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LIPOSUCTION TO LOSE WEIGHT: WHY NOT?

ramana — Mon, 02 May 2011 17:22:14 +0000

In the last two decades or so, people have recognised (mistakenly, as you will see) that surgery for weight loss means liposuction. It has become a tiresome but necessary ritual for us to explain to our patients that what we do is bariatric surgery, not liposuction. Liposuction is local removal of subcutaneous fat from a specific body part (like the belly or the thigh or butt). Bariatric surgery, on the other hand, is operating on the stomach and/or intestines to effect a reduction in one’s ability to eat food, reduce absorption of food and to promote fat-burning metabolism. Bariatric surgeons are not known to remove even an ounce of fat!

Now, everyone knows that bariatric surgery is a serious undertaking for the patient with its potential for complications (about which much has been written by us in this website). Everyone also knows that liposuction is a simple way of removing body fat without any complications. Some plastic surgeons or slimming centers may encourage this line of thinking by being effusively positive and optimistic about the benefits of the procedure.
The ethical and responsible plastic surgeons (and we know several) clearly know the place of liposuction in the management of the obese patient.
They explain the potential complications of liposuction as including infection, embolism and skin complications. They reserve it largely for spot reduction, a cosmetic indication, avoiding the obese patient who needs more than spot reduction of a few pounds of fat.
Additionally, I have always suspected that post-liposuction, the patient (whose lifestyle usually goes unchecked) puts on more fat that accumulates in other body parts, leading to an unsightly obesity. Today, my suspicion stands vindicated.
As the New York Times reports:

…fat came back after it was suctioned out. It took a year, but it all returned. But it did not reappear in the women’s thighs. Instead, Dr. Eckel said, “it was redistributed upstairs,” mostly in the upper abdomen, but also around the shoulders and triceps of the arms.

However, the human mind likes gratification, even if it lasts all of one year (heck, even one minute of a sweet treat is irresistible), and so the study shows that the women still were happy with the results of the liposuction, in spite of more belly fat than before. Irony.

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GASTRIC BYPASS: CHOOSING THE STOMA

ramana — Thu, 21 Apr 2011 00:00:49 +0000

Weight loss after the lap gastric bypass is a well known fact. What is less known is that there is a certain degree of weight regain in some patients in the long term.

Before we proceed, do you know what is a lap gastric bypass all about?

An important factor to be considered by every patient/doctor involved in a gastric bypass is how the stoma for the pouch would be created, as it is one of the known factors leading to weight regain.

The stoma is the opening we create between the gastric micro-pouch and the upper small bowel (jejunum). Too big a stoma will lead to food exiting the pouch quicker and resultant weight regain. Too small a stoma would lead to obstructive symptoms and misery.

So what is the ideal stoma size: 12 mm, 14 mm, 18 mm, or 25 mm? And how would we create this stoma? Does the stoma size stay that way all life at the same size?

Easy, tiger, easy. One thing at a time!

Ideal stoma size:
Different people seem to be using different sizes. A popular way of creating the stoma is with the EEA circular stapler and the OrVil device. The stoma created is either 21mm or 25mm in size.
The stoma is a little big but it is known to contract in size later. The risk of stenosis being highest in the circular stapler group, it is perhaps better to keep stoma size around this level. A smaller stoma may stenose and cause obstructive symptoms. The incidence of stenosis is less than 3 percent.

The hand-sutured technique (my personal favorite) is known to stenose the least in the long term. Here the stoma size is 12 mm/36 Fr. In case you are wondering how we can measure in millimeters in lap surgery, we pass a 36 Fr gastric tube through the mouth into the pouch. The anastomosis between the pouch and the jejunum is fashioned over this tube.
A stoma can be created with the Linear Stapler. This leaves the anterior (front) walls open, and need hand-suturing to complete the process. The stoma also tends to be excessively wide, in my experience. Therefore, at BMI, we don’t favor this method, preferring the hand-sewn and EEA techniques instead.
So the keen patient here would be wondering, “Which is better or best?”
Like most things in life, it depends. Each method of stoma creation has its pros and cons.
The EEA circular stapled method is quick and mechanised, so suturing is not a major issue. The stoma is reliably and safely created, with minimal leak rates. However, it is expensive, needs the surgeon to be familiar with the device, and has the highest stenosis rates. On top of that, technical disasters are not unknown (study in colorectal context).

