Treatment Options

Obesity Surgery

Why have surgery for morbid obesity?

Morbid obesity is a chronic condition. It is the second most common preventable cause of death in our society after smoking. Obesity causes many health problems including diabetes, high blood pressure, heart disease, stroke, sleep apnoea, arthritis, depression and even cancer. In most cases various diets, exercise and prescribed medications are unable to produce significant weight loss over the long term. Surgery is proven to be the most effective option in achieving sustained weight loss in morbidly obese patients.

Who is a candidate for surgery?

There are internationally recognised guidelines* for adults, which are:

• Aged from 18 to 60 years
• BMI >40 without or >35 with obesity related health conditions
   (Body Mass Index = weight (kg) / height (m)2 )
• Failed to lose weight or maintain long term weight loss with other appropriate non surgical methods
• No alcohol or drug dependency problems
• No uncontrolled psychiatric conditions
• Understand the surgery and risks
• Dedicated to change of lifestyle including diet and exercise
• Are able to undergo regular lifelong medical follow up

*Patients outside these guidelines may be also considered depending on individual circumstances.

What types of surgery are there?

Most operations work by either restricting food intake (restrictive) or preventing absorption of food (malabsorptive) or a combination of both. As a general rule operations that produce malabsorption such as Roux-en-Y Gastric Bypass (RYGB) and Bilio-Pancreatic Diversion (BPD) are highly effective however the risks of surgery and complications are greater than purely restrictive procedures. They can cause severe vitamin, mineral and protein deficiencies and are not reversible without further major surgery.

Laparoscopic Adjustable Gastric Banding (LAGB) and Laparoscopic Sleeve Gastrectomy (LSG) are both restrictive procedures that are effective, safe and suitable as first line procedures.

Laparoscopic Adjustable Gastric Banding (LAGB)

Laparoscopic Adjustable Gastric Banding involves placing a silicon band lined with a balloon around the upper stomach to create a small pouch of about 30mls. The band is connected by plastic tubing to a port placed under the skin. By injecting fluid into or removing it from the port the opening in the band can be adjusted regulating how fast the food empties. The band restricts food intake and dramatically reduces hunger.

Advantages:

• Keyhole surgery, usually takes about 1 hour and requires 2-3 days in hospital
• Safest procedure
• Adjustable
• Potentially reversible
• No malabsorption
• Disadvantages:
• Doesn’t restrict fluids – must avoid high calorie liquids
• Some foods can get stuck eg steak, white breast meat and white bread
• Mechanical problems: including infection and leakage require revision procedures in 5-10% of patients. Slippage and erosion can be major complications which occur in 1-2%.

Effectiveness: 50-60% average excess weight loss (EWL) at 2 years

Laparoscopic Sleeve Gastrectomy (LSG)

This is also a restrictive procedure. The stomach is reduced in size from a sac shape to a tube that holds around 150ml. It involves removal of over ¾ of the stomach, which is divided with a special stapling device. It used to be the first stage of the BPD bypass procedure but has been performed as a stand alone procedure for over 5 years. The operation significantly reduces hunger by reducing levels of the hormone “Ghrelin” which is predominantly produced in the upper stomach and is removed during this procedure.

Advantages:

• Keyhole surgery, usually takes just over 1 hour and requires 3-4 days in hospital
• No adjustments required
• No foreign material to get infected or leak
• No fixed obstruction for food to get stuck
• Normal dietary intake by the majority of patients
• No malabsorption
• Significantly safer than bypass surgery
• Disadvantages
• Risk of leakage from the staple line (1-2%) in the first 2 weeks is a major complication, which may require further surgery and intensive care

Effectiveness: 60-70% average excess weight loss (EWL) at 2 years

How effective is the surgery?

On average, patients will lose 50-70% of their excess body weight. Most reversible obesity related health conditions will improve or be cured with this amount of weight loss. However surgery alone does not guarantee success. These procedures help by reducing hunger and the amount and rate at which you can eat. In addition for the maximum benefit you must be prepared to follow the recommended dietary and exercise principles and undergo regular medical follow up.

What will I be able to eat after surgery?

