Surgical treatment of obesity and metabolic syndrome / diabetes
There are two types of surgical treatment for obesity and metabolic syndrome / diabetes:
- Restrictive operations, such as the gastric band, the gastric sleeve and the gastric plication.
- Operations that besides restriction cause malabsorption, such as the gastric bypass, the mini gastric bypass and the biliopancreatic diversion (duodenal switch).
These types of operation are recommended in the case of obesity for patients who have a Body Mass Index >40 or over 35 in case of a comorbidities due to obesity (e.g. type II diabetes, hypertension, obstructive sleep apnea, high cholesterol, osteoarthritis, etc.) . )
Body Mass Index is calculated from the ratio Weight in kilograms/Height in meters squared.
So for a patient with a weight of 200 kg and a height of 2 meters the BMI=200/4= 50
The latest scientific data recommend type II diabetes as an indication for obesity surgery (mainly malabsorptive) even to thinner patients with a BMI of 30 to 35, while it is still a matter of debate whether there is benefit in operating even patients with a BMI of 25- 30 with type 2 diabetes.
Recently, the scientific society International Diabetes Federation (www.idf.org) issued a statement according to which bariatric surgery should be discussed in patients with type II diabetes and with a BMI of 30-35.
It is the simplest of the operations with the least surgical risk.
Gastric band surgery involves placing a rubber band around the upper part of the stomach. Essentially, a pouch is created with a capacity of 20-30ml, compartmentalizing the stomach into two parts.
How easily food passes from the pre-stomach to the main stomach depends on the tightness the band. The tightness is regulated by a small valve that is placed in the abdomen, under the skin, in a place that is not visible. This valve is connected to a small silicone balloon that looks like an umbrella on the inside of the band. The tightening of the band makes it difficult for food to pass into the main stomach causing rapid satiety.
So, in a way, the amount of food that can go down is controlled. After the surgery, the surgeon and the dietician periodically check the weight, fat percentage and other parameters. The band is then adjusted accordingly. Band removal or reinsertion is performed only in rare cases.
The operation is carried out laparoscopically and lasts about an hour. The patient goes home the following day. International studies have shown that a loss of 40-50% of excess weight over a period of 3 years can be achieved.
Gastric balloon is an alternative method recommended exclusively for patients with lower body mass indices.
It is classified as bariatric surgery, although it does not require surgery and its placement takes place in a few minutes. This is a temporary solution, and it is imperative for the treated patients to follow a healthy lifestyle with exercise and diet to maintain the positive result.
ADVANTAGES OF THE GASTRIC BAND:
- Fast and safe operation
- Short hospitalization (1 day)
- Quick return to work and daily activities
- Small risk of major complications
- No chronic vitamin deficiency as may be the case with other types of bariatric surgery
DISADVANTAGES OF THE GASTRIC BAND:
- Need for frequent and close follow-up postoperatively
- Frequent adjustments of the ring
- High probability of minor complications related to the regulating valve
Roux-en-Y gastric bypass
This operation involves dividing the stomach in its upper part, creating a new stomach (gastric pouch) around 20ml of volume. This part of the stomach is attached to a coil of small intestine, as shown in the figure above, while the rest of the stomach is left in place. The two free coils of the small intestine are anastomosed about 100 cm from the pre-stomach.
This operation also causes rapid satiety due to the small new stomach and reduced absorption of food, because a significant length of the small intestine is bypassed.
The whole operation lasts about 2-4 hours in the hands of an experienced surgical team. The majority of possible complications concern leaks (from the anastomoses), the formation of fistulas, and perioperative thrombosis.
Hospitalization lasts 2-3 days, and the patient can return to work after 3 weeks.
This operation is highly effective and causes a significant weight loss that reaches 60-75% of the excess weight within the first 12-14 months.
This operation is a very good option for patients with a high body mass index (BMI) and coexisting diabetes.
Due to its effectiveness, it is by far the second most commonly used anti-obesity intervention in the United States.
Advantages of the operation
- It is the most effective operation (gold standard) in comparison to all other types of bariatric surgery.
- It is the oldest method (started in 1966) and so there are many years of results proving that the operation is effective, and the weight loss lasts.
- This type of surgery has the highest cure rates for diabetes (84-93%), hypertension and obstructive sleep apnea!!
Disadvantages of the operation
- It can cause chronic vitamin deficiency, osteoporosis, and anemia and thus patients must take nutritional supplements, vitamins etc., for life.
- Any complications are more complex to deal with than with the gastric band or the gastric sleeve.
Gastric Sleeve Surgery (Gastrectomy)
Laparoscopic sleeve gastrectomy is a restrictive type of obesity surgery. It bases weight loss on the reduction of stomach capacity. This method was made known by Dr. Gagner in New York, where since 2001 he began to apply it, initially, to extremely overweight patients to prepare them for a more serious obesity operation. This first experience showed that this operation in itself is particularly effective and less dangerous, which is why it has been established as one of the main surgical treatment options against obesity.
The method involves the laparoscopic or robotic removal of a large part of the stomach, around 85% of it, leaving only a small stomach tube with a capacity of 60-150 ml, depending on the technique and the surgeon. The extremely reduced capacity of the stomach causes rapid satiety, and thus we have a reduction in the amount of food taken by the patient.
In addition to the restrictive nature of this operation, there are indications that the weight loss in this operation is also achieved by the reduction of ghrelin levels in the blood. Ghrelin is normally produced by the part of the stomach that is removed in sleeve gastrectomy and is responsible for the feeling of hunger.
The operation in the hands of an experienced surgical team lasts around 2-3 hours and is considered safe compared to other types of bariatric surgery. Complications are rare and mostly involve leaks from the resection line.
Hospitalization lasts two to three days, and the patient can return to work after two weeks.
This operation is a good option for patients with a body mass index (BMI) of 40-50. While it can also be used as a first stage of treatment in extremely overweight people with a BMI over 55, before a larger operation (gastric bypass/biliopancreatic diversion). It causes significant weight loss especially soon after the operation. The percentage of excess weight lost is not as great as in procedures that are both restrictive and malabsorptive.
Advantages of the operation
- Fast, safe and with fewer possible complications.
- It does not cause chronic vitamin deficiency, osteoporosis and anemia as can be the case with malabsorptive surgery (gastric bypass/ biliopancreatic diversion).
- There is the possibility of conversion to gastric bypass, duodenal switch or to mini gastric bypass, if the loss of excess weight is not desired.
Disadvantages of the operation
- It is not preferred in diabetics and in patients with gastroesophageal reflux disease.
- A percentage of lost excess weight is regained after the first few years.
Sleeve gastrectomy is a safe and effective option for the treatment of obesity. In any case, the choice of the appropriate method must be made by evaluating the history and parameters of each patient.
Nutrition after gastric sleeve
After bariatric surgery, it is imperative that you follow a specific diet so that you do not deviate from your weight loss goal. The patients’ compliance with their new eating habits is expected to be good, since bulimic tendencies are minimized. The dietician will thus adjust the diet so that you also deal with any incidents of hypoglycemia that may occur at the beginning.
How much does a gastric sleeve cost?
For the cost of the gastric sleeve – balloon – band, you must contact the doctor. The cost of the surgery is determined after an examination of the patient.