Choice of Bariatric Procedure: A Philosophy Obtained in 20 Years of Bariatric PracticeApril 29, 2013
If you’ve wondered about the facts on bariatric surgery, I’m going to provide you with the key points for bariatric surgery procedures. Additionally, I’ll discuss solid information about each of the mainstream procedures.
Bariatric Procedure Key Points
1) Patients with the band will lose around 40% of excess weight. When there is more significant weight loss, many patients’ bands are too tight. Eventually, they cannot handle the pressure, and when the band is loosened, weight regain occurs rapidly.
2) Sleeve and bypass patients with BMIs of 35 to 40 will lose virtually all their excess weight. Those 40 to 50 have approximately 70 to 75% of excess weight. Those above 55 will lose 50% of excess weight. This means if your BMI is higher than 55, you will lose approximately 15 BMI units and still have a BMI of 40.
3) Duodenal Switch offers the best weight loss and lowest recidivism but comes at the cost of the highest risk of nutritional deficiencies. The cost is worthwhile for those with super morbid obesity and severe diabetes and those committed to taking lifetime supplements and eating adequate protein.
4) With weight loss results similar to the gastric bypass and sleeve, I do not believe that a great amount of weight loss is being gained by having the intestinal manipulation done in the bypass. Yet, the risk of anemia, bone loss, and the need for supplements still exists. At least with the switch, there seems to long-term benefit to justify manipulating the intestine.
5) All patients considering any bariatric procedure should make a contract with themselves to take recommended supplements, no matter the cost, and adhere to follow-up visits and blood work.
For the person contemplating bariatric surgery, there are many sources of anxiety. Just the decision to consider an elective operation that changes your stomach and intestine is quite thought-provoking. Potentially, even more confusing is bariatric procedure selection. Often the surgical procedure chosen is based on what friends or relatives have had done or what the doctor offers. The purpose of this article is to explain the items that are most important in this choice. They are based on years of practice and research in the field of obesity management.
When I first performed bariatric surgery, I thought it was simple. Make the stomach small, and people would eat less, lose weight, and live happily ever after. I was naïve.
Now, I know the most important aspect of a bariatric procedure is hunger suppression. Successful operations offer more than just making it more difficult to eat. They alter factors that affect hunger and satiety.
During the years that I have practiced, a great deal has happened. As an early adapter to laparoscopic procedures, I have participated in several clinical trials for new devices. In the past five years, we have transitioned our practice for primary procedures from bypass and band, to vertical sleeve gastrectomy and duodenal switch.
The basis is our research studies and clinical experience. Our practice has cared for several thousand gastric bypass patients, and I was the principal investigator for the first multicenter trial for weight regain following gastric bypass. Our sleeve experience is over 10 years, and we have performed a duodenal switch since the 1990s.
Laparoscopic Adjustable Gastric Banding (LAGB)
LAGB is a simple surgical procedure, that is initially enticing to patients. My view is buyer beware. Living with a band can be a more significant challenge than expected. Band advocates claim that it is reversible. This is not true. It is removable, and the band causes a scarring reaction that persists following the extraction and makes a conversion to other bariatric procedures more complex. Often, I hear they are less invasive.
However, all of our procedures are done minimally invasively. Recovery from band surgery is rapid. Unfortunately, as time passes and the band is filled, complications increase. As a result, the reoperation rate for bands is approximately 5% per year. The extraction rate is also not low.
I anticipate that over a ten-year duration, at best, 50 to 60% of bands will remain in place. When extracted, most require conversion to another bariatric procedure, or weight gain is inevitable. The high reoperation rate and risk of revision make me question those who highlight the reduced risk of a perioperative complication that lap band offers. After all, the revision will be more difficult than just doing a longer-lasting primary procedure.
Most importantly, the band does not impact any of the hunger signals that we have been able to study. I also question its mechanism of action. The band functions to create a high-pressure zone just past the esophagus, the tube that transports food from the mouth to the stomach.
As the pressure is raised, the esophagus has to work harder. Until the pressure reaches a certain point, the patient feels little restriction. Once too high, the pressure has an adverse impact on the muscular esophagus. This results in patients having heartburn or dysphagia when the band is too tight and then feeling no restriction when loosened. Proponents of banding believe that there is an ideal point or green zone. My experience has shown that this exists for some people. For others, the band can be frustrating to both patient and provider.
