August 2018 #obsm chat: How do you choose a bariatric procedure?
About one-third of adults in the United States have obesity. Diet and exercise are frequently suggested to help people lose unwanted or unhealthy weight. However, only ~5% of people are successful in losing weight that way and keeping it off. By contrast, bariatric surgery is associated with long-term weight loss maintenance for the vast majority of patients. In addition, the health benefits of bariatric surgery are incontrovertible. Results show improvement or remission of diabetes, high blood pressure, orthopedic issues, high cholesterol, circulatory problems, breathing difficulties, certain forms of infertility, and a reduction in risk for a number of cancers. Many patients are able to reduce the number or completely come off of medications for treatment of high blood pressure and diabetes.
Bariatric surgery can be confusing, though. There are different approaches (endoscopic, laparoscopic, robotic) as well as different specific procedures (intragastric balloons, adjustable gastric band, sleeve gastrectomy, gastric bypass, duodenal switch). For this month’s chat we are going to focus on surgical (rather than endoscopic) approaches. In general, whether these procedures are done laparoscopically or robotically will depend on surgeon preference. These approaches have similar weight loss and health outcomes.
In many bariatric surgery practices in the United States, the vast majority of procedures performed are the sleeve gastrectomy and the gastric bypass. Nationally, in 2017 almost 60% of all bariatric procedures were sleeve gastrectomies
while almost twenty-percent of procedures performed were gastric bypasses. Almost 15% of procedures were revisions or conversions (a second operation after a previous bariatric surgery). Gastric bands and duodenal switch make up the majority of the remaining surgical procedures.
There are some major and some minor differences among the procedures. Ultimately the choice will be made between each patient and their surgeons. Here are some basics about each of the major procedures:
- Sleeve gastrectomy: In this procedure, the majority of the stomach is permanently removed from the body. As shown in the figure, this procedure has been gaining in popularity since it was introduced in the mid-2000s. Some reasons for this are that it is simpler to perform than the gastric bypass and has fewer surgical complications. It is associated with good rates of weight loss and resolution of related problems such as diabetes (although perhaps a bit less than the gastric bypass and the duodenal switch). There are some potential long-term problems from this that can occur including worsening of heartburn and the potential need for being switched to a gastric bypass. This procedure is non-reversible.
- Gastric bypass: This is often called a “Roux-en-Y gastric bypass” because of the way the stomach and intestines look after the procedure is completed (they come together in the shape of a Y). The stomach is divided, and one part of the small intestine is brought up to the new stomach pouch (about the size of a small egg) connected to the esophagus. Food goes from the esophagus into the small stomach and then into a later portion of the small intestine. This procedure has been used for weight loss for many decades and has the most evidence supporting it. It is associated with a little more weight loss and a little better diabetes resolution than the sleeve gastrectomy. There are some potential long-term problems from this that can occur (such as ulcers, bowel obstructions, and a reformed connection between the two parts of the stomach). Nothing is typically removed from the body during this procedure, and while complex, it can be reversed.
- Duodenal switch: This is the least commonly performed procedure (~1% of all procedures) in the United States. In some ways it is a combination of the sleeve gastrectomy and the gastric bypass. Part of the stomach is removed as with the sleeve gastrectomy. Then part of the intestine is re-routed to be connected to what is left of the stomach. Typically the part of the intestine that is hooked up is further down than would be the case for the gastric bypass. This procedure is associated with more weight loss and better diabetes resolution than the sleeve or the gastric bypass. However, there is potential for more problems such as ulcers, bowel obstructions, and malnutrition than the other surgeries. Recently a simplified version of this procedure has become more popular, particularly outside of the United States.
- Adjustable gastric band: As seen in the figure, the gastric band has become far less popular over time. It is a synthetic band that is placed around the top part of the stomach and creating a small pouch to help people feel full earlier. A port is also implanted which allows the band to be filled with saline to make the band tighter or looser. It is associated with less weight loss than any of the other procedures, and a higher risk of needing another surgery such as repositioning or removal of the band. For these reasons, it has fallen out of favor. Other long-term potential problems include less than satisfactory weight loss, displacement, erosion of the band into the stomach, or problems with the port.
Ultimately, patients should discuss available procedures with their surgeon and health care team to pick the one that best fits their health care goals. Other procedures, such as endoscopic techniques, may be of interest as well. We will discuss those in a separate chat.
Here are the questions we will discuss in our upcoming chat:
- Who qualifies for bariatric surgery? Who should consider bariatric surgery?
- What are the benefits of bariatric surgery? Why should people consider it?
- What are the most important things to consider when picking the “right” procedure for you?
- If you have already had bariatric surgery, which procedure did you choose and why? Do you have any regrets?
- For the bariatric surgeons out there, what do you love about bariatric surgery?
- What are the best ways for us to disseminate useful information on how people can choose the right procedure for them?