When most people in Australia think of weight loss surgery, they think of the laparoscopic gastric band (lap band). This is simply because it is the commonest procedure performed in Australia. The commonest procedure performed worldwide is the laparoscopic gastric bypass. The other operation performed in this practice is the laparoscopic sleeve gastrectomy. By offering the three different types of operation, I can offer a tailored approach to your individual needs as opposed to the “one size fits all” approach of other surgeons who only offer the laparoscopic gastric band.
Weight loss surgery is commonly divided into two types of surgery, Restrictive and Malabsoptive. Restrictive procedures work by limiting the amount of food that you get in, thereby reducing your overall calorie intake. It should be remembered that restrictive operations do not affect your ability to absorb calories and therefore if you are able to get 5,000 calories in each day, you will absorb 5,000 calories and therefore not achieve the weight loss that you are aiming for. The other types of procedures are malabsorptive procedures. These procedures also reduce the amount you get in but work mainly by impairing your ability to absorb the calories that you eat. These procedures certainly produce better weight loss than restrictive procedures but come with higher complication rates, in particular vitamin and nutrient deficiencies. The Obesity Surgical Society of Australia and New Zealand (OSSANZ) has clearly stated that malabsorptive procedures are second-line procedures for those who have failed a restrictive procedure, and therefore unless you have had a previous restrictive procedure, you will not be offered a malabsorptive procedure.
When you come for your initial consultation, I will explain the pros and cons of each of the three operations that I perform. If there is a particular medical reason that I think one of these operations would be best suited to you, I will inform you of this. Otherwise, I feel it is best for you to decide which of the operations you feel most comfortable undergoing. Each of the operations has its own pros and cons and its own risk profile. You, as the patient, have to be comfortable with those pros and cons and risk profiles. Currently the laparoscopic gastric bypass is most commonly performed for diabetic patients and my other patients are split approximately 50/50 between the laparoscopic gastric band and the laparoscopic sleeve gastrectomy. To ensure that you have plenty of time to consider your options and make sure all of your questions are answered, I have a structured programme of consultations with myself and with my dietician, psychology and exercise physiology experts. This allows you time to ensure all your questions are answered before you decide which procedure you wish to proceed with.
Having decided which procedure you have decided to proceed with, the next step is to perform a gastroscopy. This involves a day stay in hospital and some light sedation. I examine the inside of your stomach for abnormalities that might impinge on your procedure and it also introduces you to my anaesthetists. My anaesthetists specialise in anaesthesia for weight loss surgery and are familiar with all the anaesthetic issues that this raises.
The day case gastroscopy allows them to perform a pre-operative anaesthetic assessment and they may, if necessary, request some additional investigations prior to surgery or recommend enhanced post-operative nursing care such as a high dependency bed. This is designed to facilitate an extra layer of safety for you, the patient, and minimise your intra-operative and post-operative risks.
I have devised a multidisciplinary team approach to weight loss surgery at the Brisbane Institute of Obesity Surgery. This involves pre-operative psychology, dietician and exercise physiology support, specialist anaesthetic support and programmed post-operative support, again from psychology, dietetics and exercise physiology. This has been designed because various studies from around the world have demonstrated that patients who have their surgery within an environment such as this achieve better results. In addition, we have a patient support group that meets on a monthly basis at Brisbane Private Hospital. The support group is free to attend and the hospital provides free car parking. This provides the opportunity for patients who are about to undergo or have undergone weight loss surgery to discuss their concerns, difficulties or lifestyle challenges. Again, access to a patient support group has been shown to enhance a patient’s weight loss outcomes. In addition, we are striving to have guest speakers present at the patient support group on a regular basis. This list of guest speakers will include plastic surgeons discussing what can be done with excess skin after weight loss, chefs talking about tips on cooking, and fashion consultants advising on clothing after weight loss surgery.
If you are considering weight loss surgery, you may have family and friends or colleagues who advise you simply to diet and exercise, and that weight loss surgery is “the easy way out”. For the obese, diet and exercise does not work in the long term and certainly surgery is not the easy way out. Myself and the team at BIOS act as your coaches and support to help you achieve the best possible outcome from your weight loss surgery but at the end of the day, you, as the individual, will have to do the hard work and have the commitment to succeed.
A laparoscopic gastric band is the commonest weight loss procedure performed in Australia. From a surgeon’s point of view it is the simplest and most straightforward of the weight loss procedures.
It involves placing a silicone band around the inlet of the stomach to create a small pouch of about 30ml capacity. The band is connected to a port that is placed underneath the skin just below the breastbone. The port allows the band to be adjusted after surgery to maintain optimal dietary restriction and weight loss.
