Bariatric surgery, or weight loss surgery, is a type of procedure performed on people who are dangerously obese, for the purpose of losing weight. This weight loss is usually achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).
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% to 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.
Indications
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/m 2 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."
Classification of surgical procedures
Procedures can be grouped in three main categories: Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.
Predominantly malabsorptive procedures
Predominantly malabsorptive procedures, although they also reduce stomach size, these operations are based mainly on creating malabsorption.
Biliopancreatic diversion
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.
Jejunoileal bypass
Main article: Jejunoileal bypassThis procedure is no longer performed.
Endoluminal sleeve
No longer only performed on mice, this surgery involved placing a 10cm long impermeable sleeve into the mouse's intestine to block absorption of food in the duodenum and upper jejunum. A study at Massachusetts General Hospital Weight Center and Gastrointestinal Unit found that mice who had the surgery ate 30% less food and lost 20% more weight than counterpart mice, while blood glucose levels returned to normal levels in all mice who had the surgery.
Clinical trials began in South America and Europe in 2009. GI Dynamics inc, is testing a new surgery-free medical device called the EndoBarrier Gastrointestinal Liner. It may offer the effective surgery free weight loss. Lining part of the small intestines from the duodenum and into the first part of the jejunum. This mechanical bypass may alter hormonal responses in the body. Resulting in metabolic changes that lead to weight loss and a potential solution for type 2 diabetes.
Clinical studies show losses 20 percent of excess weight within three months, and 30 percent of excess weight within six months. The exact nature of the link between an Endoluminal sleeve and diabetes is unknown. One theory is it may change the hormone levels originating in the intestines.
Since the preceding paragraphs, the procedure's won the European CE Mark of Approval, and is available there now. At this time no information is available about clinical trials or approval in the United States.
Predominantly restrictive procedures
Predominantly restrictive procedures primarily reduce stomach size.
Vertical Banded Gastroplasty
Main article: Vertical banded gastroplasty surgeryIn the 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.
Adjustable gastric band
Main article: Adjustable Gastric BandThe 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, and is commonly referred to as a "lap band." The first non-adjustable gastric band was patented in 1979 and successfully applied in animal experiments. An American company, INAMED Health, later designed the BioEnterics LAP-BAND Adjustable Gastric Banding System (based on the design by Kuzmak in 1986), which was introduced in Europe in 1993. Neither of these bands was initially designed for use with laparoscopic surgery. The LAP-BAND System received U.S. Food and Drug Administration (FDA) approval in June 2001. In 2000, a lower pressure, wider, one-piece adjustable gastric band called the MIDband was introduced by Medical Innovation Development of Lyon France. In 2002, a lower pressure, wider, one-piece adjustable gastric band called the Bioring designed specifically for laparoscopic insertion was introduced in France by Cousin-Biotech, and swiftly become one of the leading bands in that country. There are now a number of band manufacturers including Ethicon (Realize Band), A.M.I. (Soft Band) and Bariatric Solutions (Mini Mizer Extra).http://www.hospimedical.com/wDeutsch/for-surgeons/minimizer-extra.php?navid=2
Sleeve gastrectomy
Main article: Sleeve gastrectomySleeve 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.
Main article: Expected Weight LossThis combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6 - 12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 - 18 months.
- Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts. - Removes the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed. - No dumping syndrome because the pylorus is preserved. - Minimizes the chance of an ulcer occurring. - By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced. - Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2). - Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2). - Appealing option for people with existing anemia, Crohn's disease and numerous other condi
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