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What Are Your Weight Loss Surgery Options?

Learn More About Weight Loss Surgery 

Operations for Obesity

We can divide surgery for obesity into procedures that limit intake of calories, such as stomach stapling and gastric banding and procedures that work to disrupt metabolic pathways that lead to obesity such as sleeve gastrectomy and Roux En Y Gastric Bypass. The operations that limit intake are referred to as restrictive procedures and the other procedures are called metabolic procedures.

It is important to remember that surgery is an aid to weight loss and that ultimately it still needs to be combined with lifestyle changes. I am a firm believer that you must develop an addiction to exercise. Primitive man moved all the time and so should you. Our practice has a specialist exercise physiologist to help you start your exercise programme.

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Gastric Band

This operation is a restrictive procedure. The band is a silicon device that can be filled with saline and made tighter as required. It sits around the lower esophagus and there is an anterior gastric pouch to hold food above the band.

Some people believe the band exerts pressure on vagus nerves which results in higher blood levels of Peptide Y. This hormone results in the feeling of fullness. I am skeptical this is the mechanism of action with all people and feel that ultimately most people rely purely on the restriction the band provides. This can be dangerous as it may result in esophageal stretching or dilatation. This results in the esophagus holding greater volumes of food and therefore allowing more calories to be eaten.

A good band is one that is not relied on entirely for weight loss. It needs to be purely used as a tool. Exercise and dietary change is critical with band patients. Successful band patients literally change their entire lifestyle to achieve long-term weight loss and maintenance.

It is important to not become obsessed with the amount of fluid in your band. Everybody has different thresholds in their esophagus to pressure. Somebody with 2 mls may be completely blocked whereas somebody can tolerate 8 mls without a problem. There is no formula for adjustment and it may take some time to get the band perfect.

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THE PRO'S & CON'S

Roux En Y Gastric Bypass (RYGB)

This operation has been around for a very long time. The father of bariatric surgery was Dr Edward Mason. Dr Mason performed gastric bypass for obesity back in the 1960’s. We have more data on this operation than any other.

The gastric bypass involves making a small pouch of around 50 mls. This is also called a fobi pouch. The remainder of the stomach is left behind but will not see food again. It essentially is disconnected from food. We then bring a loop of bowel to the new smaller stomach and join them with a stapler. A further join is made between the small bowel.

In a nutshell we have a small stomach connected to a loop of bowel that will not mix with digestive juices until it reaches the second join between the small bowel. Sounds complex but the operation is actually able to be done laparoscopically and doesn’t involve much malabsorbtion at all. It works mostly by metabolic means, much like the sleeve.

The primary hormonal changes are related to disconnecting the gastric fundus ( a bit like the sleeve which permanently removes this part of the stomach). As you remember disconnecting the fundus reduces Ghrelin levels which decrease appetite. Also the effect of food entering the small bowel quickly will make you feel full quickly. This is also similar to the action of the sleeve. The fullness factor is likely more impressive with the bypass. We know that the levels of a hormone called GLP-1 are much higher after bypass. This may explain the dramatic effect RYGB has on diabetes, even without weight loss.

As you can see the bypass is a metabolic operation, however there is also a restrictive component which is likely a co-factor to weight loss. I have also been placing a ring around the fobi pouch which is thought to limit stretching of the join between the pouch and small bowel. This may be an important factor in weight regain. I use a device called the minimizer ring (pictured behind text).

My opinion is that RYGB is a great procedure for Revisional surgery. There is a much greater chance of less complications and better long term weight loss with RYGB than a sleeve. Below you will see my thoughts on the operations for revision of a gastric band.

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THE PRO'S & CON'S

Sleeve Gastrectomy

This operation involves removal of about 2/3 of the stomach. We remove the outer part of the stomach called the fundus. This leaves a stomach that holds about 200 mls of fluid or what will be an entrée size plate of solid food.

The fundus of the stomach has a number of functions including a role in the regulation of appetite. We know that at least Ghrelin is produced here. If you read the section on Ghrelin you will see that this hormone has a major role in appetite regulation. Lower blood levels means you feel less hungry.