The band produces a slow but steady weight loss. Typically a patient will lose half a kilogram per week and will take two years to attain their maximum weight loss. The other weight loss procedures have a much more rapid weight loss profile. Most patients having a band remain in hospital overnight and go home the following day, although increasingly in the United States, the operation is performed as a day case. Initially after going home, the patient will feel some restriction and will be on a largely liquid diet but by the time they return in four weeks for their first band adjustment, you will be able to eat freely. The band is then tightened up over a number of months until the appropriate point is reached for each patient. On average, it takes five adjustments to reach that ideal point or sweet point, as the Americans call it. It is important that the band is not overly tightened as this can lead to maladaptive eating. In this case, the patient finds it uncomfortable to eat normal, healthy food and therefore falls back on eating softer, sloppy foods which tend to be higher in calories and as this is purely a restrictive procedure, the patient does not lose weight. In an attempt to ensure optimal band adjustment, I see my band patients every month for the first 12 months.
There are some potential complications with the band. These vary from band slippage to more minor issues with the port. Overall, patients can expect a 20% re-operation rate in their lifetime although this varies from minor port issues to more significant issues with band removal or replacement.
If patients work with our team programme and particularly the dietary advice combined with appropriate band adjustment, the band will achieve excellent weight loss of 55% to 65% of excess weight.
The laparoscopic gastric bypass is the commonest weight loss procedure performed worldwide. It was first performed in the United States back in 1967. It produces excellent weight loss of between 65% to 75% of excess weight and obviously has a long track record. The operation involves creating a small pouch at the end of the oesophagus from the upper part of the stomach. The rest of the stomach is disconnected and left inside. A loop of small bowel, commonly 100cm in length, is then brought up and attached to the new stomach pouch. The proximal small bowel containing the digestive juices is then joined to this loop of small bowel at about 100cm. This means that when you eat, your food goes through the small stomach pouch and into the new loop of small bowel but does not meet the digestive juices for 100cm.
The procedure is performed with keyhole (laparoscopic) surgery although it is technically the most difficult operation to perform. Patients usually stay two to three days post-operatively before going home. Typically you have very little, if any, appetite for four to five months and it is during this time that you have the most rapid weight loss. It is important that you establish your health eating patterns in those first five months before your appetite returns.
The laparoscopic gastric bypass is particularly beneficial to Type 2 or non-insulin dependent diabetics. There are increasing numbers of studies demonstrating that diabetics who have this operation performed have a very rapid improvement in their diabetic control well before they gain the benefits of weight loss. This is felt to be due to the diversion of the food stream away from the first part of the small bowel, the duodenum and jejunum. Studies, particularly from the United States, have demonstrated up to 87% resolution of Type 2 diabetes following laparoscopic gastric bypass procedures. This procedure will always be my first recommendation for diabetic patients.
The laparoscopic gastric bypass is also a good operation for patients who have had gastric band surgery and who are not happy with their band or are not doing well with their band. It is possible to convert a gastric band patient to a laparoscopic gastric bypass as a one-stage procedure. It is also possible to convert a gastric band to a laparoscopic sleeve gastrectomy but this is best done as a two-stage procedure due to the high risk of a leak if the procedure is attempted as a one stage procedure.
As we have no access to the inside of the remainder of the stomach after a laparoscopic gastric bypass, it is important that the stomach is inspected by endoscope and biopsied prior to any surgery. In addition, gastric bypass patients will have to remain on vitamin supplements in the long term due to deficiencies particularly in iron and calcium absorption.
The laparoscopic sleeve gastrectomy is a relatively new weight loss procedure. It is a restrictive procedure and works by limiting the amount of food you can eat at any one time.
A laparoscopic sleeve gastrectomy (LSG) involves removing approximately two thirds of your stomach, turning your stomach into a thin tube or sleeve. The normal stomach acts as a large bag, storing food as you eat, and with a sleeve gastrectomy, you are able to eat a normal diet but in much smaller portions. In addition, the portion of the stomach that is removed produces a hormone called ghrelin which makes you feel hungry when your stomach is empty. By removing this portion of the stomach, even though you are eating less, you do not feel hungry and therefore you lose weight.
The advantage of the sleeve gastrectomy is that your anatomy is not altered. You are able to eat a normal diet but in entrée sized portions. This is felt to be particularly beneficial for men as men’s dietary issues tend to be related to portion size rather than the consumption of high calorie sweets and desserts. The laparoscopic sleeve gastrectomy does not require the same degree of intensive follow up as the laparoscopic gastric band and therefore may be better for country patients or patients who have to travel widely in relation to their work.
The laparoscopic sleeve gastrectomy produces rapid weight loss with maximal weight loss usually attained within 12 to 14 months. Most patients can expect 60% to 65% excess weight loss. A laparoscopic sleeve gastrectomy usually involves a two night stay in hospital. Obviously, as the resected part of the stomach is “in the bin”, the procedure is not reversible and in addition, there is limited long-term data weight loss data beyond seven years.
Specific risks related to the laparoscopic sleeve gastrectomy include a staple line leak. The stomach is divided and closed with a stapling device. The staple line has to heal and there is a small risk that it could leak. If this was to happen, you would require further surgery, usually laparoscopic, and possibly a stay in intensive care. If the leak is not controlled and infection results, this can become life threatening. In addition, the staple line can bleed. This is usually managed without the need for a return to surgery and occurs in less than 1% of cases. Less common complications are impairment of the stomach’s ability to empty and stricturing or narrowing of the stomach tube. These complications occur in less than 1% of cases.