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Bariatric surgery Archives | GB Obesitas

Gastric bypass surgery, pros and cons

By | Body weight regulation, Operating methods

The gastric bypass (GBP) operation has actually been around for more than 50 years, the American surgeon Edward Mason published “Gastric bypass in obesity” in 1967. The first decades this was open surgery, nowadays it is always laparoscopic. We have gained the most knowledge about the long-term effects of the operation from the Swedish SOS study (Swedish Obese Subjects study). In SOS, a small proportion of patients had gastric bypass surgery, the rest had had gastric banding surgery or a VBG. Gastric banding and VBG (vertical band-reinforced gastroplasty) both had the same principle in common, so-called “restriction”. In plain language: make the stomach smaller, so the person with obesity is forced to eat less and lose weight.

Now, however, gastric bypass proved to be in every way superior to banding and VBG in SOS and upcoming studies; it produced better weight loss and more other positive effects on health: including highly effective treatment of type 2 diabetes (even at BMI less than 35).

Gastric bypass effective

Why was gastric bypass more effective than the older methods of banding and VBG? All three procedures give the operated person a smaller stomach, but gastric bypass is different as it at the same time fundamentally counteracts the body’s own defense against weight loss: a GBP leads to the body’s so-called set point for weight (our “weight thermostat”) in the brain being lowered towards normal levels. This is achieved via a variety of positive hormonal effects in the body, which in itself come out of the intestinal bypass that is done during a gastric bypass (but not during banding or VBG). You could say that the operation has its main effect on the brain – even though you only operate in the abdomen!

Gastric bypass benefits

What are the benefits of a gastric bypass operation? It is extremely well proven and over the years refined. We know very well how a GBP should be performed technically by the surgeon. The operation provides very effective weight loss and it lasts a lifetime. You get health effects at all levels (life is extended on average 6.7 years, it is effective treatment of type 2 diabetes, sleep apnea syndrome, osteoarthritis, PCOS, high blood pressure, cardiovascular disease, fatty liver disease, gout and more. In women, the risk ofdying from a cancer ishalved .).

… and cons

What are the disadvantages? Yes there is initially about 3% risk of serious complications (mainly bleeding and leakage). These can be remedied but often require new surgery. The long-term surgical risk is ileus (in this case also called mesenterial herniation) which comes from changing the anatomy of the small intestine during bypass surgery. Ileus results in acute blockage of the intestine and one must seek emergency medical care. They can be cured, but require a new operation. In the past, this was relatively common, the risk was 5-10%, while today it is prevented at the initial operation (one “closes the mesenterial defects“). Today, the risk is instead 1-3% approximately. Other more medical disadvantages are the risk of dumping (lowering of blood sugar and blood pressure after eating certain foods), increased sensitivity to alcohol and impaired vitamin uptake. The latter is easy to prevent with vitamin supplements -but studies prove this to be difficult to maintain for life for patients (who otherwise feel excellent as a rule and perhaps have lost their previous medicines…). More about both pros and cons can be found in the annual report from the Swedish Obesity Surgery Register SOREG.

Gastric bypass or gastric sleeve?

In recent years, gastric bypass has had a “cousin” namely sleeve gastrectomy (SG). We will talk more about this in the upcoming blog. Which of the two is best? Well, both are excellent, both have disadvantages. Exactly when which of them is “best” … we actually don’t know for sure. This is being studied in Sweden via the BEST study (where GB Obesitas is involved).

Want to know more? Join us for the next information meeting!

Sleeve gastrectomy -operation, pros and cons

By | Body weight regulation, Operating methods

Gastric sleeve is the alternative name of this operation. It began to be performed in 1988, then as open surgery and as the first half of a more extensive surgery in severe obesity (biliopancretic diversion with duodenal switch). In the late 1990s, sleeve gastrectomy (SG) began to be made laparoscopic and after the turn of the millennium it was increasingly realized that a sleeve “alone” without subsequent bowel disconnection performed well for effective weight loss. After this, gastric sleeve quickly gained a rising popularity and is today the most common obesity surgery in the world, in Sweden it accounted for 45% of all obesity operations in 2018.