The second and I think more substantial metabolic effect is the feeling of fullness or satiety people get after a sleeve. This is because the stomach empties quicker and hence stimulates release of fullness hormones as the food hits the small bowel. These hormones are very important in the way a sleeve works. Some of them are also very important in blood sugar regulation, which may explain the effect on diabetic patients.

The following article is useful for patients considering the Sleeve.

9 Things you need to know about gastric sleeve gastrectomy

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THE PRO'S & CON'S

Mini Gastric Bypass

This technique can be thought of as a combination of the sleeve and the RYGB. Essentially the aim is a long skinny gastric pouch with the remainder of the stomach disconnected but not removed.

A loop of bowel is then joined to the pouch (without the roux reconstruction).

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THE PRO'S & CON'S

Oesophageal Dilatation

Oesophageal Dilatation is a problem we see post gastric banding. We also see it to a lesser extent, after gastric stapling and sometimes after Sleeve Gastrectomy. Essentially, oesophageal dilatation means that the oesophagus, which is a tube above the stomach that transmits food from mouth to stomach, becomes stretched and distended. You could think of this like a balloon that has been blown up.

This oesophagus is an organ that is supposed to transit food only. It is not meant to hold food. When food sits in the oesophagus above a band or a point of obstruction, you then get stretching of the oesophagus to accommodate food. You can think of this simply as being like a freeway which has turned into a car park. The other way of thinking about it is like again, using the balloon analogy. The balloon initially was tight before it was blown up becoming stretched out and never really returning to its normal size when the air is released.

The problem with oesophageal dilatation is that you get the ability to hold more and more food as you increase the obstruction below the oesophagus. Therefore, if you think about the gastric band, when you adjust that band you increase the pressure around the oesophagus and the level of obstruction. This then means that the oesophagus gradually stretches up above that level. The more you put fluid into the band, the more you get stretching. Another analogy of this is a bit like having a stomach above your stomach. The problem with this is that more and more food can get held in that dilated part of the oesophagus and patients will often experience the feeling that their band is loose or not tight enough. This is in fact not the case and actually the opposite that the band is too tight.

This is a difficult problem to fix and one that to be frank, cannot be fixed. Releasing the fluid from the band will have the effect of decreasing the pressure in the oesophagus and often the oesophagus will look a lot better when this is done. The problem is that then more and more food can be eaten and the patient tends to put on more weight. Increasing tightness of the band only worsens the problem and ultimately, although may give you some transient weight loss, end up with a whole range of complications in the future.

If oesophageal dilatation is severe, the band really has to be removed and from a bariatric point of view, the only real option is to convert into a gastric bypass. This also needs to be managed carefully because that oesophagus will never be the same as what it was and will always be able to hold a slightly increased amount of food even when the band is removed. Oesophageal dilatation of course, comes in all shapes and sizes and sometimes becomes so bad that it becomes impossible to do anything with.

How is oesophageal dilatation diagnosed?

Generally speaking, the critical comments made by a patient with oesophageal dilatation are that over a length of time, they feel that their band has become looser or lost fluid. They feel they can eat more food. Sometimes the patient feels that if they eat slightly too much, they will then regurgitate or vomit. Often the patient’s weight is increasing because the volume of food they are able to take in increases. The definitive mechanism for diagnosis is by using a test called a Barium Swallow. This involves swallowing some liquid contrast and having an x-ray. We often then repeat the test after swallowing either marshmallows or bread coated with barium to put the band under a little bit more pressure, which will diagnose mild or subtle oesophageal dilatation. This also helps to diagnose subtle slips or pouch dilatations. Often, I can also tell if someone has oesophageal dilatation by performing gastroscopy but it is not as sensitive as a barium test.

Removal of Gastric Band

A keyhole procedure that removes the band and port. It takes about 30 mins and I am very conservative. I don’t remove the sutures or fix any hiatal hernia.

The less done here the better as there is scarring (adhesions) left behind when a band is removed.These adhesions soften in 8-12 weeks and it is much easier to operate in the area at 3 months post removal.

This can be done as a day case or overnight operation.

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