Bariatric Surgery: Explained | Transcript

27 June 2022
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Talk Summary

In this talk, Bariatric Surgery: Explained the following points are covered:

  • The different types of weight loss surgery
    • Gastric Band / Lap Band
    • Gastric Bypass
    • Gastric Sleeve
    • SADI-S / SIPS Surgery
    • SASI-S Surgery
  • Differences in recovery and cost between the surgeries.
  • Questions from the viewers about weight loss surgery.

 

Introductions

Good evening, everybody. This is another webinar of our educational series on various aspects of weight loss surgery.

Today we’ll be touching on the different types of operations. If you were to look at the internet or look into papers and articles, you’d find there are so many different types of weight loss operations, and it can be confusing, even for doctors, let alone people who are not in the medical profession.

 

What are the different bariatric surgery options?

Let’s begin with the different types of operations. If you look at weight loss surgery, some of the older operations were the gastric bypass type surgeries which started as open surgeries. People used these about 40 years ago. You had a big open cut on your tummy, and then we would go ahead and do different types of procedures to help reduce weight in patients.

Over the years, this has evolved into small keyhole type surgery, and it’s still an evolving science, so there were different attempts at different procedures. Some have come and gone, others have stayed. The main group of operation previously, which was quite common, was the gastric band or lap band surgery. That number has slowly come down over the last three to four years. We hardly do any gastric bands now because we’ve seen all the problems that arise, as well as the inadequate weight loss and poor quality of eating. So, this is something that we have sort of given up on doing.  These days, I spend half my time taking gastric bands out.

Then there’s the gastric bypass, the gastric sleeve operation, and then some newer ones called SADI-S or SIPS (Stomach Intestine Sparing Surgery) and then a SASI (Single Anastomosis Stomach-Ileal Bypass) type surgery.

 

What is Lap Band / Gastric Band Surgery?

With the lap band, we put a little ring across the top half of your stomach and connect it to tubing that ends with a little connecting port which is under the skin somewhere in your abdomen. This is injected with saline, which squeezes or compresses that part of the stomach. This reduces your food intake. It is not very effective.

When we talk about weight loss and generally with weight loss procedures, we talk about excess body fat loss. So, if someone has 50 kilos of excess body fat, then we say whether the surgery can cause a 40% loss of that excess body fat loss.

If you look at it in that way then the gastric band result usually sits around about 40% of your excess weight lost. It is reversible, you can take it out. However, the damage that it does sometimes is not reversible. The band and the port – you can take out at any point. However, a lot of times it causes a lot of damage around the stomach, where the tubing is gone, thick scar tissue can form and your oesophagus can sometimes be damaged because it’s constantly trying to push across the obstruction in the lower end.

This is why it’s not very common now, because it requires a lot of management with injections, monitoring and trying to get the balance right. It’s very difficult and the quality of eating is usually quite poor.

 

What is a Gastric Bypass?

Now, the gastric bypass operation. This is another common operation. It’s been around for a long time. It has had multiple changes over the years. It was first done about 40 years ago and over the last five-seven years, it’s been modified further.

As a part of this category, we also have what’s called a Roux-en-Y Gastric Bypass. Then there’s also something called a One-Anastomosis Gastric Bypass. This is a very effective operation. There are long-term studies, more than 20 years of data, on what it can do. It produces very good weight loss, it can reduce reflux problems that can arise with other operations, and it can help control your diabetes, with most losing 70-90 of excess body fat, depending on the amount of the bypass that we do.

Effectively, we just staple the stomach, making it into a narrow tube. We’re not removing anything. Then we bring a loop of bowel and hook it up to this new tiny stomach. Food now travels down the new small stomach and then goes into the bowel, skipping or bypassing the early part of your bowel. This is a well-proven operation with good long-term weight loss.

There are some side effects. If you have too much sugar or refined carbohydrates it can produce symptoms of dumping, where you can get issues with low blood sugar, feeling sweaty, dizzy and rarely you can get an internal hernia.

 

What’s a Gastric Sleeve Operation?

This is the most common weight loss operation at the moment. We do this with keyholes. We go in and then we staple and remove a big section of your stomach, the patient’s stomach capacity is about a litre to a litre and a half – what’s left behind after the surgery is about 150 to 200 mils, so it’s a significant reduction in the size of the stomach.

It’s not altering the anatomy too much. We’re not re-joining bowel or rerouting your food. This will reduce the volume as well as reduce your hunger and it gives a fairly good weight loss with not too many side effects other than about 10-20% of people can get heartburn or reflux.

The weight loss you can expect with the gastric sleeve over the long run is about 60% excess body fat loss. In the short term, you can definitely do better than that. I have a lot of patients with fantastic results long term because it really requires good lifestyle changes like any of these weight loss operations.

 

What is SADI-S / SIPS Surgery?