The hand-sewn method (best demonstrated by Kelvin Higa) is also safe, reliable and avoids mechanical stapler failures and disasters. It needs the highest level of skills in the surgeon, and is more time consuming in most hands. Experts, however, can complete this quickly.

The Linear Stapler method is easy for most surgeons, but has very little to recommend it.

One final issue with the stoma: do we need stoma to be buttressed, or glued? It may by nice to do and for us to see in the operating room, but it probably does not reduce leak rates significantly. In the high-risk patient we may choose to use it. Some studies do report significant benefits in reduction of bleeding, leaks and stenoses.

The bottomline is to ask your surgeon how he would create the stoma, and what he prefers. Then make up your mind to go for it. You have more to gain by that decision: that one thing that will transform your life.

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DOES BOUGIE SIZE IN SLEEVE GASTRECTOMY MATTER?

ramana — Mon, 07 Feb 2011 22:57:50 +0000

When we started out on doing the sleeve gastrectomy a few years back, it was typically over a 60Fr bougie. The important thing, we learnt, was not to leave any part of the fundus of the stomach behind. This was the important technical thing to check. Our old patients have all done well.

Since the last couple of years, however, it has become commonplace to do tight sleeves over bougies 32-36 Fr. The idea is that a tighter sleeve is more restrictive in terms of stomach capacity and would give faster and better weight loss.

This article examines the truth.

Gagner et al had published an article in Obesity Surgery in 2008 showing better safety profile in their own series for patients who had 60 Fr sleeves compared to those who had narrower 40 Fr sleeves. Today, however, we are talking of much tighter sleeves. The question, therefore, could be “Does a sleeve twice as tight as a conventional 60 Fr sleeve give better results?”

Recent studies have shown that tight sleeves have shown good results. In fact, many of us in India have no regrets doing tight sleeves, with equivalent weight loss in the short term and 85-100% resolution of diabetes mellitus.

At BMI, we use around 34 Fr or 38 Fr, but end up with a slightly tighter sleeve because of meticulous oversewing of the staple line.

The most important consideration in designing a tight sleeve is to ensure that there is no narrowing at the level of the incisura (the sag-point of the stomach where the organ turns horizontally towards the right of the patient). A narrowing will cause a leak at the GE junction or lead to persistent vomiting later, necessitating invasive treatment later. All in all, a highly regrettable outcome could ensue, so it is wise to leave a wider incisura than make it too tight.

Some new thoughts are also currently being aired on improving outcomes after the sleeve. Could the gastric tube, detached from its greater curve attachment of gastrocolic (“greater”) omentum, get coiled up later and impair emptying of the organ? Would it be wise to re-anchor the omentum to the stomach tube?

We really don’t know yet. Interesting possibilities abound, but the truth is by no means established.

In recent times, several studies have reported no increase in complications when the staple line is not reinforced with stitches. In fact the last one I read talked of zero leaks in more than 500 cases. At BMI, we have now switched from ”meticulous suturing of the staple-line” above to stitches placed at the junction of adjacent staple lines.

And, so far, we are free from the disaster of leaks (knocks on wood).

So, if we create tighter sleeves with a narrow bougie (between 32 and 36 Fr) would we have a higher rate of strictures? No. In a recent article in a journal, Zundel et al have reported a 0.26 % stricture rate. The cause of stricture may be:

1. A hematoma (blood clot) causing compression

2. Stitch causing narrowing

3. Ischemia due to inadvertent vascular injury to branches of the left gastric artery.

4. Kinking of the gastric sleeve (due to stitches, stapling technical errors, etc). This can occur regardless of sleeve size.

