Gastric Surgery for Severe Obesity

Definition

Obesity is a medical term meaning the storage of excess fat (adipose tissue) in the body.

Description

Often referred to as a "disease," obesity is actually a sign of what may well be a spectrum of different kinds of disorders - genetic or environmental. In fact, there is no single definition of obesity. It may be simply an extreme degree of overweight, but a person can be overweight without being obese: a 250-pound six-foot linebacker, for example, may be overweight according to ordinary standards, but may actually have a below-average amount of body fat. In contrast, a person in a normal weight range but with very sedentary habits could have a small muscle mass and be storing excess fat and thus be classifiable as obese.

About one-third of all Americans are above their ideal weights as determined by standard tables, and for the majority of them, the excess weight is in the form of body fat, not muscle mass. Of this group, about half exceed their ideal weight by 20 percent or more and hence are classified as obese.

Successful programs for weight loss reduction and maintenance should be started and continue under the care of a physician. The program may include:

• A low-fat, high-complex carbohydrate, high fiber diet

• Behavior modification to change eating behavior

• Exercise

• Social support

• Medications, both over-the-counter and by prescription

Clinically severe obesity is a condition in which people are at very high risk of suffering from medical problems or even death. Consensus recommendations are to limit surgical therapies to patients with a Body Mass Index (BMI) greater than 40.

BMI is calculated by dividing the measured body weight in kilograms by the height in meters squared. The normal BMI is 20 to 25 kilograms per meters squared.

Procedure

Surgical treatment is reserved only for severely obese people who fail to respond to medically supervised treatment.

Prior to surgery the patient will be evaluated by the surgical team, a clinical dietitian and the behavioral science team, each of whom must individually agree that the patient is a good candidate for surgery. A series of preoperative blood tests and x-rays are performed following the initial evaluations.

One purpose of the evaluation is to rule out glandular and psychiatric disorders as the major causes of the severe obesity. If the person has active peptic ulcer disease or advanced heart, lung or kidney disease, surgery may not be performed. It is important to ensure that the person has an understanding of the risks of the surgery and the drastic lifestyle changes required as a result of the surgery.

Types Of Gastric Surgery

Gastric (stomach) operations are the procedures of choice. Currently there are at least two types of gastric surgeries, gastric (stomach) restrictive and gastrointestinal bypass.

Gastric Restrictive Treatment. Restrictive operations, such as gastric banding and vertical-banded (Mason) gastroplasty limit the amount of food the stomach can hold by closing off or removing parts of the stomach. Food intake is restricted by creating a small pouch at the top of the stomach where the food enters from the esophagus. The pouch can hold about 1 ounce of food.

In gastric banding a band is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach.

In vertical-banded (Mason) gastroplasty a band and four rows of staples are used to create a small pouch and a narrow passage into the larger remainder of the stomach.

Gastrointestinal bypass. In the gastric bypass procedure (Roux-en-Y), the stomach is reduced in size by applying four rows of stainless steel staples across the top of the stomach. An opening is made in the upper pouch of the stomach, and a portion of the small intestine is attached to this opening.

In the gastric bypass procedure called "biliopancreatic diversion" portions of the stomach are removed. The small pouch that remains is connected directly to the final segment of the small intestine. Some surgeons are now performing laparoscopic gastric bypass procedures.

Benefits

Immediately after surgery most people lose weight rapidly and continue to do so for 18 to 24 months after surgery.

Additionally, most obesity-related medical problems such as high blood pressure and diabetes show improvement.

Risks

Risks specifically related to gastric reduction operations can be divided into early and late complications.

The most serious early complication is death, which occurs in about 1 patient per 100. This is usually due to a heart attack or sudden irregularity in the heart rhythm, or a blood clot to the lungs. Other technical complications include leakage through the staples, injury to the spleen, bleeding, infection, heart and/or lung problems, or intestinal blockage.

The later risks may include nutritional deficiencies, anemia, gallstones, ulcers, pouch stretching, band erosion, breakdown of staple lines and leakage of stomach contents into the abdomen. Additionally, gastric bypass may also cause "dumping syndrome," whereby stomach contents move too rapidly through the small intestine. Symptoms of dumping syndrome include nausea, weakness, sweating, faintness, and occasionally, diarrhea after eating.

Patients will often test their new stomach by experimenting with excessive eating; this may be prevented by a careful postoperative diet regimen. Excessive eating following gastroplasty leads to bloating of the pouch and nausea and vomiting. If the wrong foods are eaten, the pouch can become blocked and produce the same symptoms as dumping syndrome.

Obesity treatment does not end with the completion of the surgery.

Postoperative Period

The patient will be in the hospital for about a week. The first few days are quite uncomfortable but people generally recover quickly and are walking within 2 to 3 days.

The patient will be on a liquid diet for 2 to 3 weeks, followed by pureed foods for another 3 to 4 weeks. The patient should not drive for at least two weeks or perform strenuous activity for at least six weeks.

Depending on their job the patient could return to work as early as three weeks after surgery or six to eight weeks if their job is physically demanding. The total recovery period may be up to 2 months.

Long-Term Expectations

Gastric surgery is not a magical solution to obesity. It is not intended to replace the basic sound principles of healthy eating habits and regular exercise.

Participation in a behavior modification program is vital to the long-term maintenance of weight loss.

Counseling by a dietitian helps emphasize the importance of appropriate food choices and portions. Dietitians help the person maintain a balanced diet and avoid high calorie liquids and soft foods which could defeat the purpose of the operation.

After the first few months, the rate of weight loss will decrease and some patients then start to regain some of their lost weight. Very few patients will reach their ideal body weight. Patients who come within 50 percent of their ideal body weight are considered successes.

The most common reason for weight gain is poor food selection and snacking.

If patients do not follow the dietitian's proposed diet plan, and continue with their past eating habits, they will gain weight once again.

Questions to Ask Your Doctor

Am I considered overweight, obese or severely obese?

What is my ideal body weight?

Is the obesity caused by other medical problems? What are they?

Do you recommend surgery to help reduce weight?

What type of surgical procedure do you recommend?

What are the risks and complications?

What is the long-term prognosis?