Most patients who present to a sub-specialist surgeon for Bariatric Surgery are surprisingly well-researched, but this would have required them to spend countless hours talking to friends of friends, relatives, viewing websites and trawling over internet forums. In some cases this may have been a confusing experience. Even the name Bariatric Surgery is confusing, as the derivation of the word ‘Bariatric’ pertains to pressure changes, not weight. But obesity surgery has unsatisfactory connotations to our American colleagues, so could not be countenanced for international usage. Weight loss surgery gets confused with cosmetic surgery (like liposuction) and ignores the established facts that Bariatric Surgery can lead to better health irrespective of weight loss it induces. So now we are stuck with a misnomer unfortunately.

If you can get past this you are then possibly baffled by claims of scientific validity for a variety of different procedures. Why is it not clear which operation is best? Well there are a number of reasons in my opinion.

One reason is that Bariatric surgery adheres to the well-known medical ‘law’ that if there are several different treatments available for a condition, with vociferous proponents of each, it means that there is no clearly superior treatment, and the scientific literature has been unable to reach a consensus about which is best.

In Australia, the 3 commonly-used operations are the Laparoscopic Adjustable Gastric Band (LapBand), the Roux-en-Y Gastric Bypass (or just ‘gastric bypass’), and the Sleeve Gastrectomy (sometimes shortened to just ‘sleeve’). The term ‘stomach stapling’ is also in common parlance, but is taken to mean the old-fashioned Vertically-Banded Gastroplasty; a procedure which was common until 15 years or so ago, and has been since mostly abandoned because of inferior results to more modern procedures. But remember that the modern operations of gastric bypass and sleeve gastrectomy also use stapling technology during the procedure but have nothing to do with the aforementioned stomach stapling operation which we will no longer consider.

Which of the 3 common operations is the best? This needs to be considered from both a scientific and your own personal point-of-view. The latter first: you may have a friend or relative who has been through one of the 3 procedures with good results. They may have a mature understanding of what is required for success, have extensive knowledge which they can share with you, and perhaps have even offered to be a support person during your journey to better health. If that it the case, these personal factors may be a strong factor in your choice of operation, and you should not ignore this opportunity.

From the scientific point-of-view, the truth is that each operation has advantages and disadvantages. My reading of the current state of play is that the LapBand is far and away the safest upfront operation. It is extremely rare for there to be a serious in-hospital complication¹. It is the least painful, and the quickest to recover from. However it is not 100% successful, it is 94% successful: 6% of patients will require a second operation down the track to have the LapBand removed. However the majority who proceed to have the situation surgically corrected end up with the same good long term outcome as those who had no such problem. The LapBand has good long term outcomes in terms of weight loss, remission of the co-morbidities associated with obesity, and improved survival; but not quite as good as the gastric bypass.

The gastric bypass appears to have generally superior weight loss outcomes, better control of diabetes and some other medical co-morbidities of obesity compared with the LapBand. And it too has a 6% major complication rate. But these complications occur in hospital, rather than months or years later like the LapBand. These serious complications can include re-operation for bleeding, incisional hernias, removal of the spleen, bowel blockages, and blood clots in the legs and lungs (DVT/PE). However down the track, the gastric bypass patients rarely require any further surgery. The gastric bypass may not always be able to be done with keyhole surgery, and usually requires a longer stay in hospital and at-home recovery period, but not by much.

The sleeve gastrectomy is a different beast. In some respects it falls midway between LapBanding and gastric bypass. Its weight loss may be better that the LapBand (although long term data is lacking), but not quite as good as the gastric bypass. Like the LapBand it can almost always be done with keyhole surgery, and the recovery period falls somewhere in the middle too. However, the surgery involves permanently removing the majority of the stomach from the body. In this respect it is more ‘radical’ than the other 2 operations, and is obviously completely irreversible in case something goes wrong. Which doesn’t often happen, but when it does it is catastrophic, and leakage from sleeve gastrectomy can be very difficult to manage for both the patient and the surgeon, and has been reported to take up to 9 months to heal in some instances. The operation is open to criticism from some quarters because it excises the stomach for a benign (non-cancerous) condition, and rightly so in my personal opinion, particularly when other good alternatives exist. That’s not to say that good surgeons don’t get good results – they do, and the ‘sleeve’ as it is affectionately known may remain part of the Bariatric Surgery landscape, and indeed may be particularly suited to niche applications such as revisional (second-time) surgery.

