Tomorrow when Dr. Malick begins my surgery, he will be performing a Gastric Sleeve. For me, it wasn’t a difficult decision to make. I have suffered from osteo-arthritis since I was in my early 20s. With the knee replacements, my knees were taken care of but I still deal with arthritis in my neck, upper back, ankles, wrists and hands. This means that NSAIDS will be in my future. With the Roux-en-Y, the tablets fall in such a way as to sit in the same spot in the pouch every time. Especially with NSAIDS, this can lead to ulcers so no Roux-en-Y for me. The Lapband is not covered by MSP (Medical Services Plan) and costs about $15,000 thus not an option for me. The Duodenal Switch is not available where I live so that left me with the sleeve. What I like about the sleeve is that there is no malabsorption and there is significant weight loss. And of course, much lower chance of an ulcer.
Of course, everyone has to make their own decision. It is important to consider the pros and cons carefully, so I have made a list below. This is a long post, but I hope you find it helpful.
According to the Mayo Clinic:
In a sleeve gastrectomy, part of the stomach is separated and removed from the body. The remaining section of the stomach is formed into a tube-like structure. This smaller stomach cannot hold as much food. It also produces less of the appetite-regulating hormone ghrelin, which may lessen your desire to eat. However, sleeve gastrectomy does not affect the absorption of calories and nutrients in the intestines.
- The first pro is that the procedure reduces hunger. The surgery cuts out more than 60% of your stomach. This reduces the concentration of biochemicals in your stomach that cause the sensation of hunger.
- The second pro is that there is no band or other permanently restrictive device or foreign body left in your body after the surgery.
- The third pro is the large amount of weight you lose after having the procedure. Different websites report different ranges of weight loss. One site reported 30-50% weight loss in the first 6-12 months. Another site estimated that people who undergo this procedure achieve 40-60% weight reduction over the first 1-2 years.
- A fourth pro is that the significant weight loss resulting from the bariatric surgery will generally lead to improvements in blood pressure, diabetes, sleep apnoea, joint pain, reflux and fatty liver etc.
- A fifth advantage of the gastric sleeve is there is no malabsorption of nutrients. As noted above the gastric sleeve surgery is a restrictive procedure as opposed to one that is malabsorptive. You will be able to eat what you previously did but will need to eat in much smaller amounts and may find some foods physically uncomfortable to consume. And, because you are eating less you will need to ensure that you eat nutrient dense foods, not junk foods!
- A sixth pro of surgical treatments is that the risk of surgery is often less than the risks caused by severe obesity.
- A final pro is that another surgery called a gastric bypass or duodenal switch can be performed after this procedure.
- The foremost downside of gastric sleeve surgery is that it is irreversible. It is a permanent procedure.
- The second downside is that the procedure is expensive and not usually covered by medical insurance companies or medicare
- As the gastric sleeve is a surgical procedure there could be post-operative complications such as infections, pneumonia and bleeding. As the procedure involves stapling part of the stomach, leakage is always possible. If leakage occurs it may cause infection and other health problems. The more obese you are prior to surgery the higher the risk of complications. However, the literature indicates a mortality risk of less than 0.3%.
- The fourth issue with gastric sleeve surgery is that it only restricts your capacity to consume solid foods not liquids. There are high energy liquid foods that if consumed after a gastric sleeve will prevent weight loss. Drinking high calorie liquids frequently enough could even cause weight gain. Be warned, having a gastric sleeve does not mean you can get away with eating and drinking what you like
- A fifth issue is that after a gastric sleeve the remaining stomach will gradually stretch and permit larger meals. If you make unhealthy food choices you may gain weight.
- A sixth issue is that because 60% of your stomach has been removed your stomach space is much smaller and you will feel full more quickly. If you overeat or swallow poorly chewed food you may feel uncomfortable and vomit.
- A seventh issue is that you will need to reframe your relationship and attitude towards food because you will not be able to eat what and how you did previously. There will be a mourning involved. You will need to get used to watching other people eat in a way you no longer can.
- An eighth issue is acknowledging that most people eat psychologically, not in response to hunger. So, despite some people saying the gastric sleeve operation reduces the production of the hunger hormone, most of my clients don’t eat because they are hungry. Most people eat because they are bored, upset, or out of habit. If people on the planet only ate when they were hungry then none of us would be fat! So, even after having the gastric sleeve you will need to exercise ongoing commitment to healthy eating and exercise.
According to the Mayo Clinic:
In Roux-en-Y gastric bypass, the surgeon creates a small pouch at the top of the stomach. The pouch is the only part of the stomach that receives food. This greatly limits the amount that you can comfortably eat and drink at one time.
The small intestine is then cut a short distance below the main stomach and connected to the new pouch. Food flows directly from the pouch into this part of the intestine. The main part of the stomach, however, continues to make digestive juices. The portion of the intestine still attached to the main stomach is reattached farther down. This allows the digestive juices to flow to the small intestine. Because food now bypasses a portion of the small intestine, fewer nutrients and calories are absorbed.
- Up to 96 percent of patients see a cure or improvement of their diabetes.
