Gastric Reduction (Bariatric Surgery)

Excess weight is not only an aesthetic problem, but a serious disease - obesity is a long-term, chronic and systemic metabolic disease that affects all aspects of a person. It shortens life and worsens the quality of life.

The international BMI index is used to determine the degree of obesity.

• BMI values ​​are:
  • < 18.5 - Underweight
  • 18.5 - 25 - Normal body weight / Ideal weight
  • 25 - 30 - Overweight / Overweight
  • 30 - 35 - Obesity I. degree / Mild obesity
  • 35 - 40 - Obesity II. degree / Moderate obesity
  • 40 and more - Obesity III. degree / Severe obesity

Along with obesity come accompanying diseases (ABCD – adiposity-based chronic disease):

• Diabetes mellitus type 2
• High blood pressure (hypertension)
• Elevated blood fat levels (dyslipidemia)
• Sleep breathing disorders (Obstructive sleep apnea – pauses in breathing)

Obesity treatment is a very demanding process.

• It includes complex changes in habits – diet, sedentary lifestyle, leisure activities, stress elimination, enough sleep.
• Anti-obesity drugs (Antiobesity drugs) are prescribed to patients who have not adjusted their weight by at least 5-10% even after 6 months of diet measures.
• Gastric bypass surgery.

A suitable candidate for surgery is a patient aged 18-60 years:

• with a BMI of 35 and above - if there are concomitant diseases (ABCD)
• every patient with a BMI of 40 and above

However, an examination by an anesthesiologist is also necessary, who will decide whether the patient is able to undergo general anesthesia. When deciding on surgery, the benefits and risks of the procedure must be considered.

In gastric banding, the stomach is constricted from the outside using a ring (balloon banding).

• In the past, banding was done with tape (rigid banding)
• Today, a silicone band is used, the volume of which can be changed (AGB – adjustable gastric banding)

The ring around the stomach makes the stomach smaller and limits the amount of food that the stomach can take in.

This creates a feeling of fullness more quickly. By compressing the stomach, the insistent feeling of an empty stomach disappears.

This technique has been performed since 1993, access to the stomach is via laparoscopy - (without the need to open the entire abdominal cavity).

Weight loss is around:

• 11 lbs (5 kg) during the first month
• up to 44 lbs (20 kg) during the first year
• around 66 lbs (30 kg) within 2 years of the procedure

Today, this operation is abandoned because the results are not satisfactory in long-term follow-up. This is because there is a yo-yo effect (regaining weight).

The stomach volume is reduced by folding the stomach walls and stitching them together.

The operation can be performed laparoscopically (LGCP - laparoscopic greater curvature plication), but there are several complications with this operation:

• The stomach wall usually needs to be stitched in 2-3 layers
• The embedded (invaginated) part of the patient's stomach irritates
• Common complications such as loosening of stitches, perforation of the stomach, excessive narrowing - stenosis
• Need for repeated surgery due to complications

This operation is currently performed very rarely.

The reduction of the stomach is achieved by removing - resecting - a larger part of it.

The operation is currently performed laparoscopically, it is also referred to as gastric tubulization - Vertical Sleeve Gastrectomy (the stomach is originally shaped like a bag, it changes into a cylinder - a tube).

This is therefore a major operation that irreversibly changes the shape and volume of the stomach. The volume of the stomach is reduced from 1.5 liters to about 150 ml (5 fl oz). The cells in the stomach responsible for the feeling of hunger (cells that produce the hormone ghrelin) are also partially removed. The portions of food that the patient eats are significantly smaller.

Weight loss is greater than with gastric banding and is around:

• 22 lbs (10 kg) during the first month
• up to 66 - 88 lbs (30 - 40 kg) during the first year
• around 110 lbs (50 kg) within 2 years of the procedure

Complications may occur:

• Gastric leakage at the site of resection with the need for reoperation
• Reflux - heartburn

Gastric bypass means bridging (bypassing) - the basic principle is an operation in which part of the stomach is connected to the small intestine.

A larger part of the stomach, duodenum, and part of the small intestine are bypassed (bridged).

This combines the reduction of the stomach with the reduction of the surface area through which nutrients are absorbed.

We distinguish several types of gastric bypasses:

• ROUX-Y gastric bypass (RYGB)
  • The Roux en Y gastric bypass connects the reduced stomach to the intestine and the intestine to each other. The small intestine is thus shaped like the letter Y.
• Minigastric bypass - MGB (Omega Gastic Bypass - OGB, One Anastomosis Gastric Bypass - OAGB)
  • Omega Loop Bypass connects the reduced stomach to the intestine using one anastomosis. The intestine is shaped like the Greek letter omega - Ω.
• Biliopancreatic diversion (BPD)
  • Biliopancreatic diversion serves as a complementary operation. It is performed if the desired weight loss has not occurred after gastric resections. In this bypass, the digested food reaches the last part of the small intestine - this significantly reduces the absorption of nutrients and helps to lose more weight.
• Newer procedures: e.g. SASI Bypass (Single Anastomosis Sleeve-Ileal/Sleeve-Jejunal bypass) combines the reduction of the stomach (resection) with the connection (bypass) of the duodenum to the lower part of the small intestine.

After gastric resection or gastric bypass surgery, the desired weight loss occurs. The weight loss depends on the initial degree of obesity; patients can lose up to 110 lbs (50 kg) or more.

Immediately after surgery, a specific diet must be followed:

• First 2 weeks: liquid diet
• 3rd - 4th week: pureed diet
• 5th - 6th week: soft diet

The patient must be prepared for the fact that the portions of food that he can eat are smaller. It is necessary to eat slowly and drink enough fluids. It is necessary to exclude soft-drinks from the diet.

Bypass surgeries that shorten the journey of food also limit absorption (they are referred to as malabsorption surgeries). This way, fewer vitamins (especially those soluble in fat: vitamins A, D, E, K), but also calcium, enter the body. The stomach is important for iron absorption - after gastric resection, patients often suffer from iron deficiency anemia (sideropenia).

Patients often have to be monitored and take vitamin supplements for life. Patients are usually informed about dietary changes before surgery, as they are part of the initial weight loss method.

Another major benefit is the management and stabilization of diabetes, high blood pressure and other comorbidities (ABCD), as well as improved mobility.

Any surgical procedure can be accompanied by complications.

• Early complications include bleeding, infection, impaired healing.
• Individual procedures have their own specific complications - slipping of the bandage, separation of the sutures or perforation of the stomach (gastric perforation) with the release of stomach acid into the abdominal cavity with inflammation (peritonitis), intestinal obstruction and others
• Late complications are mainly failure of treatment with the return of obesity, limited absorption of vitamins A, D, E, K, calcium and iron. Heartburn and altered perception of tastes and smells of food and drinks
• After bypass surgery, diarrhea may be present due to too rapid passage of food from the stomach to the intestine (dumping syndrome)