CHOOSING THE “RIGHT” WEIGHT LOSS SURGERY PROCEDURE
There are several safe and effective methods of surgical weight loss available today. Each bariatric procedure can offer different weight loss results with differing mechanisms and there is no single surgery that is best for every patient. Currently, “sleeve gastrectomy” will be the procedure of choice for the vast majority of “primary” patients with “uncomplicated” morbid obesity.
TYPES OF WEIGHT LOSS PROCEDURES OFFERED AT ISTANBUL BARIATRICS
There are two “classes” of weight loss procedures:
Restrictive operations: Weight loss is mainly achieved by limiting food intake by reducing the size of the stomach.
Combination of restrictive & malabsorptive operations: Weight loss is achieved both by limiting food intake, as well as limiting the absorption of calories in the intestinal tract by by-passing a portion
of the small intestine. The amount of malabsorption is dictated by the length of the intestine that is by-passed.
Sleeve gastrectomy (SG) is the most commonly performed bariatric procedure all over the world. It certainly became the new “gold standard” among all other bariatric procedures. Also known as the gastric sleeve, sleeve gastrectomy is the most physiologic weight loss procedure with the best risk/benefit ratio. It is also the most “versatile” procedure which can allow a second weight loss procedure (ie: gastric by-pass or duodenal switch) to be performed in the future.
How does Sleeve Gastrectomy work?
During your surgery, we will make 5 millimetric incisions and insert various laparoscopic instruments, and remove about 80% of your stomach. Avoiding a large incision will result in less pain, early mobilization/discharge and return to work about one week after surgery. Surgery leaves a banana-shaped gastric tube, the so-called “sleeve” that secures weight loss mainly by restricting food intake. Stomach capacity is reduced from about 1 -1.5 liters to roughly 120 ml. The total removal of gastric fundus (the upper part, “the dome” of the stomach) reduces both fasting and the postprandial blood level of the hormone “ghrelin” (hunger-stimulating hormone). Ghrelin levels will be reduced because this hormone is mainly produced in the gastric fundus.
Following surgery, patients will eat less and will not crave between meals because appetite will also be reduced. Sleeve gastrectomy enables the patient to diet properly for extended periods of time. It is now also shown that it has a similar effect on type II diabetes compare to gastric bypass.
The advantages of Sleeve Gastrectomy:
Fastest weight loss procedure allowing “shorter” operations.
The easiest surgical weight loss method with the lowest complications.
Average first-year excess weight loss (EWL%) is 87% in our series.
EWL% and type II diabetes control at 5 years are similar to gastric bypass.
The decrease in blood Ghrelin levels (the appetite hormone).
Further and fast weight loss due to immediate appetite control.
Controlled portion sizes.
Less pain (usually pain medication is needed for only a couple of days).
Shorter recovery time (most return to work in 1 week).
Decreased nutritional deficiency because the intestine absorbs normally.
No dumping syndrome as seen after the gastric-bypass/duodenal switch.
Significantly less complications than gastric-bypass/duodenal switch.
Easy convertability to all other procedures.
Any disadvantages of Sleeve Gastrectomy?
None! Only in patients with severe gastroesophageal reflux disease, sleeve gastrectomy may worsen the reflux symptoms. Rarely de-novo reflux may occur after a narrow sleeve which may require medications. So probably in patients having severe erosive esophagitis or patients having Barrett’s esophagus with dysplasia, a gastric by-pass may serve better.
Gastric Bypass (Roux-en-Y gastric-bypass)
First, a small stomach pouch, approximately one ounce or 30 ml in volume, is created by completely dividing the top of the stomach from the rest. Next, the first portion of the small intestine is divided and one part of this divided small intestine is brought up and connected to the newly created small stomach pouch. The other part of the divided small intestine is connected to the small intestine further down so that the stomach acids and digestive enzymes from the by-passed stomach and the first portion of the small intestine can eventually mix with the food.
How does it work?
The gastric by-pass works through several mechanisms. First, similar to most bariatric surgeries, the newly created stomach pouch is considerably smaller, and the person can only get significantly smaller meals, which means fewer calories are consumed because of restriction. Additionally, as there is a segment of small intestine with no food going through it, there is less absorption of calories and nutrients.
Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse the primary mechanisms by which obesity induces type 2 diabetes.
Enables significant weight loss comparable to sleeve gastrectomy (65% excess weight loss at 5 years).
Restricts the amount of food that can be consumed.
Produces favourable changes in gut hormones, which reduce appetite and enhance satiety.
Very effective to treat “reflux” in the case of severe GERD or Barrett’s.
The remnant 90% of the stomach cannot be endoscoped and permanently unreachable without intervention.
Technically more complex and challenging than sleeve gastrectomy, and has higher complication rates.
Can lead to long-term vitamin/mineral deficiencies, particularly in vitamin B12, iron, calcium, and folate and therefore requires strict adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance.
If weight gain occurs, revisional surgery is extremely difficult.
No proven advantage on type II diabetes control compare to sleeve gastrectomy.
Current status of gastric-bypass:
Gastric-bypass is universally being abandoned as a primary weight loss procedure! Numbers being performed are declining worldwide and it is no more considered as the “gold-standard” for primary patients who are the first time candidates for weight reduction surgery. The new “gold-standard” in primary patients is sleeve gastrectomy. Gastric-bypass, however, still is an extremely important operation for re-do’s and in patients with extremely narrow sleeves as a salvage procedure. Currently a newly developed form, the so called “mini” gastric-bypass is under supervision.
Single Anastomosis Duodenal Switch(SADS)
SADS is one of the most complicated weight loss surgeries that induces weight loss by a “sleeve gastrectomy” in addition to an intestinal bypass.
It packs a one-two punch against obesity. It does so by combining two surgical techniques: restriction/Ghrelin reduction and malabsorption optimally combined!
The restrictive and ghrelin reduction component involves “sleeve gastrectomy”. Your bariatric surgeon would divide the stomach vertically and remove around 70% of it. The stomach that remains is shaped like a banana and is about 100 to 150 ml or 6 ounces.
Malabsorption means decreasing the number of calories and nutrients the body absorbs. The malabsorptive component involves rearranging the small intestine to separate the flow of food from the flow of bile and pancreatic juices. Doing so will also allow to by-pass a couple of meters of the small intestine. The food and digestive juices interact only in the last 18 to 24 inches of the intestine, all allowing malabsorption.
The procedure can be performed laparoscopically, meaning that your surgeon makes small incisions as opposed to one large incision.
Why is it done?
Most surgeons will not perform duodenal switch surgery unless you are super-super obese (BMI>60) or you have severe type II diabetes.
That said, this complex surgery does have more complications and still must be considered as an experimental procedure in primary patients until we have long term results. Also, it may not be the right choice for certain high risk individuals, including those with heart failure and sleep apnea. In certain re-do’s however, it can be an excellent option. Our international advisor Dr. Roslin is one of the pioneers and experts of duodenal switch. You will talk to our highly experienced surgeons (including Dr. Roslin if you may wish) to determine if the duodenal switch is right for you.
There is no surgical solution for obesity endemic! Obesity is chronic. It is an unfortunate truth that both surgeons and the patients have to face. Therefore; re-do’s or revisional procedures are being increasingly performed worldwide. Some patients are having their 4th or 5th weight reduction procedures.
And no re-do is easy!
For around 10% of the patients, one weight loss surgery will not be enough to provide satisfactory long-term weight loss and a revision will be necessary if the patient's general medical condition permits. Surgical options will depend on the type of initial surgery or procedures and will be determined after a comprehensive evaluation of the patient, including an upper gastrointestinal fluoroscopy/endoscopy and other diagnostic studies.
Most revision operations are performed laparoscopically, but open surgery may be required depending on the amount of scarring from the prior surgery. This will be discussed and determined during your one-on-one consultation with our surgical team which will certainly include Dr. Roslin from the U.S.
Revision options may include:
Adjustable gastric band to sleeve gastrectomy, duodenal switch or gastric-bypass.
Sleeve gastrectomy to gastric-bypass or duodenal switch
Conversion from prior anti-reflux operation to sleeve gastrectomy, duodenal switch or gastric-bypass.