Is Surgery Right for You?

Obesity is a dangerous disease leading to shortened lifespan and poorer quality of life. It can have deleterious effects on a person’s body and also on the mind. Simple everyday tasks can become challenging for a person with obesity who must also deal with social, psychological, and health problems. In its severe form, obesity can lead to serious health problems, poor quality of life, and a shortened life span. Obesity is a chronic disease that is difficult to fight alone. The vast majority (97%) of patients will have struggled with multiple diets only to find the weight has come back on.

Examples of obesity related problems:

diabetes, high blood pressure, heart disease, sleep apnea, high cholesterol and triglycerides, shortness of breath, asthma, joint or back problems, arthritis, heartburn or acid reflux, infertility, sexual dysfunction and impotence, polycystic ovarian syndrome, kidney dysfunction, depression/psychosocial dysfunction, cancer cases, fatty liver, gallstones, headaches and migraines, blood clots or venous insufficiency and urinary incontinence.

The treatment of obesity starts with changes in diet and eating pattern and an increase in activity levels. The patient should be evaluated by a group of healthcare providers including doctors, dietitians, behavioral therapists, and fitness specialists. When diet and exercise attempts fail, the doctor may choose to add medications or refer the patient for more radical interventions including radiologic (link), endoscopic (link) or surgical (options). 

These interventions are effective but can cause side effects and can carry some risks. Therefore, the decision to undertake any of these options is taken after a thorough and comprehensive evaluation with the patient.  The patient’s body mass index (BMI) should be at least 30 kg/m2 to consider any of these interventions.

Surgery Options:
1. Laparoscopic Roux-y-gastric bypass (LRYGB)

Description: The Roux-y-gastric bypass (RYGB) is one of the oldest operations performed for the treatment of morbid obesity. It was started in the United States in the late 1960s after surgeons observed weight loss following operations done for peptic ulcer disease. It is the most popular bariatric operation in the United States. It is done laparoscopic using small “key hole” incisions in most cases.

The steps of the operation include:

1. 1. Dividing the stomach into 2 parts: A small “pouch” measuring around 30ml and the rest of the stomach that will no longer be in contact with food. The division is accomplished by staplers (see link to staplers)
2. 2. The next step is to divide the small intestine again with staplers and bring the intestine to the pouch and create a connection between the pouch and the small intestine (anastomosis). The intestine carrying the juices from the stomach, liver (bile) and pancreas is connected to the intestine about 100 to 150 cm away from the pouch (see diagram). This way all the digestive juices mix with the ingested food and absorption of calories should be normal.

Results:
Weight loss starts immediately after the operation and continues up to 12 to 18-months after surgery and averages about 30% of the weight. After the second year, weight regain is expected and increases with time. However, most patients are still able to maintain a weight loss of around a fourth of their initial weight even after 10 or 15 years.  

More importantly, gastric bypass has been shown to be the most effective treatment for diabetes and many obesity-related health problems such as high blood pressure and sleep apnea. Most patients feel better and healthier. In fact, several studies have demonstrated that patients who undergo gastric bypass live longer and develop less cancer than other obese patients who don’t receive bariatric surgery. 

Risks and Side Effects: Immediate serious risks following RYGB occur in 5% of patients and include the risk of deep vein thrombosis (blood clots), pulmonary embolus, leak and deep abdominal infection, bleeding and intestinal blockage. Most will appear within the first few days. Some of these complications are best managed with early re-operation. The risk of death is less than 0.3% in experienced bariatric surgical centers such as ours.
Long term side effects include temporary hair loss, occasional fatigue, anemia, vitamin deficiency, gallstones and loose skin. That is why it is important to maintain regular follow-up and perform blood tests at least twice a year.
Dumping syndrome is a known side effect of the gastric bypass and consists of a set of symptoms that appear after eating high caloric food. These symptoms include fatigue, dizziness, near fainting, fast heartbeat, cold sweats and are related to low blood sugar in the blood. It is paradoxical but eating sugary food will stimulate the pancreas to release large amounts of insulin which in turn lower the blood sugar. Dumping syndrome is preventable but avoiding eating high calorie foods and relying more on vegetables and proteins. 

Life after the Lap RYGB:
The average operation takes about 90 minutes and the average stay in the hospital is around 2 days. The phases of diet include clear fluids for three days, thick fluids for five days and soft food for one week. Thereafter food intake becomes normal. Most patients return to work within 10 days of the operation and resume exercise three weeks later.
Long-term commitment to healthy eating habits and regular activity are important to guarantee the success of the operation.

