Dr. In My Area No Longer Does Lapband. Ugh!

[NaNa 878]

Parrisel,

You mentioned:

And the real tragedy is that she will find a doctor or NP who will consent to the fill, putting into place a trajectory that could very well lead to erosion or slippage. And she risks becoming another "band complication" statistic, all through her own faulty logic, with the complicity of the specialist allowing her to get restriction far too tight for the original intent of a lapband.

Here is the thing that many people don't realize, patients ARE NOT TRUTHFUL on their intentions to their fill giver. MOST surgeons DO NOT know how tight our bands are. Some patients will not be truthful, and say, they DO NOT VOMIT and can eat solids.

This is another big frustration to surgeons and why many surgeons are moving away from the band because of DIS HONEST patients. When a patient gets a fill, the surgeon WILL ASK THEM, how do you feel? The patient drinks the Water, the surgeon does not know if the Water is sitting in the patients chest, and drizzle through, it is UP TO THE PATIENT to be honest as far as how much they can eat and whether or not they can eat solids without vomiting.

Most surgeons tell patients to come back immediately or within 2-5 days if they can't eat solids, many patients do not go back if their bands are too tight.

Lap band fill adjustments are not an exact science you have to tweak the fill to get it just right and sometimes it takes going back and forth to get to the sweet spot.

Even fills done under Fluoroscopic does not tell the whole story because fills can also tighten up even further and sometimes it takes 2-3 weeks before a fill settles in and the patient really feels it.

So the patient is the driver in how tight their band stays, not the doctor. or fill giver.

[Essence33 90]

Hi Essence,

Overall my sister is doing ok, the issues that she's had over the years has been, one hospitalization for ulcers, when the had to remove part of her stomach due to the staples, so she has a "Sleeved like stomach WITH staples.

She had a revision surgery about 8 years ago, and she had many complications with that, but she healed and recovered, but she did not lose any weight. When she first had the surgery, she lost all of her weight and was skinny like Most Sleeved people, but eventually gained it all back.

The weird thing is she still can't eat that much food after 30 years, but she learned to EAT AROUND her surgery and ate sweets, and her stomach stretched back out too big to help with weight loss, if she wants to lose weight now she has to do it the old fashion way with diet and exercise.

The only negative things I've seen her do for MANY years is that when she eats, she will vomit her food, it's not like a Lap bander getting food stuck and just upchuck slime undigested food, it's REAL vomit (gross) and she gets SICK ALL THE TIME, and she says it because of the staples in her stomach, I have to be honest -- SHE VOMIT EVERY SINGLE DAY...I am not sure if this is healthy or not, but she's had to have her teeth capped twice.

I DO NOT VOMIT AT ALL with my Lap band because I don't keep it too tight and I chew well, so her vomiting seems to be uncontrollable due to the staples in her stomach.

Another negative, she will get sick with Hypoglycemia (dumping like syndrome) this is SOMETHING THAT MANY SLEEVERS get too, and this is disrupting her life, if we go out to a restaurant and eat, she can't eat certain things, and she has these attacks now every day, her symptoms, are weakness, shakiness, and feeling faint, she CANNOT work due to all this. When she gets an attack, she has to sit down and hold her head down, and drink cold Water, I asked some Bypass people what can she do to help her, she's been to specialist and they told her to modify her diet, but that is still not working, so now when she gets an hypoglycemia attack she drinks or eat some juice or Peanut Butter crackers. Also Hypoglycemia can get dangerous and life threatening if it chronic and if you have frequent fainting.

Many people do not tell you the negative side effects of these surgeries, I am being honest. so it is your choice whether you would like to get the Sleeve or Lap Band, however, the Lap band requires MUCH MORE maintenance than a Sleeve, and if you are self pay for lap band you must be AWARE of the cost of complications IF they happen, fill cost, Upper Gi costs if needed.

I do not recommend the band to people unless they have a good income or insurance for upkeep, and willing to change their lifestyle.

This is a difficult decision to make, the Sleeve seems easier if you don't have complications, once the surgery is done, the only thing you need to do is keep up on your Vitamin supplements.

