BARIATRIC SURGERY OPTIONS:

Bariatric Surgery Comparison Table

It is commonly accepted by many health professionals, and the wider public, that a person wanting to lose weight can do so simply by restricting their dietary intake – energy in – and adhere to a well-planned exercise regime – energy out.  So why is obesity still one of the most significant health issues facing Australians today? Clearly, the weight loss struggle is more complicated than balancing energy, otherwise we would not have the global obesity epidemic on our hands.  Research has highlighted two factors that point towards the reduced efficacy of diet and exercise in the treatment of obesity.  First is the body’s natural resistance to weight loss, and second is the body’s tendency to regain any weight that is lost.  This article explores these concepts further and discusses a proven solution in bariatric surgery, comparing the different kinds of surgery for weight loss.

Stored fat is a feat of evolution but it now poses a health risk

Without the capacity to store energy, we would not have survived periods of famine throughout millions of years of evolution.  So previously, our body’s ability to store fat was a very positive adaptation to the harsh environment we found ourselves living in.  Now that most people are no longer living through periods of famine, our relationship with fat has changed.  While some fat is an essential requirement of a healthy diet, accumulating excessive amounts of body fat has a detrimental effect on our health by increasing the risk of chronic diseases, such as diabetes, heart disease, cancer and stroke.  Unfortunately, most people in the developed and developing world are storing too much energy as fat, and are considered overweight or obese.

The Set Point Theory

You may notice when you reduce your calorie intake, that you experience an increase in feelings of cravings and hunger.  You might also find that your metabolic rate is reduced and be less satiated by what you do eat.  This happens because the body sees a reduction in calorie intake as a threat to its survival, and it’s working hard to prevent any considerable weight loss from occurring.  This mechanism has been described as the set point theory.  The theory states that the body will work to maintain its weight and body fat level with an internal metabolic thermostat, even if a person’s weight is too high.  So no matter how hard some people might try, they just can’t seem to keep weight off, even after sticking to a well-planned diet and exercise regime.  Furthermore, when a person is successful in losing weight, their body will typically try to return to the previous set point, encouraging excess weight to be regained, as if the body has a memory of its previous and highest set point.  This can cause the person to get stuck in a vicious cycle, known as weight cycling or yo-yo dieting.

Bariatric Surgery: a proven solution

Bariatric surgery, or the surgical treatment of obesity, is a proven solution which treats obesity by shifting the body’s metabolic thermostat or set point.  Bariatric surgery encompasses a number of procedures, designed to help obese people lose weight.  It achieves this by reducing the size of a patient’s stomach, which gives a sensation of satiety before the patient has consumed an excessive amount of food.  There are currently several different bariatric surgical procedures available.  The table below (Table 1) outlines four of the most common procedures carried out in Australia, including the gastric balloon, gastric band, gastric sleeve and gastric bypass.

The gastric balloon is a medical procedure specifically designed for long-term, sustainable weight loss through a combination of a non-surgical procedure and forming healthy lifestyle habits.  The balloon is placed temporarily, usually for around six months, and encourages portion control and prevents over-eating.  Gastric banding is a weight-loss surgical procedure utilising an adjustable band placed around the top portion of the stomach that works by inducing a feeling of fullness by triggering signals to be sent to the brain.  The sleeve gastrectomy, or gastric sleeve, involves the removal of a portion of the stomach, leaving the stomach volume at 15% of its original size.  The gastric bypass involves re-routing of the small intestine to a stomach pouch, much smaller than the original stomach.

 

Table 1 A Comparison Table of Bariatric Surgeries

	Gastric Banding	Gastric Sleeve	Gastric Bypass	Gastric Balloon
Technique	Laparoscopic (keyhole) procedure which does not require any cutting or stapling of the stomach	Laparoscopic (keyhole) procedure where part of the stomach is divided and removed	Laparoscopic (keyhole) procedure which involves dividing the stomach and rerouting it to the small intestine	Non-surgical procedure involving insertion of gastric balloon into stomach whilst deflated, through an endoscopic procedure, for which you will be slightly sedated. The balloon is then filled with a saline solution. After 6 months, the balloon is removed under the same conditions
Reversibility	Reversible	Irreversible	Potentially reversible (very difficult)	Reversible
Operating Time	60 Minutes	60 – 90 Minutes	90 – 120 Minutes	20 Minutes
Advantages	The normal process of digestion is not altered Lowest risk of potentially serious operative complications Can be easily removed Significant improvement or resolution of diabetes	Avoids a foreign object around the stomach Least after care requirements Reasonable eating quality Significant improvement or resolution of diabetes	One of the best long term options for weight loss Greatest improvement or resolution of diabetes	Non-surgical procedure Will be removed after 6 months Appetite suppression and portion control
Risks/ Complications	Blood clots Band or port infection Band slippage or pouch enlargement Erosion of the band into the stomach Acid reflux Food intolerance 5-10% chance of needing corrective surgery	Bleeding or blood clots Leakage from the staple line Acid reflux 20% risk of Barrett’s Oesophagus 20-30% revision rate	Normal digestive process is altered Bleeding or blood clots Anastomotic leakage from the surgical anastomosis Vitamin deficiencies (some are irreversible) Abdominal wall and internal herniae Ulcer and dumping syndrome 20-30% revision rate	Oesophageal reflux Oesophageal or gastric ulcers or perforation
Average Hospital Stay	1 night	3-4 nights	4-7 nights	Day procedure
Average Time Off Work	1 week	1-2 weeks	1-2 weeks	A few days, or can be up to 2 weeks
Eating Quality	Food can get stuck if not properly chewed, bread and steak are not well tolerated	Good, most food types are well tolerated	Good, although some foods can cause dumping syndrome	Good, most food types are well tolerated
Follow Up	Regular follow up every month is needed to correctly adjust the band in the first 18 months Once the goal weight is reached, follow up once every 3-6 months is recommended long term	Regular follow up is recommended every 3 months for the first year, or until the goal weight is reached Once the goal weight is reached, a yearly follow up is recommended to check on the progress	Regular follow up is recommended every 3 months for the first year, or until the goal weight is reached Once the goal weight is reached, follow up every 3 or 6 months to check the progress and vitamin levels	Regular follow up is recommended
Excess Weight Loss	50-70%	60-70%	60-80%	An average weight loss of 10-15kg over 6 months. After 12 months, patients have lost over 3 times the weight of diet and exercise alone

Choosing the right operation for your circumstances so you achieve the weight loss results you desire, is a decision which needs to be made based on what you wish to achieve and the associated risks involved.  This decision requires careful consideration and it is important to note that these procedures are designed to help you lose weight, but they are not cures for obesity.  Bariatric surgery, in combination with lifestyle changes and the support of your health team is what will help you succeed in your weight loss journey.

By LANE EDWARDS, APD