What is done is that the greater curvature of the stomach is freed from the tissues attached to it (known as the gastrocolic omentum) using a vessel sealing device like the Harmonic Scalpel or the Ligasure. This is the first step of the sleeve gastrectomy procedure, as well.

However, unlike the sleeve, here we do not use the stapler to remove 80% of the stomach. We merely imbricate/plicate the stomach using running stitches from above downwards, layer by layer, till most of the stomach is pushed inwards, creating a narrowing of the passage, and a tunnel along the lesser curvature, just like the sleeve.

Lap Gastric Plication

In the same vein, if someone wants to reverse the procedure, the stitches may be removed by laparoscopy (making this a potentially reversible procedure like the Lap Band), though this would neither be a good thing nor a great experience!

Some patients have significant reflux symptoms after LGP, as after the sleeve, as we have discussed before.

It is possible that the stitches may give way later and hamper the weight loss, but preliminary results, as presented in the recent International Conference of Obesity in Stockholm, show good results akin to the sleeve.

More info later!

(pic source: here)

I am  excited (only in a manner of speaking) to announce to you a NEW series of articles for the layman who has just heard of bariatric surgery. This will be part of a new page. You will find, over the next several weeks, more and more articles that don’t deal with each issue in the kind of depth that you find in my regular articles, but function rather like a ‘Weight Loss Surgery For Dummies’. In fact, this is what I think I will call this series. Maybe this could be a book in the future and my retirement plan!

Oh, wait, this book has already been written!

So, a new series called ‘The Complete Idiot’s Guide To Weight Loss Surgery” is going to start. The reason for this is that a lot of viewers/readers of this site, as well as BMI patients, are happy merely with a ‘Do This, Not That’ kind of approach, and don’t much care for the heavy science in the regular articles.

That said, in my opinion, the ‘heavy’ articles are the meat-and-potatoes of this site, and I hope this will become like a Wiki for obesity surgery. This site is meant to be a highly referenced source of reliable evidence-based and practical information regarding obesity and weight loss surgery in the internet, without the overt commercialisation, mis-representation and selling in many sites.

Stay tuned for more good stuff, and keep visiting.

If you like this blog, please do consider subscribing to our RSS feed. It is easy, and at the lower right side of the front page!

This article discusses these issues. Please buckle your seat belts!

First things first, who doesn’t know what a sleeve (as this operation will from now on be called) is and what it is for? Please refer to our Procedures page and also search this site for many other articles on this popular weight loss procedure.

Normally, the weight loss expected out of the sleeve is in the whereabouts of 50-80 percent of excess body weight. This is usually achieved in the vicinity of one year and may go on till three years, after which time there is usually no inherent weight loss from the surgery. This does not mean you will stop losing weight after that time. You could lose weight if your diet and exercise plans are on the spot. But in practice, weight loss plateaus in and around the third year. A recent study from India published in the journal SOARD reports a nearly 75 percent weight loss of the sleeve in three years.

(the stomach being stapled at BMI, Kolkata. Procedure done at Belle Vue Clinic)

So, the weight loss curve hits a plateau at a point in time. In itself, this is a benefit, as sleeve patients would shrink to oblivion otherwise! So, now that the weight loss plateau is upon you, what to do?

(the stapling process proceeds towards the direction of the foodpipe/esophagus)

Before we answer this, let us eliminate one important cause of weight regain* after the sleeve: a residual fundus. This means that the upper baggy part of the stomach, which is the source of the hunger hormone ghrelin, has not been fully removed by the surgery (usually a technical error). If this is detected, it is bad news.

*The definition of this is taken to be a weight regain of 10 kgs from the nadir (bottom) of the weight loss curve.

(the resected stomach being removed through one of the port sites)

In order to get the desired weight loss, re-surgery has to be undertaken. In such a case, we do one of the following:

1. Re-sleeve: using an endoscopic stapler, the extra fundus (the culprit) is excised. An option to create a narrower sleeve is also possible, but would mean more staplers, and higher cost.

2. Convert to a Roux-en-Y gastric bypass: especially if the patient is super-super-obese (BMI more than 60), where the sleeve is usually the first of a two-stage operative strategy. An alternative we can explore in the Western/Muslim/non-vegetarian super-super-obese patient is the Duodenal Switch (DS). The reason for this is that these patient classes usually eat enough proteins by way of meats. This is a very crucial consideration as the DS causes severe malabsorption of proteins and fats and can cause debilitating malnutrition in the vegetarian patient.