There’s a newer type of operation called a SADI-S SIPS (Stomach Intestine Sparing Surgery) procedure. This is where a gastric sleeve is done and then the bowel is bypassed at the same time. This is what we call a malabsorptive operation. The amount of bowel that is skipped in the bypass is quite long. So, you have a very short section of the bowel that’s actually absorbing nutrients hence it produces good weight loss. However,  it also increases the risk of nutritional problems.

With any weight loss operation, you’re going to have some amount of nutritional problems. So, it then comes down to weighing the benefits of each operation for an individual patient.  For some patients, the offset of decreased nutrition is still okay, provided they are coming for follow-ups and complying with the medication and vitamin requirements.

 

What is SASI-S Surgery?

Then there’s a new one called a SASI-S procedure. This is what’s called a sleeve gastrectomy and allele bypass, where a sleeve gastrectomy is done and the bowel is joined straight onto the sleeve. In the previous SADI-S procedure, it actually joined to the duodenum or the ileum, the first part of the small bowel. Here, the procedure will join the stomach to the small bowel, directly to the sleeve. This will give you good weight loss and it still has a connection to the other side of your bowel. Therefore, this is not a complete bypass of that whole section. As a result, you still get some nutrition going down the other way. It’s meant to be less problematic in terms of nutrition.  However, you can still get bile reflux and you can get ulcers at the joint if you take medication like Nurofen or other anti-inflammatory drugs, or for someone who smokes.

It’s also a relatively new operation, not many have been done around the world – less than 0.5% of operations of these types of surgeries are SASI-S procedures. So, these are all fairly new, from the last four to five years, with very limited long-term outcome data.  So, this type of surgery may look promising but we can’t be sure what the long-term issues are going to be.

 

How do I know which surgery is best for me?

How do we know what’s the best surgery for me?  Patients always ask me this. Some people come in with a preconceived idea that this is the best operation for them, others come in not really knowing what’s good for them. This is something that we work out at the first consult. We go through patients’ history, we have a good chat and see what their eating habits are, what other medical problems they may have, what their starting weight is and what their end game is, to where they want to get down to in terms of their weight.

Based on that then we can decide what would be the best option for that individual person because there’s not really one operation that’s going to fix everybody’s problem. Hence it’s a very tailored service that we offer. We go through things and then we come up with the best plan of action in conjunction with all the other health professionals that work with us – dietitians, psychologists, exercise physiologists and all these allied health professionals. Together we come up with a good plan as to what can help patients get good long-term weight loss.

We’re not trying to produce something that’s going to give you good weight loss for a year or two and then put weight back on. We want patients to have a successful outcome in the long term with these types of surgery.

 

What are the differences in recovery?

Pretty much all the with my patients, whether it’s a sleeve a bypass, or even if I did a revision operation from a previous gastric sleeve to a bypass, or a band or bypass, for whatever reason, then most of the time patients are spending one to two nights in the hospital.

You’ll be able to start driving in about a week and most people are back to work in 10 to 14 days. It’s not something that’s going to set people back for too long, provided you don’t have any issues or complications, which occur less than 1% of the time.

When you look at weight loss surgery, the major complication risks are things like leakages from those cut edges and bleeding. However, any of those major issues should occur less than 1% of the time. In my hands, it is much less than that. The average industry standard should be around 1% or less.

 

What are the differences in cost?

Okay, so there are cost differences between different operations, mainly depending on the complexity and time taken to do the operation.

If we look at, for example, a gastric band – if you’ve got private health insurance you’re looking at about $3000 plus. You get some money back on a rebate with that.

If you look at a gastric bypass, you’d be paying around $5900 and then if you’ve got private health you’ll get about a $1000 back, so $4000 plus dollars out of pocket costs.

With a gastric sleeve, it’s about $3000, plus out-of-pocket costs. When we are uninsured then the cost goes up significantly because then the hospital fees have to be paid by the patient, the anaesthetic fees and a few other things all need to be paid by yourself.

Whereas, when you’ve got private health insurance, then they cover most of the costs of surgery.

 

Questions from viewers:

That concludes the session and if anyone would like to ask some questions just use the chat feature. We can go through that quickly and clarify any doubts.

 

What happens if we have reflux and does it get worse with the gastric sleeve operation?

Depending on your reflux symptoms, there are various grades of reflux. Some people might get a little bit of reflux just because they ate something not right that day, or ate too much or had too much alcohol.  These patients may not necessarily have worsening symptoms.

So, most of the time I would do an endoscopy, where we’ll put a camera down and have a look on the inside to see if there are any complications from reflux.

You can have severe esophagitis or another condition called Barrett’s esophagus, where the lining of your gullet or your esophagus has changed because of constant acid reflux.

In those instances, it’ll be better to do an operation which is uh less refluxogenic or has less chance of producing reflux, like a gastric bypass.

