Morbid Obesity Surgery
Laparoscopic obesity surgery is an operation for people who have serious health problems because of their weight. Laparoscopy is a way of performing surgery using small incisions. Laparoscopic surgery uses a special instrument called the laparoscope which helps doctors to see organs inside the abdomen.
What is morbid obesity?
Morbid obesity is diagnosed by determining Body Mass Index. An individual is considered morbidly obese if he or she is 100 pounds over his/her ideal body weight, has a BMI of 40 or more, or 35 or more and experiencing obesity-related health conditions, such as high blood pressure, diabetes and coronary artery disease.
Despite anti-obesity drugs, low-calorie diets, exercise and behavior modification techniques, bariatric surgery is the most effective treatment in terms of long-term weight loss, improvement in cardio metabolic risks and quality of life and decline in overall mortality.
What are the treatment options?
Medication: In 1991, the National Institutes of Health Conference concluded that non-surgical methods of weight loss for patients with severe obesity, except in rare instances, are not effective over long periods of time. It was shown that nearly all participants in any non-surgical weight-loss program for severe obesity regained their lost weight within 5 years. Although prescriptions and non-prescription medications are available to induce weight loss, there does not appear to be a role for long-term medical therapy in the management of morbid obesity. Medications that reduce appetite can result in 5-10 kilos weight reduction. However, weight gain is rapid once medication is withdrawn. Various professional weight loss programs use behavior modification techniques in conjunction with low caloric diets and increased physical activity. Weight loss of one to two pounds per week has been reported, but nearly all the weight loss is regained after 5 years.
Surgery: A number of weight loss operations have been devised over the last 40-50 years. The operations recognized by most surgeons include; vertical banded gastroplasty, gastric banding (adjustable or non-adjustable), Roux-en-Y gastric bypass, and malabsorbtion procedures (biliopancreatic diversion, duodenal switch).
The vertical banded gastroplasty involves the construction of a small pouch that restricts the outlet to the lower stomach. The outlet is reinforced with a piece of mesh (screen) to prevent disruption and dilation.
The laparoscopic gastric band involves placing a 1 cm inch belt or collar around the top portion of the stomach. This creates a small pouch and a fixed outlet into the lower stomach. The adjustable band, which was approved by the FDA in June 2001, can be filled with sterile saline. When saline is added, the outlet into the stomach is made smaller which further restricts food from leaving the pouch.
The gastric bypass procedure involves dividing the stomach and forming a small gastric pouch. The new gastric pouch is connected to varying lengths of your own small intestine constructed into a Y-shaped limb (Roux-en-Y gastric bypass).
The malabsorbtion operations cause weight loss by decreasing absorption of calories from the intestines. These operations involve reducing the stomach size and bypassing most of the intestines. Choosing between the different operative procedures involves the surgeon’s preference and consideration of the patient’s eating habits.
Advantages of the laparoscopic approach
- Reduced post-operative pain
- Shorter hospital stay
- Faster return to work
- Improved cosmesis
Who should be considered for laparoscopic obesity surgery?
The following guidelines for selecting patients for obesity surgery were established by the National Institute of Health:
- Patients should exceed ideal body weight by approximately 45.5 kilos 100% above ideals body weight.
- Patients should have no known metabolic (chemical breakdown of food into energy) or endocrine (hormone) causes for the morbid obesity.
- Patients should have an objectively measurable complication (physical, psychological, social, or economic) that might benefit from weight reduction. This includes hypertension, diabetes heart disease, breathing problems or lung disease, sleep apnea and arthritis.
- The patient should understand the full importance of the proposed surgical procedure including suspected risks and complications.
- The patient should be willing to be observed and followed by a medical professional for many years.
- The patient should have attempted weight reduction using medical treatment without success.
In some instances, a patient who is not quite 45.5 kilos or 100% above the ideal body weight is a candidate for surgical intervention. This patient should have a significant medical problems that could benefit from weight reduction.
- A thorough medical evaluation to determine if you are a candidate for laparoscopic obesity surgery by your physician.
- Supplemental diagnostic tests may be necessary, including a nutritional evaluation.
- A psychiatric or psychological evaluation may be required to determine the patient’s ability to adjust to changes after the operation.
- Consultation from specialists, such as cardiologist, pulmonologist or endocrinologist may be needed depending on your own specific medical condition.