3. A banded sleeve. This adds an additional restrictive element to the sleeve, but has the disadvantages that a Lap Band normally carries (which is another full article). In short, high explantation rates, erosions, prolapse of gastric mucosa, esophageal dilatation, etc.

In a special section on sleeve gastrectomy published June 2010 in the journal Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, I quote:

Similar to the banded gastric bypass, a band can also be placed in SG performed as ‘‘primary banded sleeve gastrectomy,’’ as published by Alexander et al. In this series of 27 patients, a band of 6 cm length made of biologic tissue (AlloDerm) was placed approximately 6 cm below the gastro-esophageal junction.

This is same, but different, compared to the former “secondary” sleeve banding described by Greenstein.

In some cases, improper eating (large feeds, drinking colas and binge eating) can cause the gastric tube (sleeve) to become dilated. Though the initial surgery may have been perfect, the end result is similar to that of a residual fundus after primary surgery: inadequate weight loss, or an early weight loss plateau. This is the reason it is critical to screen patients before surgery for eating disorders and psychiatric conditions that make for unreliable post-op compliance (which means we don’t want to operate on patients who won’t listen to us, and are likely to screw up the results of surgery and give us a bad name).

Let’s get back to the originally asked question. If you underwent a gastric sleeve surgery, and there were no operation-related problems and you lost 70-75% of your excess body weight in, say, three and a half years, BUT you put back 5 kgs in the last few months, what to do?

First, we evaluate the stomach: is it dilated? Is there a residual fundus?

If there is no surgically significant problem, we must get back to basics.

Our strategy is simple:

1. Motivation: talk, talk and more talk. Help the patient understand how results should be the focus, not eating.

2. Eliminate processed foods, sugars, sweetened beverages, alcohol, and other such temptations.

3. Reserve grains as a cheat meal, not as a daily component of the diet.

4. Put some patients on a low-carb diet.

5. Careful food journaling and monitoring of nutritional intake. An online journal may be kept for free at www.fitday.com (or similar sites).

6. Fish oil capsule supplements: 1.8 to 3 grams daily (around 6-8 caps daily).

7. Activity guidance: walk, cycle, play, climb, skip. Don’t sit, slouch, drive, ride.

8.  Exercise: strength training with cardio, both HIIT and long-slow cardio.

Once we hit the system with renewed vigor, you will soon be back on track with weight loss!

References:

1. Revisional bariatric surgery for inadequate weight loss. Gumbs AA, Pomp A, Gagner M. Obesity Surgery, Sept 2007.

2. Re-sleeve gastrectomy. Baltasar, et al. Obesity Surgery, Nov 2006.

3. The Spanish study on sleeve gastrectomy outcomes. Obesity Surgery, Sept 2009.

4. French prospective multicenter study: results at 1 and 2 years. Nocca, et al. Obesity Surgery May 2008.

5. LSG with minimal morbidity. Rubin, et al. Obesity Surgery Dec 2008.

6. Greenstein’s article link in SOARD.

7. Banded Sleeve Gastrectomy. Alexander et al. Obesity Surgery, Sept 2009.

(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

We have all heard of this saying, and all of us agree. A skilled laparoscopic surgeon plots to take out huge tumors and cysts through the keyhole method, while the dinosaur surgeon tends to think of employing his hands to remove organs (like the appendix) that may have been better left alone.

Let me tell you a small story about myself. Not too long ago, at a Bariatric Surgery conference three or some years back, I had a chat with a renowned endocrinologist who was known for his work in obesity and diabetes. At that time, I was 86 kgs heavy, and most of it was fat. A hard-working surgeon, I was in the peak of physical un-fitness and a heart attack waiting to happen. My resting heart rate was always around 100 and my blood glucose was similarly poised over the century mark. I asked this gentleman how I could improve my markers and lose my fat. I also didn’t want to become a diabetic, I said.

He told me what anyone in his position would have: take a metformin pill, and do some walking. If your sugar levels go up, we will add another drug, he said.

I thought long and hard over what he said. I embarked on a new journey in life: a life of health and fitness. I trained hard and started IF (Intermittent Fasting). After an year of blundering along, I found my groove and results came in: resting heart rate down to 6o, blood glucose and lipid levels normal, and body fat well down (BW now 75 kgs).

To come back to the point, the doctor I asked hit my problem with the drug hammer he was holding by default. I did the smart thing by trying something different. I now firmly believe that everyone should try healthy eating and exercise in order to improve health and reduce body fat. As bariatric surgeons, we should not use the surgery hammer to hit every obese patient. When there is clear burden of disease (diabetes, hypertension, sleep apnea, gallstone disease, etc.) and the level of obesity is such that it is statistically unlikely to come off with lifestyle regulation, we recommend bariatric surgery. Not otherwise.