5. Fistula: the associated inflammation causes narrowing.

6. Band removal cases, usually associated with much fibrosis.

7. Mucosal edema and food impaction can also cause acute blockage.

References:

1. Gagner M, Deitel M, Kalberer TL, et al. The Second International Consensus Summit for Sleeve Gastrectomy, March 19-21, 2009. Surg Obes Relat Dis. 2009;5:476–485.

2. Frezza EE, Reddy S, Gee LL, et al. Complications after sleeve gastrectomy for morbid obesity. Obes Surg. 19:684–687.

3. Lalor PF, Tucker ON, Szomstein S, et al. Complications after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2008;4: 33–38.

4. Zundel, et al. Strictures After Sleeve Gastrectomy.

Surg Laparosc Endosc Percutan Tec, Volume 20, Number 3, June 2010

5. DE Bellanger, FL Greenway. Laparoscopic Sleeve Gastrectomy: 529 cases without a leak.

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IS DIABETES CURABLE BY SURGERY?

ramana — Sun, 06 Feb 2011 10:11:13 +0000

Note: This article discusses only Type II Diabetes Mellitus

It has always been a given for generations that ‘once a diabetic, always a diabetic’. Absolutely like the truism for high blood pressure, asthma and hypothyroidism. You know that if you are unlucky enough to get these labels stuck on you, you are going to take pills or injections all your life and suffer the disease as it progresses into making each organ weaker than ever before. No more.

Riya, a plump 50-year-old diabetic who was taking insulin injections for many years, was fed up of her lifestyle and the fact that she was developing complications of diabetes and high blood pressure. Being highly educated, she searched the Internet for newer options. Every website she visited mentioned high cure rates after gastric bypass surgery. She came to us at Belle Vue Clinic, where we did the same surgery on her (keyhole method). Riya’s blood sugar, always in the high 300s, normalized immediately after her surgery. Discharged after a couple of days, she joined back her school in a week, no longer worried about her blood sugar. Her colleagues are now asking her about her secret – how did her weight and blood sugar get under control so quickly?

In 1994, an American doctor called Walter Pories published a scientific paper provocatively titled, “Who would have thought it? An operation is the cure for Type II Diabetes Mellitus!” This paper showed the astonishing results that an operation called gastric bypass led to patients getting cured of diabetes in nearly 90 percent of cases. Blood sugar levels stay normal even several years after the operation.

Since then, this kind of operation, called ‘Metabolic Surgery’ or ‘Bariatric Surgery’ has become a standard across the globe.

What is done in the gastric Bypass?

We staple the stomach to form a very small pouch. When swallowed food comes from the food-pipe into this pouch, it meets a dead end. So we need to create a way for the food to go down. To do this, we take the small intestine up and create a channel between it and the stomach pouch. So, now the food goes into the small gut, bypassing most of the stomach and upper small bowel.

How Does This Work?

This works by reducing the stomach’s capacity to take in food, leading to satiety upon consuming a small portion of around an ounce of fluid. There is reduced spike in blood glucose after food (less volume + less absorption= low nutrient absorption).

The net effect of this operation is that undigested food reaches the small bowel, leading to the release of some hormones called incretins. These incretins (a group of around 200 chemicals) act to bring down the blood sugar levels and also halt the deterioration of pancreatic hormonal function that is the hallmark of Type II Diabetes Mellitus.

It is now clear that the alarming rise in cases of diabetes is linked to the widespread obesity in towns and cities. Indeed, 80 percent of new diabetics are fat to varying degrees. So far, doctors have been advising diabetics to lose weight by diet control and exercise, and to take medicines for diabetes. To a large extent, this is a hit-and-miss method of treatment, as there is no sure and predictable response in patients, largely because everyone differs in how strictly they follow their dietary discipline. Most people cheat on their diet, don’t exercise beyond the irregular morning walks and keep getting new complications of diabetes every year.

