What is Laparoscopic Bariatric (Obesity) Surgery and how is it performed?

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Obesity Treatment Options

Obesity is managed by conservative (diet and exercise), medical and surgical approaches. The decision of which treatment is best for you depends on factors such as your BMI, waist circumference and also the presence of other medical problems. Usually combinations of the various approaches are used, directed by guidelines such as the NICE guidelines for NHS patients, although the clinicians overall judgment presides. All studies that directly compare surgical with conservative treatments conclude that surgery is superior in providing long term, sustained weight loss.

The focus of this website is the surgical treatment for obesity.

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Is Surgery Suitable?

The National Institute for Health and Clinical Excellence (NICE) have produced guidelines on obesity. It stated that those who have a BMI over 40 or a BMI over 35 accompanied by an existing condition which would benefit from weight loss, are suitable for surgery. Ideally you would have tried to lose weight by diet and exercise and can demonstrate to your surgeon that you will be able to persevere with such measures after the surgery. Obesity management is a lifelong process and not a quick fix. It involves preparation for the surgical procedure and also continual cooperation after the surgery to accompany the weight loss process.

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Different Types Of Surgery

There are various types of operation available for weight loss. They generally fall into two categories:

  • Malabsorptive surgery
  • Restrictive surgery

Malabsorptive surgery is a process where the anatomy is surgically altered such that food bypasses the areas where it is absorbed the most. Restrictive surgery is where the stomach is either divided or has a band wrapped around it to make its spaces effectively smaller thus giving a feeling of fullness with less food. Operations are either open – where the abdomen is opened with a large cut or laparoscopic (key-hole surgery). Both techniques have their advantages and disadvantages, and are best discussed with your surgeon taking individual circumstances into account. The advantages of the laparoscopic approach is that it usually provides:

  • Reduced post -operative pain
  • Shorter hospital stay.
  • A faster return to work
  • A lower mortality (death) rate compared to other surgical treatment options.

Occasionally the operation cannot be performed laparoscopically and a larger incision has to be made (open surgery). If you have an open procedure you will have a longer abdominal scar and you will need to stay in hospital longer and it will take longer to return to your normal activities. Factors that may increase the possibility of the surgeon converting to an open procedure are a history of previous abdominal surgery that has caused dense scar tissue, or bleeding problems during the operation. The decision to convert to an open procedure is based strictly on patient safety.

Download the NICE (the National Institute for Health and Clinical Excellence) guidance on Obesity [Download]

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Laparoscopic Adjustable Gastric BandingLaparoscopic Adjustable Gastric Banding

Laparoscopic Gastric Banding involves the placement of a constricting band around the top of the stomach, creating a small pouch and a narrow passage into the remainder of the stomach, therefore restricting food intake. The Gastric Band is adjusted to a level where it will slow the passage of solid food. It will have little if no effect on the passage of soft or liquid foods such as sweets or cakes. The Gastric Band is intended to be in place permanently.
The surgery is generally carried out laparoscopically (keyhole surgery). The surgeon will use 4-5 small cuts (1 – 2 cms in size) to enter the abdomen through cannulae (narrow tube like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small cannula. A picture is projected onto a monitor giving the surgeon a magnified view of the stomach and other internal organs. The entire operation is performed through the small holes, after the abdomen has been filled with gas. The gas is removed after the operation is completed. The Gastric Band is carefully placed around the top portion of stomach and secured in position with stitches. An access port is attached to the band and placed under the skin, to allow for adjustments of the band in the future.

The following animation demonstrates the procedure:

Once the silicone band has been fitted, it can be adjusted without further surgery, depending on dietary intake and weight loss. The band is adjusted by injecting fluid through the skin into the access port.

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Gastric Band Adjustment

Band adjustments take place in an outpatient setting and take approximately 30 minutes. Adjustments are tailored to suit individual needs but usually take place from 6 weeks onwards following surgery and then periodically to limit dietary intake and achieve optimal weight loss. The first band adjustment is usually performed in the X-ray department. Once the band is adjusted, you are asked to stand up and to swallow some fluid that shows up on X-ray. This swallow test is performed to confirm that the gastric band is in the correct position for optimal weight loss. If you develop unexpected problems with a gastric band, we may perform another X-ray swallow to confirm that the band has not moved.

