Bariatric Surgery/Obesity Surgery/Weight Loss Surgery
Types Of Surgical Procedures
Bariatric Surgeons first began to recognise the potential for surgical weight loss while performing operations that required the removal of large segments of a patient's stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, Bariatric Surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the years these procedures have been continually refined in order to improve results and minimise risks. Today's Bariatric Surgeons have access to a substantial body of clinical data to help them determine which weight loss surgery should be used and why.
We recommend you visit Dr David Joseph for a consultation to discuss your health and lifestyle goals and determine the best surgical option for you. He performs two of the most common bariatric surgery procedures to achieve successful weight loss results.
There are two basic approaches that weight loss surgery takes to achieve change:
Restrictive procedures that decrease food intake. This includes Gastric Sleeve (Sleeve Gastrectomy).
Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool. This can also incorporate an element of restriction. This includes Gastric Bypass.
Gastric Sleeve (Sleeve Gastrectomy)
Gastric Sleeve is now the most commonly performed Bariatric Surgery and brings an excellent balance of long term sustained weight loss, together with a great quality of life.
The procedure is performed using a few small laparoscopic (keyhole) incisions, and creates a long narrow stomach which is smaller in volume 200-300 mL instead of the usual 1000-1300 mL. The excess portion of stomach is permanently removed. The food passes through the smaller stomach similarly to the originally sized one, entering the small intestine via the normal end of the stomach.
The procedure is successful due to several effective mechanisms all working together. Firstly, patients are now very satisfied with a much smaller portion of food and feel full earlier. Secondly, the hunger drive is diminished for at least 9-12 months due to the removal of the top portion of the stomach (fundus) which produces a lot of the hormones that normally drive hunger (Ghrelin amongst others). The ability to absorb nutrients is essentially unchanged, although a few patients may have low vitamin B12 or low Iron levels long term.
Patients experience excellent weight loss success and long term maintenance and are able to tolerate a normal range of food choices.
The Gastric Sleeve has shown positive results for patients with mild to moderately controlled Diabetes.
Female fertility can improve following Gastric Sleeve surgery, with more likelihood of a healthy weight full term delivery than a Gastric Bypass. (please note: pregnancy is not advised in the first 6-12 months after bariatric surgery)
There can be some long term Vitamin B12 or Iron deficiencies for a small percentage of patients.
Gastric Bypass Surgery has been very popular overseas for many years and can result in excellent long term sustained weight loss. The procedure is performed using a few small laparoscopic (keyhole) incisions, and creates a small portion of narrow stomach which is disconnected from the rest of the stomach. Some small intestine is then brought up to join this now smaller piece of stomach allowing the ingested food to “bypass” the majority of the stomach, and the first 1-2 metres of small intestine (most people have 4 metres or more of small intestine).
Gastric Bypass surgery works by combining both restrictive and malapsorptive methods. By reducing the physical size of the stomach patients become fuller faster so are therefore likely to eat less, while the “bypassing” of a section of the intestine means the absorbtion of calories and nutrients consumed is reduced.
There are 2 main types of Gastric Bypass performed, the Single Loop (Omega Loop), and the Roux-en-Y Bypass. As a guide, the Single Loop procedure is more commonly used, while the Roux-en-Y might be preferred if patients suffer from severe reflux symptoms (heartburn).
Excellent weight loss success and long term maintenance.
Gastric Bypass is ideal for patients with very poorly controlled Diabetes or Dyslipidaemia (high cholesterol).
Patients may need some vitamin and nutritional supplements long term as there is a risk of medium to long term nutritional deficiencies.
Female fertility can improve following Gastric Bypass, but there may be a slightly increased risk of pre-term and underweight birth neonates.
Some patients may develop an intolerance to certain foods if they suffer from Dumping Syndrome.
Revision Bariatric Surgery
In addition to Gastric Sleeve and Gastric Bypass, Dr Joseph also performs Revision Bariatric surgery for patients who have undergone a previous bariatric procedure, most often Gastric Bands and sometimes Gastric Sleeve. The reasons for considering revision surgery may be due to lack of weight loss, weight regain, significant reflux symptoms or other problems. The exact reasons why these problems occur are quite complex.
Revision Bariatric surgery may be a good option for some patients. There are a number of options available:
Gastric (Lap) Band to Gastric Sleeve
Gastric (Lap) Band to Gastric Bypass
Gastric Sleeve to Re-Sleeve
Gastric Sleeve to Gastric Bypass
Dr Joseph has seen excellent results with the most commonly performed revision procedure - a Gastric Band to Gastric Sleeve. Over the last few years he has seen patients do almost as well as those who have had a Gastric Sleeve as a primary procedure.
The decision of what is best for the patient will likely require some investigative procedures to be conducted to look at the stomach prior to deciding on a surgical plan, of course the goal outcome will also direct the decision.
Pre and Post Operative Information
Pre Operative Care
All Weight Loss Surgery patients are required to commence an Optifast based diet for a period of 2-3 weeks prior to surgery. This diet induces a change to the patient’s metabolism putting it into a Ketotic state, known as Ketosis. During this period the patient’s diet will be restricted, with only certain additional foods allowed (your dietitian will provide clear direction tailored to you). There are no carbohydrates, sugars, fruits or juices etc. permitted during this Optifast period.
The ketosis will result in fat stores coming out of the liver to provide the metabolic fuel your body needs. During surgery, it is necessary to retract the liver – the reduction in fat stores in the lead up to surgery allows for this to be done safely without risk of damaging or tearing the liver during the procedure.
Some patients may note that they can lose 5-10% of their body weight during this period. (It would be terrific if this were sustainable long term, but Optifast isn’t sustainable over time).
Most mediations can continue until the day of surgery, and they will be recommenced post operatively under our direction. There are several blood thinners and anti-platelet agents that will need to be stopped between 2-10 days prior to surgery depending on the particular medication. We will provide advice tailored to each patient.
Post Operative Care
The small keyhole incisions are all closed with dissolving stitches which are all placed under the skin so that patients will never need to see them. We also use steristrips and waterproof dressings to ensure the skin heals in a clean and dry environment. Patients can bathe or shower with these dressings in place, however they should be patted dry afterwards.
Dressings are normally removed 10 days after surgery and the incisions should have healed nicely by then.
Most patient’s post-operative discomfort has settled by the time of discharge from hospital. Some patients may however require a small amount of oral medication to help manage ongoing discomfort for a week or so. This can include Panadol, Panadeine Forte, Endone, or occasionally other medicines.
Routine medications can be recommenced as directed in the post operative phase and any blood thinning agents that patients were previously taking will also be recommenced as directed by the medical team.
Many patients will be directed to take a PPI (Proton Pump Inhibitor) such as Nexium, Somac or Losec for a certain period after surgery to reduce stomach acid production.
Post Operative Diet
Bariatric Surgery will help patients to start their weight loss journey, however, in order to achieve successful long term results - dietary and behavioural changes are necessary. Each patient will be given specific dietary advice based on their personal requirements, but the following are very brief recommended guidelines following surgery.
Week 1 Liquid nourishment
Weeks 2 - 4 Pureed food
Week 4 + Commencement of soft solid diet.
Detailed dietary information will be provided by the practice dietitian prior to surgery.
As a guide, most patients need 2-3 nights in hospital post-op, and depending on the work in which you are employed, anywhere from 3-14 days off work. Most patients can start walking within a few days, and more vigorous exercise within 3 weeks.
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