Bariatrics is a branch of medicine that deals with the causes, prevention and treatment of obesity. The basic principle of bariatric surgery is to restrict food intake and decrease the absorption of food in the stomach and intestines.
PROCEDURES AND INFORMATION GUIDE
Morbid obesity can lead to serious health problems like heart attacks, stroke, diabetes mellitus, chronic bone and joint disorders, dyslipidaemia and obstructive sleep apnoea as well as exasperate any underlaying medical condition that a patient may have. Such illnesses may affect a person’s quality of life and reduce lifespan. In order to achieve a person’s ideal weight, you should consistently consume a balance and healthy diet along with doing regular exercise. Thus an earnest effort must first be made to adopt a healthy lifestyle before turning to bariatric surgery.
In view of that, bariatric surgery or obesity surgery is only performed for morbidly obese individuals under well-defined medical indications or for patients who present with life threatening family history of disease. This surgery includes sleeve gastrectomy, gastric plication and gastric bypasses. Bariatric surgery is the most effective treatment for morbid obesity. It has been shown to have unprecedented improvements in health and reduces long term mortality due to various medical illnesses.
Note : We do not offer Lap Banding treatments.
Sleeve Gastrectomy is a procedure that involves dividing and removing a part of the stomach (greater curvature) to create a smaller stomach pouch. This procedure is performed laparoscopically (keyhole) using the combination of specialized staplers and sutures.
Dato Gee uses a 3 step technique for his surgeries which is the normal stapling process followed by surgical plication (overstitching of both sides of the remaining stomach) or “hidden seaming” of the staple line. Finally omentum (internal visceral fatty tissue) is stitched along incision line to form a barrier against any potential leakage and to strengthen the stomach immediately and this expedites the healing process.
Patient outcomes after bariatric surgery have been shown to be beneficial with improvements in either weight loss and/or resolution of obesity related medical diseases like diabetes mellitus, hypertension, dyslipidaemia, fatty liver and obstructive sleep apnoea. Other benefits seen after weight loss include relieve of joint pains over the knees and hips. Chronic back pain may also be alleviated after weight loss. However, just like any other medical procedures, no guarantee of any weight loss or benefit is made.
Weight loss and long term maintenance of weight would depend greatly on your commitment to a change in lifestyle and consumption of food and beverages after the surgery. This change include new eating and drinking techniques, a healthy choice of food consumption, regular intake of adequate protein and vitamin supplements, reduction of carbohydrates and sugary food and beverages, regular physical activities and the need for a regular follow up with facilitator. Surgery is a tool to augment this positive change of lifestyle. Hence weight regain after an initial weight loss may occur if you resort back to unhealthy eating and drinking habits and a lack of physical activity.
Excess weight loss of 70% in the first year and 60% in the fifth year after Sleeve Gastrectomy have been seen in large scale studies. You may lose more than your desired weight after bariatric surgery, or may lose only a little weight or even gain weight after bariatric surgery. Patients may be successful in losing excess weight, extending their lifespan, enhancing their quality of life and improve their appearance and self-confidence. This change in weight is unpredictable and varies from person to person.
As in any type of surgery, each patient is at a risk for complication(s), regardless of the bariatric surgeon’s reputation and expertise. Some adverse events which increase surgery risk, hospital stay, and mortality are common to all abdominal operations, while some are specific to bariatric surgery. There are no guarantees that a significant complication will not occur in any patient. The most significant complications that may occur include leakage from the stapled ends of the stomach, bleeding, strictures, infection and breathing complications, among others. Fortunately all these complications are uncommon.
There is a low risk of mortality from bariatric surgery due to various medical and surgical reasons, just like many other types of surgery. Mortality rates for the Sleeve Gastrectomy & Roux en Y gastric bypass ranges from 0% to 1.1%, depending on different studies. The surgical and post-surgical complications will be discussed with you during the clinic visits. Complications and mortality are affected by pre-existing medical diseases like the degree of obesity, diabetes mellitus, heart diseases, etc. You are encouraged to understand more about the surgery and its complications prior to the surgery, through reliable sources. Dato and ABA welcome any on-going questions regarding complications, as we realize complications are a concern to any patient.
No patient should have obesity surgery who is not ready to accept the possibility of a need for a re-operation. This may occur in up to 1- 5% of bariatric surgery patient. Reoperations or other therapeutic procedures include endoscopy, stomal dilatation, internal hernia repair, bowel obstruction surgery, etc. Most of the conditions requiring reoperations are not common. A revision surgery may also be required for weight regain.
After surgery care
After surgery program is an important part of weight loss success and prevention of complications like nutritional deficiencies. After bariatric surgery, you must be on long term and sometimes life-long vitamin supplementations, routine health screenings and dietary plans. Regular visits to your local dietician or GP and on-going education is recommended for 5 years after the surgery.
Following any massive weight loss program, skin over the arms, legs, tummy, face, neck and anywhere else may sag, droop, wrinkled or hang in large folds. Patients may opt for skin reconstruction surgery under a plastic surgeon. If so, please discuss with your consultant on the appropriate time after surgery for skin reconstruction.