Laparoscopic Gastric Band surgery is the safest type of weight loss surgery currently available. There are still risks common to any operation such as bleeding, infection or blood clots. There is around a 1 in 2000 chance of dying from Gastric Band surgery. Risks associated with a gastric band include band slippage, pouch dilatation or band erosion. These risks are unusual but may require the band to be repositioned or removed with further surgery. Problems with the adjustment port can be managed easily under a local, numbing, anaesthetic.

Results from Laparoscopic Gastric Band surgery are quite variable. While most people do very well, there is no guarantee and some people fail to lose any weight at all. Up to one in four people do not lose as much weight as they would have hoped following Gastric Band surgery. Do not expect the band to physically stop you eating. Food will still get through if you are determined. It is important to learn to work with the Gastric Band, as a partner, to enable optimal weight loss. If the Gastric Band is too tight, you will eventually either stretch the pouch above the band, or increase the amount of soft foods that you eat. Both problems are likely to lead to Gastric Band failure.

The following rules will help towards successful weight loss with a Laparoscopic Gastric Band:
Eat three regular meals a day
Drink fluids between, not with meals
Stick to textured foods. If you don’t need a knife and fork to eat it, you shouldn’t be having it
Avoid overeating. If you feel uncomfortable after a meal, you have probably eaten too much too quickly
Sit at a table to eat, without distractions such as television
Eat for 20 minutes then stop. You don’t need what you haven’t eaten
Enjoy leaving food on your plate
Attend for regular follow-up, including nurse and dietetic appointments as well as band adjustments
Attend a patient support group
Plan 20 minutes of aerobic exercise 5 times per week. Exercise to a level where you are out of breath, but can still talk in sentences
Contact your local bariatric team should you develop any problems or concerns
Contact your local bariatric team should your weight loss halt at any time. Do not feel a failure, it is important that we know so that we can help

The above points are helpful for long-term success with all types of weight loss surgery, but particularly with the Laparoscopic Gastric Band. If you are not able to make this commitment, then may be a Gastric Band is not the right procedure for you.

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BypassLaparoscopic Gastric Bypass

In some patients a Gastric Bypass (RNY) may be the most appropriate weight loss procedure. Gastric Bypass combines the restriction found with Gastric Band surgery, with a small element of malabsorption. A small pouch is formed at the top of the stomach. This pouch is then joined to the bowel lower down. Patients find that their portion size is significantly reduced and rarely feel hungry after Gastric Bypass surgery. As well as eating less, you will only absorb part of the calories that you have eaten. Some patients feel unwell when they eat sweet foods after Gastric Bypass. This feeling is known as 'dumping'. Some people find dumping to be an advantage of Gastric Bypass, particularly if they have difficulty controlling their sweet or chocolate intake.

Food that is eaten misses out, or bypasses, the first part of the small bowel after Gastric Bypass. The new connection has a dramatic effect on blood sugar levels after Gastric Bypass surgery. Patients with adult onset, or type 2 diabetes can revert to normal blood sugars within a few days of their surgery. Over 80% of diabetic patients can leave the hospital without the need for insulin after Gastric Bypass surgery. This affect is less likely the longer you have had diabetes and the more insulin you are on.

Although Gastric Bypass is now routinely performed laparoscopically, it is still major surgery. It involves a permanent change in your gut anatomy. There is around 1 in 200 chance of dying and a life long risk of nutritional problems following Gastric Bypass.

The following animation demonstrates the procedure - The blue liquid represents food, while the yellow liquid represents the body's natural digestive juices. The food only starts to be digested once the two flows of liquid meet:

 

Risks of Gastric Bypass surgery include bleeding, infection, leakage of bowel content, hernias or twisted bowel. In some patients the new stomach join up can narrow and will need to be stretched. Patients need to take life long supplements of vitamins, iron and calcium and require regular blood tests to check that they are not running in to problems. Although weight loss is most dramatic in the first six months after Gastric Bypass surgery, this tails off and there is a tendency for some patients to regain weight after the first three years. One in ten patients fail to maintain their weight loss over the long term, following Gastric Bypass surgery.

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SleeveLaparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy is another purely restrictive procedure. It involves the permanent removal of about two thirds of the stomach. The outer 'sleeve' of stomach is removed and the edges sealed using staples. The remaining stomach forms a long, narrow tube through which the food can pass. Portion size is reduced, resulting in significant early weight loss. Most patients expect to lose just over half of their excess weight after Laparoscopic Sleeve Gastrectomy.

