Mr Majid Hashemi discusses the advances in weight loss surgery and improving quality of life for obese patients.
A lot has changed in bariatric surgery since 2001 when many still regarded bariatrics as cosmetic. Now it is accepted that sustained weight loss that follows successful bariatric surgery leads to vast improvements in quality of life and the reversal or improvement in co-morbidities.
In December 2001 as a newly appointed consultant with the encouragement of my then-colleague, Mr John Cochrane, I performed my first gastric band. The laparoscopic approach and the ease of application of the gastric band found a ready and eager reception amongst the patient population and referrers alike. By 2005 I was receiving more than 200 new referrals a year, and performed six or more laparoscopic bands in a day. TThe Evolution of Bariatric Surgeryhe procedure proved to be quick, safe and even suitable for day surgery.
Sarah, that first patient, still has her gastric band 11 years on and has become a good friend, but of the nearly 500 bands that I have placed since then, more than 30 have been taken out. Until 2005, the gastric band made up the vast majority of obesity procedures I did. However, by 2012 only 10 per cent of my cases were gastric banding.
In 2004 I started performing the gastric bypass as a more durable and effective alternative. This was a more complex procedure and in order to minimise the risk on the heavier or sicker patients, a two-stage solution was formulated. I used the sleeve gastrectomy (where about 70 per cent of the stomach is removed) as a first step; patients would then lose some weight and a year or so later would be at lower risk for a longer anaesthetic that was required for the full bypass. After a while, I found that the majority of patients who had had a sleeve gastrectomy no longer needed any form of bariatric surgery. They were achieving weight loss of about 60 per cent of their excess weight and their co-morbidities improved significantly. The sleeve gastrectomy therefore became the third bariatric option.
The ideal patient for the band is a non-diabetic volume eater with a BMI greater than 40, who is likely to comply and adopt a sensible balanced diet in the longer term. Previous, initially successful, attempts at weight loss (even if the weight is all subsequently regained) is a good prognostic indicator.
Success requires a determined effort by the patient and binge eating and a high intake of sweets and `meltable' calories will defeat the objective. The band is a purely restrictive procedure.
Laparoscopic Roux-en-Y Gastric Bypass (RYGBP)
The bypass superseded the band and since 2006 I have been offering this as the default procedure for all - although always guided by the patient's own choice. The ideal candidate is a patient with a BMI of 40, but those with a BMI of 35 or above with a co-morbidity would also benefit. The effect on diabetics is dramatic and all experience improvement with more than 50 per cent able to come off all their diabetic medication within the first three months after surgery.
Patients who are enrolled in fertility programmes often opt for bariatric surgery to increase their chances of conception and to reduce the risks of complications during pregnancy and labour.
As well as this mal-absorptive effect, the RYGBP is effective in leading to weight loss due to restrictive and anorectic mechanisms. The small pouch and the narrow outlet from the pouch provide a restrictive component and patients modify their eating pattern as a result.
Post operatively, supplementation with Vitamin B12 and vitamin D and over-the-counter combined mineral and multivitamins such as forceval or sanotogen gold are routinely recommended.Other micronutrient deficiencies that can rarely develop include those of thiamine, folate, and the fat-soluble vitamins and I recommend blood tests for all these at six monthly and then annual intervals.
Laparoscopic sleeve gastrectomy
Although less technically demanding than a gastric bypass, this is still a very major procedure and the key is in careful patient selection and counselling. However, it has advantages in that it can be completed in an hour and requires a one- or two-day stay in hospital. The sleeve gastrectomy is extremely effective provided it is properly performed and properly calibrated.
There is no need for band adjustment, no risk of emergency re-intervention being required for band slippage or erosion as there is with the gastric band, and no added risk of small bowel obstruction with an internal hernia as there is in a bypass.
I also warn all sleeve patients of the risk of weight regain and the risk of exacerbation of reflux. In such an event a laparoscopic conversion to a gastric bypass is possible.
The gastric bypass in particular seems to cure diabetes in many patients, and allows patients to come off their medication. The most amazing thing about this observation was that the diabetes goes away or improves even before any weight loss has been achieved, sometimes within days of the surgery. This observation suggested there is something about the prevention of contact between the food and the upper gut that leads to this phenomenon.
The Endobarrier is a new device that seeks to exploit this observation. It is a 60cm sleeve made of special plastics that is placed by means of an endoscope. There is no cutting or abdominal surgery involved. There is a good response with weight loss and diabetes and this occurs soon after device insertion. The Endobarrier is then endoscopically removed after one year.
Safety and training
Bariatric surgery can be complex and obese patients tend to have pre-existing co-morbidities that increase their risks in general and reduce their ability to withstand complications. I have preformed nearly 900 cases with no mortality.
It is universally accepted that technical competence is essential to the objectives of safe bariatric surgery. Sometimes less emphasis is placed on the technique being performed within the context of a properly configured service. Patient selection, procedure allocation and aftercare are, by necessity, multi-disciplinary processes.
The peri-operative environment involves input from professionals from the wider organisation and outside the influence of the immediate bariatric team itself and so a large number of variables are introduced that can impact the outcome of surgery, and so clear and reliable care pathways, together with excellent communication ensures excellent outcomes.
The bypass is the most complex of the procedures. It gives the best weight loss and is the surgery of choice in diabetic patients because of the striking results - cure or remission of diabetes in over 80 per cent of patients. It is also the default procedure for the obese patient with reflux or a hiatus hernia because it provides a diversion of the gastric and biliary juices.
The sleeve gastrectomy is extremely effective provided it is properly performed and properly calibrated.
The gastric band is simple and quick to place and also effective but needs a lot more work on the part of the patient and requires adjustments over time. A proportion of these bands need to be removed over time.
The Endobarrier is an exciting new development; simple to put in, requiring a quick general anaesthetic and an endoscopy. Initial results suggest it is a very effective alternative for patients with diabetes. It is removed after one year so there is a risk of weight regain. The appeal is that it is reversible and removable with no lasting scarring.
We have come a long way since 2001. The range of procedures available allows a tailored approach to each patient. There is general acceptance of the benefits of sustained weight loss. Bariatric surgery is very safe when properly performed by experienced and trained teams and the benefits far outweigh the risks of surgery.