MIMIMISER GASTRIC RING INFORMATION
This ring is not a Gastric Band (which is placed around the stomach). This is a permanent ring that is set loosely around the oesophagus after your sleeve surgery has been performed. It is designed to help STOP the stomach re-expanding which can happen after the first 12 months especially if you do not follow the guidelines with your portion control. And yes you can have this ring placed after you have been sleeved at a later stage. The ring is permanently sutured into place to stop it from slipping. If your surgeon feels you will have difficulty with portion control, weight regain and advises you to consider the ring then he will discuss this with you at consultation. There is an additional cost for the ring and this is listed in the Optional Extra part of your quote.
While traditional gastric bypass surgery results in excellent weight loss, the procedure is technically challenging and the mini-gastric bypass procedure has gained popularity in recent years. The mini-gastric bypass is quicker, technically easier and carries a lower complication rate compared to traditional gastric bypass surgery, 2.9% (2012 MGB study).
The mini-gastric bypass procedure is restrictive and malabsorptive. This means that the procedure reduces the size of your stomach, restricting the amount you can eat. The procedure also reduces absorption of food by bypassing up to 6 feet of intestines. Gastric bypass and the mini-gastric bypass are both malabsorptive and restrictive procedures. Gastric sleeve and the Lap Band are restrictive procedures.
The mini-gastric bypass was developed to reduce operating time, simplify the procedure and reduce complications. Recent studies show that it does reduce operating time, may lead to similar weight loss (some studies show that mini-gastric bypass may actually produce more weight loss), and reduce overall complication rates compared to gastric bypass surgery (Gastric Bypass Compared to Mini-Gastric Bypass).
Mini-gastric bypass is a quicker operation compared to traditional laparoscopic gastric bypass surgery. Operating times are reduced, on average by 50 minutes (Laparoscopic Roux-en-Y Versus Mini-Gastric Bypass for the Treatment of Morbid Obesity).
- The stomach is divided with a laparoscopic stapler. Most of the stomach is no longer attached to the esophagus and will no longer receive food. Your new stomach is much smaller and shaped like a small tube.
- Between 2 to 7 feet of intestines are bypassed. The surgeon will attach the remainder of the intestines to the new stomach.
- Food now flows into your small tube-like stomach and then bypasses between 2 to 7 feet of intestines where it resumes the normal digestive process in you’re the remaining intestine.
Benefits of Mini-Gastric Bypass Compared to Gastric Bypass Surgery
- Shorter operating time.
- Less re-routing of the intestines.
- One fewer anastomosis (connection of intestines), which in theory means less chance of a complication.
- Technically easier for the surgeon.
- Similar weight loss and recovery.
Additional Risks with Mini-Gastric Bypass Compared to Gastric Bypass Surgery
Severe acid-reflux. Because the pouch is small and the remainder of the stomach is still connected to the intestines. It is possible for gastric juices to travel down the intestines and into the new pouch.
Full Gastric Bypass
Gastric Bypass is the current “gold standard” weight control operation, and is the most frequently performed bariatric (obesity) procedure world wide (65% of operations). It is the operation to which all other procedures are compared, and it has the best known long term results. But your surgeon is the most qualified person to recommend which surgery suits you the best.
The operation is popular because:
- It produces massive and appropriate weight loss in most patients. Median weight loss at 12 months is 60-70% excess weight, with consequent loss (or cure) of complications of obesity such as diabetes, lipid abnormalities, sleep apnoea etc.
- The operation can be done at an acceptable mortality (0.5 – 0.01 %). Morbidity (significant post operative illness) is low and post operative side effects and nutritional deficiencies are only rarely severe. B 12 and Iron are a predictable problem as the stomach is by-passed. Calcium may also be required because of the duodenal bypass and reduced amounts of post operative food eaten.
- World wide there is >15 years of experience with the operation with weight loss maintenance of approximately 50% of excess weight. There is little variation in results from hospital to hospital and country to country.
The operation is truly a by-pass of the stomach. The stomach is by-passed so that food eaten goes into a small gastric pouch and then into a loop of small bowel (the jejunum).
How Does it Work:
Weight is lost by the following 5 mechanisms:
- Satiety is induced by the small gastric pouch, and through the “switching off’ of the hormones that cause hunger. Most patients go many months before they have any recognisable hunger sensations.
- Over-eating is prevented by the small pouch. Too much food causes discomfort and vomiting. In some patients a ring can be put around the pouch to further prevent overeating (the Banded Bypass).
- The operation causes intolerance to sweets and high density carbohydrates (fatty, oily food) as the rapid presence of sugar or large volumes of carbohydrate in the small bowel leads to unpleasant symptoms called “dumping”.
- There is trivial malabsorption of fat as the food eaten is initially not mixed with bile and pancreatic juice. There is no protein or carbohydrate malabsorption.