When you’ve got reflux, it’s important to evaluate how bad it is and then we would decide what to do. A lot of times, if reflux symptoms aren’t too severe, patients tell me it’s started once they started putting on a lot of weight on and then when we do a sleeve they find significant improvement with the reflux.

Whereas in the same setting, if someone’s got very significant reflux prior to surgery and they’ve got like a hiatus hernia, we fix that up and do a sleeve and they’re usually all right.

But, it depends on the individual and depends on how bad the reflux symptoms are.

 

What is the most common surgery – sleeve or gastric bypass?

The sleeve gastrectomy is the most common operation I do, and not only me – worldwide and Australia-wide. If you go to UK, or if you go to the US, the sleeve is the most common operation.

The second one would be the bypass. In my practice, about two-thirds would be a sleeve, and a third of my operations would be gastric bypass, which is in keeping with what is seen throughout Australasia and internationally.

The gastric sleeve is a good operation for a big cohort of patients. The bypass it’s reserved generally for people who may require them more, it has a little bit more maintenance issues over the long term.

 

If someone is 76kg, and 1.6 metres tall, will they qualify for weight loss surgery?

We’ll need to calculate the body mass index, just looking at that it’s unlikely. You can go to our website, there’s a BMI calculator. If you punch your numbers in, it’ll give you a number which is your body mass index. That’s a relatively accurate measure, and that’s what all the hospitals and societies use as a guideline to whom we can offer this operation.

We are governed by that and it’s important to be at least 35 and above. Sometimes we do consider between 30 to 35 if you are fully controlled by weight-related conditions like severe diabetes if someone’s got very severe obstructive sleep apnoea, blood pressure issues related to their weight, then we can consider for a BMI of 30 to 35. Most of the time, it needs to be above 35 BMI for surgery.

 

I have a Hiatal Hernia, can this be repaired at the same time as weight loss surgery?

Yes. That’s not uncommon, a lot of times we do an operation we’ll suddenly discover patients had a hiatal hernia, it’s standard practice for myself to fix that at the time of the actual weight loss operation. If you don’t do that at the time then it can cause problems with regard to reflux and lots of other issues. It’s ideally fixed at the same time because the operation is all in the same area, it doesn’t really take me that much longer and it’s pretty straightforward. It’s something that we do on a weekly basis, it’s not an issue at all to fix a hernia.

 

Some people say they can’t absorb Panadol after having the sleeve done, is this common?

No, not at all. Panadol is one of the most common pain relief medications we give and it’s not really all absorbed in the stomach, most of the absorption happens in the bowel and we are not changing anything there. We give Panadol routinely after surgery and when you go home after an operation like this, Panadol is the basic type of pain relief that we offer. Generally, with a gastric sleeve, it’s not going to be a problem to absorb any medication. Essentially, it’s not really going to be a major drama.

 

Do I need to stop taking aspirin when I have weight loss surgery?

It depends. I have done lots of sleeve gastrectomy surgeries on patients who are on aspirin because they need it for their heart condition. The indication of why you’re on aspirin is very important. If it’s just something that the doctors put on just as a prophylactic thing, it would probably be good to stop. But if someone’s had a cardiac stent, they’ve got a heart issue. and the cardiologist thinks they need to be on this to help reduce a heart attack risk then we will have to balance the risk of bleeding and usually, aspirin’s not a problem.

We’ve done lots of surgeries with patients on aspirin and that’s never an issue.

 

Am I best to have a child before or after surgery? Is it best to do the surgery after having my last child?

It all depends on your age and issues with fertility. Weight loss surgery has been proven to reduce complications during pregnancy and also to increase fertility, and increase chances of having children.

If someone’s struggling to conceive and their weight is the problem then having a weight loss operation is going to improve things for you, and reduce issues.

Whereas if you think fertility is a not a problem and your BMI is not super high, then it may be worth having a child and then completing your family, and going on to have the weight loss operation, then it’s going to be less of a problem.

I’ve given a number of patients advice to not have any children in the first year, year and a half, and then oops, an accident happens and then they come back in three months after an operation, and ask “Doc, what do I do?” It’s really difficult to manage because when you are losing weight you’re trying to balance your nutrition, but your eating is still not optimal. and then if you get pregnant, then you know trying to balance everything is a really difficult thing.

Therefore, it’s generally advisable that you wait for a year to a year and a half after a weight loss operation before going on to have children. It’s usually not a problem and when we compare a lot of studies, that have compared patients having children before and after weight loss surgery, there are no issues with the children. The only thing is that the babies can sometimes be a bit smaller for the gestational age, compared to uh pre-weight loss surgery. Otherwise, there are no other major issues related to that, so no problems with having children after weight loss surgery.

 

Closing remarks

Thank you everyone for coming online and spending your evening with us. If there are any further questions that you would like to chat about, or if you’ve got any questions just book in to come and see us. I’m more than happy to go through things with you. Otherwise, we’ll catch up in the next meeting. Bye!

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