by Conor Magee MD FRCS.
Specialist Registrar in Oesophago-Gastric Surgery, Phoenix-Health Bariatric Fellow
These short articles will briefly describe the three commonest procedures that surgeons in the United Kingdom use in the treatment of morbid obesity. I hope the article is pitched at a level such that new readers of wlsinfo find it informative without being too complex, and that older hands at wlsinfo may find new nuggets of information that will be helpful.
It is clear from my own readership of the wlsinfo site that there are a lot of very informed members out there, particularly those who have undergone weight-loss surgery. There is a natural tendency for those who have undergone one form of surgery to "champion" it to newcomers to the board; the "bandsters" and "switchers" come to mind. This is encouraging for bariatric surgeons because we know that bariatric surgery is the only effective treatment for morbid obesity.
However, as a bariatric surgeon, I am aware that all operations have both benefits and shortcomings. There is no single operation that is best for all patients. All patients are individuals and it is through expert assessment by experienced bariatric teams that the best operation can be chosen and performed to allow safe, effective weight-loss to take place.
The information contained is a result of my own experiences as a surgeon and research I have carried out. I am grateful to David Kerrigan for his training and insights in this article and to Ken Clare who suggested I write a series of articles.
At the risk of boring those who find this kind of stuff of little relevance, I have hyperlinked a number of recent scientific articles that may be of interest to some readers. The abstracts are freely available but a journal subscription may be required to access the full text.
Any errors are, of course, mine and mine alone.
The Obesity Problem
Obesity is a progressive, debilitating illness that shortens life and is associated with a number of serious medical problems in particular diabetes. Around one fifth of adults in the United Kingdom are thought to be obese, and numbers are increasing.
For most people the gain of a few pounds can be managed by an increase in exercise and mild dietary changes. For people whose weight gain is more significant- a few stones or more- stringent diets and exercise can be beneficial. There are also a number of drugs that can aid weight loss and evidence shows that for groups of people who are self-motivated with regard to exercise and diet and who can tolerate the side-effects of drugs, weight loss can take place. Generally, these measures result in a 10% fall in body weight. If you weigh 15 stone you could lose 1.5 stone, or sometimes more. However, if you weigh 30 stone then a 3 stone loss in weight will still leave you at 27 stone. Still dangerously overweight and at risk of future medical problems.
Weight loss or bariatric surgery is the only proven way of achieving significant, long-lasting weight loss. Losing weight is the most effective way to treat medical problems caused by obesity. Although by no means perfect and not for every one, bariatric surgery works.
We determine the success of bariatric surgery by looking at the amount of excess weight lost at two years. The excess weight a person carries is the amount of weight they carry in addition to their ideal weight. For example if I weigh 150kg and my ideal weight is 100kg, then the excess weight is 50kg. Now, if I lose weight and now weigh, 110kg I will have lost 40kg. Therefore the percentage of excess weight lost is 40 divided by 50 multiplied by 100- 40/80 times 100= 80%.
Two important trials have shown the clear benefits of bariatric surgery compared to tablets and diet treatment. An Australian trial showed gastric banding patients lost 68% of their excess weight at two years compared to only 18% for the non-surgical patients. A Swedish study showed that after ten years gastric bypass surgery patients maintained an average 25% loss of starting weight, whereas the medically treated patients gained weight!
The benefits of bariatric surgery have been recognised by the United Kingdom government as the best way to treat morbid obesity.
Surgery for Morbid Obesity
At present there are three operations for morbid obesity. They are the Laparoscopic Adjustable Gastric Band-(LAGB), the Roux-en-Y Gastric Bypass and the Duodenal Switch. It is interesting to note that the media still refer to "stomach stapling" procedures for obesity when the gastric band has no stapling at all! The gastric band is the commonest procedure performed in the United Kingdom, the gastric bypass is performed in much fewer numbers and the duodenal switch is only performed in a handful of centres.
Risks and Benefits of Surgery
When discussing an operation it is the natural tendency of the surgeon to particularly concentrate on its risks and complications. This is not because of our melancholic nature, but because we know that to achieve the benefits we have to inflict trauma on the patient. The anaesthetic profession refer to surgery as "controlled trauma" with good reason. Any textbook of operative surgery will have a short section on the advantages and benefits of a procedure followed by a much longer section discussing risks, disadvantages and complications. Please do not infer that because I concentrate on the negative side of a particular operation that this means I would not offer or support the use of it! I believe that all the operations discussed here can be excellent options in achieving weight loss, but I also believe the best outcomes depend on using the operation best suited to the individual patient.