Type of Operation

Restrictive and Malabsorptive

Restrictive

Laparoscopic Roux-en-Y Gastric Bypass (RNYGB) or OAGB/MGB

Laparoscopic Sleeve Gastrectomy (SG) with Duodenal Switch(DS) or SADI-S

Sleeve/Tube/Vertical
Gastrectomy (SG)-complete

Laparoscopic adjustable gastric band (LAGB)

What does the Operation entail?

Thumb sized 12-15cm long stomach pouch connected to the small bowel. Food & digestive juices join about 1/3 the way down the small bowel i.e.1/3 small bowel and most of stomach is bypassed.

Sleeve Gastrectomy performed first. The duodenum (first portion of the small bowel) is then connected to the last 300cm of small bowel. Food and digestive juices join in the last  75-100 cm of small bowel i.e. 3/4 of small bowel is bypassed.

Stomach is divided vertically and 4/5 of the stomach (greater curve side) is removed leaving a long narrow tube with a capacity of about 75 cc (1/8 pint). Pylorus (the stomach outlet valve) is retained. No re-routing of bowel.

An adjustable silicone ring (band) is placed around the top part of the stomach creating a small 15 cc pouch.

Procedures

One Anastamosis Gasric Bypass OAGB

SADI-S

Complete Uniform Sleeve – dividing stomach 1-3 cm from the pylorus to 1/2cm from the angle of His

How does it works?

·  Significantly restricts the volume of food that can be taken.
·  Mild malabsorption
·  "Dumping Syndrome" when sugar or fats are eaten. Forced to change the way one eats.
·  Reduces the appetite to an extent by reducing Ghrelin

·  Moderately Restricts the volume of food that can be taken.
·  Moderate malabsorption of fat causing diarrhea and bloating and smelly stools

·  Significantly restricts the volume of food that can be taken.
·  Also removes the part of stomach that produces the appetite producing hormone, Ghrelin
·  NO malabsorption
·  Hardly any dumping

·  Moderately restricts the  foods that can be taken. Doesn’t restrict sugary stuffs or liquids.
·  Only procedure that is adjustable
·  Delays emptying of pouch
·  Creates sensation of fullness

How much Weight Loss is achieved?

·  65% excess weight loss
·  More failures (loss of <50% excess weight) than the DS

·  80-90% loss of excess weight
·  More patients lose too much weight or develop nutritional problems than the RNY

·  65% excess weight loss at 2 years
·  pts may resort to eating wrong foods & put on weight

·  40-55% excess weight loss.
· Requires the most effort of all procedures to be successful. Person has to be very compliant

Cured? When?
1.Diabetes II
2.Hypertension
3.Sleep apnoea
4.Metabolic  Syndrome
5.Joint Problems

Unrelated to wtloss1,4
– 70% within 1-30 days
– 40% within 3 months
–100% after wt loss
– 90% within 30d
– 60% after wt loss

Unrelated to wt loss 1,4
– 90% 1- 30 days
– 80% within
– 100% after weight loss
– 100% Metabolic surgery
– 60%

Totally weightloss-related
– 65% within 3 months
– 60% within 6 months
– 80%  within 3 months
– 70% within 3 months
– 60% after weight loss

Totally weightloss-related
– 50% after weight loss
– 40% after weight loss
– 60%  after weight loss
– 60%  after weight loss
– 50%  after weight loss

What Dietary Modifications should be made in the long term?
(you should remember  that Excessive carbohydrate/
high calorie intake will defeat all procedures though less with those of Malabsorption

·  Patients must consume 3 small high protein (total 60gm/d) meals per day
·  Must avoid sugar and fats to prevent "Dumping Syndrome"
·  Vitamin B12 & D, Ca, Fe deficiency/ protein deficiency -usually preventable with supplements
·  Weight gain may be due to eating too much food with time

·  Consumption of fatty foods causes diarrhea and malodorous gas/stool.
Take High protein (60-100 gram/d)  diet along with vegetables as in RGB
·  Failure to adhere to vitamin supplement regimen and  high protein meals more likely to result in deficiency than with gastric bypass
·  May require revision to help prevent the nutritional deficiencies

·  Must consume small amounts of food. Should stop eating once you feel full
·  No dumping, no diarrhoea
·  Weight regain may be more likely than in other procedures if dietary modifications not made. Have to avoid sugary /calorie-dense foods as they are absorbed easily.