Laparoscopic Sleeve Gastrectomy was originally designed as a first procedure, to be followed by more radical surgery (duodenal switch). More recently we have found that a lot of patients who have this operation do not require any further surgery.

Laparoscopic Sleeve Gastrectomy is often recommended in very large patients (BMI over 60) in whom a Laparoscopic Gastric Bypass may be considered too high a risk. There is an estimated 1 in 500 chance of dying following Laparoscopic Sleeve Gastrectomy.

While Laparoscopic Sleeve Gastrectomy can produce good early weight loss, there is a greater than one in three chance of inadequate or late weight gain. This chance is high because Sleeve Gastrectomy is often performed in heavier patients. Up to half of patients may need to have further surgery at a later date in order to gain further sustained weight loss.

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Gastric Balloon

The Gastric Balloon is an inflatable balloon that is positioned in the stomach. The gastric balloon does not require surgery or a general anaesthetic to be placed. Gastric Balloons are not designed to be permanent and usually have to be removed after six months.

A Gastric Balloon can be placed during a gastroscopy using a mild sedative. The balloon is placed in the stomach and then inflated using up to 500ml of saline fluid. The balloon fills the stomach, reducing the space for food. When used with the appropriate dietary support, people can lose an average of 20kg (three stone). With continued support the weight loss can be maintained after balloon removal.

The Gastric Balloon can be useful in people with a lower BMI, particularly where rapid weight loss is required for a particular event. An example may be where weight loss is recommended prior to an orthopaedic operation. It is licensed for use in people BMI 28 and above. The Gastric Balloon can also be used as an initial weight loss aid to prepare patients for a permanent procedure such as Gastric Band or Bypass.

The Gastric Balloon is the safest weight loss procedure available, but permanent weight loss cannot be guaranteed. Severe motion sickness is common in the first few days after Gastric Balloon insertion. This feeling should settle after a period of rest, but can lead to requests for the Gastric Balloon to be removed prematurely.

If the Gastric Balloon deflates or bursts while in the stomach there is a very rare risk of bowel blockage, which may require emergency surgery. The Gastric Balloon fluid is often coloured with a blue dye so that a leak can be identified before it causes a problem.

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Expected Weight Loss

It is important to be realistic about the amount of weight you expect to lose following surgery. Patients lose an average of half of their excess weight over two to three years after gastric band insertion. If for example you currently weigh 20 stone and your ideal weight is 10 stone, then you may achieve a five stone weight loss. This is an average, some people will lose a lot more than this but some people will lose less. The average expected weight loss after gastric bypass is up to 70% of your excess weight (Up to seven stone in the example above). If you learn to work with a gastric band, there is no reason why you will not lose as much weight with band surgery as you would with a gastric bypass. There is, however, no guarantee that you will lose any weight at all, particularly with a gastric band. The advantage over dieting alone is that there is a greater chance that the weight will stay off. The degree of weight loss may not seem huge but is enough to produce significant long-term health benefits.

Keys to success following weight loss surgery include:

  • Following the appropriate changes to your eating habits that have been advised
  • Relearning the feeling of satisfaction after eating and knowing when to stop
  • Instead of seeing how much you can eat, try to see how little you can eat to remove hunger
  • As well as controlling diet it is important to increase activity levels. Regular daily activity is best
  • Joining a local patient support group and keeping up with the follow-ups that are scheduled with your local bariatric team will all build toward long-term success
  • If you have difficulties after band surgery, it is important not to give up and do not feel a failure. Often a brief adjustment to band or lifestyle can bring you back on track.

 

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Making A Decision

Deciding which procedure is right for you can be very difficult. It is important to research all procedures carefully. Information should be gleaned from as many sources as possible. It is recommended that you take advantage of on line patient forums and local patient support groups, to meet with people who have been through the decision making process.

While the surgeon and team will advise you on what is appropriate for you, it is important that the final decision is your own. Any operation is hard work and certainly not a quick fix. Unless you take responsibility for the whole process, surgery is unlikely to be right for you.
Below is a list of the most common surgical weight loss procedures to help you with your decision:

Table of common surgical weight loss procedures

Many surgeons will advise that a gastric band will not work in someone with a BMI over 50. This is not true. Many of our most successful gastric band patients started with a BMI over 50 or even 60. Significant weight loss is possible, it just takes a lot longer. If the main reason you are overweight is that you are hungry all of the time and have large portions as a consequence, then a gastric band can work well for you.

