Bariatric Surgery: Indications and Risks

According to the Centre for Disease Control (CDC) more than one third of the American population is obese. Obesity comes with a host of co morbidities ranging from type 2 diabetes mellitus to heart problems to arthritis and stroke. Obesity is crudely defined as having a body mass index (BMI) of more than 30. Bariatric surgery is a branch of surgery that helps obese individuals in reducing their weight and reduces the risk of suffering from the co morbidities of obesity by modifying the passage through which food passes through the body. Earlier bariatric surgeries were open surgeries and came with a significant mortality. Now as we switch to a laparoscopic mode, bariatric surgeries have become a safe way to help obese individuals. About 196,000 bariatric surgeries happen annually in the USA.

Procedure

There are many types of bariatric surgeries. Most of them are done laparoscopically. To begin the surgery you will be given a general anaesthesia hence you will be unconscious throughout the procedure and hence won’t feel any pain. A tube will be passed through your mouth into your wind pipe to ensure proper breathing during the surgery. Your surgeon will make small incisions on your abdomen to introduce ports into your abdominal cavity through which instruments and camera will be inserted to facilitate the surgery. Carbon dioxide is pumped into the abdomen to inflate it for better visibility. The surgery then proceeds according to the type decided upon by you and the surgeon.

• Laparoscopic adjustable gastric band: a small pouch is created by placing a band around the opening of the pouch. This makes you feel full after eating a small amount of food. The inner lining of the band has an inflatable band which is filled with saline, whose amount can be adjusted. You will be required to make multiple visits to your surgeon to adjust the size of the gastric band that suits you best. If the band is unhelpful in losing weight or leads to problems your surgeon may remove it.
• Gastric sleeve: your surgeon will remove majority of your stomach leaving behind a thin banana shaped sleeve which has been closed with surgical staples. As the size of the stomach has been reduced you feel full after eating less amount of food.
• Gastric bypass: this procedure is also called a roux-en-Y gastric bypass surgery. First a small stomach pouch of approximately 30 ml is made from the upper part of the stomach by dividing it from the rest of the stomach. Next the intestine is divided and the lower portion is attached to the stomach pouch so that food goes directly from the stomach to the distant part of the small intestine. Finally the top cut portion of the intestine is joined to the small intestine downstream so that the digestive juices from the stomach and the bypassed intestine can eventually mix with the food.
• Biliopancreatic diversion with duodenal switch: first a large portion of the stomach is removed leaving behind a thin banana shaped sleeve. The duodenum, which is the first part of the small intestine, is then divided from the stomach just downstream to the outlet of the stomach. A segment of the end portion of the small intestine is then connected to the stomach so that food passes from the stomach to the end of the small intestine, bypassing majority of the gut. The bypassed intestine which carries bile and the pancreatic juices is connected to the end of the small intestines so that the digestive juices mix with the food.

Indications for Bariatric Surgery

Bariatric surgery is indicated for individuals with

• Body Mass Index (BMI) greater than 40
• BMI between 35 and 39.9 accompanied by weight related health problems like type 2 diabetes mellitus, hypertension or severe sleeping problems
• Problems in a healthy body weight for a sustained period of time even when under a medically supervised dieting
• Weigh 100 lbs more than ideal body weight

Preparation

To prepare for the surgery you will have appointments with several health care providers like dieticians, surgeons, internists, and psychiatrists. Your doctor will take a detailed history and do a thorough physical examination. Multiple blood tests will be ordered to check for your fitness for the surgery. If you are a smoker you will be advised to stop smoking at least 6 weeks before the surgery. Your dietician will explain the diet restrictions that you will be facing after the surgery and help you prepare for it. Your surgeon will explain the procedure to you and will also you guide you through the preparations for the surgery. A psychiatrist will evaluate you to ensure that bariatric surgery is the right choice for you. It is advisable to incorporate lifestyle changes before surgery to bring the blood sugar level to normal before the surgery as this will reduce the chances of complications after the surgery.

Risks of Bariatric Surgery

Immediate risks associated with the surgery are:

• Bleeding during the surgery
• Infection
• Leak from your gut
• Adverse reaction to the anesthesia
• Blood clot formation: the risk of increases as the duration of the surgery increases. These clots may get lodged in the lung and cause a pulmonary embolism.

Long term risks of the surgery are:

• Malnutrition
• Dumping syndrome: caused due to bypassing large portions of the small intestine; leads to diarrhea, nausea, and vomiting
• Bowel obstruction
• Hernia
• Stomach perforation
• Low blood sugar.

Recovery

After the surgery, you will be kept at the hospital for mentoring. You will not be allowed to ingest anything orally for about two days to give time to your stomach and intestine to heal. After that, your dietician will ask you to follow a very strict diet for the next 12 or so weeks. You will start taking food in the form of liquids and then proceed to add semi-solid food followed by solid food. Your dietician will inform you about which food and beverages to avoid. With the food regimen, you will be prescribed vitamin and mineral supplements to ensure adequate nutrients to reach your body. Walking and moving around the house will help you recover quickly. There will be frequent checkups scheduled with your doctor for the first few months after the surgery to monitor your recovery and weight loss. You may experience body aches, feeling of tiredness, hair fall and thinning, and mood swings during the first few months after the surgery. In addition to weight loss, there will also be an improvement in your lab reports for type 2 diabetes mellitus, in the blood pressure readings for hypertension, and a reduction in the symptoms of gastro Esophageal reflux disease.

Resources:

• American Society for Metabolic and Bariatric Surgery
• National Institute of Diabetes and Digestive and Kidney Diseases Health Information Center
• Centers for Disease Control and Prevention