In contrast, both the LapBand and gastric bypass are fully reversible (with another operation). In the case of the Lapband this takes under 30 minutes and can be done as day-surgery. In the case of gastric bypass this is more complicated, but in some cases not unduly difficult.

There is a new kid on the block; the gastric plication, which may steal some of the sleeve gastrectomy’s thunder. It could potentially reduce the size of the stomach almost as much as the sleeve, without having to permanently remove the stomach. In essence a running hem-line is stitched along the full length of the stomach, folding the stomach in so it becomes more like a tube and has much less storage area. It could be used with or without a LapBand and looks to me like it would only take 30 minutes or so to do. However this procedure is purely experimental at this stage, and has not be proven to be effective yet. It should probably be done only under conditions of monitored clinical trials at this time, which have not yet commenced in Australia.

Not all surgeons do all operations, and there may be very good reasons why this happens. They may extensive experience in one over the other, and have good results in their hands. The local facilities may be more suited to one more than the other, or they may interpret the scientific literature to favour one. There is no right or wrong answer, and this is where you need to listen to your surgeon very clearly so you understand what options are available, and what is recommended to yield the best results in your unique case. Chances are this question has been raised many times before, and so he/she will be able to explain very clearly what is in your best interests. However you should still be part of the decision-making process.

References:

1. Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in community setting: weight loss and surgical outcomes. NQ Nguyen, P Game, J Bessell, T Debreceni , M Neo, C Burgstad , P Taylor , G Wittert. Submitted for publication.

The New England Journal of Medicine is universally recognised as the premier medical journal in the world (along with The Lancet). This means they can afford to be picky and publish only the research of the very highest quality. In essence they can confine themselves to the ground breaking scientific news that scoops the other journals, and has the potential to change the way we practice medicine.

So it is a very big deal when not one, but three papers appear in the same journal announcing that Bariatric Surgery performed considerably better than traditional medical therapy in obese patients with type 2 diabetes, independent of weight loss.

The New England Journal of Medicine published two randomized trials [1,2] along with an accompanying editorial [3]. In both studies, Bariatric Surgery induced remission and was associated with a significant improvement in diabetic control over and above medical therapy, both conventional and intensive.

According to Dr Paul Zimmet (Heart and Diabetes Institute, Melbourne, Australia) and Dr George Alberti (King’s College Hospital, London, UK), “the studies . . . are likely to have a major effect on future diabetes treatment”. They also suggested that “such procedures should no longer be considered as a last resort in diabetes” and “might well be considered earlier in the treatment of obese people with type 2 diabetes. Who could predict that years after the discovery of insulin that surgeons would be challenging the physician’s territory for treating diabetes?”. Wow, that is an attention-grabbing statement!

One must always take into account that Bariatric Surgery is associated with procedural risks and possible long-term problems due to nutritional deficiencies.

At the Obesity Surgery Society of Australia & NZ conference in Darwin recently, Dr Phil Schauer from The Cleveland Clinic, Ohio, USA was the invited guest speaker. He reported on his study; The Surgical Treatment and Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE).

Dr Schauer and colleagues enrolled 150 obese patients with uncontrolled type 2 diabetes and randomly assigned them to a) medical therapy, b) gastric bypass, or c) sleeve gastrectomy. The main study outcome looked at HbA1c levels <6.0% after 12 months of treatment, which is a marker of desirable diabetic control. This was achieved by 12% of the standard medical therapy group, and in 42% of the gastric bypass group. Although diabetic control improved in all three groups, improvements were significantly greater in the surgical groups, as was weight loss and improvement in insulin resistance.