At our seminars, I describe the band as a diet with a seat belt. By this, I mean it does not create the same feeling of anorexia that is seen following the stapling procedures. It will force you to eat slowly and chew your food. It will make it more difficult to eat meat products and bulky vegetables often, though it will not make you less hungry and thus encourage the consumption of foods that pass the bands easily. These include things like ice cream and cheese doodles, crackers, and pretzels. Furthermore, there is no accurate method to predict who fill thrive or fail with a lap-band.
Interestingly, public awareness of these facts is increasing. While the term lap-band is still commonly searched on the internet, more patients and practices are turning to other procedures. In the last two years, band sales have declined by 40% in the United States. I believe that this is happening because of patient communication. More now realize that the marketing and results are not equal.
Do we still offer bands? The answer is yes. I have seen some great results. However, in the last year, our group removed 80 bands with conversion to other bariatric procedures. None of the patients that had the band removed wanted to be in this group. All selected their procedure hoping it would provide long-term control. I expect this trend to continue. In general, once a medical device declines, there is usually no recovery.
Roux en Y Gastric Bypass (RYGB)
Many of my colleagues consider the gastric bypass the gold standard of bariatric procedures. Despite being a strong advocate during the first portion of my career, I have begun to question this viewpoint. At first, I was a lone wolf. Now an increasing number of domestic and international surgeons have changed their approach. In the bariatric video textbook, recorded more than three years ago, I projected that the sleeve would equal bypass, and then there will be growth in the duodenal switch. I am certain that this is what is happening.
I performed my first gastric bypass in residency and then did an open bypass until 2000. We shifted to laparoscopic gastric bypass and did open switches on some of our largest patients. In the early to mid-2000s, an increasing number of our old bypass patients returned. They were complaining not just of weight regain, but severe hunger. They begged us to give them back the feeling they had immediately after surgery. We realized that many were having symptoms of hypoglycemia, and proved this hypothesis in a published research paper. After eating, their sugar would rise, insulin would be secreted, and then their sugar would rapidly fall. When this happened, they would become very hungry and eat what was available.
To be clear, I think that gastric bypass is a great weight loss operation. Where I disagree with many of my colleagues is that I believe that the amount of weight regain and the return of hunger are underestimated. Thus, I do not believe that the bypass anatomy is the best construction to maintain weight loss.
Why not? Let me begin by dispelling a common misconception regarding gastric bypass. Patients are told that bypass is the operation of choice for sugar eaters and snackers. The theory goes that if you eat sweets, you will develop the symptoms of dumping. These symptoms are so unpleasant that you will refrain from snacking. The problem is that this is not true. While some get terrible symptoms, most do not. Additionally, there has never been a study done that shows that those who do dump, lose more weight. There are now two well-done research papers that show that the symptoms of dumping do not correlate with weight loss.
After analyzing numerous patients with weight regain, what happens is that when foods that provoke insulin such as sweets are eaten, blood glucose declines after a rapid spike. This sharp decline causes the patient to be hungry and eat often. Thus, it is our contention that when bypasses fail, it is because of inter-meal hunger.
To be clear, weight regain is inevitable with any bariatric procedure. My concerns regarding bypass are the return of hunger and the few options available when weight regain occurs. As a tertiary referral practice, we see numerous patients with weight regain following bypass. The most effective approach is converting to a duodenal switch, but this is a complex procedure. Other approaches, such as endoscopic suturing and even banding, are simpler but less effective.
Because of these concerns, we decided to think about methods to improve the bypass. Our biggest concern was that after adaptation, many patients developed rapid emptying. With the fast passage of food from their pouch, they became hungry shortly after eating. As a result, we felt that the bypass would need a valve. An option would be to place a ring, as is done in a modified version of the bypass called a Fobi Pouch. This is the operation that Randy Jackson of American Idol had. Our concern is that placement of a band or ring will cause similar long-term complications as the lap-band. A better option is to preserve the valve that naturally exists at the bottom of the stomach called the pylorus. Pylorus means gatekeeper in Latin. Thus, it would seem logical that if we want to leave food in the stomach longer, we should preserve the gatekeeper. Also, we questioned what was achieved with the bypass aspect of the RYGB procedure. With gastric bypass, most surgeons have a short biliopancreatic limb, a 1.5-meter alimentary limb, and an unknown common channel. This means there is plenty of intestine. With adaption, it is hard to believe that there is any malabsorption. As a result, virtually all calories eaten will be absorbed by the body.