2- Laparoscopic Mini-gastric bypass (LMGB)

Description: The Mini-gastric bypass or one anastomosis gastric bypass is another variation of the gastric bypass. There are two major differences between the MB & RYGB: The gastric pouch in the MGB is longer. More importantly there is one connection between the gastric pouch and the small intestine. The MGB may have the advantage over the RYGB in being simpler and quicker as an operation. Weight loss seems to be equal among the two procedures with a tendency to have more diarrhea and mal-absorption with the MGB.

The major concern with the MGB is the exposure of the gastric pouch to the irritating juices of the bile and pancreas, which in the long-term might lead to damage, ulcers and possible cancer in the lining of the stomach pouch. We do not have strong evidence to support that claim and long-term data on the MGB is still lacking. Although criticized early on by many American bariatric surgeons, the mini-gastric bypass has become a standard operation in many European countries. 

Results:
Long-term results with the MGB are similar to the RYGB with around 30% percent weight loss and improvement or resolution of obesity related comorbidities.

Risks and Side Effects:
Immediate serious risks following MGB occur in 3% of patients and include the risk of deep vein thrombosis (blood clots), pulmonary embolus, leak and deep abdominal infection, bleeding and intestinal blockage. Most will appear within the first few days. Some of these complications are best managed with early re-operation. The risk of death is less than 0.3% in experienced bariatric surgical centers such as ours.
Long term side effects include stomach ulcers, gastritis, bile reflux, temporary hair loss, occasional fatigue, anemia, vitamin deficiency, gallstones and loose skin. That is why it is important to maintain regular follow-up and perform blood tests at least twice a year.
Diarrhea and passing gas is a common occurrence after the MGB. 

Life after the Lap MGB:
The average operation takes about 60 minutes and the average stay in the hospital is around 2 days. The phases of diet include clear fluids for three days, thick fluids for five days and soft food for one week. Thereafter food intake becomes normal. Most patients return to work within 10 days of the operation and resume exercise three weeks later.

Long-term commitment to healthy eating habits and regular activity are important to guarantee the success of the operation.

3- Laparoscopic Sleeve Gastrectomy (LSG)

Description: The Laparoscopic Sleeve gastrectomy is the most common bariatric surgical procedure performed in Qatar and worldwide. The idea of the sleeve is to reduce the capacity of the stomach by around 70% leaving the rest of the digestive system intact. Around 70% of the stomach on the left side is removed and the remaining part of the stomach now looks like a tube or a “banana”.

The sleeve gastrectomy started as a part of an operation called the duodenal switch (DS). The DS operation includes bypassing a large segment of the intestines to decrease the absorption of calories and fat. It is one of the most difficult operations to be performed laparoscopically. Surgeons who attempted this operation in the 90’s faced a lot of difficulties and so they divided the operation into two phases. They would start with the laparoscopic sleeve gastrectomy first and then a few months later complete the duodenal switch, at which time the patient would have lost weight and the operation would be easier. To everyone’s surprise the sleeve gastrectomy alone led to substantial and sustained weight loss and that led to the adoption of the sleeve gastrectomy as a recognized primary bariatric operation.

Results:
Long-term results with the SG are comparable with the RYGB. The weight loss in the first 2 years is around 30% of the weight. As in all bariatric operations, weight regain is expected after the first year. Changing eating habits, especially avoiding sugars and sweets is key to ensuring long-term weight loss. Sleeve gastrectomy is also quite effective in treating or improving obesity related health problems such as diabetes and sleep apnea among others.

Risks and Side Effects:
Immediate serious risks following LSG occur in 2% of patients and include the risk of deep vein thrombosis (blood clots), pulmonary embolus (PE), leak and deep abdominal infection, bleeding. Most will appear within the first few days. Some of these complications are best managed with early re-operation. Leaks from the staple line can sometimes be managed without an operation using stents but many patients who develop a leak will be best treated by converting the operation into a bypass. The risk of death is less than 0.3% in experienced bariatric surgical centers such as ours.
Long-term side effects include acid reflux in around 20-40% of patients. As with all bariatric operations, some patients will regain weight with time. It appears that weight gain is related to re-expansion of the stomach. Vitamin B-12 levels should be monitored regularly to prevent deficiency.

Life after the LSG:
The average operation takes about 60 minutes and the average stay in the hospital is around 2 days. The phases of diet include clear fluids for ten days, thick fluids for ten days and soft food for ten days. Thereafter food intake becomes normal. Most patients return to work within 10 days of the operation and resume exercise three weeks later.
Long-term commitment to healthy eating habits and regular activity are important to guarantee the success of the operation.

4- Laparoscopic Adjustable Gastric Band (LAGB)

Description: The Laparoscopic Adjustable Gastric Band (LAGB) was the first bariatric operation performed with small incisions. It was described in the early 1990’s and quickly became the most widely performed bariatric operation in Europe and the Middle East. Enthusiasm for the band has gradually waned because of disappointing long-term results. It took many years before it spread to the United States because it wasn’t until 2001 that the Food and Drug Administration (FDA) approved it.

