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Bariatric

Laparoscopic surgery is a procedure designed for individuals who are significantly overweight. This technique utilizes a specialized telescope, known as a laparoscope, to observe the stomach, enabling the use of smaller incisions in the abdomen.


What is Severe Obesity?

Morbid obesity is characterized in several ways. One method is by using the Ideal Body Weight standard, which considers being about 100 pounds (45.5 kg) or 100% over the ideal body weight as morbidly obese. This benchmark is based on the Metropolitan Life Insurance Company's height and weight charts. The Body Mass Index or BMI is another common metric used. It calculates obesity based on a person's height and weight and is generally more accurate than ideal body weight calculations. The Center for Disease Control (CDC) reports that obesity rates have been steadily increasing, with a prevalence of around 25% in most U.S. states. This condition is associated with serious health complications, including hypertension, diabetes, sleep apnea, and coronary artery disease.

Various methods have been suggested for the treatment of severe obesity, often termed "morbid obesity." These include diets low in calories, the use of pharmaceuticals, behavior modification, and exercise therapy. However, surgical intervention is the only method that has proven effective in the long-term management of this condition.

What Causes Severe Obesity?

Severe obesity, a complex disorder affecting both appetite regulation and energy metabolism, is likely influenced by a combination of factors. These include genetic, psychosocial, environmental, social, and cultural elements, which interact in various ways. This condition is not merely a result of an individual's lack of self-control.

The underlying causes of severe obesity are complex and not fully understood. People with obesity often have a higher set point for stored energy. This altered set point might be due to several factors, such as a low metabolism with reduced energy expenditure, excessive calorie consumption, or a mix of both. Additionally, there is scientific evidence to suggest that obesity might have hereditary components.


What are the Treatment Options?

Medical Treatment

The National Institutes of Health Conference in 1991 reached a conclusion regarding weight loss methods for individuals with severe obesity. It was found that non-surgical approaches, barring rare exceptions, fail to maintain effectiveness in the long term. Participants in non-surgical weight loss programs for severe obesity tend to regain their lost weight within a five-year period.

Regarding the use of medications, both prescription and nonprescription types aimed at weight loss do not offer a sustainable solution for managing morbid obesity. A rapid weight regain is common once these medications are stopped. Professional weight loss programs, employing low-calorie diets, increased physical activity, and behavior modification techniques, have reported an initial weight loss of one to two pounds per week. However, this weight loss is almost invariably regained after five years.

Surgical Treatment

Over the last 40 to 50 years, a variety of surgical weight loss procedures have been developed. Recognized operations by most surgeons include Roux-en-Y gastric bypass, adjustable and non-adjustable gastric banding, sleeve gastrectomy, malabsorption procedures like biliopancreatic diversion and duodenal switch, and vertical banded gastroplasty.

In the Roux-en-Y gastric bypass, the stomach is divided to create a small pouch, which is then connected to a Y-shaped section of the small intestine (Fig. 1). The laparoscopic gastric banding procedure involves placing a half-inch band around the upper part of the stomach, forming a small pouch with a controlled outlet to the lower stomach, which can be adjusted by filling the band with saline to restrict food exit from the pouch (Fig 2).

Sleeve gastrectomy entails removing around 75% of the stomach, significantly reducing its volume (Fig 3). Malabsorption surgeries lead to weight loss by limiting calorie absorption, achieved by reducing stomach size and bypassing a major portion of the intestines (Fig 4).

Vertical banded gastroplasty constructs a small stomach pouch with a restricted outlet to the lower stomach, reinforced with mesh to maintain its integrity.

The choice among these surgical options depends on the surgeon's preference and the patient’s dietary habits.

What are the Advantages of the Laparoscopic Obesity Surgery?

Advantages Include:
  • - Decreased pain after surgery
  • - Shortened duration of hospitalization
  • - Reduced complications related to surgical wounds
  • - Quicker resumption of work activities
  • - Enhanced cosmetic outcomes

Who Should Be Considered For Laparoscopic Obesity Surgery?

The National Institute of Health has set forth specific criteria for selecting candidates for obesity surgery:

  1. Candidates must have a Body Mass Index (BMI) of at least 40 kg/m2, or a BMI of at least 35 kg/m2 accompanied by related health issues like type II diabetes, hypertension, or sleep apnea.
  2. Patients should not have any identifiable metabolic (related to the body's energy conversion process) or hormonal (pertaining to endocrine functions) reasons for their extreme obesity.
  3. Eligible patients must exhibit obesity-related complications that are quantifiable and likely to improve with weight reduction. Such complications can range from high blood pressure (hypertension), elevated blood sugar levels (diabetes), cardiovascular diseases, respiratory disorders, obstructive sleep apnea, to joint problems like arthritis.
  4. Patients are required to have a comprehensive understanding of the surgical procedure, encompassing its potential hazards and side effects.
  5. The patient must be committed to long-term medical observation and follow-up care.
  6. The individual should have a history of unsuccessful weight reduction attempts through conventional medical treatments.

