Surgical Procedures for Obesity

Obesity is a long-standing, deteriorating medical condition, which is incurable, but there is a continuous treatment which improves the disorder. Although it is optional, surgery is a common method of treatment amongst obese people. Normally, the criteria consists of two of the following:

•    Body mass index (BMI) above 35 alongside medical issues associated with obesity like hypertension, diabetes, increased cholesterol or sleep apnea.

•    BMI of above 40 with no medical problems.

•    Unsuccessful medical management in improving the condition.

The types of surgeries have transitioned over time. They can be categorized as gastric restrictive procedures which aim at limiting the level of food intake and combination restrictive/gastrointestinal bypass approaches which “restrict” the quantity of food as well as causing food to be absorbed incompletely. 

 

Gastric restrictive procedures

Vertical banded gastroplasty

One variation is the vertical banded gastroplasty (VBG), which at times requires support from a Silastic ring.  By “stapling” the stomach, VBG reduces its volume to around 15ml. A Silastic ring prevents the stomach from expanding.  The procedure results in a small stomach “pouch” where food from the esophagus enters and a bigger stomach which isn’t “stapled” into which small food quantities from the “pouch” stomach moves. The procedure makes one feel full earlier than normal, thus consuming only small amounts which will not make the smaller stomach to distend. Continuation to eat beyond the point of feeling full makes a person nauseate, throw up or feel pain consequently making one to stop eating. Therefore, the obese should adapt to their new modified stomach sizes by limiting the amount of food that they eat to avoid throwing up and feeling pain. If an expert doctor does the VBG, the death rate as a result of the procedure is normally less than one percent. 

The surgery can cause various problems such as dangers of infection, blockage of the outlet, requiring the redo of the surgery.; leg or lung blood clots; bleeding; deficiencies associated with metabolism and nutrition and periodic throwing up. After surgery, a patient can gradually develop deficiencies in vitamins (particularly Vitamin C) and minerals, causing anemia or softening of bones. Apart from getting a long-term treatment, the patient should be observed and monitored by a doctor who is knowledgeable in the long-standing problems.

The surgery leads to the reduction of excess body weight by 40 to 50%, and normally the patient maintains a half of the excess weight loss after five years. The body weight increases gradually after the one or two years. 

To avoid nausea and throwing up as well as getting other long-standing complications, a patient needs to eat a special diet. Besides, eating of calorie-dense liquids like ice cream or typical soda will help a patient partially avoid the “restriction.”

A patient needs long-standing changes in their eating behavior for the effectiveness of the surgery to be realized.  Nevertheless, VBG has proven to be an effective obesity treatment option. 

 

Laparoscopic Gastric Banding

Laparoscopic gastric banding is another type of gastric restrictive procedures.  The surgery was approved in the United States in 2001 and is prominent because it is advanced; it uses a laparoscope (a device which is put into the cavity of the abdomen). A patient takes just a few days to recover from the procedure. The upper part of the stomach is tied with an adjustable band, making the stomach capacity to reduce. Just like VBG, laparoscopic Gastric banding restricts the quantity of food intake.

The European literature, where the operation has been carried out for an extended period of time, indicates that the excess body weight loss as a result of this procedure is similar to that which is caused by vertical banded gastroplasty. The U.S clinicians show less loss of body weight than the European clinicians. Adverse effects of this procedure comprise of slippage and erosion of the band; dilation of the gullet and infections. The majority of these compilations many necessitate the removal of the band.

 

The results, problems, and Nutritional Deficiencies arising from the surgery

The following are values of the mean approximated loss of excess body weight and problems as shown by Obesity Research 2008 study:

• At 7 years: less than 50% loss of  excess body weight
• At 9 years: less than 40 % loss of excess body weight

Main late problems associated with this particular operation: 

• Erosion of band into the stomach: 3.3%
• Slippage: 6.5 %
• Leakage: 9.8%
• Main reoperation: 24.4%

Gastric Banding Nutritional Deficiencies:

• The surgery itself rarely causes remarkable nutritional deficiencies
• Thiamine deficiency in case of constant vomiting
• Periodic protein deficiency from "induced" changes in diet.

The lap band, a modification of gastric banding, and whose uses ceased in the 1980's due to high number of bleeding and obstruction cases, isn’t as invasive as the banding procedure. If the need arises, the doctor can tighten or loosen the band appropriately. This procedure is usually used by clinicians on people aged 60 to 65 years who don’t qualify for surgical treatment method.

 

Combination restrictive/malabsorptive approaches

Roux-en-Y Gastric Bypass is believed to be the "gold standard" in surgery treatment for obesity. This procedure includes both a “restrictive” approach by reducing the stomach capacity through stapling its upper part as well as a "malabsorptive” aspect which involves directly bringing-up and linking a section of the small intestine to the stomach.

Unlike the old intestinal bypass surgery this procedure usually causes only slight nutrients malabsorption. Gastrointestinal hormonal changes occur as a result of this operation, consequently leading to reduced hunger and improved fullness.  People who get this surgery lose remarkable weight amounts, especially fat. The procedure leads to excellent weight maintenance since weight increases just slightly in the following years.  Obesity operations require long-term follow-up of the patient and treatment of the medical issues such as Vitamin B12 deficiency, as well as anemia, and so does this procedure.

Mean approximate loss of excess body weight and medical problems:

• At 2 years: estimated 66% loss of excess body weight
• At 10 years: more than 50 % loss of excess body weight

Main problems associated with this particular surgery:

• Stomal ulceration at the area of “attachment" of the small intestine to the stomach
• The stomach outlet becomes “narrow," causing nausea and vomiting
• Intestinal components leakage
• Inability to eat large quantities of food
• "Dumping Syndrome” which makes one nauseate, vomit, diarrhea, flush, feel abdominal pain as well as fast heartbeats after eating food, particularly, carbohydrates.

Roux-en-Y Gastric Bypass leads to deficiency of nutrients such as iron, vitamins, folate, calcium, thiamine and protein

Being a laparoscopic procedure, Roux-en-Y Gastric Bypass helps patients to recover fast although they experience many severe surgical problems.

 

Biliopancreatic bypass procedures

These procedures, involve the diversion of the liver’s and pancreas’s digestive juices to the end of small bowel close to the entryway of the colon. Therefore, food goes through the stomach, quickly moves through the small intestine, where nutrients are primarily absorbed, and then it enters the large bowel, where of the excess water in the stool is removed.  This leads to significant malabsorption of nutrients which results in a remarkable weight loss. Since there is marked impairment of absorption of vital nutrients, there is a significant possibility of a patient suffering from vitamin, mineral, and protein-calorie deficiency.   These procedures are mostly avoided because the high malabsorption of essential nutrients can cause long-standing problems.