Selecting the proper bariatric procedure is key for all prospective surgical candidates. The final choice is and will remain the patient's choice. However, your surgeon should guide you through this decision making process. Some bariatric procedures perform better than others [long term weight loss] while demonstrating significant long term side effects. Others may have a lower performance profile but will demonstrate negligible long term side effects. All patients should evaluate the expected long term weight loss versus the potential for long term side effects.

 

The concept a bariatric surgical procedure should take care of all the patient's weight problems and issues is erroneous and misleading. This office cautions all patients to understand a bariatric procedure is a surgical tool given to patients to help them manage their weight. All potential bariatric patients must realize that post bariatric surgery long term success requires their active, life long participation with a mandatory change of life style, eating habits and exercise routine.

 

Therefore, prior to selecting a bariatric procedure, all patients must commit themselves to the following.

 

1. Change of Life Style: All patients must eliminate social problems and situations promoting overeating and dedicate essential time to change their eating habits and exercise routine. A bariatric patient who claims he or she has or will not have the time to eat or exercise properly and sufficiently is not a surgical candidate. For this reason, some patients may require psycho-social counseling to achieve these life style changes.

 

2. Change of Eating Habits: All patients must change their eating habits and adopt a three meals per day, no snacking-grazing schedule. Proper eating habits include essential recognition of "satiety", essential nutritional education and meal time eating routine.

 

3. Change of Exercise Routine: All morbidly obese patients undergoing a bariatric procedure must commit to change their exercise routine when feasible and start a minimum of five time per week exercise / session of one hour.

As soon as patients understand and adopt these future commitments, they can select the most appropriate bariatric procedure for them.

 

Selecting a Bariatric Procedure

 

This office follows simple guidelines when helping patients select a bariatric procedure.

 

First, we differentiate morbidly obese patients and super-obese patients [i.e. patients 450p and over or with excessive BMI].

 

For the morbidly obese patient population, the best overall performing bariatric procedure remains thelaparoscopic gastric bypass with the Roux Y Limb [LGBRY]. It offers the most significant weight loss with the least or most negligible long term side effects. The only long term side effect which could have significant impact for certain patients is a low, post-operative iron absorption. Thus patients with chronic iron deficiency anemia may be routed toward other procedures. Surgical complications in Bariatric Centers of Excellence remains negligible and are well documented. In the normal patients population [excluding high risk patients with special requirements such as Jehovah Witnesses patients, etc] surgical mortality in high volume bariatric services is nil to negligible. The laparoscopic gastric bypass with Roux Y Limb currently is our first line bariatric procedure or the so-called "Gold Standard".

 

The safest procedure in the morbidly obese patient population remains the Laparoscopic Placement of the LapBand™. This procedure has a definite appeal to patients looking for the least invasive procedure with highest safety record. However the overall surgical performance of this procedure lags behind the laparoscopic gastric  bypass with Roux Y Limb. The long term weight loss of patients with a Lapband™ is in general inferior to patients who underwent a laparoscopic gastric bypass. Nonetheless, this office has seen numerous patients with Lapband™ reach and maintain their target weight. Furthermore, recent studies are now demonstrating adjustable gastric band procedures are associated with a high rate of mechanical complications requiring a second surgical procedures in over 50% of all patients. For these reasons, the LapBand™has lost its marketing appeal and more and more patients are selecting the Laparoscopic Sleeve Gastrectomy instead.

 

The laparoscopic sleeve gastrectomy as a primary bariatric procedure is a newer procedure and has demonstrated a surprising, unexpected significant and prolonged weight loss comparable to other procedures.  After 10 years, these results appear to be sustained. Long term results will need to confirm their long term validity. 

 

Morbidly obese patients seeking more aggressive bariatric procedures should be cautioned and  understand the long term impact of the bariatric procedure on their life.  More aggressive bariatric procedures such as the laparoscopic duodenal switch, BPD, etc perform better by creating  severe malabsorption which in turn has known, sometime irreversible and life altering side effects. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This office does not routinely recommend more radical bariatric procedures for the morbidly obese patient population except in particular settings such as revision of previously failed bariatric procedures, etc. Some surgeons in the US are now routinely performing these radical bariatric procedures in the morbidly obese patient population. Although improved early results are reported, critics are arguing the long term side effects remain staggering and too detrimental for these procedures to be promoted in routine, clinical settings.

 

These procedures on the other hand have a place in the management of the super-obese patients.

 

In the super-obese population, the laparoscopic duodenal switch is considered a valid surgical option. These patients, some of them with weight over 500 and 600 pounds may accept to expose themselves to major side effects as they are debilitated by their weight and co-morbid conditions. In addition, although a majority of these patients will do well with a laparoscopic gastric bypass, a significant number will simply not lose enough weight. A laparoscopic or open duodenal switch has been shown to help these patients, take them to an acceptable weight and maintain them at that weight.

 

The long term side effects of these procedures such as the duodenal switch prompted some surgical teams around the country to seek alternative bariatric procedures designed to avoid these standard complications. One of the bariatric hybrid procedures now commonly used by this office is the staged laparoscopic sleeve gastrectomy followed six months later by a completion laparoscopic gastric bypass with Roux Y Limb. This technique will allow super-obese patients to lose an average of 100 pounds after the initial laparoscopic gastrectomy and then undergo a laparoscopic gastric bypass that will bring them to their target weight. The advantage of this technique is that it is technically easier to perform in this patient population and does not expose these patients to the risks and complications of extreme malabsorption.

 

Lastly some patients who have decided to undergo a laparoscopic duodenal switch, have opted to undergo the two stages laparoscopic duodenal switch. As an initial step they undergo the gastric reduction portion of these procedure or laparoscopic sleeve gastrectomy. Many of these patients will continue to have the second portion of the duodenal switch but others will change their mind and undergo another, less aggressive secondary laparoscopic procedure. Therefore, morbidly obese  patients who are avid advocates of the laparoscopic duodenal switch may want to consider the two-stage laparoscopic duodenal switch.

 

The bariatric surgery landscape is constantly changing. It is essential that all prospective patients understand the risks, benefits and long term results of each procedure they are investigating. The policy of this office is to help patients select the safest bariatric procedure with the optimal risks-benefits ratio.