Obesity is a lifelong problem. Surgery is not a cure, but a means of controlling the incurable. It is therefore important not to expect a single operative procedure to solve all weight problems without continued support. This may include help with behavioral changes from a nurse specialist or clinical psychologist.
Factors that reduce the chances success of weight loss surgery include patients over the age of 50 and patients with limited mobility, type 2 diabetes or hypothyroidism. However, in these groups, even a modest amount of weight loss can still carry significant health benefits.

My personal view is that a young person of childbearing age may be better off considering gastric band surgery, rather than any of the more radical options. It is easy to adjust, to improve nutritional intake if and when required. As medical advances proceed, the future may bring a non-surgical option for sustained weight loss. The patient at least then has the option to have the band removed, with no long-term consequence.

As a gastro-intestinal surgeon, I cannot help but be concerned that following gastric bypass there is a large section of stomach that cannot be viewed later on in life. This can make investigation and treatment of stomach problems such as ulcers or growths much more difficult.

Gastric Band surgery, however, does not work for everyone. While some people do exceptionally well with a Gastric Band, up to a quarter of patients fail to lose a significant amount of weight. A proportion of these have further surgery to either replace the band or convert to a gastric bypass. The risks of redo surgery are far higher than the first time round and are best avoided. It therefore makes sense that if you know you wouldn’t do well with a gastric band, then it may be better to opt for one of the alternatives.

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Pre Operative Preparation

Patients who are having Laparoscopic Bariatric (Weight Loss) Surgery will be asked to make appropriate changes to their diet and activity levels to have the greatest chance of success. It is important that patients get in to a habit of eating three regular meals a day, avoid snacks and avoid drinking while eating. We ask that patients continue regular activity of at least 20 minutes, five times a day. It is better to choose something that you enjoy and that can be fitted in to your daily routine. We also recommend that all patients attend a local support group to meet patients that have had the type of surgery that is being considered.

Patients who are able to make the above changes are more likely to have a successful long-term result from Laparoscopic Weight Loss Surgery.
We ask our patients to have a strict two-week diet prior to surgery. A very low calorie diet is prescribed for this period, with the aim to reduce the size of the liver. This is often called the 'Liver Shrinking Diet'. We expect patients to lose an average of 5kg over this period, which is a sign that the diet has been adhered to. The liver is immediately above the top part of the stomach involved in most Laparoscopic Weight Loss Surgery. There is a risk of damage to the liver if it has not reduced in size. This can lead to complications that may result in the procedure being abandoned. Patients are normally weighed on the day of surgery to ensure they have completed the diet. If your weight has not reduced, the procedure may then have to be cancelled.

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The Operation - Day of Surgery

The procedure will be carried out under a general anaesthetic (except for a Gastric Balloon), which means you will be asleep throughout. The operation will take between 1-2 hrs although you may be away from your room longer than this as you will spend some time in the theatre recovery area.

A cuff will be around your arm to check your blood pressure, and your pulse will be checked at the same time. These observations will be carried out at frequent intervals. It is usual for you to feel drowsy for several hours and you will also be given oxygen through a face mask until you are more awake. When the Anaesthetist is satisfied that you are recovering well from the anaesthetic, you will be taken back to your room.

Feelings of sickness are not uncommon after surgery. It is important that you inform the nurse looking after you at an early stage as prolonged vomiting can pull on the internal stitches. Anti sickness medication can be given which will rapidly ease any feeling of sickness. Pain relief is given in the early post-operative period. Some patients experience pain from trapped wind during this time that is not completely controlled with pain relief medication. Common symptoms include pain behind the breast bone or into the left shoulder. It is important that you inform your nurse as symptoms can be relieved with simple remedies such as peppermint water or getting up and moving about. Most patients experience minimal pain after the first day.

Patients are normally able to go home within 24 hours of a Laparoscopic Gastric Band procedure. Patients usually go home between two and four days after laparoscopic Gastric Bypass or Laparoscopic Sleeve Gastrectomy surgery.