Bariatric surgery is very popular right now for people who are considered morbidly obese and have tried other weight loss programs and diets but have not been able to lose the weight needed to get them closer to a healthy weight. This type of surgery is not to be taken lightly as there are risks when any surgery is performed. There are also complications and side effects of surgery that need to be understood before someone really looks to this type of procedure to lose weight.
Several different procedures can be performed however we will discuss the two most popular types of bariatric or weight loss surgery that are performed today. We will discuss what the prerequisites are to be considered for this type of surgery as well as the workup and information that needs to be imparted on the patient considering this. We will also discuss the potential complications for each type of surgery and what if any reversals can be done. This type of surgery is designed for people who are morbidly obese, especially those who are at least 100 pounds overweight and are in reasonably good health otherwise.
The first type of surgery discussed today is gastric bypass surgery. It is commonly called the “stomach stapling procedure” by most laymen. In this procedure, the largest portion of the stomach is stapled off and a small pouch is formed that holds approximately ½ cup of food at a time. This procedure is considered safer than procedures in the past where the rest of the stomach was removed completely during surgery. The intestine is then rerouted to a lower area of the small intestine which reduces the number of nutrients that are absorbed by the body. This procedure works both on the premise of restricted amounts of food and drink taken in and promotes reduced absorption of nutrients, which both promote weight loss.
Some advantages of this procedure are that in clinical studies average excess weight loss with this procedure was 75-90% when checked over one to five years postoperatively. Long-term maintenance of ideal weight can be achieved by the patient as long as they adhere to the diet and routines that are given to them to use after surgery.
Some of the drawbacks of this surgery are that the stomach can be stretched out again if the patient does not stick with the diet prescribed after surgery. This includes large amounts of liquids as well as foods. Malabsorptive procedures can cause issues such as malnutrition, anemia, and bone disease have been reported. The patient will need to take multivitamins with iron and minerals to get all the nutrients that their body needs to be healthy. This procedure can weaken the immune system due to fewer nutrients being absorbed, so patients risk succumbing to viral and bacterial infections. Patients complain of liquid and frequent stools after surgery, which does regulate itself with time in some patients. Gall stones are frequently found after this type of surgery and the gall bladder may need to be removed if this happens. This type of surgery is harder to reverse than the next surgical procedure that we will discuss.
The second type of surgery is newer and is reportedly safer to use as it can be adjusted or reversed without undue complications if needed. It is called lap band surgery and it is the most popular type of weight loss surgery at this time due to the facts stated above. The lap band is a restrictive band that is placed around the top of the stomach and separates the stomach into two parts. This makes the person feel full after eating small portions of food. In this type of procedure, the digestive process is not bypassed but digested normally. The person just cannot eat large amounts as they did before.
The restrictive bands can be adjusted as needed to be more or less restrictive as needed for the particular patient. This surgery is easily reversed as well which does not leave patients with the long-term decreased absorption of nutrients as the earlier surgeries caused in patients.
The main issues with this surgery are that leakage can occur around the band, nausea and vomiting can occur, and the band can slip or migrate to a place it should not be in. If this does take place, the band can be adjusted with a minimally invasive procedure whereas the previous surgeries could not be fixed this way.
There have been many surgical approaches to obesity. Most surgical procedures for the treatment of serious overweight may roughly be classified as either being directed toward the prevention of absorption of food (malabsorption), or restriction of the stomach to make the patient feel full (gastric restriction). Jejunoileal bypass, the first weight loss surgery is undertaken thirty years ago, has now been abandoned because of severe complications such as poor subsequent malnutrition, fatal cirrhosis, or renal failure.
Biliopancreatic by-pass, gastric by-pass, and gastric partitioning (stapling) are the current weight loss surgeries, but the long-term side effects have not yet been determined. The most common malabsorption and gastric restriction surgical technique is the gastric bypass. For example, some overweight patients have received implantation of one or more bulking prostheses to reduce stomach volume. The prosthesis limits the amount of food the stomach can hold and as a result, causes the patient to feel full.
Another weight loss surgery is a restrictive method, which surgically makes the patient’s stomach smaller by removing or closing a section of the stomach. This surgical procedure also causes the patient to feel full.
Another surgical procedure for weight loss is the gastric bypass procedure. Open gastric bypass surgery is a surgical procedure used to decrease the size of a patient’s stomach, which includes transecting the patient’s stomach and constructing a pouch from a portion of this stomach as well as connecting the pouch to the intestine so that the digested food from the pouch moves into the small bowel. This type of procedure limits the amount of food that is completely digested or absorbed. Although gastric bypass surgery helps to lose weight and relieves life-threatening diseases associated with extreme obesity, there are several major complications that may require additional treatment. Such surgical interventions are very invasive, and each form of surgery may involve complications. Restrictive surgery may entail a risk of vomiting, for example, and gastric bypass surgery may result in unpleasant consequences known as dumping syndrome. Other complications include pouch enlargement, marginal ulceration, and staple line separation (dehiscence).
Endoscopic surgeries used to assist weight loss are primarily focused on the placement of a balloon or other space-occupying device in the patient’s stomach to fill portions of the stomach to provide the patient with the feeling of fullness, thereby reducing food intake. However, such surgeries have been discontinued because, while they were shown to be better than restricted diets in losing weight, their long-term use was associated with severe risks such as gastric ulceration and migration of the balloons into the small intestine resulting in intestinal obstructions.
There are currently two weight-loss surgeries that have been reported to successfully produce long-term weight loss. They include the Roux-en-Y gastric bypass and the biliopancreatic diversion with duodenal switch (BPD). Both surgical procedures reduce the size of the stomach and shorten the effective length of the intestine available for nutrition absorption. Reduction of the stomach size leads to decreased stomach capacity and the ability of the patient to absorb food. Bypassing the duodenum makes it difficult or unable to digest fats, high sugar, and carbohydrate-rich foods.
The most common currently performed weight loss procedure is Roux-en-Y gastric bypass (RYGB). This procedure is highly complicated and is usually utilized to treat people with morbid obesity. One aim of the surgery is to provide feedback to the patient by producing a dumping syndrome if they do eat these fats, high sugar, and carbohydrate-rich foods. Dumping occurs when carbohydrates in food directly enter the jejunum without being first conditioned in the patient’s duodenum. The result is that most part of the fluid is discharged into the food from the intestinal lining. The total effect makes the patient feel light-headed and leads to severe diarrhea.
A successful weight loss surgery is commonly defined as one that results in at least 50 percent excess weight loss within two years. Although advantageous in the long run, the acute risk-benefit ratio of weight loss surgeries has reserved these invasive procedures for morbidly obese patients according to the NIH consensus conference on obesity surgery (BMI greater than 40 kg/m2). Therefore, weight loss surgeries are not an alternative for the majority of overweight people unless and until they become profoundly overweight and are suffering serious attendant complications.
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