing the risk for iron, calcium, B12 and protein malabsorption as well.

This procedure is logical, very sensible and is currently being studied as a possible alternative to Roux Y gastric bypass.

Laparoscopic sleeve gastrectomy with duodenal ileal bypass

After the sleeve gastrectomy is created, the first part of the duodenum is divided and anastomosed to the ileum (the common channel) 250cm proximal to the ileo-caecal valve. This is a form of modified duodenal switch procedure.

The operation, advantages and disadvantages are very similar to the one described above.

 

Conclusions

This blog introduces the readers to few of the newer operations and possibilities, not a comprehensive analysis of all the bariatric operations available.

No doubt the lists of possible surgeries to combat morbid obesity and metabolic syndrome will increase in the future.  Only with vigorous research and longer duration of follow up, will one procedure prove to be more effective than others and hopefully it is also the one with the least undesirable side effects.

 

The many different options or the different type of bariatric surgeries does not take away from the fact that success does not depend on the choice of operation alone.  It is very much a co-operative effort from the family practitioner, physician, surgeon, dietician, exercise physiologist and most importantly the patient’s compliance and determination to affect a permanent behavioural modification and attitude change towards eating.

Thorough pre-operative assessment is important to assess each patient’s expectation, motivation and understanding of bariatric surgery. Failure of weight loss maintenance may be traced back to many factors and revisional surgery is not the solution to all cases.

The other important factor to consider is the duration and frequency of follow up visits. With gastric bands multiple initial visits are necessary for band adjustments (a study from Melbourne reported that a minimum of 13 band adjustments are needed to achieve 50% excess weight loss in the first 2 years) and there is a high re-operation rate in the long term. With gastric bypass ongoing visits to screen for micronutrient deficiencies are necessary to ensure adequate replacements.

In parts of Australia limited access to research facilities or specialized bariatric surgeons, the long travelling distance is prohibitive to long term follow up and emergency surgery may not available if an acute complication arises. Therefore patients should consider all pertinent factors carefully before deciding on which bariatric procedure suits them best.