Most of these patients who undergo the gastric bypass procedure are also very obese. Says Dr. Arindam Ghosh, a bariatric surgeon based in Ludhiana’s Apollo Hospital, “Many of my diabetic patients are obese Punjabis weighing up to 200 kgs. Some of them live in the US and Canada, where the obesity levels are far greater than in India.”

Even though increasing numbers of our patients are searching the Internet daily for information, awareness levels are still abysmal. Patients think surgery involves physical removal of fat from their body. The younger generation is taking the lead. Yogesh Sharma, a 19 year old student who weighed 168 kgs, came to me for surgery to reduce his weight and cure his diabetes after convincing his parents that his decision was the correct one. To their credit, the Sharmas saw merit in the scientific approach. Most people are, however, very scared of the very word ‘surgery’ and would rather see their lives slowly but surely getting spoiled by disease.

Many people like Ruchita Doshi, a 57-year-old lady who has undergone spine surgery, regret their decision, “I wish I had undergone bariatric surgery before. My obesity led to arthritis and spine disease for which I needed to spend rupees three lakhs on treatment. Now they say I cannot be operated as I am undergoing dialysis because of diabetic nephropathy (end stage kidney disease).” Ruchita shares the opinion of many doctors that surgery for diabetes cure would have offset the costs of the complications of the primary disease. What are you doing about your obesity and diabetes?

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ALCOHOL CAUSES OBESITY – LET’S ANALYSE

sarfaraz — Wed, 03 Nov 2010 16:16:26 +0000

Alcohol has been in the center of research in the past few decades for a lot of reasons. While nobody with a sane mind questions the vices of smoking, sensible drinkers have hotly contested the alcohol debate.
We know that alcohol is very high in calories, and it also can affect the way the body metabolizes energy. The body reacts by storing it as fat rather than using it as fuel 1. However, the relationship of alcohol and obesity is far more complex than perceived earlier.
It is no longer assumed that alcohol consumed in moderate quantities and evenly spaced out can cause obesity. On the contrary, researchers believe that it may have beneficial effects on health as far as obesity is concerned 2.
This is what Dr R A Breslow, Ph D had to say after conducting a national survey in USA, “In our study, men and women who drank the smallest quantity of alcohol – one drink per drinking day – with the greatest frequency – three to seven days per week – had the lowest BMI’s while those who infrequently consumed the greatest quantity had the highest BMIs”. 3
So, more than one drink a day, and certainly binge drinking, is likely to increase your weight, while lesser amounts evenly spread won’t.
What however can determine and confound the effects of alcohol consumption on weight gain is the environment in which one is drinking. Eating high calorie snacks, little activity and smoking often go together with a drinking session, which compounds the problem as each on their own have been linked to weight increase.
A paper by Arif et al from Texas, USA published in 2005 shed some more light on the alcohol debate. It stressed that the beneficial effect of drinking disappears beyond consuming two drinks a day and may actually result in weight gain with heavy drinking 4.
Hence the bottom line about the effects of alcohol on obesity may be summed up as follows. On the basis of recent research data available we may safely conclude that alcohol in moderate consumption may be safe (lets not rush to call it healthy and advocate it as a routine measure to prevent obesity) whereas consumption in large quantities and especially when associated with high calorie snacks may be highly detrimental.

1. Zurlo F, Lillioja S, Esposito-Del Puente A, Nyomba BL, Raz I, Saad MF, Swinburn BA, Knowler WC, Bogardus C, Ravussin E. Low ratio of fat to carbohydrate oxidation as predictor of weight gain: study of 24-h RQ. Am J Physiol. 1990; 259:E650–657.
2. Jequier E. Alcohol intake and body weight: a paradox. Am J Clin Nutr. 1999;69:173–174.
3. Breslow RA, Smothers BA. Drinking patterns and body mass index in never smokers: National Health Interview Survey, 1997–2001. Am J Epidemiol. 2005;161:368–376.
4. Ahmed A Arif and James E Rohrer. Patterns of alcohol drinking and its association with obesity: data from the third national health and nutrition examination survey, 1988–1994. BMC Public Health. 2005; 5: 126.