- Up to 90 percent of patients see a cure or improvement of their high blood pressure.
- Up to 80 percent of patients see a cure or improvement in their sleep apnea.
- Patients see a lessening of pain related to osteoarthritis.
- Patients see a lessening of their gastric reflux symptoms.
- Some patients see an improvement in their fertility.
- Patients experience great weight loss. Patients can maintain an average of 65 to 70 percent of excess weight loss at five years after surgery. In other words, they can expect to lose 65 to 70 percent of the amount that they’re overweight.
- Patients experience better long-term weight loss than with diet, exercise and medication.
- On average, patients experience more weight loss than with behavioral modification.
- Patients are less likely to gain back the weight they’ve lost than are patients of some of the other weight loss procedures.
- Patients experience rapid weight loss, and they can achieve most of the weight loss within the first year.
- The small gastric pouch forces patients to modify their diets.
- Some patients experience what’s known as the dumping syndrome (a major discomfort!) if they eat something too high in sugar or fat.
- Because the stomach is divided and the small intestines are rerouted, leakages can occur right after surgery.
- Because Roux-en-Y is surgery, it can involve complications such as pulmonary embolism (a blood clot to the lungs), bleeding, infection, stricture (a severe narrowing of the hookup of the stomach to the intestine due to scar tissue), hernia, and even death.
- Ulcers can occur at the hookup of the stomach to the intestine.
- You may regain some of the weight you’ve lost if you don’t watch your diet and follow an exercise regimen.
- You may have gas, and it could smell worse than it did before surgery (though your doctor can help with this).
- For the rest of your life, you’re at a slight risk for intestinal obstruction.
- You have to modify your diet.
- You may experience more-frequent bowel movements.
- You may experience nutritional deficiencies and, therefore, you have to take nutritional supplements for the rest of your life.
- You may experience the sickening sensations of dumping syndrome if you eat something too high in sugar or fat.
- The surgery to reverse Roux-en-Y gastric bypass is more difficult than Roux-en-Y itself, so the reversal surgery is not readily performed.
According to the Mayo Clinic:
In the adjustable laparoscopic gastric banding procedure, a band containing an inflatable balloon is placed around the upper part of the stomach and fixed in place. This creates a small stomach pouch above the band with a very narrow opening to the rest of the stomach.
A port is then placed under the skin of the abdomen. A tube connects the port to the band. By injecting or removing fluid through the port, the balloon can be inflated or deflated to adjust the size of the band. Gastric banding restricts the amount of food that your stomach can hold, so you feel full sooner, but it doesn’t reduce the absorption of calories and nutrients.
- While gastric bypass surgery and lap-band surgery are now both performed laparoscopically, there is no cutting of internal organs with the lap-band procedure and therefore the surgery is considered less invasive.
- With lap-band surgery, patients are in and out either the same day or after a one-night hospital stay. Because there is more tissue damage, gastric bypass patients are normally in for two or three nights. Lap-band surgery itself also takes less time.
- Again, because it’s a less invasive surgery, lap-band patients are able to resume their normal activities within a week or so.
- The lap band is adjusted by filling or extracting a saline solution. Your surgeon can make adjustments according to how much weight you’re losing, how you’re feeling, how much food you’re able to eat and other variables.
- Although the lap band is considered a permanent solution, and although removing it can be problematic and cause problems, it is removable and approximately 25 percent of people who have lap-band surgery end up having the device removed
- Because the lap band does not bypass the stomach, you will properly absorb the nutrients you consume. This can be a major problem in those who have had gastric bypass surgery, who can end up with malnutrition diseases normally seen in third-world countries.
- The success rate of the lap band procedure really depends on your definition of success. Depending on the study, the average weight lost and sustained is around 50 to 60 pounds. Most people do not achieve the weight loss necessary to be in their desired and healthiest weight range, but they do decrease their risk of morbidity by a considerable rate. The success rate is substantially improved with the patient’s determination to follow a healthy diet and exercise program and get the lap band adjusted as needed. Certainly some people do achieve dramatic weight loss and keep it off.
- If your medical insurance does not cover weight-loss surgery, the lap band procedure is generally less expensive than gastric bypass. But this cost balance can tip the other way if additional surgeries are necessary because of complications.
- Yes, the success rate is in both the pros and the cons. While your morbidity rate is decreased substantially after having the surgery, the surgery itself does not ensure success. You will have to change the way you eat, exercise and think about food, and there are ways to consume too many calories even when using the band correctly. For example, you can easily consume high-calorie liquids such as milkshakes and creamed soups. You can also eat small amounts continuously throughout the day, adding up to too many calories consumed and no weight loss.
- Complications are common, although newer techniques have decreased the rate. Some studies show as many as 50 to 70 percent of patients have complications requiring additional surgery.
- Some insurance companies have stopped paying for lap-band surgery because of the risk of future surgeries, including gastric bypass if the individual either does not achieve enough weight loss with the lap band or has complications that do not allow her to continue on with its use.
