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 (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.
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:
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 after a few months the patient can eat a completely 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
Although only performed on mice at present, this surgery involved placing a 10cm long impermeable sleeve into the 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.
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 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 , 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.
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.
Intragastric balloon
This surgery involves endoscopic placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5-9BMI over half a year. While not yet approved by the FDA the Intragastric balloon is approved in Australia, Canada, Mexico, India and several European and South American countries.
Mixed procedures
Mixed procedures apply both techniques simultaneously.
Gastric Bypass Surgery
Main article: Gastric bypass surgeryThe most common form of gastric bypass surgery is the Roux-en-Y gastric bypass. 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.
The gastric bypass is the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005, dwarfing the number of Lap-Band, duodenal switch and vertical banded gastroplasty procedures. Since the gastric bypass has been performed for almost 50 years, surgeons have become very comfortable with, and aware of, the risks and benefits of the procedure. The gastric bypass operation has become the "gold standard" in the U.S. for comparison with new procedures. A factor in the success of gastric bypass surgery is strict post-surgical adherence to a gastric bypass diet.
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.
Implantable Gastric Stimulation
This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a
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