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THE OBESITY PILL-A MYTH?

ramana — Wed, 27 Oct 2010 13:59:41 +0000

I, like many others, have long believed that science will, one day, announce the discovery of a pill that will end obesity. One pill, and pow! no more cravings, and fat will melt off your muscles like wax from a lit candle.

(pic: bmj.com)

Many companies have clearly shared that fantasy or vision. Billions of dollars are at stake to be the one to discover the ultimate pill. The Ultimate Pill™ will have the following characteristics:

1. Help burn fat

2. Allow you to eat normally without putting on fat

3. Have no side effects

4. Be cheap and easily available

5. Reverse obesity-related changes (this is perhaps taking things too far)

Obviously, we are nearly talking science fiction here.

The various drugs that have been used in the past are now mere footnotes in the history of obesity medicine. Heard of fenfluramine? A few years back, rimonabant was said to be the wonder drug, working through some mysterious cannabinoid receptors in the brain (how exotic it sounds!). That fell through, because people were getting depressed enough to commit suicide.

Sibutramine and Orlistat have been heavily prescribed by physicians around the world to effect weight loss short of bariatric surgery. Sibutramine causes appetite suppression, while orlistat affects fat absorption and allows unhealthy eating without the fear of weight gain. So they said.

We have said it before that orlistat can cause liver problems, and is a candidate for withdrawal. Now the world is told that sibutramine has been withdrawn in the US, Canada and Europe because of heart attacks (the SCOUT study).

The BMJ says:

The therapeutic cupboard containing antiobesity drugs has never been well stocked. The European Medicines Agency (EMA) recently decided that sibutramine must follow the example of rimonabant, withdrawn last year because of safety concerns. This leaves just one drug—orlistat—to face the rising tide of obesity across the continent. The demise of sibutramine carries both irony and wider messages for the management of obesity.

Sibutramine fell at the crucial hurdle of cardiovascular risk. Arterial disease—which leads ultimately to myocardial ischaemia, heart failure, and stroke—affects most obese people to some degree and is their major cause of death. Much evidence suggests that weight loss decreases morbidity and mortality associated with cardiovascular disease,3 and this is an important justification for all antiobesity measures, including drugs. Unfortunately for sibutramine, an interim analysis of the SCOUT (Sibutramine Cardiovascular Outcome Trial) study found that the drug increased morbidity from cardiovascular disease. The odds were always stacked against sibutramine, because cardiovascular risk is embedded in its mechanism of action. Sibutramine acts centrally to reduce food intake; it inhibits the presynaptic reuptake and degradation of serotonin and noradrenaline, thus enhancing the appetite suppressing actions of both neurotransmitters.

Why drugs have not yet worked for weight loss in obese patients may be due to the fact that obesity is a heterogeneous disease with multiple factors, whereas the drug tends to be focal in its mechanism of action.

So, sadly, another drug has failed. The role of bariatric surgery is as crucial as ever. It is now the only scientifically proven method of weight loss. What is more, it is safe and effective. As study after study keeps showing us. But will the naysayers hear the truth?

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DEPRESSION AND SUICIDES AFTER BARIATRIC SURGERY- FACT OR MYTH ?

sarfaraz — Sun, 01 Aug 2010 07:41:10 +0000

In the last decade there has been a spurt in the number of cases of bariatric surgery. While a lot is said about the huge benefits of such procedures, the critics have also been pointing out the disadvantages of the procedure.

One such area of concern has been the depression and even suicidal tendencies seen in some cases after bariatric surgery. There are various case reports of depression and suicides after bariatric surgery in the literature ^1-4.