- From two to 10 percent of patients experience a condition where the band grows into their stomach. This takes place over a long time and is normally diagnosed after approximately two years. Because the band no longer restricts food intake, this makes the patient hungrier and able to eat large meals, thereby gaining weight. This requires removal of the band.
- A small percentage of patients cannot tolerate the band, a foreign object, being in their body at all. These people experience excessive vomiting and a feeling of profound discomfort. The only recourse is to remove the band.
- In up to 18 percent of patients the lap band can slip, making the pouch above the band too large. This causes vomiting and acid reflux. This can be fixed by repositioning the band.
- Up to five percent of patients experience a leak in their bands. This causes the band to be ineffective since it does not remain inflated enough. The leak is usually not found until the patient has stopped losing weight for quite a while. The band will have to be repaired or replaced via surgery.
- Up to 20 percent of lap-band patients have problems with the port, the location where the solution is inserted. This includes port flip, in which the port section of the lap band flips over and is therefore inaccessible, port dislocation, where it moves to a different location around the stomach, or port leak, where the solution leaks out through the port. All of these problems require surgery to address.
- Up to 17 percent of lap-band patients experience a condition where the stomach pouch above the band enlarges. This can sometimes be fixed by varying the amount of fluid in the band and sometimes requires surgery to fix.
- An enlarging of the esophagus, this is can be caused by the band being overfilled and can be resolved by deflating the band.
- Up to 70 percent of patients experience nausea and/or vomiting, with different causes. Sometimes this can be controlled by avoiding certain foods and eating a specific way.
- A large number of people experience GERD after lap band surgery. This is a painful condition wherein the acid from the stomach goes up into the esophagus. Over time, this acid can cause damage. This condition can be improved by dietary choices. Also, many people who previously suffered from GERD find relief after lap band surgery.
- There are risks associated with any surgery, and lap-band surgery is no exception. First is the risk associated with general anesthesia, including stroke, heart attack and death. These occurrences are very rare, but the risk of them increases for the very people getting lap-band surgery, those with obesity, diabetes, sleep apnea and high blood pressure, along with other medical conditions not associated with obesity. Surgery always carries other risks including blood clots, infection and perforation of organs.
From the Mayo Clinic:
As with sleeve gastrectomy, this procedure begins with the surgeon removing a large part of the stomach. The valve that releases food to the small intestine is left, along with the first part of the small intestine, called the duodenum.
The surgeon then closes off the middle section of the intestine and attaches the last part directly to the duodenum. This is the duodenal switch.
The separated section of the intestine isn’t removed from the body. Instead, it’s reattached to the end of the intestine, allowing bile and pancreatic digestive juices to flow into this part of the intestine. This is the biliopancreatic diversion.
As a result of these changes, food bypasses most of the small intestine, limiting the absorption of calories and nutrients. This, together with the smaller size of the stomach, leads to weight loss.
Pros and Cons:
- About 70% of the outer curvature of the stomach is removed which reduces the amount of food you can eat. The stomach retains normal function, the pylorus continues to control food moving from the stomach into the intestine, and as a result DS patients do not experience “dumping”.
- A benefit of removing a portion of the stomach is that it also greatly reduces the amount of ghrelin producing tissue and the amount of acid. Ghrelin is the “hunger hormone” and reducing the amount produced suppresses the appetite.
- The remaining stomach is about 3-5 oz or holds approx 90 to 150mL in volume. After DS patients can consume a wide variety of foods and after about a year can consume approx half of their preoperative volume.
- A DS patient’s stomach tends to be bigger than RNY and Lap Band patients. The reason is that DS weight loss is maintained through malabsorption rather than caloric restriction and because of the increased protein requirement (since 40% is malabsorbed) more room is needed to consume 100 grams of protein a day. DS patients don’t dump because their pylorus remains in use, so there are no food’s they “can’t” eat. With this freedom comes responsibility, patients need to eat protein based meals following surgery to stay healthy.
- Some patients choose DS surgery because they prefer unrestricted food options or because they need to continue taking NSAIDs.
- The small bowel is divided approx 2 inches into the duodenum. The common channel, where food and bile mix and nutrients are absorbed, is usually 75 – 100 cm.
- Only absorb 20% of the fat you consume. Eating too much fat can cause loose stools. The inability to absorb fats also interferes with absorption of the fat-soluble vitamins A, D, E & K.
- Only absorb approx 60% of the protein you consume. You must intake between 80-120g of protein a day.
- Only absorb 60% of complex carbohydrates and 100% of simple carbohydrates.
- Gas and stool tend to be stronger smelling due to the intestine re-routing and can be enhanced if you eat too many simple carbs.
- Vitamin and mineral supplementation is vital and a requirement to maintaining good health.
- Routine blood work is mandatory. Adjust supplements as necessary.
- Weight maintenance is achieved through malabsorption. The malabsorption component is attributed to the higher % excess weight loss (EWL) long term when compared to other bariatric procedures. Basic vitamin requirements – multivitamin, calcium citrate, vitamin A, vitamin D, zinc.
- The Duodenal Switch weight loss surgery procedure has seen the highest rate of type 2 diabetes cure, often before leaving the hospital following surgery!