Bariatric Surgery Information

What is Bariatric Surgery?

Brief History

		This discipline of surgical practice has evolved since the mid-1970’s following the observation that certain types of ‘stomach’ surgery caused permanent weight loss.
		Pioneering surgeons have adopted and modified these procedures for the specific intention of causing weight loss in obese individuals.
		The rapid evolution of keyhole surgery and scientific information has enabled more refined surgical techniques to be developed.

Types of Operations in use (and out of use)

How Surgery helps with weight loss:

To maintain weight, the body needs a fixed amount of food energy per day. This amount can be estimated accurately for any given age, weight, gender and body make-up. If the body gets more than this amount, it increases its fat stores. If the body gets less, these stores are used up.

Reducing Intake

		All surgical weight-loss procedures act by limiting the amount of food that gets into the body through the digestive system - stomach and intestines. This limitation could occur in any of three ways:
		1. Simple mechanical restriction of intake capacity – much like a stopcock or throttle valve
		2. Reduction in the drive to eat (less appetite – more fullness)
		3. Reduction of absorption into the body of food that passes through the intestines
		Most effective operations offer a combination of some or all of these basic mechanisms.

The Choice of Operation

Modern effective operations offer a varying combination of these 3 elements. The following are the most recognised operations. Each of these has advantages and disadvantages, making each suited to a particular kind of patient. Part of the purpose of your assessments is help the Team as a whole advise which may be best for you.

Bariatric Operations are classed into 3 groups:

Restrictive: These procedures cause a physical reduction of the pathway for food in the upper digestive tract. The restriction can be either fixed or adjustable. These procedures require intensive patient coaching and long term follow-up for long term success.

		Vertical Banded Gastroplasty (fixed restriction - not recommended)
		Sleeve Gastrectomy (fixed restriction)
		Adjustable Gastric Banding (adjustable restriction)

Malabsorbtive: These procedures bypass a large proportion of the intestine without influencing the intake of food. Due to a high incidence of long term complications, these procedures are now considered obsolete. Patients with these procedures should be closely monitored for nutritional complications.

Jejuno-ileal bypass (not recommended)

Combined Procedures: A combination of restriction of the upper food pathway with variable length intestinal bypass. These procedures tend to give the best results, but require thorough patient coaching and long term follow-up.

		Roux-en-Y Gastric Bypass
		Bilio-Pancreatic Diversion
		Sleeve Gastrectomy with Duodenal Switch

Other Procedures

		Gastric Balloon (temporary benefit – rarely used due to poor results)
		Gastric Pacing (limited results data)

Surgery Comparison Table

Procedure	Gastric Balloon	Gastric Band	Gastric Sleeve	Gastric Bypass	Gastric Sleeve with Duodenal Switch
Effects	Variable loss of appetite Minimal restriction	Variable restriction Little change in appetite	Moderate restriction Loss of appetite	Moderate restriction Loss of appetite Aversion to sweet foods (dumping syndrome)	Moderate restriction Loss of appetite Malabsorption
Surgical Issues	Endoscopy placement	Keyhole Surgery 4-5 small cuts	Keyhole Surgery 4-5 small cuts	Keyhole - 5-6 small cuts Open - 15-30cm cut	Keyhole - 5-6 small cuts Open - 15-30cm cut
Surgery Risks	Mortality < 1in 2000 Complications 1 in 200	Mortality: 1 in 2000 Complications: Early 1 in 100 Late 1 in 20	Mortality: 1 in 500 Complications: 1 in 20	Mortality: 1 in 200 Complications: 1 in 20	Mortality: 1 in 50-100 Complications: 1 in 10
Hospital Stay	Day-case	Day-case or 1 night	2-3 nights	2-4 nights (keyhole or open)	2-4 nights (keyhole or open)
Recovery	1 day severe nausea for up to 1 wk	1-2 weeks	2-3 weeks	2-3 weeks	2-3 weeks

Expected Weight Loss	10-20% Excess weight	50% Excess weight	50-60% Excess weight	60-70% Excess weight	70% Excess weight
Long Term Effects	Short term only – max 6 months. Weight gain likely on removal of Balloon	Band adjustments necessary for weight loss. Dietary and lifestyle control necessary for success	Loss of restriction in 15% with weight regain. Dietary and lifestyle control necessary for success	Restriction decreases after 1 year to stabilise weight loss. Appetite remains less Dumping may fade after 1 year. Dietary control still necessary	Appetite remains less but able to eat meals. Loose motions with flatulence. Dietary control still necessary
Long Term Problems	Weight regain	Band Failure 1 in 20 ‘flipped port’ 1 in 50 Slippage 1 in 50 Erosion 1 in 50 Band removal 1 in 10	Loss of restriction Return of appetite Further surgery to maintain weight loss	Nutritional deficiency (Iron, Calcium, Vitamins) Internal hernia / Adhesion problems. Incisional Hernia (open surgery)	Protein Malnutrition Vitamin/mineral deficiency (Iron, Calcium, Vitamins A,D,E,K). Internal hernia / Adhesion problems Incisional Hernia (open surgery)
Dietary Supplements	None	None	None	Multivitamin x1 daily Iron + Calcium: If at risk	Multivitamins x3 daily High protein diet Iron + Calcium

Process of Care

How should patients requesting Bariatric Surgery be managed?

Patient Selection (NICE criteria)

The criteria for appropriate use of the above surgical procedures has been thorough international review. In the UK, the National Institute for Clinical Excellence (NICE) have published the following eligibility criteria:
Consider surgery if all of the following conditions are met:

		the person has a BMI of 40 kg/m2 or more, OR a BMI of 35 to 40 kg/m2 plus other significant disease that could be improved with weight loss
		non-surgical measures have failed to achieve or maintain clinically beneficial weight loss for at least 6 months
		the person has been receiving or will receive intensive management in a specialist obesity service, such as psychological support

Patient preparation and counselling

All patients planning to undergo Bariatric surgery require thorough preparation. This should include the following:

		Access to consultation with a physician to determine suitability for surgery.
		Consultation with the operating surgeon to discuss the appropriate procedure and risk management.
		Thorough dietetic counselling for pre-operation preparation and post-operation dietary rehabilitation.
		Psychological assessment or counselling should be offered
		Discussion of their case at a multi-disciplinary team meeting

Aftercare responsibilities of Doctor and Patient

		Post-Bariatric surgery, patients require regular follow-up by the multi-professional team.
		Follow-up should be for a minimum of two years, but a commitment to lifelong care should be offered.
		There should be defined outcome expectations
		There should be defined pathways to manage poor outcomes

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