Recently a paper published in a reputed journal made an attempt to analyse this rather alarming problem ⁵. After critically analyzing these papers it was suggested that some papers suffered from methodologic problems such as small sample size, failure to use validated assessments of psychopathology and absence of appropriate comparison groups (for example , how many candidates were already depressed and having suicidal ideation before bariatric surgery).

One study found out that many of the patients undergoing bariatric surgery already have psychiatric disorders in the form of anxiety , mood , and personality disorder ⁶. In another study the extremely obese subjects were found to experience increased suicidal ideation than their normal weight counterparts ⁷. This may be partly responsible for the increased negative psychosocial effects seen in patients after bariatric surgery.

On the other hand, there are many papers that suggest that Bariatric surgery is associated with significant improvements in psychosocial status. Most psychosocial characteristics, including symptoms of depression and anxiety, health-related quality of life, self-esteem, and body image, improve dramatically in the first postoperative year.^8-13

Unfortunately, a minority of patients appears to struggle with numerous psychological issues postoperatively. Although the evidence submitted in the literature to prove the adverse psychosocial outcome arising as a direct result of bariatric surgery is far from convincing due to the reasons stated above, it is probably a good policy to involve a mental health professional in all cases before performing such surgery.

References:

1. Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients–what have we learned? Obes Surg. 2000;10(6):509-513.

2. Hsu LK, Benotti PN, Dwyer J, et al. Nonsurgical factors that influence the outcome of bariatric surgery: a review. Psychosom Med. 1998;60(3):338-346.

3. Waters GS, Pories WJ, Swanson MS, Meelheim HD, Flickinger EG, May HJ. Long-term studies of mental health after the Greenville gastric bypass operation for morbid obesity. Am J Surg. 1991;161(1):154-157.

4. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357(8):753-761.

5. David B. Sarwer, Anthony N. Fabricatore, P et al. Primary Psychiatry. 2008;15(8):50-55

6. Kalarchian MA, Marcus MD, Levine MD, et al. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2)328-334.

7. Dong C, Li WD, Li D, Price RA. Extreme obesity is associated with attempted suicides: results from a family study. Int J Obes (Lond). 2006;30(2):388-390.

8. Bocchieri LE, Meana M, Fisher BL. A review of psychosocial outcomes of surgery for morbid obesity. J Psychosom Res. 2002;52(3):155-165.

9. Herpertz S, Kielmann R, Wolf AM, Langkafel M, Senf W, Hebebrand J. Does obesity surgery improve psychosocial functioning? A systematic review. Int J Obes Relat Metab Disord. 2003;27(11):1300-1314.

10. van Hout GC, van Oudheusden I, van Heck GL. Psychological profile of the morbidly obese. Obes Surg. 2004;14(5):579-588.

11. Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-648.

12. Herpertz S, Kielmann R, Wolfe AM, Hebebrand J, Senf W. Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obes Res. 2004;12(10):1554-1569.

13. van Hout GC, Boekestein P, Fortuin FA, Pelle AJ, van Heck GL. Psychosocial functioning following bariatric surgery. Obes Surg. 2006;16(6):787-794.

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GASTRIC PLICATION: A NEW WLS PROCEDURE!

ramana — Sun, 18 Jul 2010 04:22:12 +0000

Many bariatric surgeons are excited about the procedure Gastric Plication (LGP) as a bariatric procedure. It promises to be a simple method (remember, “Less Is More!”) that gives weight loss results as good as sleeve gastrectomy without even the risks of that procedure (staple line leaks (read part one and part two here) or bleeding).

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!

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A NEW PAGE STARTS!

ramana — Wed, 07 Jul 2010 10:23:53 +0000

(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!

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WEIGHT LOSS PLATEAU AFTER SLEEVE GASTRECTOMY: WHAT NOW?

ramana — Wed, 30 Jun 2010 16:09:41 +0000

Weight loss plateaus may occur in certain patients who have undergone a sleeve gastrectomy as a primary bariatric procedure. What are the causes? What is the next step?
What is the prognosis for these patients?

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.

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