A Brief Overview Of Morbid Obesity Surgical Treatment

Surgical procedures to help control obesity generally are divided into two categories: malabsorptive and restrictive.

Malabsorptive Surgical Procedures:

These procedures decrease intestinal absorption by the patient. Although there are some more radical procedures, the most widely used method is the Roux-en-Y Gastric Bypass. In this procedure, the surgeon utilizes staples to construct a proximal gastric pouch with an outlet that is a limb of the small bowel, thus bypassing most of the stomach and some of the small intestine.

Complications associated with the Roux-en-Y Gastric Bypass are:

  • Disruption of the staple line forming the proximal gastric pouch. (1)
  • Gastrointestinal leaking at the anastomosis (0.5%-3.9%). (1) (2)
  • Long-term, micronutrient deficiencies, particularly of B12, Folate and Iron. (15) (16)
  • “Dumping syndrome” a gastrointestinal distress reaction to sugar intake. (15)

Complications associated with gastric bypass surgery are often the result of cutting and suturing of the gastrointestinal tract. Disruption of the staple line used to create the small proximal pouch in gastric bypass surgery has frequently been cited in literature (1) as well as leaking and ulceration at site of the anastomosis of the small bowel.

Another common complication associated with gastric bypass surgery is the occurrence of long term micronutrient deficiencies, particularly of vitamin B12, folate, and iron (15)(16). This vitamin deficiency is commonly treated with oral supplements; but, sometimes conservative treatment is not effective and long-term complications may result (4). In addition to vitamin deficiencies gastric bypass patients commonly react to the ingestion of substances with a high sugar content with gastrointestinal distress. This is referred to in the literature as “dumping syndrome”.

Weight loss results from the Roux-en-Y Gastric Bypass vary widely but it is generally reported that weight loss is greater in the first year after surgery with successive years resulting in a slowing in weight loss and even weight regain. Oh CH et al. (5) reported a median percentage excess weight loss (%EWL) of 68.5% in the first year post Roux-en-Y Gastric Bypass, a 71.18 %EWL after two years, 69.28 %EWL after 3 years and 57.49 %EWL after four years. These results indicated a slight weight regain by some patients after the first year post surgery. In a longer term follow-up study, 6 to 9 years, of Roux-en-Y Gastric Bypass patients by Avinoah E. et al. (6) a greater significance of weight regain with longer follow-up was indicated; weight loss results showed that 24% of patients had become morbidly obese again, 74% had more than 50 %EWL and only 7% had 100 %EWL.

Restrictive Surgical Procedures:

These procedures decrease the amount of solid food a patient is able to ingest. Common restrictive surgical techniques are:

  • Vertical Banded Gastroplasty (VBG)
  • Silicone Ring Gastroplasty (SRG)
  • Gastric Banding

In the Vertical Banded Gastroplasty and Silicone Ring Gastroplasty, reduction in stomach size is achieved by using rows of staples to create a small stomach pouch along the lesser curvature of the stomach. The pouch outlet (stoma) is reinforced with a marlex band or silicone ring, sometimes placed through a hole in the stomach created by a circular stapler. Complications associated with the VBG and SRG include:

  • Operative Complications: leakage (2.6%) (7), sepsis, pneumonia (5%) (8), deep vein thrombosis (0.1%) (6), (1%) (7)
  • Disruption of the staple line over a period of time leading to weight regain (2.8%) (4), (5.4%) (8), (45%) (9), (48%) (9)
  • Obstruction/Stenosis of the reinforced stoma outlet (2%) (8), 4% (11), 10.4% (9), 14%(13)
  • Migration and/or erosion of the reinforced band or ring (1.6%) (11)
  • In Gastric Banding, a small upper pouch and reinforced stoma are created in one step by placing a band or ring around the upper stomach. This procedure avoids the complications associated with staple line leakage and disruption, but is believed to have been associated with a higher rate of pouch enlargement and obstruction (14).

References:

  1. Martin Louis et al., Comparison of the Costs Associated with Medical and Surgical Treatment of Obesity, Surgery, 1995, 599-607
  2. Capella R. F., Capella J. F., Reducing Early Technical Complications in Gastric Bypass Surgery, Obesity Surgery, 7, 1997, 149-157
  3. Paganini A. M., Guerrieri M., Feliciotti F., Lezoche E., Laparoscopic Adjustable Silicone Gastric Banding (LASCG) for the Treatment of Morbid Obesity, Surgical Technology International V, 1996.
  4. Martin L., Hunter S., Lauve R., O’Leary J.P., Severe Obesity: Expensive to Society, Frustrating to Treat, But Important to Confront, Southern Medical Journal, Journal of the Souther Medical Association, Volume 88, Number 9, September 1995, 895-902.
  5. Oh C. H., Kim H. J., Weight Loss Following Transected Gastric Bypass with Proximal Roux-en-Y, Obesity Surgery, 1997, 7(2), 142-7
  6. Avinoah E., Ben-Yehuda A., Ovnat A., Pilpel D., Charuzi I., Long-term Weight Cjanges after Roux-en-Y Gastric Bypass for Morbid Obesity, Harefuah, 1993, 124(4), 185-7, 248
  7. Ashley S., Bird D. L. Sugden G., Royston C. M. S. Vertical Banded Gastroplasty for the Treatment of Morbid Obesity, British Journal of Surgery, 1993, 80, 1421-23
  8. Fox R., Oh K. I., Fox K., Vertical Banded Gastroplasty and Distal Gastric Bypass as Primary Procedures: A Comparison, Obesity Surgery, 6, 1996, 421-425
  9. MacLean L. D., Rhode B. M. Forse A R., Late Results of Vertical Banded Gastroplasty for Morbid and Super Obesity, Surgery, 1990, 107, 20-7
  10. Owen ERTC et al. Gastroplasty for Morbid Obesity: Technique, Complications and Results in 60 Cases, British Journal of Surgery, 1998, 76, 131-5
  11. Desaive C., Critical Review of a Personal Series of 1000 gastroplasties, International Journal of Obesity, 1995
  12. Svenheden K-E., Akesson L-A., Holmdahl C., Naslund I., Staple line Disruption in Vertical Banded Gastroplasty, Obesity Surgery, 7, 1997, 136-138
  13. Hocking M. P., Kelly K., Callaway C. W., Pouch Outlet Obstruction Following Vertical Ring Gastroplasty for Morbid Obesity, The American Journal of Surgery, 1990, 160, 496-500
  14. O’Brien P., Brown W., Smith A., McMurrick P.J., Stephens M., Prospective Study of a Laparoscopically Placed, Adjustable Gastric Band in the Treatment of Morbid Obesity. British Journal of Surgery, 85, 1999, 113-118.
  15. National Institute of Health Consensus Statement, Gastrointestinal Surgery for Severe Obesity, 1991, 9:1.
  16. Provenzale D., Reinhold RB., Golner B., Irwin V., Dallal GE., Poulos N., Sahyoun N., Saloff IM., Russell RM., Evidence for Diminished B12 Absorption after Gastric Bypass: Oral Supplementation does not Prevent Low Plasma B12 Levels in Bypass Patients, Journal of American College of Nutrition, 1992, 11(1), 29-35