After the initial phases (4 weeks) you will be able to eat 3 small meals per day. You will be encouraged to make healthy choices and will be able to eat most foods. Attempts to overeat may cause discomfort and vomiting and may damage the gastric pouch or tube by overstretching which can reduce the effectiveness of the procedure. Drinking high calorie liquids (alcohol, soft drinks, milkshakes etc) may limit your weight loss.

With the gastric band, some foods such as steak, white breast meat and white bread are prone to blockage and should be avoided. These foods are usually well tolerated after a sleeve gastrectomy.

What are the risks of surgery?

All surgery has risks. These must be considered in context of the risks from obesity related health conditions and shortened life expectancy from morbid obesity.

The risk of death is less than 1:2000 for the restrictive procedures performed laparoscopically as a primary procedure compared with 1:250 for open bypass procedures.

There is a risk of infection and bleeding.

There is a low risk of conversion to an open procedure.

There is a low risk of damage to other organs during the procedure including the oesophagus, stomach, bowel, liver and spleen.

There is a risk of deep venous thrombosis and pulmonary embolism (DVT/PE) or blood clots to the legs and lungs. You will receive blood thinning injections to reduce this risk.

For the sleeve gastrectomy there is a risk of leakage of the staple line. This is an uncommon but serious problem that may require further surgery, intensive care and a prolonged stay in hospital.

For the gastric band there is a long term risk of slippage, erosion, infection and leakage that may require revisional surgery, intensive care, a prolonged stay in hospital, or for the band and/or port to be removed.

Revisional surgery for patients with a previous weight loss procedure is more complicated and has higher risks

Who should perform your surgery?

Surgery in morbidly obese patients can be challenging and technically demanding. Our Surgeons have specific subspecialty training in Upper Gastrointestinal Surgery. In addition to performing surgery for weight loss, they perform major operations for cancer and a variety of complex advanced laparoscopic (keyhole) operations and endoscopic (telescope) procedures. They have extensive experience in managing both elective and emergency problems in this region of the body.

How soon can I have the surgery?

You will need to complete a comprehensive preoperative assessment before proceeding with surgery. After your initial visit we will arrange for you to see our bariatric assessor, dietician, exercise physiologist, perform blood tests and a gastroscopy so we can fully assess the stomach prior to proposed surgery.

The bariatric assessor is a physician who will assess your medical conditions, ensure you are suitable for surgery, exclude any treatable causes of obesity and perform a psychological assessment to ensure there are no underlying issues, to assess eating behaviour and ensure you are mentally prepared for the recommended surgery and lifestyle changes. Routine blood tests are reviewed and other specific investigations and referrals to specialists may be arranged.

The dietician will review your current diet, discuss dietary phases following surgery, assess nutritional requirements, vitamin supplementation and supervise the very low calorie diet (VLCD) “Optifast” when required before surgery to commence weight loss and reduce the size of the liver.

Exercise physiologists are trained professionals who assess and provide medically supervised exercise programs for people with health conditions including cardiovascular disease, arthritis and morbid obesity.  They will help improve your fitness for anaesthetic and surgery and optimise your exercise and activity after surgery.

The final decision to proceed with surgery is made on the recommendations of the whole team and will be discussed with you in a subsequent consultation.

You will be expected to demonstrate that you have made reasonable attempts to lose weight with other measures before considering surgery.
It is desirable to lose or at least maintain your weight prior to surgery to decrease the risks involved. You will need to follow the advice of the assessing team prior to surgery.

If you gain weight whilst being assessed for surgery or fail to attend the required consultations your procedure may be postponed or cancelled.

Do I have to quit smoking? (for the smokers)

Smoking is the leading cause of preventable deaths in our society. The health benefit gained from smoking cessation is even greater than from losing excess weight. In addition smoking considerably increases the risks of anaesthetics and surgery including infections, lung complications, DVT/PE and impairs the healing process. For this reason we insist that you quit smoking before having any surgery for morbid obesity. Your GP or our assessors can help with your options.

Where can I find more information?

www.weightlosssurgery.com.au
www.ossanz.com.au
www.ifso.com
www.foodtalk.com.au - Recommended reading: “The Food and Nutrition Guide to Gastric Banding” and “The Pocket Gastric Band Guide” available from this site

What now?

If you are ready to make this important life changing decision please contact my office for an appointment. At the initial consultation, I will perform an assessment, discuss the surgical options, answer any other questions you may have and begin your pathway to a better health and lifestyle.