Bariatrics for weight-loss: Promises to keep
Bariatric surgery has become the treatment of choice for millions of patients who suffer of morbid obesity and need to lose the extra weight for medical reasons. Moreover, the results of bariatric techniques are quite spectacular both as to weight loss and the improvement of overall health as bariatrics seem to be able to “take away” chronic diseases such as diabetes mellitus, sleep apnoea and gastroesophageal reflux. This is why more and more obese patients tend to take recourse to bariatric surgery as they consider it as an ideal solution to their problem. However, most of them know little about these procedures.
“Nowadays, we apply four different surgical techniques for treating morbid obesity. The most popular, if I may say so, are the “Roux-en-Y” gastric bypass and the gastric sleeve surgery. Both procedures aim at reducing stomach size. Another procedure is the gastric band, which is simple but has proven to be less effective and is, therefore, less preferred. Finally, the biliopancreatic diversion is also a drastic solution, explains Dr. Dimitris S. Mousiolis, General Surgeon – Bariatric, Laparoscopic, Colorectal Surgery (www.dmousiolis.gr).
It is quite impressive that the two most popular bariatric techniques applied today were actually discovered by chance. Roux-en-Y gastric bypass was initially developed as a treatment for stomach ulcers, as it involves the removal of the larger part of the stomach followed by the connection of the remaining segment of the stomach with the small intestine. When Dr Edward Mason of the University of Iowa applied the technique on an obese female patient in 1966, he discovered that she started to lose weight. Thereafter, he started operating upon patients with morbid obesity aiming at weight loss. However, Roux-en-Y gastric bypass was rendered even safer around the end of the 1990s, when surgeons were able to apply this procedure via laparoscopy.
The gastric sleeve was discovered in 2000, when Dr Michel Gagner, a then surgeon at New York’s Mount Sinai Hospital, was called to operate on a severely obese female patient. During the first stages of the surgical procedure the patient developed oxygen deficiency and the surgeons had to halt the procedure and close. By that stage, Dr Gagner had only managed to cut out the largest part of the stomach, leaving behind only a small sac. He believed the operation had failed, but, to his great surprise, the patient lost a lot of weight after the procedure.
According to Dr. Mousiolis, “the gastric sleeve is currently the surgical procedure of choice for morbid obesity. Through laparoscopy, the surgeon removes part of the stomach and shapes the remaining muscle into a tube that looks like a sleeve. This reduces the size of the stomach and consequently eliminates the feeling of hunger, as the portion of the stomach that is removed is the one in which ghrelin, the “hunger hormone”, is produced. The entire surgical procedure requires general anaesthesia and lasts approximately 3 hours. The patient is then transferred to a room for recovery and follow-up and stays in the hospital for approximately 4 days to receive parenteral nutrition. The patient has no post-operative pain and is mobilized immediately after surgery. After a period of 30 days of adjusted diet (mostly puree and soft foods, as well as plenty of liquids), the patient may eat almost all foods but in very small quantities. After six months, the patient is able to easily handle small portions of food as stomach has grown to a limited but expected post-op size. The patient’s stomach will never grow back to its pre-operative size. It is important to keep in mind that weight loss is fast without the patient feeling hungry or being in need of strict medical follow-up”.
Contrary to the above, in Roux en-Y gastric bypass the stomach is divided just below the cardioesophageal junction to form a small gastric pouch of approximately 30 gr capacity. The pouch is then connected to the small intestine. Gastric fluids circulate through a gastrojejunal anastomosis and the digestive system resemble to the letter Υ. Depending on the length of the deviated small intestine, there are several variations for a gastric bypass. This technique offers significant freedom in diet and greater weight loss compared to the gastric band.
“The adjustable gastric band was invented in 1983 by Lubomir Kuzmak and applied for the first time via laparoscopy in 1992 by Dr Mitiku Belachew. The first decade of the 21st century saw a mass increase of gastric band procedures. Namely, the gastric band, composed of a biocompatible, silicon-like material, is placed around the top portion of the stomach shaping it into an ‘hourglass’. The band fills up with liquid through a port that is implanted into the subcutaneous tissue of the abdominal wall and, thus, its internal diameter reduces narrowing down the “neck” of the hourglass. This procedure can change a patient’s eating habits completely. After surgery the patient must eliminate all sugar and fat-rich soft foods and liquids from his diet as these foods can pass through the band and the patient will keep eating until he or she feels full. The patient must also learn to chew his or her meals well and stop eating as soon as he or she feels full. These rules must become part of daily routine, otherwise the body will react through vomiting, which will jeopardise the outcome of the procedure. Patients with gastric band must be followed-up regularly until their weight settles. Average weight loss is 4 kilos per month” points out Dr Mousiolis.
Finally, biliopancreatic diversion is a procedure that supplements the gastric sleeve by reducing the amount of calories and nutrients absorbed through the small intestine. This is achieved through rerouting of the food stream in the small intestine. This manipulation allows us to reduce the absorbing capacity of the small intestine and leads to significant hormonal and metabolic changes.
“The biliopancreatic diversion is actually a supplement to gastric sleeve and is advised in cases of severely obese patients, as well as in patients with type-2 diabetes mellitus or hyperlipidemia, and specific patient groups (e.g. patients with bulimia). It is also a procedure of choice when all other weight loss procedures have failed”, points out the doctor.
Last but not least, Dr Mousiolis adds that “every candidate for bariatric surgery should bear in mind that these procedures must only be performed by surgeons with great experience in gastrointestinal surgery, working with a qualified team in well-equipped operating facilities and offering long-term follow-up services. One should not forget that, as with all other surgical procedures, bariatric surgery involves a relevant risk of complications. Therefore, the candidate patient must be well informed before selecting the appropriate surgeon and, thereafter, doctor and patient together must discuss and agree upon the appropriate technique for treating the problem”.
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