What Preparation is Required?
  1. Prior to surgery, it is vital to have a comprehensive health check-up to assess if laparoscopic obesity surgery is suitable for you.
  2. Consultation with healthcare specialists, such as heart experts (cardiologists), lung specialists (pulmonologists), or hormone specialists (endocrinologists), may be necessary based on your unique health needs.
  3. Prior to the operation, a thorough cleansing of your bowels and intestines is required as per your surgeon's instructions.
  4. Ensure to bathe on the evening prior to or on the morning of the surgical procedure.
  5. A psychological assessment might be needed to evaluate your mental preparedness and ability to adjust post-surgery.
  6. Obtain a detailed nutritional assessment as part of the pre-operative diagnostic evaluations.
  7. Abstain from consuming any food or drinks past midnight before your surgery, with an exception for essential medicines with a minimal amount of water, as approved by your surgeon.
  8. Provide written agreement for the surgery after thoroughly understanding the risks and benefits explained by your surgeon.
  9. Discontinue certain medications, such as pain relievers (aspirin), blood-thinning drugs, inflammation-reducing medicines, and Vitamin E, for a specified period before the operation.
  10. Halt the use of diet pills or herbal supplements like St. John’s Wort at least two weeks prior to the surgery.
  11. Consider quitting smoking before the surgery, which might be a prerequisite in some cases.
  12. Participate consistently in an Obesity Support Group for ongoing support and guidance.
  13. Plan for post-operative home care and assistance as needed.
  14. Bring your Continuous Positive Airway Pressure (CPAP) machine to the hospital if you are using one for sleep apnea.


About the Surgery

During a laparoscopic surgery, surgeons make several tiny incisions (ranging from 1/4 to 1/2 inch) to access the abdomen using trocars, which are slim, tube-shaped tools. A laparoscope, attached to a small video camera, is inserted through one of these trocars. This setup broadcasts an enlarged image onto a television screen, allowing the surgeon to view the stomach and other internal organs in detail. Typically, four to six small incisions are made to insert trocars, through which specialized surgical instruments are used to conduct the surgery.

The surgery is carried out inside the abdomen, which is inflated with Carbon dioxide (CO2) gas to create space for the procedure. At the end of the operation, the CO2 gas is expelled from the abdomen.

What is Next if Laparoscopic Surgery is Not Possible?

If the laparoscopic approach is unfeasible, certain conditions may necessitate or lead to the transition to a traditional "open" surgery.

These conditions can range from substantial scarring due to previous abdominal surgeries to challenges in visualizing organs, or issues with bleeding encountered during the surgery.

The Day of the Surgery: 
  1. Anticipate arriving at the medical facility on the morning scheduled for your surgical procedure.
  2. Once there, you will be provided with a hospital gown to change into as part of the pre-operative preparations.
  3. A medical staff member will establish an intravenous (IV) line in your vein, which is essential for the administration of medicinal agents during the operation.
  4. Administering pre-operative medications is a standard procedure.
  5. You'll have a consultation with the anesthesiology specialist to go over the specifics of the anesthesia planned for your procedure.
  6. Since the surgery will be conducted under general anesthesia, you'll be in a state of induced sleep throughout the procedure, which could last several hours.
  7. Following the surgery, you'll be transferred to the post-operative care unit, where you'll stay until you awaken completely. Subsequently, you'll be moved to a regular hospital room.
  8. It is usual for patients to spend at least the first night post-surgery in the hospital, with some requiring additional days of hospitalization for comprehensive recovery post-procedure.

Outcomes of Laparoscopic Obesity Surgery:

Achieving Weight Reduction

Reports indicate a marginally higher effectiveness in weight reduction with gastric bypass compared to gastroplasty or gastric banding. However, all methods demonstrate positive outcomes. A majority of cases show at least a 50% reduction in excess weight within the first year post-surgery. For all procedures, weight loss typically progresses for 18 to 24 months following the operation. It's usual to experience some weight regain two to five years post-surgery.

Impact on Associated Health Issues

Surgical interventions for weight loss have shown to positively affect conditions such as obstructive sleep apnea, diabetes, hypertension, and elevated cholesterol levels. Numerous patients have noted enhancements in mood and various areas of psychosocial well-being following the surgery. 


