Which bariatric surgery is the best for me?

a chapter by Dr.Kular, Founder President International MGB-OAGB Surgeons Organisation.

 

Everyone wants to be fit and run away from obesity as fast as possible. We are always in search of a method which can make our transition from “a heavy person” to “a thin person”, but, we want a smooth and a safe medical journey. If we get a method which can be claimed to be safe, simple and effective, every obese person would like to undertake that. There are more than 30 odd types of bariatric/weight loss procedures commonly available and no single procedure can be claimed to be the best. Still, there is a lot of controversy in Bariatric surgery. When we start our search for the best weight loss/bariatric surgery, there are quite a few questions which arise in our mind frequently;

 

Which bariatric surgery is the safest?

Which weight loss surgery is the best?

Which Gastric bypass is safe?

How much weight will I lose after bariatric/weight loss/gastric bypass/gastric sleeve surgery?

What are the chances of gaining weight after weight loss/ bariatric surgery?

What is the risk involved in weight loss/bariatric surgery?

What are the complications/side effects of weight loss or bariatric surgery?

Who is the best surgeon for bariatric or weight loss surgery?

Which hospital is best for weight loss/bariatric surgery?

Should the bariatric/weight loss surgery be reversible?

Can the bariatric or weight loss surgery be re-done in cases of weight regain?

What are the long-term changes or side effects we can have? How to avoid these?

 

 

Here, we will try to answer all the above questions. We need to look into the experience and results/data coming from the different corners of the world, and then we compare all this and come to the conclusion. We need to focus and define our needs and expectations from a bariatric / weight loss procedure;

 

Safety, Efficacy, Durability & Reversibility – Do we need all of these?? Yes??

 

Safety/ Low Risk – There is no controversy that all of us would like to have a low risk bariatric/weight loss surgery if it is available. Okay, now, what is it that brings risk to the bariatric/ heavy patients? Why should obese patients have risk involved in surgery?

 

Surgery & anaesthesia duration – The need for surgical procedures with short surgical and anaesthesia time; “WE NEED PROCEDURE OF A SHORT DURATION”

 

Many Morbidly obese patients have a cocktail of medical diseases like sleep apnea, high blood pressure, diabetes, underlying cardiac disease, breathlessness, high blood cholesterol, more chances of clot formation in the blood. Some super obese patients can barely walk. So, we need a procedure, which should be short, thus less amount of anaesthesia helping the patient getting out of the bed faster & thus fewer chances of clot formation in the legs further preventing these clots to move up into the lungs. Here is the average timing of the common surgical procedures when we look into the data available worldwide;

 

Laparoscopic Gastric Band: 30 – 60 mins

Laparoscopic Gastric Bypass (Roux-en-Y): 1.5 hours – 3 hours

Laparoscopic Sleeve Gastrectomy: 1 hour to 1.5 hours

Laparoscopic Mini Gastric Bypass:  30 – 60 mins

Laparoscopic Duodenal Switch: 2.5 hours to 4 hours

Laparoscopic Biliopancreatic diversion: 2 hours to 4 hours

Laparoscopic Ileal interposition with or without sleeve gastrectomy (IP): 4 hours to 8 hours

 

It is simple to make out which of the above procedures takes less time and thus less anaesthesia and hence would help the patient come out of anaesthesia quickly and make them able to walk early, thus decreasing all the risk involved.

 

 

Surgical and anaesthesia timings results;

 

  1. Gastric band and Mini Gastric Bypass - Shortest

  2. Laparoscopic Sleeve Gastrectomy - Medium

  3. Laparoscopic RNY Gastric Bypass –  Long

  4. Others – Further Longer.

 

So, no controversy on the issue of the surgical and anaesthesia timing!

 

Minimizing the leaks - Which surgery has the lowest leak rate? –Will depend on the following factors;

 

a. "Number" of surgical joints(anastomosis) in the procedure.

b. What is the pressure being generated inside the new small stomach? Procedures with smaller stomach pouches and tighter outlets will have higher internal pressure after eating.

c. Is there any impinging foreign body on the new gastric pouch, causing erosion and external pressure on the new stomach?

 

Number of Joints;

 

Laparoscopic Gastric Band: 0 joints + Foreign body in the form of the synthetic band + High pressure in the pouch because of the tight outlet after banding.

Laparoscopic Gastric Bypass (Roux-en-Y): 2-3 joints, no foreign body, low pressure

Laparoscopic Sleeve Gastrectomy: 0 joints, no foreign body, highest pouch pressure (tight and long tube with tight natural pyloric valve at the outlet)

Laparoscopic Mini Gastric Bypass:  1 wide joint, Minimum pressure, widest outlet, no foreign body.

Laparoscopic Duodenal: Multiple joints, no foreign body, low pressure

Laparoscopic Biliopancreatic diversion: Multiple joints, low pressure, no foreign body

Laparoscopic Ileal interposition with or without sleeve gastrectomy (IP): Maximum joints, no foreign body.

