What’s the Best Weight Loss Procedure for You?March 10, 2016
Even if a patient has researched and decided what weight loss procedure they would like to undergo, I feel it is important to review all of the procedures available to make certain they have all the information they need to make an informed decision. It is not uncommon for a patient to say “I didn’t know that” as I review the procedures with my patients.
As I meet our patients for the first time, I try to understand what brought them to see me, and what their primary goal is. Some of the common goals my patients have are to be alive and have good health to spend time with the children in their lives, treat diabetes, increase their mobility and improved overall health.
It is important to me that my patients understand the role that surgery plays in life-long weight loss for long-term success. Every patient is unique and there are many factors to consider when choosing a bariatric procedure. Below is a brief overview of the considerations that I discuss with my patients during their first clinic visit.
Knowing the Difference Between Weight Loss Procedures
First, a patient must understand the difference between a metabolic and non-metabolic operation. For many years, the understanding of how bariatric surgeries worked was based on the concepts of restriction and malabsorption. It is true that all operations create restriction which means because of a small pouch or a narrow passage for food, eating anything more than a small meal can be very difficult. Those who try to eat more that the operation allows will develop discomfort or vomiting. Historically, operations such as horizontal stapling, the Vertical Banded Gastroplasty (VBG), and more recently the Laparoscopic Adjustable Gastric Band (Lap-Band) were based primarily on the concept of restriction and are not metabolic operations.
Unfortunately, although restriction alone can help some patients lose weight in the short term, many patients develop chronic, severe heartburn, nausea, and vomiting due to what is essentially an obstruction of the gastrointestinal tract. This is why surgeries such as horizontal stapling, the VBG, and the Lap Band fall out of favor. Additionally, bariatric surgeons often have to re-operate on these patients to relieve an unforgiving blockage.
I have what I call the “Broccoli Test for Operations.” Broccoli is a super food, and if an operation makes it so that you cannot eat broccoli but instead have to live on mashed potatoes and soup, then we, as bariatric surgeons, have not done our job.
As it turns out, the concept of malabsorption is not the primary driver of weight loss either. There is another word that goes with malabsorption, and that is diarrhea. An operation commonly performed in the 1970’s called the Jejunoileal Bypass was based primarily on malabsorption, and those patients would eat whatever they wanted. The food would pass through them rapidly (i.e. severe diarrhea), but the long-term complications from this operation were so severe that they all had to be reversed. The Duodenal Switch can cause malabsorption if too much small intestine is bypassed, and these operations usually have to be revised.
What it Means That an Operation is Metabolic
So if it is not restriction or malabsorption that primarily drives weight loss, then what is it? What does it mean that an operation is metabolic? Procedures such as the RNY Gastric Bypass, the Vertical Sleeve Gastrectomy, and the Duodenal Switch are able to effectively manipulate the gut hormones that control hunger, feeling full, and metabolism. Another way of saying an operation is metabolic is that it achieves neurohormonal modulation. By changing the way food goes through the gastrointestinal tract, we change the hormonal signals to the brain that tell you when you are hungry, when you are full, and whether or not the body is starving for calories.
One of the major reasons diets fail with long term weight loss is that when you diet the body thinks you are starving to death, and actively counteracts the weight loss. Unfortunately, the same powerful system that protects us from starvation makes it nearly impossible for many people to lose weight and then keep it off. Currently, metabolic operations are the only way we are able to disrupt this system.
Although patients are not hungry and are eating much less, the metabolic breakdown of fat is increased. This is the “magic” of metabolic operations and the reason why the Gastric Bypass, which was first performed in 1967, is still commonly performed today. I recommend that patients undergo metabolic operations, such as the Vertical Sleeve Gastrectomy and the Gastric Bypass. Another major criteria is how much weight a patient needs to or expects to lose. On average, patients lose more weight with the Gastric Bypass than the Sleeve Gastrectomy. The average excess weight loss with the Gastric Bypass is 70-75% and with the Sleeve Gastrectomy is 60-65%.
If a patient’s primary goal is to lose as much weight as possible then the Gastric Bypass is a great option for them. Although there is more weight loss with the Gastric Bypass, that operation may be technically difficult to perform when the BMI is above 70, and the Sleeve Gastrectomy has been a great option for these patients. Once patients with a BMI above 70 have lost a significant amount of weight with the Sleeve Gastrectomy then conversion to Gastric Bypass or Duodenal Switch is possible if the patient so desires.
Treating diabetes with surgery has been a radical idea that has taken a few years and some great studies for the medical community to accept. The fact is that the Gastric Bypass, the Sleeve Gastrectomy, and the Duodenal Switch have much more power than medications alone to improve diabetes. If a patient’s primary goal is to treat diabetes then I usually will recommend the Gastric Bypass as this has been shown to improve blood sugars and reduce need for medications immediately after surgery for most patients. However, the Sleeve Gastrectomy also helps treat diabetes and seems to catch up with the Gastric Bypass with its ability to reduce HgA1c at one year. Studies have also demonstrated the Duodenal Switch to be effective in treating diabetes.
Laparoscopic, Minimally Invasive Surgery
Fortunately, the safety of bariatric surgery has improved dramatically since the 1970’s, and with the advent of laparoscopic, minimally invasive surgery bariatric surgery ranks among the safest operations available. On average, there is less weight loss with the Sleeve Gastrectomy, there does not appear to be many long-term risks associated with this operation. Currently, some patients with the Sleeve Gastrectomy develop heartburn and reflux. Although the Gastric Bypass has more weight loss on average, there are long-term risks of developing bowel obstructions and ulcers. Most commonly patients that develop ulcers are taking NSAIDs, smoking cigarettes, or drinking alcohol, it is possible to develop ulcers without these activities. The Duodenal Switch has higher risks of long-term malabsorption and vitamin deficiencies due to the fact that most of the small bowel is bypassed with this procedure.
Even if an operation is performed perfectly, there are long-term considerations. The risks of a surgery must be balanced with the benefits.
Patients who suffer greatly with heartburn need to know that the Gastric Bypass is one of the best operations to treat heartburn. The Gastric Bypass is also a great operation to repair a hiatal hernia, which is when the stomach moves above the diaphragm behind the heart. As previously mentioned, the Sleeve Gastrectomy can be associated with causing heartburn. What I usually advise is that if you have heartburn before the Sleeve you will probably have heartburn after the Sleeve. Heartburn does go away for some after the Sleeve, but I never advise anyone to expect that, and some without heartburn may develop it after the Sleeve Gastrectomy.
In the end, deciding which bariatric operation is right for you is a personal and critical decision. My last major criteria is that I want my patients to be comfortable with the decision they have made and that they have been given all the information they need to make a truly informed decision.
ABOUT THE AUTHORJason Reynoso M.D. works at Honor Health Bariatric Center. He has held appointments as Clinical Attending General Surgery at the VA Medical Center in Omaha and Research Associate at the Center for Advanced Surgical Technology at the University of Nebraska Medical Center. Dr. Reynoso is a Fellow of the American College of Surgeons, a Regular Member of Sages, and a Fellow of the American Society of Metabolic and Bariatric Surgery.