However, if you get the Band, you will need to see your surgeon every 4-6 week for at least a year for optimal weight loss, and after you get to your green zone, then you really don't need to see your surgeon unless you have issues, but again the lap band after care is crucial for success.

I hope this helps you make a decision

Good luck and stay in touch regardless if you go Sleeve or Lap band, I am wishing you the best in whichever decision you make.

Thanks again. I am starting to just do this without any surgery, because the sleeve staples same to be the problem for real. Your sister situation I'm thinking is the staples doing that. That's the one thing I can't put my thoughts around. Having my inside staple. After a while its sure to give you problems.

Now the band is what I want, however, the after maintenance is my problem. Being single with no help may not be good for me. The after care can become expensive. The insurance denied me 4 times, claiming I have no serious issues. My weight can be control with a good diet and exercise S.O.B. Been there done that. I need a darn tool.

Back to the hypoglycemia with sleeves and bypass patients. Yes, I've read that and also been told that by doctors. I actually have those episodes sometimes now. If I wait to long to eat, I get shakey, weak, and lightheaded. I usually eat Peanut Butter then I'm back to normal. I went to the doctor and they said, "I'm not diabetic nor hypertension." However, its my stubbornness that cause this.

I am not a Breakfast person. I get up at 7am off to work and eat like 3ish or 7ish at night. Its a bad habit I have. Then when I finally eat, its bad choices. And I eat lots of it. So, that's where I am guilty at. Anyhow, I'm rambling on. Thanks

[SandyM 1,956]

I had appt with surgeon yesterday and asked if he was going to stay in lapbanding and he said he still prefers it over all WLS. He said that the aftercare people seek and receive after banding is the very thing that skews it's success rate. He said if people were more compliant and surgeons were more on top of it, the numbers would show a lot better. He also said his wife and partner attended a WLS conference last week and surgeons there were saying they are seeing a lot more sleeve issues than in the past. After all, it's still pretty new. And like he said, what do you do about it after it's gone?

[Sydney Susan 333]

Nana said: her vomiting seems to be uncontrollable due to the staples in her stomach

Why would the staples per se make her vomit? People havw staples or clips for all sorts of operations - have had cancer I'm full of the darned things. I have impacts from the tissues that were operated on, but not from the staples themselves - they are specifically selected to be inert.

Do you mean her reduced stomach size causes her to vomit? Just like the lapband, eat too much or too fast and stuff will come back up. Personally I've never vomited (I have the sleeve), but I chew well and never gulp food.

As people have said, you have to work with whatever surgery you have - and getting the surgery you intuitively feel most comfortable with is a good first step to making that happen consistently.

[Sydney Susan 333]

(Dr) also said his wife and partner attended a WLS conference last week and surgeons there were saying they are seeing a lot more sleeve issues than in the past.

Do you have more information than this? It's hard to get good long term data (on decent population samples and with control groups), and anything that's available will be lapped up on this site.

[Sydney Susan 333]

Nan's said: Many people do not tell you the negative side effects of these surgeries, I am being honest.

The very best we can do on this site is be honest about our own surgery and post-surgery experiences... And not cast aspersions on others experiences. The fact is there are a great many experiences - they are all valid but none of them, individually, tell a reader what that person's experience will be if he/she decides to go ahead with a particular type of surgery. Encouraging a diverse range of comments makes that clear to readers.

[mistysj 1,940]

Stomach stapling is. It the same as the sleeve or bypass. Stomach stapling is a very old bariatric surgery that is not performed anymore. Staples in and of themselves are not the problem. For the sleeve, some surgeons don't even use staples. Some use dissolvable sutures. Some use staples for the initial closure, but suture over the staple line, completely covering it. This is to protect against leaks for the first 6-8 weeks until the suture line is totally healed. This is bet sleeve patients have a graduated diet from liquid back to solid, and this is why the (very small) risk of leaks goes down to nearly zero at the 6-week mark.

Please don't mix up your bariatric procedures when you are making decisions regarding surgery. You need all the facts.