- A written consent for surgery will be needed after the surgeon reviews the potential risks and benefits of the operation.
- The day prior to surgery, you will begin a clear liquid diet.
- Blood transfusion and/or blood products such as platelets may be needed depending on your condition.
- Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery.
- It is recommended that you shower the night before or morning of the operation.
- After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
- Drugs such as aspirin, blood thinners, anti-inflammatory medications and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
- Quit smoking and arrange for any help you may need at home.
How is laparoscopic obesity surgery performed?
In a laparoscopic procedure, surgeons use small incisions to enter the abdomen through cannulas. The laparoscope, which is connected to a tiny video camera is inserted through the small cannula. A picture is projected onto a TV giving the surgeon a magnified view of the stomach and other internal organs. Five to six small incisions and cannulas are placed for use of specialized instruments to perform the operation.
The entire operation is performed inside the abdomen after expanding the abdomen with Carbon dioxide (CO2) gas. The gas is removed at the completion of the operation.
What happens if the operation cannot be performed by the laparoscopic method?
In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the open procedure may include a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.
The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.
What should I expect the day of surgery?
- You will arrive at the hospital the morning of the operation.
- Preparation before surgery often includes changing into a hospital gown.
- A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during your surgery.
- Often pre-operative medications are necessary.
- You will meet the anesthesiologist and discuss the anesthesia.
- You will be under general anesthesia during the operation, which may last for several hours.
- Following the operation you will be sent to the recovery room until you are fully awake. Then you will be sent to your hospital room.
- Most patients stay in the hospital the night of surgery and may require additional hospital days to recover from the surgery.
What are the expected results after laparoscopic obesity surgery?
Weight loss: The success rate for weight loss is reported as being slightly higher with gastric bypass operation than the gastroplasty or gastric banding, but all techniques show good to excellent results. Most reports show a 40-50% loss of excess weight for the gastric banding and vertical banded gastroplasty and a 65-70% loss of excess body weight for the gastric bypass after 1 year. The malabsorbtive operations generally achieve an average body weight loss of 70-80% after a year. Weight loss generally continues for all the procedures for 18-24 months after surgery. Some weight gain is common about two to five years after surgery.
Effect of surgery on associated medical conditions: Weight reduction surgery has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure and high cholesterol. Many patients report an improvement in mood and other aspects of psychosocial functioning after surgery. Because the laparoscopic approach is performed in a similar manner to the open approach, the long-tern results appear to be similarly good.
What complications can occur?
Although the operation is considered safe, complications may occur as they may occur with any major operation.
The immediate operative death rate for any of the laparoscopic obesity procedures is relatively low in the reported case series (less than 2%). On the other hand, complications such as wound infections, wound breakdown, abscess, leaks from staple-line breakdown, perforation of the bowel, bowel obstruction, marginal ulcers, pulmonary problems and blood clots in the legs may be as high as 10% or more. In the post-operative period other problems may arise that may require more surgery. These problems include pouch dilatation, persistent vomiting, heartburn or failure to lose weight. In a rare individual, reversal of the operation is necessary due to a complication of surgery. Complication rates with secondary surgery are higher than after the first operation.
After gastric bypass, nutritional deficiencies such as Vitamin B-12, folate, and iron may occur. Taking necessary vitamin and nutrient supplements can generally prevent them. Another potential result of gastric bypass is Dumping Syndrome. Abdominal pain, cramping, sweating, and diarrhea characterize dumping Syndrome after eating drinks and foods that are high in sugar. Avoiding high sugar foods can prevent these symptoms. After the malabsorbtive operations, the same nutritional deficiencies that occur after gastric bypass may occur, as well as protein deficiencies. Diarrhea or loose stools are also common after malabsorbtion operations depending on fat intake.
Women who become pregnant after any of these surgical procedures need special attention from their doctors and clinical care team. In general, complication rates of the laparoscopic approach are equal to or less than the conventional, open operations. Following obesity surgery, patients must re-orient themselves and adjust to the effect of a changing body image. As with any operation, there is a risk of a complication. However, the risk of one of these complications occurring is no higher than if the operation was done with the open technique.
When to call you doctor?
- Persistent fever over 39 C
- Increased abdominal swelling or pain
- Persistent nausea or vomiting
- Persistent cough and shortness of breath
- Difficulty swallowing that does not go away within a few weeks
- Drainage from any incision
- Calf swelling or leg tenderness