 

Results;

 

Mini Gastric bypass stands out as it has Minimum internal pressure, widest gastric outlet, no foreign body and only one joint. This one joint is the Stomach to the Intestine joint(Gastro-jejunostomy), which has the minimal reported leak rates when compared to other joints like intestine to the intestine, or joints under the bands or rings. (Reason – Stomach is more vascular and thus stomach intestine joints heals better than others)

 

 

Efficacy and durability – Which bariatric procedure is the most effective and durable?

 

Efficacy comes from the underlying mechanism which is working for a particular surgery –

 

  1. Purely restrictive procedures – Makes you eat less.

  2. Restriction+ decreased absorption  - Makes you eat less & also absorb less.

 

Gastric band and Sleeve Gastrectomy – “Restriction only” procedures.

 

RNY Gastric bypass, Mini Gastric Bypass (MGB) are “combination procedures” – Restriction + Decreased Absorption

 

BPD & DS– Mainly mal-absorptive.

IT – Mainly altered absorption.

 

 

Durability – If the small pouch after bariatric surgery starts dilating or growing big – you are bound to gain weight. What causes the pouch to enlarge in size after years of bariatric surgery? It is the internal pressure of the pouch.

 

Data on the pouch pressures;

 

As per an Italian study, the pressure in Mini Gastric Bypass/ one anastomosis gastric bypass is low. Thus, we expect the pouch to dilate less over a period of time. Also, these patients would have less nausea and vomiting.

 

 

Long-term weight loss – All the studies show Mini Gastric bypass resulting in maximum long-term weight loss, even better than RNY Bypass. Purely malabsorptive procedures like BPD, Duodenal switch etc. also give good long-term weight loss, but, higher deficiencies owing to more malabsorption.

 

So, combination procedures tend to give us a good long-term weight loss and fewer chances of deficiencies as compared to purely malabsorptive procedures.

 

 

Should the bariatric procedure be reversible or not?

 

As a matter of common sense, we would not like to burn our boats. The commonest question after bariatric / weight loss surgery is …am I disturbing the natural system too much? Should it be done or not? What if I lose too much?? What if I want my system back…. means reversal?

 

Where is the need for reversal??

Psychological reasons – If you feel too much tight after bariatric surgery. Making the stomach smaller in size is the basic mechanism in all the procedures. What if it seems too tight to you? Can we reverse it? If there is a procedure available, that can be easily reversed, all of us would like to opt for that.

 

Too much weight loss – What if you lose too much of weight? Need to reverse in case of such rare happening??

 

Mini Gastric Bypass is reported to be an easily reversible procedure.

Gastric band is reversible – but, impacted bands are the difficult most to take out.

 

What if you gain weight after bariatric surgery? All of us know that bariatric surgery is a big help for weight loss, but no procedure is a guarantee for lifelong weight loss – We have patients who can have 10 bottles of soft drinks, multiple chocolates in a day, take sweet tea like 10 times a day?? This is too many calories; any procedure will start giving way in such difficult patients. How can we change our lifestyle permanently?? If you are addicted to sugars or high calories, you got fair chances for weight regain. But, what a doctor should be able to do for you in such a scenario?? – Revising the pouch, increasing the length of the bypass etc.

 

Mini Gastric bypass has been reported to be an easily revisable procedure.

Sleeve gastrectomy can be converted to a gastric bypass or a mini gastric bypass.

RNY Gastric bypass revision is more complicated as compared to the above two.

 

 

 

What are the long-term changes or side effects we can have? How to avoid these?

 

It’s very simple to understand that after bariatric surgery you get a substantial weight loss. It’s usually like one person getting out of your body. What will happen to your body after such high weight loss?? You can become weak and can have deficiencies of certain nutrients.

 

What to do?? Don’t go in for bariatric surgery, lol! and keep carrying that extra weight on your back and live with this punishment for life. In addition to this lot, many obesity-related diseases catch you, like diabetes type 2, breathlessness, heart attacks, high cholesterol, stroke, sleep apnea etc.

 

How to handle the deficiencies after bariatric surgery??

 

  1. Vitamins – But, mind it only vitamin or tablets are not going to do everything. Vitamins are required as supplements, but, these are not a replacement for diet.
     

  2. Healthy, balanced diet – If your body keeps getting enough nutrition, we should see no deficiencies. Thus, one needs to understand that we want to lose weight, but not lose bones and the muscle. So, we should take the adequate protein and the calcium from our diet, like milk, non-veg food, soybean, lentils/legumes etc. Our diet department will help you train in the diet management after bariatric surgery. Also, some exercise is required to save the muscle from getting wasted.

 

 

If I have to still do exercise and watch my diet…. where is the fun getting the bariatric surgery done??

 

Bariatric surgery is a tool…a strong tool which will get you to your target easily. It is easy to maintain afterwards, but, everything needs some maintenance. Morbidly obese patients carrying so much of extra weight cannot run for hours every day, cannot keep dieting for rest of the life….it has been well studied by science that once you are entrapped in Morbid Obesity, the exit is not that easy….and that’s the reason why we generally don’t see an obese patient becoming thin on his own for rest of the life. This is the reason…...why we need Bariatric Surgery, but a safer one!

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Dr. Kular is the founder President of MGB & OAGB International Surgeons Association  OSSI Executive;

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