Bariatric Surgery in 2020

For many obese patients, losing weight goes far beyond vanity. The health burdens of obesity have a vast and devastating effect on one’s health and mental well-being. Not only does obesity contribute to the decline in the quality of life, but it is also a major cause of serious and potentially life-threatening diseases such as type 2 diabetes, heart disease and stroke.

When all other weight loss options have been exhausted, bariatric surgery can be a successful intervention in combating obesity. It does not replace healthy habits, but it can help reduce food intake and induce metabolic or hormonal changes that play a role in hunger and satiety.

Who Qualifies for Bariatric Surgery?

Bariatric surgery isn’t “the easy way out” when considering weight loss options, and certain medical guidelines are necessary to qualify for weight-loss surgery. According to the National Institutes of Health, candidates for weight loss or bariatric surgery have a minimum body mass index (BMI) of 40, or a BMI of 35 in combination with additional medical issues caused by obesity that require treatment.

Minimally Invasive Laparoscopic and Robotic Surgery

Bariatric surgical procedures are performed using minimally invasive techniques. With the use of laparoscopic and robotic surgeries, patients experience less postoperative complications, have a quicker recovery and return to normal activities sooner.

Minimally invasive surgeries have eliminated the need for a surgeon to make large incisions to allow his or her hands to enter the body cavity and manipulate surgical tools. Both laparoscopic and robotic surgeries require a series of small incisions only large enough for the insertion of specially designed surgical instruments and a video camera. This camera allows the surgeon to noninvasively see inside the body of the patient while miniature surgical tools are used to perform the operation.

The use of robotics, such as the da Vinci robotic surgery system gives the doctor improved maneuverability and a high-definition 3D camera for better visibility and more range of motion. With the video projected onto a screen, the surgeon is able to direct the surgical tools for successful bariatric surgery.

Surgery Procedures

Bariatric surgery aids in weight loss by restricting the amount of food the stomach can hold, causing malabsorption or through a combination of both. Bariatric procedures can also cause hormonal changes and metabolic effects that can lead to dramatic improvements in weight loss and health risks associated with obesity.

The most common minimally invasive bariatric surgery procedures are:

  1. Gastric sleeve
  2. Roux-en-Y

1. Laparoscopic Gastric Sleeve Surgery

Gastric sleeve surgery permanently reduces the size of the stomach by creating a long, tubular portion that is then directly connected to the small intestine. Shaped similar to a banana, the “sleeve” of stomach remaining will be about 20% the original size and more quickly move food into the small intestine. Greatly reducing the size of the stomach limits the amount of food intake and can decrease the amount of time it takes to feel full. In addition, the surgery will decrease the distribution of the appetite boosting hormone, ghrelin, produced in the stomach.

The Surgery

  • General anesthesia will put the patient to sleep for the duration of the surgery that will last about an hour.
  • Small incisions will be made in the upper abdomen for access to the stomach.
  • Carbon dioxide gas will inflate the abdominal area improving the visual ability of the video camera.
  • The surgeon will place the specially designed surgical instruments and a camera into the abdomen.
  • A Bougie tube will be inserted into the stomach through the mouth. This will be used as a sizer for the narrowed vertical sleeve of stomach.
  • The surgeon will use a surgical stapler along the side of the Bougie tube to create a long, tubular pouch.
  • Once the stomach has been successfully divided, the surgeon will remove the excess abdomen through one of the incisions.
  • The surgeon may then test for leaks using a dye study or upper endoscopy.
  • The patient’s incisions will be sutured and they will be sent to recovery.

Although patients will be admitted to the hospital for the procedure, most are usually discharged after 1 or 2 nights. In general, most patients find the pain easily managed, and find they can take less pain medication than recommended. Within 2 to 4 weeks, most patients return to work.

2. Roux-en-Y Gastric Bypass

In a Roux-en-Y (roo-en-wy) gastric bypass surgery, the surgeon cuts across the top of the stomach creating a new pouch about 1 ounce in volume—the size of a walnut—sealed away from the remaining stomach. Because the smaller pouch bypasses the remaining larger portion of stomach but the digestive juices and enzymes are still used to aid in food digestion, the small intestine is surgically formed into a Y shape. With one connection made to the bypassed stomach, the other is made directly to the new pouch allowing food to travel directly to the lower part of the small intestine more quickly. This surgery also reduces the size of the stomach, limiting food intake and decrease the distribution of ghrelin into the system. 

