6 minute read
Jason Free
Weight-loss and Well-being
WITH THE INCREASING POPULARITY OF BARIATRIC SURGERY WORLDWIDE, THERE HAS BEEN A SUBSEQUENT INCREASE IN THE NUMBER OF PEOPLE DEVELOPING PROBLEMS FOLLOWING SURGERY, OR PEOPLE NOT LOSING AS MUCH WEIGHT AS INITIALLY HOPED FOR. AS A RESULT, BARIATRIC SURGEONS ARE PERFORMING INCREASING PROPORTIONS OF REVISIONAL PROCEDURES. DESPITE THE MASSIVE POSITIVE IMPACTS BARIATRIC SURGERY HAS ON BOTH THE PHYSICAL AND MENTAL HEALTH OF PEOPLE, THERE ARE CERTAIN DRAWBACKS WITH EVERY TYPE OF WEIGHT-LOSS PROCEDURE. SOME OF THESE ISSUES ARE MILD AND MANAGEABLE, HOWEVER THE QUALITY OF LIFE OF MANY PEOPLE IS AFFECTED TO THE DEGREE WHERE THEY REQUIRE RE-OPERATIONS TO IMPROVE THEIR WELL-BEING: REVISIONAL BARIATRIC SURGERY
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Gastric Bands
Australia more than other parts of the world has seen gastric bands become the predominant bariatric procedure performed over the previous decade. Over 100,000 people in Australia have received a gastric band since 1994. Many people with gastric bands have either had a great deal of success followed by complicated band issues, or have never really succeeded to losing as much weight as they initially hoped for. Sometimes the distortion of the gastro-oesophageal anatomy can produce symptoms that manifest themselves many years later. The common problems seen are band slippage, pouch or oesophageal dilatation, and excessive scar formation beneath the band. These problems lead to symptoms of severe reflux and vomiting/regurgitation after meals. The options available to patients in this setting include removal of the band, attempt at repositioning the band to a more functional position, or removing the band and converting to another weight-loss procedure. Band removal and conversion to another bariatric procedure is becoming increasingly common.
The most common option is conversion to a gastric bypass. Band removal and conversion to a gastric bypass can be performed safely in the same procedure in many cases, saving the patient an additional general anaesthetic and operation. Sometimes the scarring or distorted anatomy as a result of the band necessitates removal of the band and a delay of about 3 months before a later conversion to a bypass. Conversion from a band to a sleeve gastrectomy is also possible however surgeons who do this generally delay the sleeve gastrectomy several months due to the higher risk of a combined procedure. The risk of a sleeve gastrectomy leak of the staple line is dramatically increased in this setting, and can be an extremely difficult problem to deal with, potentially leading to a prolonged hospital stay. Gastric bypass is generally accepted to be the most effective option to induce further weight-loss after a failed gastric band. Evidence demonstrates better long term weight-loss, improved food tolerance, and a better quality of life with gastric bypass relative to sleeve gastrectomy following removal of a band. The consensus among international consensus meetings is that a conversion of a band to a bypass is the preferred operation.
Sleeve Gastrectomy Insufficient weight-loss, or late weight regain following Sleeve Gastrectomy
Revision of Gastric Bypass or SADI procedure
Sleeve gastrectomy has become the predominant bariatric procedure in Australia since 2010. Its popularity has arisen due to its fewer long term side effects relative to the gastric band, however it too does have issues which potentiate reoperations. Some patients can develop symptoms months or years after a sleeve gastrectomy, most commonly acid reflux at the gastro-oesophageal junction. This occurs in about 25 percent of patients after a sleeve gastrectomy, and mostly is mild and easily managed. This reflux can be incapacitating and can severely affect the quality of life of some patients. The reflux in this scenario relates to the high intraluminal pressure of the sleeve, compared to the highly compliant stomach that has been removed. This is a different mechanism to the weakened gastro-oesophageal sphincter seen in non-sleeve patients and therefore merely attempting to repair a hiatal weakness at the diaphragm is not reliably helpful. Some patients may develop a late stricture of the sleeve. This is usually amenable to dilatation, however sometimes patients require multiple dilatations, and often require temporary stenting. Often a sleeve can twist or become torted causing problems with eating habits. In these cases contrast swallow imaging will demonstrate the problem. Often simply forming a gastropexy to the remaining omentum to fix the sleeve in a satisfactory position will help. Occasional patients may develop “functional failure”. This term describes people experiencing dysphagia, or lack of emptying of the sleeve. Nuclear medicine studies may demonstrate extremely slow emptying, despite an anatomically normal sleeve. Even though a sleeve gastrectomy is irreversible, patients with symptoms relating to these problems still can be helped. Consensus among bariatric surgeons is that many patients with sleeve related problems do extremely well with a conversion to a Roux-en-Y gastric bypass. This involves dividing the top portion of the sleeve and attaching a small bowel limb to it, thus providing a low pressure outlet for the gastric acid. A conversion to a gastric bypass is likely to cure the reflux in the vast majority of patients. As longer term data becomes evident, we are now beginning to see many patients developing late weight regain following a sleeve gastrectomy. This can occur in up to 40-50 percent of patients, especially those with a BMI over 45. Often patients will not lose as much weight as they initially hoped for, or may have good weight-loss initially and then regain weight years later. Emerging evidence is revealing Sleeve Gastrectomy is not providing sustained long term weight loss in patients with a very high BMI. Options in this case would be to attempt “re-sleeve” which is potentially dangerous and would lead to similar problem at a later date. More often is conversion of the Sleeve Gastrectomy to a Gastric Bypass or SADI procedure. Conversion to gastric bypass has traditionally been the accepted operation following a “failed” sleeve gastrectomy. Again recent data suggests patients undergoing conversion to gastric bypass are still not doing as well as initially hoped for in terms of weight-loss. The Single Anastomosis Duodeno-Ileostomy (SADI) procedure has emerged as a procedure providing the greatest weight-loss of all the commonly performed weight loss procedures. It has the longest lasting effects, with less late weight regain and no increase in side effects relative to the gastric bypass. It can be performed following a sleeve gastrectomy for insufficient weight-loss, or as a primary bariatric procedure for very obese patients. The SADI procedure is now being performed at many specialist weight-loss centres throughout the world and is becoming the preferred option for failed sleeve gastrectomy.
Occasionally a patient who has had one of these operations my still have issues or weigh regain as described above. After a gastric bypass some patients still can have dilation of the gastric pouch -which has been created.
We generally perform CT fizzogram scans which provide 3-dimensional models of the stomach and we can do volumetric analysis of the bypass or sleeve to assess for any dilation. Following a gastric bypass, it is still possible to perform revisional “pouch reduction” type surgery and restrictive procedures in many of these patients. Even following a SADI procedure if a patient has reflux or insufficient weightloss there are always options to assist in further weight-loss. Many patients may have been left feeling not fully satisfied following their primary procedure, whether due to lack of weight-loss or problematic symptoms. There are solutions to almost every problem. Patients who feel like they have to live with disturbing symptoms affecting the quality of life should be reassured that we can do things to improve their well-being.
DR JASON FREE SPECIALIST BARIATRIC SURGEON MBBS BVSc (HONS) FRACS