Risks Associated with Laparoscopic Obesity Surgery:

Despite its overall safety, laparoscopic obesity surgery, like any significant surgical intervention, carries certain risks. The risk of mortality immediately following these laparoscopic procedures is comparatively low, under 2% as per case studies.

Nevertheless, there's a slightly elevated chance of encountering various complications, such as infections at the incision site, wound separation, abscess formation, leaks from the staple line, bowel perforation, obstructions in the bowel, development of marginal ulcers, respiratory complications, and leg blood clots. In the period following the surgery, additional complications might emerge, potentially necessitating further surgical procedures.

Post-operative complications can include issues like pouch enlargement, persistent vomiting, acid reflux, or inadequate weight loss. In some situations, it may be necessary to revise or even reverse the initial procedure, with these secondary surgeries typically carrying higher risks of complications.

Gallstones, often found in obese individuals, can cause symptoms that become more noticeable after weight loss. To manage this, doctors may prescribe medications to reduce bile (such as Actigall or URSO) or recommend gallbladder removal during the primary surgery. It's crucial to discuss these options with both your surgeon and physician.

Following gastric bypass surgery, there is a risk of developing nutritional deficiencies, particularly in Vitamin B-12, folate, and iron, which can usually be prevented through proper supplementation. "Dumping Syndrome" is another potential side effect, characterized by abdominal discomfort, cramping, sweating, and diarrhea after consuming sugary foods and beverages; this can be mitigated by avoiding such foods.

Similar deficiencies and issues, including protein deficiencies and loose stools related to dietary fat intake, can occur after surgeries that cause malabsorption.

Pregnant women who have undergone these surgeries require specialized care and monitoring. The likelihood of complications from laparoscopic methods is generally on par with or less than traditional open surgeries. While surgical procedures inherently present risks, the likelihood of experiencing these complications is not higher with laparoscopic methods compared to open surgeries.


Post-Surgery Expectations: 

After undergoing laparoscopic surgery, it's important to understand what to expect during your recovery.

Hospital Stay: Typically, your hospital stay will range from 1 to 3 days. During this time, you may have a nasal tube, which will be removed before you can eat or drink.

Pain Management: Pain levels after laparoscopic surgery are generally mild, though some patients may require pain medication. Your surgeon will discuss any necessary dietary changes during your first follow-up visit. Pain medication will be provided as needed to ensure your comfort during the healing process.

Early Mobility: On the night of the surgery, you'll be encouraged to sit in a chair, and by the following day, you should start walking. Engaging in breathing exercises is also a key part of your early recovery.

Resuming Diet: Within the first or second day after surgery, an X-ray of your stomach may be conducted to ensure that the stapling of your stomach is secure. If all is well (which is usually the case), you'll gradually transition to a diet that includes liquids, starting with one ounce per hour. Depending on your surgeon's guidance, you may progress to consuming baby food or pureed foods. This liquid or puree diet will continue until your surgeon evaluates your progress approximately 1-2 weeks after you return home.

Physical Activity: Patients are encouraged to walk and engage in light physical activity as part of their recovery.

Recovery Timeline: Although many individuals begin feeling better within a few days, it's important to remember that your body needs time to heal. Most normal activities, including showering, driving, climbing stairs, working, and light exercise, can typically be resumed within 1-2 weeks.

Follow-Up Appointment: Be sure to schedule a follow-up appointment with your surgeon within 2 weeks after your operation to monitor your progress and address any concerns.


When to Reach Out to Your Doctor:
  1. Prolonged fever surpassing 101°F (39°C).
  2. Experiencing chills.
  3. Sustained coughing and breathlessness.
  4. Difficulty in swallowing that persists for more than a few weeks.
  5. Discharge from any surgical incision.
  6. Any bleeding.
  7. Difficulty in swallowing that persists for more than a few weeks.
  8. Discharge from any surgical incision.
  9. Swelling in the calf or tenderness in the leg.

Important Note: The above information is not a substitute for a thorough discussion with your surgeon regarding the necessity of laparoscopic obesity surgery.

If you have inquiries about the appropriateness of obesity surgery for your situation, alternative options, billing, insurance coverage, or your surgeon's qualifications and expertise, please feel free to contact us.

Should you have any questions pertaining to the surgical procedure or post-operative care, it is advisable to engage in discussions with your surgeon either prior to or following the operation.

The visual content has been generously provided by the American Society for Metabolic Bariatric Surgery.

Color images: Atlas of Minimally Invasive Surgery, Jones DB, et al. Copyright 2006 Cine-Med.

Dr. Yiannis P. Ioannou is a member of the Surgical Society of American Gastroenterology Surgeons