“There was quite a large difference between the surgical and medical group in terms of the success rate,” Dr Schauer said in his presentation. “All of the gastric-bypass patients who reached HbA1c <6.0% (good diabetic control) did so without any medication; they were weaned off all their tablets, including insulin.” They were also able to reduce cardiovascular medication use (blood pressure pills).

Dr Schauer also discussed the second study published in the New England Journal of Medicine, by Dr Geltrude Mingrone (Catholic University, Rome, Italy). This paper reported on 60 severely obese patients with advanced type 2 diabetes randomly assigned to a) gastric bypass, b) biliopancreatic diversion (BPD), or c) conventional treatment (individualised medication therapy and strictly-monitored diet and lifestyle interventions). Note that BPD is rarely performed in Australia within the context of Bariatric Surgery, as it is considered more radical than the other available operations.

The main study outcome was remission of diabetes for one year or longer, without the use of diabetes medication.

By the 2 year mark, 75% of those in the gastric bypass group had complete remission of their diabetes and were able to stop all diabetes medications. In contrast, none of the patients in the medical group had entered remission.

Senior author Dr Francesco Rubino (Weill Cornell Medical College, New York, USA) when the study was first presented said: “Although Bariatric Surgery was initially conceived as a treatment for weight loss, it is now clear that surgery is an excellent approach for the treatment of diabetes and metabolic disease.”

Although BMI is correlated with the risk of developing diabetes in the general population, Dr Mingrone’s study calls into question the current use of a strict BMI cutoff as a stand-alone criterion for surgical indications, given that resolution of diabetes was independent of weight loss with gastric bypass (as has been described in previous studies). Such findings confirm that the effects of Bariatric Surgery on type 2 diabetes may be attributed to the mechanism of surgery rather than solely as a consequence of weight loss.

Most guidelines indicate that Bariatric Surgery should be performed only in patients with type 2 diabetes who have a BMI of >35. However the International Diabetes Federation last year changed its guidelines to recommend that Bariatric Surgery be considered as a reasonable treatment option in those with a BMI of 30 – 35 if the patient has poorly controlled diabetes.

1. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012; DOI:10.1056/NEJMoa1200225. Available at: http://www.nejm.org.
2. Mingrone G, Panunzi S, De Gaetano A, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012; DOI:10.1056/NEJMoa1200111. Available at: http://www.nejm.org.
3. Zimmet P, Alberti GMM. Surgery or medical therapy for obese patients with type 2 diabetes? N Engl J Med 2012; DOI:10.1056/NEJM1202443. Available at: http://www.nejm.org.

When an obese person undergoes gastric bypass surgery, family members may also lose weight and adopt healthier habits, according to a study published in the October 2011 edition of the Archives of Surgery.

We already know that children with obese parents are more likely to be obese, and that obese children become obese adults. There is also evidence that weight loss surgery in parents can indirectly affect the weight of children: One study showed that children of obese mothers were half as likely to be obese if they were born after she underwent bariatric surgery compared with children born before she had the surgery.

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A research project recently completed by The University of Adelaide extracted data from the prospective databases of two Adelaide bariatric surgeons and independently examined the results. The methodology focused on weight loss outcomes of 2 procedures; RYGB (1995-2009; n=609; 493F:116M; 42.4±0.4yrs) and LAGB (2004-2009; n=686; 555F:131M; 37.2±0.4yrs).

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Joseph Proietto. MJA 2011; 195: 144–146.

In the current issue of the Medical Journal of Australia, Joseph Proietto, the Professor of Medicine at The University of Melbourne, lays out the clearest framework yet for the management of obesity in Australia. The journal also saw fit to headline this paper with an Editorial, which stated that “Greater availability of gastric banding may well have some impact on the burden of chronic disease in our society” (Katelaris A. Let’s not admit defeat in fighting obesity. MJA 2011; 195: 107).

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