Choosing your surgery

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Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%.

The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes. However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities.

A medical guideline by the American College of Physicians concluded
* "Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m2 or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor–patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption."
* "Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery."

When determining eligibility for bariatric surgery for extremely obese patients, psychiatric screening is critical; it is also critical for determining postoperative success. In patients with a body mass index of 40 kg/m2 or greater, there is a 5-fold risk of depression, and half of bariatric surgery candidates are depressed.

Procedures can be grouped in three main categories:

  • Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.

This complex operation is also known as biliopancreatic diversion  (BPD), or Scopinaro procedure. This surgery is rare now because of problems with malnourishment. It has been replaced with the Duodenal switch, also known as the BPD/DS. Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum  and jejunum.
In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.

Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventative measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones.

Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.

For more information on the Duodenal Switch at DSFacts altho not a medical web site, is very well informed. Just be aware that it is run by a volunteer.

  • Predominantly restrictive procedures primarily reduce stomach size:
  • Vertical Banded Gastroplasty: Also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach. This procedure is not very common.
  • Adjustable Gastric Band: Also known as the “Lap-Band”, the restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically.
  • Vertical Sleeve Gastrectomy: Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.
  • Mixed procedures apply both techniques simultaneously
  • Roux-en-Y gastric bypass: Also known as the “gastric bypass”, is the gold standard of WLS. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration. However, evidence is growing that the resolution of some co-morbiditors such as diabetes may not stay resolved.
  • Sleeve Gastrectomy with Duodenal Switch: A variation of the biliopancreatic diversion includes a Duodenal switch. The part of the stomach along its greater curve is resected. The stomach is “tubulized” with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75-100 cm from the colon.

There is no surgery that is superior to another for everybody. The best you can do is do your research, look at ALL the facts, talk to your doctor, and decide FOR yourself what you can and cannot live with. There are restrictions to each type that a doctor can discuss with you.