Why did sleeve gastrectomy quickly become so popular? Firstly, it is easier for a surgeon to learn (you avoid the intestinal disconnections in a gastric bypass operation), it is perceived as “milder” than bypass with less risk of dumping and no postoperative ileus.

Gastric sleeve mechanisms of action

How does a sleeve work? It is a gastric operation, where you surgically remove 85% of the stomach (you remove the “outer curve” of the stomach). However, you do not operate at all on the intestine. Removed part of the stomach is taken out of the body. There are several mechanisms of action: at the beginning it is clearly restrictive, i.e. the stomach is very small and limiting. In the long run, however, the effect on our hunger hormones is central; just as with gastric bypass, a gastric sleeve lowers our set point for weight in the brain stem to more normal levels. The daily routines required after an SG are the same as after a bypass -you have to adapt to the new anatomy of the stomach, as well as what you can now tolerate or can not tolerate eating and drinking: 5-6 small meals per day, at least 1.5 L of water per day, be physically active and take daily vitamin supplements.

Sleeve gastrectomy pros and cons

This is an excellent operation,as well as with bypass, it has pros and cons. There have been some misconceptions about sleeve gastrectomy; sometimes it has been described as “being able to eat the cake and still keep it” (i.e. gain effective weight loss without having to exert so much, avoid dumping risk and not have to take vitamins) which is definitely incorrect: a sleeve operated person needs to do their daily routines in exactly the same way as a bypass operated one. Exactly when a sleeve is the best to choose we do not know (that’s why GB Obesitas is included in the BEST study). But the following has been our view based on clinical experience so far:

Gastric sleeve does not result in any increased ileus risk, unlike gastric bypass. You generally don’t become as dumping sensitive (which is a bit for better or worse, some patients like that they can dump sometimes). Vitamin uptake is impaired, but probably less pronounced so than after a bypass.

The disadvantages are the risk of worsened reflux symptoms (heartburn, acid reflux) and unclear long-term effect on weight. The operation is also not possible to restore to normal anatomy. However, the effect on wieght loss of a sleeve if necessary (usually due to weight gain) can be strengthened with an additional operation: it can be turned into a gastric bypass or a SASI.

Will sleeve gastrectomy continue to be the world’s most common obesity operation in 10 years? The future and -BEST study -will tell us this. Follow us!

Fast track surgery at GB Obesitas

By | Operating methods, Our research | No Comments

If you can carry out a bariatric procedure in anaesthesia faster without the quality going down, then you have won a number of things: the patient is immobilized for a shorter period of time which reduces the risk of blood clots; the anaesthesia itself becomes shorter and produces less side effects.

Our surgical team led by Dr. Gislason has been working on creating as smooth processes around surgery as possible for more than ten years. We have two surgeons working on the patient at each surgery procedure, which reduces the surgical time for a gastric bypass or sleeve gastrectomy to an average of 35 minutes. The turnaround time between two patients in the operating room is, thanks to good teamwork, 10-15 minutes (in the normal hospital environment the switching time between surgeries is often 30-60 minutes). This means that we can operate more patients per day, without any individual patient in any way getting worse care or attention. It also makes it possible for us to keep prices down on our private operating packages.

This fast track concept attracts other teams from Europe and the rest of the world to make study trips and learn how to get the flow to work better at their home clinics. These study visits are organized in cooperation with Medtronic -maybe you will meet a visiting colleague when you are staying with us!

The concept has also been described in research articles by our team (Link No. 1), and we have authored chapters on the subject in textbooks for bariatric surgeons – see below!

Gislason H, Jacobsen HJ, Bergland A, Aghajani E, Nergard BJ, Leifsson BG and Hedenbro J. Fast Track in Bariatric Surgery: Safety, quality, teaching aspects, logistics and cost-efficacy in 8000 consecutive cases. Book chapter in: Minimal Invasive Bariatric and Metabolic Surgery. Principles and Technical Aspects. Eds. Lucchese M & Scopinario N. Springer 2015.