·  Must consume less than fist size amount of food at any stage. Eat 3-4 times a day
·  Certain foods can get "stuck" if eaten (rice, bread, dense meats, nuts, popcorn) causing pain and vomiting.  
·  No drinking with meals and no snacking in between meals

What Nutritional Supplements are required for life?

·  Multivitamins-B12,D
·  Calcium
·  Iron
·  Rarely Se, Zn
·  Protein Supplements in first 3 months

·  Multivitamins – B12,D
·  Calcium
·  Iron, ?Se,Zn
·  Protein supplements for life?

·  Multivitamins - B12, D 
·  Iron, ?Se,Zn
·  Protein supplements in the first 6 months

·  Multivitamins, D

What are the Potential Problems in the  long run and immediate peri-operative period?

·  Dumping syndrome
·  Ulcers, Stricture, Perforation
·  Internal Hernias - Bowel obstruction
·  Hypoglycaemia – especially if wrong foods are eaten – may need reversal
·  Anemia
·  Nutritional/Vitamin deficiencies (Iron, D, B12, folate)
·*Leak from staple line or  anastamosis 0.5% to 0.01%

·  Nausea and vomiting
·  Heartburn
·  Severe diarrhea, foul stools
·  Kidney stones
·  Stricture
·  Ulcers (less than RNY)
·  Nutritional/ Vitamin deficiencies (Vit A,D,E,K) ?Loss of too much weight requiring reoperation
·*Leak 1% (much less when it is done in 2 stages)

·  Nausea and vomiting
·  Leak/abscess 1- 0.1%
·  Bleeding
·  GORD/heartburn
·  Inadequate weight loss
· Weight regain
· Nutritional/Vitamin dedficiencies (Iron, B12, D)

·  Slow weight loss/ very little weight loss (higher failure rate)
·  Slippage/ increased pouch formation
·  Gastric Erosion
·  Infection
·  Port problems
·  Heartburn
**20% Re-operation rate
** Least operative Risks but high complication rates with time
**50% Removed by 5 years

Hospital Stay

1-2 days

1-2 days

1-2 days

1 day

Time off Work

1-3 weeks

1-3 weeks

1-3 weeks

1-3  week

Operating Time

<1   hours

1-1 ½ hours (2nd stage DS/SADI-S)

½ - 1 hour

½ hour

What operation should you undergo to get the best result?
All the patients are required to be followed for life to get better results and prevent malnutrition problems.

·  BMI 35 - 55 kg/m²
·  Heartburn/reflux
·  Diabetes
·  PCOS, metabolic
    syndrome
·  ?Diet compliance
·  sweet tooth/ snacker/ grazer

*RGB Low maintenance, but has problems of dumping, ulcer, internal hernia requiring surgeries. Further surgeries for Weight gain difficult.

·  BMI >55 kg/m²
·  exteme carbohydrate eater
·  Diabetes
·  PCOS, metabolic syndrome
·  ?Diet compliance
·  Remember the higher overall incidence of complications than other procedures.

*DS Low maintenance but require intense observation. May require surgeries for nutritional problems. SADI may have to be converted to DS for bile reflux

·  As ‘first stage’ in high risk or very heavy patients (BMI > 60 kg/m²) because of very low complication rate due to quicker operating time and recovery.
·  As a primary procedure for BMI <45 kg/m² instead of band

*SG Very Very Low maintenance, but may require surgeries for acid reflux/ heartburn. DS/SADI can be added for weight gain

·  Best for patients who are well motivated and very disciplined in following dietary restrictions and exercise regime.
 
·  BMI >45 kg/m²

* LAGB High maintenance. Problem with band fills. Complications high and require surgeries for complications and failure. 50% removed by 5 yrs, 65% by 7 yrs, & 100% by 10 years

What makes the weightloss surgery safe?

·  Experience of the surgeon
·  comorbidities like diabetes less than 4

·  Experience of the surgeon
·  comorbidities less than 4

·  Experience of the surgeon

·  Experience of the surgeon