Vertical Sleeve Gastrectomy (VSG) and Duodenal Switch Pyloric Preserving Surgery
There are two bariatric procedures that allow us to preserve the pyloric valve, the vertical sleeve gastrectomy, and the duodenal switch. Many think of the sleeve as a new bariatric procedure. The sleeve was first described by Dr. Doug Hess, as part of the duodenal switch.
What a sleeve means is that the stomach is changed from looking like a kidney-shaped bean to a banana. What is called the greater curvature is removed, and the stomach becomes a narrow tube. Many things happen. A small amount of food makes the tube stretch and creates pressure. This stimulates satiety sensors. Also, the portion of the stomach removed makes many of the signals that tell the brain that you are hungry. The best-studied is a hormone named ghrelin.
Sleeves are very effective in making you eat less and be less hungry. The first sleeves done were performed on patients that planned to have a duodenal switch. The switch adds an intestinal bypass placed beneath the pyloric valve, to the sleeve gastrectomy.
Dr. Michele Gagner decided to stage the procedure. He performed the sleeve first and then planned to return to the operating room and add the intestinal bypass at a later date. Weight loss with the sleeve alone approached gastric bypass. Therefore, several patients did not require the second stage. With further refinement and reasonable weight loss at five years, the sleeve has become a primary bariatric procedure.
Since that time, much has been learned about the proper technique for sleeve gastrectomy and what is required to have lasting weight. Unfortunately, there is still considerable variation, and experience with the procedure does matter. With bands declining in popularity, surgeons with limited experience have been offering sleeve gastrectomy.
As far as technical matters, patients always speak about the bougie size. While the bougie serves as a guide, the most important thing is where the staples are placed. A well -done sleeve starts 3 to 4 cm from the pylorus, carefully preserves the angle of the stomach, and excludes the fundus. The staple lines should be straight, and Hiatal hernias corrected.
In terms of weight loss, the sleeve is similar to gastric bypass at both one and three years. Of all the bariatric procedures I have performed, it has the least amount of issues after the perioperative period. In comparison to bypass and switch, the early complications appear to be lower. However, it is a stapling procedure, and thus there is a small chance of leak or breakage of the staple line. If this occurs, it can take months to treat, and these leaks can be more difficult to treat than those from gastric bypass.
Patients also should be told that weight loss is generally 15 to 18 BMI units. For both sleeve and bypass, if your BMI is higher than 55, you are most likely to still have a BMI higher than 40, three years after surgery. Finally, you have to realize that the sleeve is an eat less operation. With time, the sleeve will stretch, and you will be able to consume more. If you do, you will gain weight. There is no funny math, and calories eaten will be absorbed.
In the last several years, when we want to add an intestinal component or bypass to our procedures, our preference has been to place the bypass beneath the pyloric valve, performing a duodenal switch. Our research has demonstrated many advantages. The duodenal switch offers patients the most significant weight loss, and the best chance to maintain their weight. Countering this is the risk of micronutrient deficiency and malnutrition.
In my opinion, many surgeons who do not offer duodenal switch surgery, denigrate the procedure without proper thought. With experience with both bypass and switch, I believe that most overestimate the nutritional consequences of the switch, and underestimate what occurs with bypass.
With both, patients who do not take supplements or eat adequate protein will have issues. The loose bowel movements can be titrated by preserving adequate bowel length. Many of these concerns are overstated because few surgeons have the confidence to perform the procedure laparoscopically. Judging by the attendance in our courses, and requests to observe cases, the popularity of the procedure is beginning to rise.
A duodenal switch combines a sleeve gastrectomy, constructed larger than when a sleeve is done as a primary procedure, with an intestinal bypass. As the gatekeeper or pylorus is preserved, this allows for a greater bypass to be performed without frequent diarrhea. It is our practice to preserve three meters of the intestine with a common channel of 1.25 meters to 1.5 meters. Most people have 7 to 8 meters of the intestine.
With the DS, people will absorb 70% of total calories, 30% of fat, but 100% of simple carbohydrates like sugars. Alcohol also will be completely absorbed. It is imperative that patients consume 100 grams of protein and supplement vitamins A, D, E, K, as well as iron and calcium. Two multivitamins per day are also recommended.