The gastric band is made of silicon and is wrapped around the upper part of the stomach to restrict the passage of food from the esophagus down into the stomach. On the inside of the band there is a balloon that can be inflated to tighten the opening further and deflated to loosen it up. The adjustments are done by injecting a needle into a reservoir that is implanted under the skin. The reservoir and the band are connected via a long tube.

Results:
There are distinct advantages to the band including its simplicity as an operation, low immediate risks and the fact that it is adjustable. Unlike the gastric bypass and sleeve it may not necessarily decrease hunger or Ghrelin levels so in a way the struggle with fighting hunger persists. That is why results depend more on the patient’s commitment to dietary and lifestyle changes. Results vary a lot depending on how close and intense the follow-up is. Some patients achieve excellent results on follow-up of more than years. However at least 50% of patients have poor weight loss or have to remove the band for reasons such as band malfunction, slippage and erosion.

Risks and Side Effects:
Immediate risks following gastric band placement are uncommon but can include DVT, PE, injury to the stomach and esophagus. The risk of mortality related to the operation is very low (less than 1 per 1000). Long-term problems though are common and present in more than 50% of patients. Most require band replacement, removal with alternated bariatric operation. Examples include acid reflux, dilation of the esophagus, band slippage, and band erosion inside the stomach, cracks in the band, tubing or reservoir.

Life after the LAGB:
The average operation takes about 60 minutes and the average stay in the hospital is around 1 days. Many patients go home the same day. Most patients return to work within 10 days of the operation and resume exercise three weeks later.
The phases of diet include fluids for three weeks. At week #4 we start adjusting the band and further tightening is done in clinic with follow-up depending on weight loss and food tolerability. Some adjustments will need X-ray guidance. Food intake after the band becomes more difficult because some foods such as bread and chicken become difficult to swallow. It is important for patients to chew well and take time during a meal. It is also important to avoid taking foods with high calorie content that are easy to swallow because that would defeat the purpose of the band. Long-term commitment to healthy eating habits and regular activity are important to guarantee the success of the operation.

5- Laparoscopic Greater Curvature Plication (LGCP)

Description: This operation was described by an Iranian surgeon, Dr. Ahmad Talebpour. In this operation, the stomach is folded unto itself in multiple layers to make it smaller and less likely to distend. The operation starts by liberating the stomach, sealing and dividing all the small blood vessels on the greater curve of the stomach. Folding is then done with multiple sutures in layers. The operation there does not require any staples and is done laparoscopic.

Results: The LGCP is a new operation so long-term results are not available. It might be suitable for some patients, especially those who are not very obese and those who have had previous operations and need revisional surgery. More long-term data is needed before we consider the LGCP as a standard bariatric operation.

Risks and Side Effects:
Immediate risks following the LGCP include DVT, PE, perforation of the stomach and bleeding. The risk of mortality related to the operation is low (less than 0.3%). Long-term problems, including weight regain might occur if some of the sutures disrupt. There is also concern that re-operation after the LGCP might be difficult, making revisional bariatric surgery in this group of patients potentially risky.

Life after the LGCP:
The average operation takes about 60 minutes and the average stay in the hospital is around 2 days. Nausea and vomiting is very common the first few days and more pronounced than in other bariatric operations. The phases of diet include clear fluids for ten days, thick fluids for ten days and soft food for ten days. Thereafter food intake becomes normal. Most patients return to work within 10 days of the operation and resume exercise three weeks later.
Long-term commitment to healthy eating habits and regular activity are important to guarantee the success of the operation.

6- Biliopancreatic Diversion (BPD), Duodenal switch (DS) or Single anastomosis duodeno-ileostomy (SADI)

Description: The main feature that distinguishes these types of operations is limiting absorption of calories, especially fat by limiting the length of bowel used in digestion of food. In a sense it is more of a radical bypass. On the other hand the stomach is kept a bit on the large side allowing patients to eat larger quantities to avoid protein malnourishment. There are many variations to this approach and these are referred to as BPD, DS or SADI.

Results:
The long-term results of the BPD, DS and SADI are the best in terms of weight loss and resolution of obesity related co-morbidities. The average % weight loss is 30-35% of the weight even after 10 and 15 years.

Risks and Side Effects:
Because of the severe shortening of bowel length side effects related to poor intestinal absorption are quite common. These include diarrhea, foul smelling stools, foul smelling gas, vitamin deficiency, osteopenia, poor vision, protein loss etc.. Follow-up of nutritional and vitamin deficiencies is very important.
Because these operations are more complicated than the gastric bypass or sleeve, the decision to proceed with these is taken after a comprehensive multi-disciplinary evaluation. In general, we reserve these operations to patients who have gained a lot of weight after first or second operations or those who have extreme obesity.