In other words, as specialists dealing with obesity and related diseases, we should have a broad perspective. We are always in danger of using a narrow knife-wielder’s perspective and eyeing every patient as a potential victim. We must be very careful. At BMI, we never stop telling each other this.

In clinical practice, the psyche of the patient is very important. But a more important factor (and an often unrecognized one) is the psyche of the doctor.

Each time, I sigh. It means another ten minute lecture is due on my part. I have to teach an important lesson to the patient (not to mention the family) all over again.

So my lecture goes somewhat like this:

Why are you here? Because eating the way you do has led to a level of obesity that is dangerous to your health and even your very existence. You have suffered endlessly because of your obesity. You have lived through your own self-recrimination, the admonishment of your family, the chiding and teasing of your friends, and countless other miseries unique to the severely obese individual.

Eating the kind of foods the way you have been eating has caused you so many life-threatening diseases like diabetes, sleep apnea and hypertension. Eating sugars and junk has brought you to surgery as a last resort.

So why are you not looking further ahead to being leaner and healthier? Why are you looking back to eating the same kind of way that has made you what you are today? Look at this thing in perspective. You have a whole new life ahead. Plan on how you can make the most of this with your new-found health and look. Liberate yourself from guilt and misery. Focus! The goal is health and leanness, not food. Focus! Look, you are several trouser sizes down! Look, you look great in that new slim-fit T-shirt! Look, people are wide-eyed at your transformation. Look, your husband thinks you are beautiful again!

Don’t miss these achievements. None of this is possible if you think surgery is your destination. It is not. Surgery is your vehicle. It will take you where you would never have dreamed of reaching. But you will do so only if you keep sight of your goals. That is what is called FOCUS.

People forget the fact that lasers are only applicable in a handful of situations across specialities, with the most use being in retinal surgery and dermatology.

Now, this article in the New York Times will add fat to the fire. A company called Zeltiq Aesthetics has brought the Zerona laser to the fore. This four armed machine points red beams at the fat rolls and some sessions later, the inches will have disappeared. At least, in theory.

(pic from Flickr.com)

Talking of which, here is a randomized study on the subject. Interestingly, Zeltiq’s motto is ‘More science, less fat’. Hmmmn. Sounds like BMI!

Even if the laser works (and I can clearly see some drawbacks with it), there is a good chance that commercial abuse will occur widely.

The theoretical argument of the fat (literally) melting and leaking into the lymphatic system to be subsequently metabolised in the body has some flaws, IMO.

This would work if the body is in a metabolically demanding situation (as in exercise and fasting), when the released fatty acids and glycerols (which components make fat) would be metabolised for energy. This would result, indeed, in fat loss.

However, if the patient (or client) has a bag of fries and a sandwich with a Frappuccino, this is not likely to happen.

More information is obviously needed before we judge this product, and you know where to stay tuned for this. Don’t you?

Halfway through my practice, a couple of trucks bearing sand and soil, came to the ground and started dumping them near me. I had to escape the dust and fumes, and abandoned the training.

(An Indian truck looks like this; pic source- from here)
But the disquiet of an incomplete session did not leave me as I proceeded home.

I live on the sixth floor of a building in Kolkata. As a routine, I never use the elevator, as part of my NEAT principle (check out the link).
Today, I decided to make a workout of my return home from the ground floor.
I walked to the floor above with one kettlebell (Kali- the 25 kg bell), ran down and brought back the other one (Sita- the 17 kg). Then I ran all the way down to the ground floor and back up. Now I had to carry one bell to the next floor, run down to two floors below, bring the other bell back, and then run down all the way to the ground floor and back. In other words, whenever both bells were on one floor, I had to run down to the ground floor and back up.
So, to put both bells up from, say the 3rd to the 4th floor, I carried one bell up straight from the 3rd to the 4th, ran back to the 2nd floor, sprinted up (two stairs at a time) to the bell at the 3rd floor, and carried it up to its partner in the the 4th floor. For the next round, I would start by going down to the ground floor and sprinting up all over again.
I calculated the floors and steps run in the few minutes of this workout:
1st- 2
2nd- 3
3rd- 6
4th- 7
5th- 8
6th- 9
TOTAL—35 floors
18 steps per floor—630 total steps up.
I am not calculating the steps run down.
At the end of it, my legs were saying, “PLEASE!!”
I was happy. No excuses training. That is what I want. So, the next time I take 3 kettlebells out, I know I would love the return of the kettlebells home.