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Bariatric surgery, also known as weight loss surgery, refers to the various surgical procedures performed to treat obesity by modification of the gastrointestinal tract to reduce nutrient intake and/or absorption. The term does not include procedures for surgical removal of body fat such as liposuction or abdominoplasty.
For individuals who have been unable to achieve significant weight loss through diet modifications and exercise programs alone, bariatric surgery may help to attain a more healthy body weight. There are a number of surgical options available to treat obesity, each with its advantages and pitfalls. In general, bariatric surgery is successful in producing (often substantial) weight loss, though one must consider operative risk (including mortality) and side effects before making the decision to pursue this treatment option. These procedures have a high success rate and can be carried out safely.
Weight-loss surgery is a life-changing surgery. It is not a medical cure. It is intended for those who are morbidly obese and have weight related health problems.
Selection Criteria
There are a number of widely accepted criteria which make a patient suitable for Bariatric or weight loss surgery:
- Weight greater than 45kg above the ideal body weight for sex, and height.
- BMI > 40 by itself or >35 if there is an associated obesity illness , such as diabetes or sleep apnoea
- Reasonable attempts at other weight loss techniques
- Age 18-65
- Obesity related health problems
- No psychiatric or drug dependency problems
- A capacity to understand the risks and commitment associated with the surgery.
- Pregnancy not anticipated in the first two years following surgery
There is considerable flexibility in these guidelines. Patients as young as 12 have been
offered surgery. Sometimes a lower BMI between 30-35 is accepted if comorbidities exist.
Check out your BMI here
Obesity- Surgical options
Laparoscopic Adjustable Gastric Banding
Adjustable gastric banding. In this procedure, a hollow band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.
Advantages:
- Keyhole approach resulting in less scarring or wound problems. Earlier return to work (1-2 weeks)
- Adjustable - by filling port the outlet size can be reduced
- Reversible - by removing fluid or the band.
- No malabsorption
- Lower risk
Disadvantages
- Easy to cheat if chocolates or sweets taken.
- Mechanical problems:
- prolapse
- pouch dilatation
- food bolus obstruction
- slippage of the stomach through the band erosion
- infection of the band or port leak
- Revision rate ? 5 -10%
- An entree portion forever.
Optimal pouch capacity 30 mls
Usual weight loss With Lap Band 50-60% of excess weight lost in 2 yrs
Bilio Pancreatic Diversion BPD
 These operations combines removal or exclusion of 2/3rds of the stomach along with a long intestinal bypass which significantly reduces the absorption of fat. The capacity to eat is greater than with the other operations, and the eventual weight loss is the best of all the operations but if fatty foods are overeaten e.g. a hamburger and fries then diarrhoea and foul flatus will result.
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Advantages:
- Greater stomach capacity (200-250 mls) therefore can eat a small main meal instead of
- an entrée portion.
- Best weight loss of all techniques 70-90% EWL over 2yrs
- Weight loss is well maintained
- Adjustable and partially reversible, but only by further surgery.
- A very good option for revision if other techniques have failed.
Disadvantages:
- Open operation ( usually), therefore greater operative risks e.g infection, bowel leak, clots to legs and lungs wound infection and hernia, chest infection. Risk of Death 1:200
- Malabsorption to some minerals vitamins and Protein . Patients must commit to taking lifelong supplements of the fat soluble vitamins ( A D E K ) Calcium and sometimes Iron.
- Risk of deficiency state e.g. Iron deficiency anaemia or osteoporosis if supplements not taken.
- Take longer to recover ( 6-8 weeks off work)
- Requires removal of Gall bladder because of high incidence of stone formation
- Increased stool frequency 2-4/day
- Flatulence if fatty foods eaten
Sometimes it is offered to patients as part of a two stage Bypass operation particularly if they are super obese ( BMI>60) because it allows good weight loss until the patient gets down to a safe weight and the more radical bypass can then be offered laparoscopically when they are at a safer weight.
The residual stomach capacity is about 200mls so a generous entree should be possible.
The weight loss seems to be of the same order as a lap band ( 50-60% EWL) over two years but it is not adjustable.
It might also be a good option if patients have a problem with their lap band requiring revision, have already lost a lot of weight and don't want a full bypass.
Tube Gastrectomy or Gastroplasty
This is a relatively new approach. It is the first component of the duodenal switch operation and involves removing the lateral 2/3rds of the stomach with a stapling device. It can be done laparoscopically (keyhole surgery) but is not reversible. It basically leaves a stomach tube instead of a stomach sack.
This is the first component of a BPD-DS where the stomach is reduced in size by removing the lateral 2/3rds leaving the stomach in the shape of a tube.
Sometimes it is offered to patients as part of a two stage Bypass operation particularly if they are super obese ( BMI>60) because it allows good weight loss until the patient gets down to a safe weight and the more radical bypass can then be offered laparoscopically when they are at a safer weight.
The residual stomach capacity is about 200mls so a generous entree should be possible.
Issues with Tube gastrectomy
1. Stomach tube may stretch up over time leading to late weight regain. The extent of this is currently unknown
2. The amount of weight reduction is in the region of 40-60% of excess wt lost over the first 1-2 years.
3. It is a good option for people living in remote areas because it is a "set and forget" operation which requires little post operative follow up or nutritional supplements
4. There is no malabsorption to nutrients
5. If weight is regained the second stage of the BPD the intestinal bypass can be added... often laparoscopically as well.
Gastric Roux-En-Y Bypass
 Here a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the absorption of nutrients and thereby reduces the calorie intake.
Advantages:
- "Dumping syndrome" if sweets and chocolates taken
- Good operation for sweet eaters
- Long track record
- Tend to lose a little more weight than gastric band
Disadvantages:
- Open surgery therefore increased risks
- Longer recovery time
- Permanent
- Not reversible
- Staple line leak
- Minor late weight regain 10-20% after 2-5 yrs
- Nutritional/ mineral supplements required
Residual stomach capacity: 30-50mls
Estimated weight loss: 60-70% EWL over 2 years.
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