The Surgery

  • Taking a few hours, the patient will be under anesthesia during the operation.
  • The surgeon will make a series of small incisions in the abdomen.
  • Carbon dioxide gas will be introduced to inflate the abdominal cavity to improve visibility.
  • The video camera and other specially designed surgical instruments will be inserted.
  • A small pouch—about 1 ounce in volume—will be separated from the majority of the stomach and first part of the small intestine and closed off with staples.
  • The larger portion of stomach will not be removed. It will continue to produce digestive juices that will be delivered to the small intestine.
  • The surgeon will divide the first segment of the small intestine into a Y shape. They will then bring that first segment up and connect it to the new stomach pouch.
  • The second portion of the divided small intestine is then reconnected to the bypassed stomach allowing stomach acids and digestive enzymes to mix with food.
  • The patient’s incisions will be sutured and they will be sent to recovery.

Admitted to the hospital for 1 or 2 nights, patients generally return to work within 2 to 4 weeks.

Bariatric Surgery Benefits

  • On average patients will lose 60-70% of their excess weight. With the most weight loss being in the first 6 months after surgery.
  • Clinical trials and studies have proven bariatric surgery leads to improvement or the resolution of many obesity related health problems such as
    • Type 2 diabetes
    • Hypertension
    • High cholesterol
    • Sleep apnea
    • Asthma
    • Joint pain
    • Depression
    • Gout
  • Overall improved quality of life 

Gastric Sleeve and Roux-en-Y Surgery Complications and Risks

While minimally invasive surgeries are generally safe, complications and risks, like with any other surgery, could possibly occur.

Following surgery, patients may experience

  • Nausea, vomiting or constipation.
  • Heartburn or reflux
  • Narrowing of the stomach sleeve
  • Trouble absorbing certain nutrients
  • General anesthesia risks such as breathing problems.
  • Other possible side effects can include infection, bleeding and blood clots in legs.

In rare cases, a leak along the staple lines is possible.

Revision Surgery

Revision weight loss surgery is performed when a previous weight loss operation has not proven successful. Though there are many reasons for a revision surgery to be done, it is often more complicated and involves the conversion to another form of weight loss surgery to help with additional weight loss or to correct complications that may have occurred due to the first surgery.

Dependent on the particular lifestyle and surgical situations of the patient, the doctor will do an examination that may include an esophagram and an x-ray of the esophagus and stomach for proper evaluation before making recommendations.

Recovery

Post surgery, rest and recovery will be important. Recovery time from these procedures varies from patient to patient. Bariatric surgery requires a 6-week transition to retrain the stomach. Patients will need to follow a liquid diet and introduce normal foods slowly. They will move from a liquid diet to a soft diet such as cottage cheese, yogurt or soup, then transition slowly to a solid diet over several weeks. The doctor, nurse, or a dietician will help with which foods and beverages are good and which should be avoided.

Bariatric surgery is a treatment option that should be recognized as a tool in weight loss. Lifestyle adjustments such as diet, physical activity and possibly psychological changes will be required to maintain a healthy weight.

The amount of weight loss after surgery will depend on the individual and the post operative care taken for recovery and healthy lifestyle habits. No surgery is sure to produce and maintain weight loss alone. It is not a replacement but may make it easier to consume fewer calories and be more physically active.

Is Bariatric Surgery A Good Choice For Me?

Bariatric surgery is a safe and effective treatment option for those affected by severe obesity. However, all surgeries present possible risks that vary with each patient. Bariatric surgery is a major decision that should be considered carefully. Clear communication is needed between doctors and their patients to ensure bariatric surgery is the right weight loss plan.

Dr. Andrea Pakula is a member of the American Society of Metabolic and Bariatric Surgery. A leader in the field of Minimally Invasive Bariatric procedures, she provides her patients with the best bariatric surgery options: Gastric Sleeve, and Roux-en-Y Gastric Bypass and specializes in revision surgeries to improve the negative results of previous weight loss surgery. All weight loss options are expertly performed using advanced robotic technology and minimally invasive techniques for improved patient care.