- 85-90% of diabetics have their diabetes completely resolve, often before they leave hospital. The mechanism for this is not known but it may be due to bypass of the duodenum and pancreas.
What is Achieved by the Operation?
First and foremost the operation achieves weight loss. Significant weight loss will then have an effect on the physical and psychological consequences of obesity. These effects however, are not as predictable as the weight loss.
The operation allows the average patient to lose 60 – 80% of their excess weight in 12-18 months. After this most patients re-gain some weight. This weight gain occurs for a variety of reasons such as poor compliance with diet and exercise and physiological adaptation of the body to the operation. At 5, 10 and 15 years the weight loss stabilises at approximately 50-70% of excess weight. Weight regain may be preventable through dietary compliance.
Approximately 5-15% of patients will not lose adequate weight with the operation . These patients cannot be reliably identified pre-operation but weight loss failure is very uncommon apart from in the super obese (BMI >50) who may still lose significant weight. More “aggressive” surgery is possible but leads to severe nutritional problems in some patients. Re-operations for “failure” can sometimes be difficult and may have variable success.
For most patients the operation will result in the average patient losing 60-80% of excess weight which means they will still be a little overweight but will have lost enough weight to reduce their obesity related risk profile to that approximating the normal population.
What is Life Like With a Gastric By-Pass?
Patients get used to eating three to 6 small meals a day. Usually 25% of previous serves. When going to a restaurant they can eat an entree sized meal and feel satisfied (while they watch their friends over-eat with an entree, main and dessert).
Sweets and fatty foods are poorly tolerated and best avoided. These foods will cause “dumping” due to the rapid presence of high osmolarity fluid in the small bowel. Symptoms are nausea, dizziness, palpitations, sweating and abdominal discomfort. To avoid dumping, high sugar and fat content foods should be avoided and food should be eaten dry and not mixed with fluids. Otherwise apart from a commitment to “healthy eating” no other foods are specifically banned. Snacking especially with junk foods is to be avoided as it will greatly negate the effects of the surgery.
Multivitamins and B12 need to be taken by all. Menstruating females need iron supplements, post-menopausal women will need calcium (as well as some premenopausal women and some men). These requirements are life long.
Recovery, Pain and Complications After Bariatric Surgery – What to Expect
Recovery, pain and complications are very individual so please don’t compare your recovery with the next patient.
After surgery you will have some belly pain, particularly at your incision sites. The incision sites, typically 3-5, are between 5mm and 12mm in length. This is where the surgeon inserted ports to access your abdomen.
Pain is usually not an issue. Yes, you will be in some discomfort. This is particularly true during the first two weeks and is very evident when you twist your torso. Pain can be managed well with medication. You’ll be encouraged to get up and move every day after surgery. The first few days usually include walks around the house. After a week you may be asked to take 20 minute walks twice a day. Gradually increasing exercise is encouraged with each week after surgery. Again, follow your surgeons instructions. Be prepared to be tired as you lose weight fast and adjust to a lower calorie diet. Fight through this phase. It does pass. A regular exercise routine will help your body adjust.
You will typically be required to stay overnight in the hospital 1-2 nights. Once you are discharged you’ll be required to follow a strict diet. A liquid diet (soft food) is usually required for the first week after surgery. This may include water, pureed soft foods, and soup (some shake maybe require for some patients). Follow the dietary instructions from your surgeon and dietician and not Dr Google or your girlfriends. After two weeks, soft foods are introduced. And after a month you’ll be back to normal foods. However, you’ll be asked to follow a new diet that will include more protein, vegetables and fruit. Your stomach is much smaller and there is no room for junk food or carbonated drinks (you need to maximize nutrients from every bite you eat). You will be given a guide, food stages, food selections, a list of 8 Golden Rules.
Complications can occur with each procedure. They range in severity from minor to significant. Minor complications include hernias at the surgical site, ulcers, and minor incision infections. Major complications typically occur within the first three weeks after surgery. Significant complications include staple line leaks, pulmonary embolisms, and strictures, among other risks. These should be managed promptly by your surgeon. Before surgery you should be made aware of the risks and signs and symptoms of these complications.
Bariatric Surgery Using Robotic Procedures
Both sleeve gastrectomy and gastric bypass surgeries are almost always performed using minimally invasive techniques—either laparoscopic surgery or robotic-assisted surgery, (possibly with da Vinci® technology) through a few small incisions . Dato Gee performs both minimally invasive laparoscopic and robotic-assisted surgeries. To perform a laparoscopic bariatric surgery, surgeons use special long-handled tools while viewing magnified images from the laparoscope (camera) on a video screen.
With robotics your surgeon sits at a console next to you and operates using tiny instruments through a few small incisions. A camera provides a high-definition, 3D magnified view inside your body. Every hand movement your surgeon makes is translated by the robotic system in real-time to bend and rotate the instruments with precision. The surgery technique for each treatment is the same but the delivery of the precision of movement and surgical incision is more exacting using the robotics.
Robotics does add an extra cost to your surgery of about 10K Aud.