Life after the BPD/DS/SADI:
The BPD/DS/SADI operations take 2-4 hours to complete laparoscopically. The average length of stay in the hospital is 2 days. The transition of diet from liquids to solids takes about two weeks. Most patients return to work within 10 days and to exercise within three weeks of the operation.
As mentioned earlier, long-term nutritional deficiencies are common so it is important to stay on vitamins lifelong and follow-up periodically with blood tests and visits to the doctor.

7- Revisional Bariatric Surgery

Description: Some patients regain weight, don’t lose much weight or develop complications related to their bariatric operation. In such patients revisional or corrective surgery may be required. Revisional surgery is sometimes needed to fix problems such as ulcers, intestinal blockage, leaks that don’t seal or nutritional deficiency. It may also be needed in case of failure to lose weight or in case of insufficient weight loss.
Many patients do not necessarily need surgery and can be helped with various approaches including diet, behavioral therapy, medications and endoscopic interventions. The team at Aman hospital has vast experience in revisional bariatric surgery and we welcome the challenge of taking care of patients with such difficult problems.

Results: The long-term results of revisional surgery are good if the problem has been diagnosed and characterized properly and remedial surgery is well chosen and well done.

Risks and Side Effects:
Revisional surgery is more difficult and thus carries a higher rate of complications and side effects compared to primary bariatric operations. It should be performed by experienced bariatric surgeons or endoscopists in specialized centers such as Aman Hospital.

Life after Revisional Surgery:
Revisional operations can sometimes be easy with short operative times and hospital stay. Other times, this type of surgery can require open rather than laparoscopic surgery and necessitate a long time in the hospital. Most revisional operations aim at fixing or improving on a problem, so it is expected that most patients would be and feel better.

8- Endoscopic Gastric Balloon

Description: The balloon is placed inside the stomach with the guidance of an endoscope, which is a long tube with a camera at the end that would allow the surgeon to see inside the esophagus and stomach. It is done with the patient under heavy sedation but not general anesthesia. The balloon is inserted in the stomach and then filled with a salt-water solution at a size ranging from 500 to 700 ml. A Blue dye (Methylene Blue) is added to the solution to color it.

This procedure is best suited for a patient who:

1. – is not physically fit for major surgery at all
2. – needs to lose weight to make further surgery safer
3. – is unable to lose weight with the regular ways but does not want to have surgery
   

Results:
Weight loss after the intra-gastric balloon is not as dramatic as with bariatric surgery. The expected weight loss is around 8-15 kgs over 6 months. The balloon has to be removed within 6 months to minimize the risk of small intestinal blockage. As such most patients will regain weight after balloon removal.

Risks and Side Effects:
The placement of the balloon is very safe and the risks are uncommon but may occur. The most serious risk is hurting the esophagus causing a puncture (occurs at a rate of 1/500).
Side effects including nausea, vomiting, heartburn, chest pain, abdominal pain and may necessitate admission to the hospital for IV fluids and medications. They generally subside in 1-5 days.
There is a small risk that the balloon may spontaneously deflate and exit the stomach into the small intestines causing an intestinal obstruction. That is why we use the blue dye in the balloon so when the balloon gets punctured the blue dye is absorbed by the stomach lining and goes into the blood stream. The color of the urine becomes greenish alerting the patient to call the doctor so the balloon can be promptly removed.

Life after the Balloon:
The average procedure takes about 30 minutes. Most patients go home shortly after but some require staying in the hospital at least 24 hours for intravenous fluids, painkillers and medications for nausea. The early phases of diet consist of clear liquids with gradual transition to full fluids and soft food over 4 weeks.

It is important to use the balloon as a helping tool so the patient should take advantage of it and limit the intake of high caloric foods containing sugar and fat. He/she should start a graduated exercise program.

The balloon needs to be removed in 6 months or less. It is also removed with the help of the endoscope under heavy sedation.
The main risk of the balloon removal is injury to the stomach or esophagus.

Post Bariatric Surgery Body Contouring
The skin often stretches after massive weight loss in patients who undergo bariatric surgery. This results in ugly saggy skin in the arms, breasts, abdomen, back, and between the thighs. Body contouring aims at restoring the skin to a near-normal state by removing the extra stretched skin and fat in those areas. The individual procedures include arm lift, breast lift, tummy tuck and thigh lift. When done in combination the procedure is referred to as body contouring.

There are other bariatric procedures that are novel, under development, or under investigation.