Link No 1: https://w ww.ncbi.nlm.nih.gov/pubmed/22116595

Optimized anaesthesia, optimized pre and postoperative care

By | Our research | No Comments

One of the things our patients tend to be most concerned about when we discuss bariatric surgery at info meetings and first visits is the anaesthesia. Becoming anesthetized (gastric bypass and sleeve gastrectomy are performed in full anesthesia) is always a feeling of loss of control, you do not know for sure what is going on. Our staff know how you feel and we will take good care of you. We are constantly trying to improve everything we do, and that also applies to the anaesthesia. More than ten years ago, our team published (link no 1) a study on how to make the anaesthesia smoother. Already during this study, we shortened the time from start of anaesthesia to start of operation from 23 minutes<to 8 minutes; And the time from the end of surgery to wake-up from<6 minutes to 2 minutes (!).

ERAS -enhanced recovery after urgery

We have also worked to make patient care after surgery as good as possible. This is done according to evidence-based guidelines, called ERAS (read more here, link No. 2) . The goal is that you as a patient should have as little side effects of the anaesthesia (nausea, etc.) and the actual surgery (pain) as possible.

All of these are examples of our philosophy within the team and the clinic: that everything that can be improved all the time should be worked actively with -and this we hope and believe that you as a patient will also benefit from.

More studies from our team can be seen below!

Bergland O, Bergland A, Gislason H, Rader J. The implementation of the ERAS protocol in high-volume bariatric surgery: complications and anaesthetic considerations in 5068 consecutive morbidly obese patients. Accepted for publication in Acta Anesth.

Karlsson A, Wendel K, Polits S, Gislason H, Hedenbro J. Preoperative nutrition and postoperative discomfort in ERAS settings: A randomized study in gastric bypass surgery. Obes Surg 2016;26:743-748

Link No 1: https://www.ncbi.nlm.nih.gov/pubmed/19025533

Link No 2: www.erassociety.org

Distal gastric bypass and SASI -alternatives to standard operations

By | Operating methods, Our research | No Comments

The basic operations with us, as in the rest of Sweden, are the surgical procedures gastric bypass and sleeve gastrectomy. These complement each other in a good way, both in terms of advantages, disadvantages and efficiency. For the vast majority it is enough to choose between these two.

But sometimes we see special cases; one example is those with an extra high BMI (BMI above 50). Here, a “regular” gastric bypass can often be quite sufficient even in the long run -but not always. What to do then?

 

Alternative options to standard gastric bypass

Our surgeon team has researched the alternatives to standard gastric bypass -you will find a list of publications below. In order not to make it all too technical and complicated, one can say that the effectiveness of the surgery can be adjusted based on how long a portion of the intestine is disconnected (if the extra-long section of the bowel is disconnected, it is called a distal gastric bypass) or how long a part that remains from the mini-stomach to the large intestine-thus how many centimeters of small bowel that are exposed to the food after the procedure. The shorter this distance is, the more effective weight loss -but also the higher the risk of side effects.

A new option, at high BMI or when a gastric sleeve does not prove to work fully, is the operation SASI (single anastomosis sleeve ileal bypass). Watch our information video here on our site here for more information on SASI!

We will look at your specific situation in connection with our first visit with checklisting. If you might be eligible for any of our more “special” procedures, we’ll discuss it with you. Then we also discuss what special things you will need to consider afterwards (for example, more ambitious follow-up with blood tests, etc.).

 

Scientific work on surgical methods

Leifsson BG, Gislason H. Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: Technique and experience with the 150 first patients. Obesity Surgery 2005;15:35-42.

 

Nergaard BJ, Leifsson BG, Hedenbro J, Gislason. HG. Gastric bypass with long alimentary limb or long pancreato-biliary limb-Long-term results on weight loss, resolution of co-morbidities and metabolic parameters. Obes Surg 2014;24:1595-1602.

 

Shah K, Nergard BJ, Fagerland M. Gislason H. Limb length in gastric bypass in super-obese patients – importance of total alimentary small bowel tract. Accepted for publication in Obesity Surgery.

 

Shah K, Nergard BJ, Fagerland M. Gislason H. Distal gastric bypass – 2 m bilipancreatic limb construction with varying lengths of common channel. Accepted for publication in SOARD.