The advantage is that many patients lose over 80% of their excess weights. For patients with BMI’s greater than 55, this is the only procedure where the majority will not be morbidly obese three years after surgery. The resolution of diabetes also exceeds the gastric bypass. Finally, it is, in my opinion, the best option for sleeve patients with inadequate weight loss.
We have recently completed a study that compares bypass, sleeve, and switch. Interestingly, the switch did not cause the pathological reduction in blood glucose levels that we have seen with gastric bypass following carbohydrate challenges. We believe that this data is important and is a reason why DS offers better long-term weight loss.
Another key component for the long-term results is the length of the intestine bypassed. By preserving the gatekeeper, a shorter intestinal length can be handled. This results in being a long-lasting control mechanism. Once eating increases, the shortened intestinal length prevents all that is eaten is absorbed. This protects against rapid weight regain unless a large number of simple carbohydrates are consumed.
Some Final Thoughts
In bariatric surgery, we still have not answered a philosophical question. Is the role of surgery to provide weight loss, and then hope the patient learns techniques to maintain? Or, should it offer a lasting control mechanism? To have long-lasting control, either permanent restriction with a band-type apparatus has to be placed, or the intestine short-circuited.
Gastric bypass does not short-circuit the intestine in an effective manner. Whenever the intestine is manipulated, there is a risk of vitamin deficiency, anemia, bone hunger, and small bowel obstruction. This increases as the length of the bypass is increased. Thus there is no perfect procedure. Matching patient and their objectives are essential. Duodenal Switch has the most weight loss and exerts lasting control. The cost is the greatest risk of nutrient deficiency.
In our practice, the sleeve has become our most common procedure. For those with the highest BMI’s or who are on injectable therapy for diabetes, we believe there is a great advantage for duodenal switch. Also, for patients that want the most definitive procedure and the most significant weight loss, the switch may be attractive. They must understand the lifetime commitment required to take supplements.
Both band and bypass have lost favor. With bands, many are not satisfied and require revision. Bypass offers excellent weight loss, but we believe that the recidivism is underestimated. We have seen similar weight loss results with the sleeve, with a lower risk of nutrient deficiency, as the intestine is not changed. If the intestine is altered, we believe that the advantages offered by the duodenal switch at least justify the risks. There is better weight loss, lower weight regain, and better resolution of co-morbid conditions caused by obesity.
From a patient's perspective, do not have your choices limited by what the local center offers. New is not always better. I see no advantage for gastric plication as compared to a well-done vertical sleeve gastrectomy. The idea that the entire stomach is preserved is ridiculous. There is no use for the damaged, congested portion. Combining with lap band is like taking sand and water and expecting to get oil. It will leave the patient with only complex choices for revision if not successful.
A novel procedure that I believe has promise is a single anastomosis or loop duodenal switch. This avoids an attachment, and we have begun to utilize certain complex patients and revisions.
Obesity is a complex process without a cure. With surgery, it remains a struggle. In my opinion, the role of surgery is to provide a lasting control mechanism that assists the patient in this challenge. With time, I have realized that bands alone and gastric bypass are less efficacious for many recipients than hoped. Whereas weight regain will occur with the sleeve, it can easily be converted to switch. The switch offers the most definitive bariatric option. However, compliance with diet and supplements is essential, and weight regain can still occur.
In conclusion, a bariatric procedure choice is an important decision. However, as important is the development of a structured lifestyle. Patients who have the best long-term results have a routine. They eat the same things at the same times and become more active. Obesity is a chronic disease or condition. While surgery can offer a lasting control mechanism, it is not a cure, and all patients must always understand its limitations. Finally, it is of the utmost importance to take supplements and have adequate follow-up, so the chance of replacing one issue with another is limited.
ABOUT THE AUTHORMitchell Roslin, MD, FACS is the Director of Bariatric Surgery at Lenox Hill Hospital and Northern Westchester Hospital Center. He has performed bariatric surgery since 1994 and is internationally renown in the field. In addition, to his clinical work he has authored numerous research articles and chapters in medical textbooks. Dr. Roslin has appeared on Good Morning America, Nightline, CBS Early Show, World News Tonight and countless other media outlets.
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