[mistysj 1,940]

Oh and hypoglycemia and dumping are completely different things. Hypoglycemia is low blood sugar. It is related to diabetes. Dumping is a symptom of partially undigested food entering the intestine. It has to so with faster transit time between the stomach and intestines. It is rare. Very few RNY patients dump, and a vanishingly small number of Sleevers do.

[No game 14,437]

Yes misty and Susan usually I would urge people to read these forums for information. But after reading the amount of misinformation here in this thread alone? Not to mention several others, I would urge a person researching WLS look at independent sources for factual information.

[No game 14,437]

Sleeve Gastrectomy FAQ's

Can the staples tear out?

No. Once you have recovered from the surgery, your body's own scar tissue heals the stomach tissue together, just as your skin stays healed long after sutures or staples are removed. Staples are made of titanium. You can have an MRI scan, and you can go through the detectors at the airport without any problems.

AND TO THIS I SAY I HAVE TITANIUM RODS IN MY HIP FOR OVER 30 YEARS... And I'm still here

Video of the staples <a data-ipb='nomediaparse' href='http://m.youtube.com/watch?v=7MRWaAlaJF8&desktop_uri=%2Fwatch%3Fv%3D7MRWaAlaJF8'>http://m.youtube.com/watch?v=7MRWaAlaJF8&desktop_uri=%2Fwatch%3Fv%3D7MRWaAlaJF8</a>

What are the advantages of the operation over gastric bypass?

There is no rerouting of the intestines, and no new connections need to be made. This makes it safer, easier, and faster to perform. The lack of rerouting eliminates the late risk of bowel obstruction from internal hernia that comes with the gastric bypass operation. Finally, the lack of rerouting also reduces the risk of Vitamin and mineral deficiencies.

What are the disadvantages as compared to gastric bypass?

The main disadvantage is that we don't have long-term data to document that weight loss will be maintained. The operation is not reversible, in that part of the stomach is removed and thrown away. It can never be replaced. (On the other hand, there should be no reason to want to put it back).

What are the advantages of the sleeve over the gastric band?

With the sleeve there is no foreign body to break, slip, or erode. There is nothing to be adjusted. Reoperation rate for these complications is therefore eliminated. Weight loss is faster and more reliable with the sleeve. The feeling of fullness that you get from the sleeve is much more satisfying than the feeling of obstruction or discomfort that you get with the gastric band. Few patients vomit after the sleeve, while many patients continue to have vomiting episodes long after they have their gastric bands placed.

What are the disadvantages as compared to the gastric band?

The band is reversible; the sleeve is not. Unfortunately this turns out not to be much of an advantage of the band, as the only reason to remove a band is for complications.

Is removing the stomach safe?

This type of stomach removal has been performed with the Duodenal Switch procedure since the mid-1980s. It does involve stapling, just like gastric bypass, and has similar risks.

How much weight will I lose?

This is obviously a key question. Unfortunately, there is no long term data to give us a good answer. Preliminary data suggests that weight loss may be similar to that attained with Roux-en-Y gastric bypass.

[No game 14,437]

Stupid app double post

Once again OP do your research

[Madam Reverie 2,958]

Here is an academic overview of the various bariatric procedures with a bit of excess 'science stuff' thrown in. No opinion. No bias. Published 2012 by the UK Royal College of Physicians.

If anyone requires further clarification to the sources contained (hopefully its been copied successfully), please see the reference list at the end. This will provide you (licensing permitting) with a link to those original source documents so you can do your own further research/analysis.

Any questions or queries, please do not hesitate to ask.

Revs x

Overview of bariatric surgery for the physician

• Keng Ngee Hng, Specialty registrar in gastroenterology1 ⇓ and Yeng S Ang, Consultant gastroenterologist and honorary lecturer2

+

Author Affiliations

• ¹Salford Royal NHS Foundation Trust

²Faculty of Medicine, University of Manchester, Oxford Road, Manchester

• Address for correspondence: Dr KN Hng, 4 Fern Close, Shevington, Wigan WN6 8BL. Email:keng_ngee@hotmail.com

Abstract

The worldwide pandemic of obesity carries alarming health and socioeconomic implications. Bariatric surgery is currently the only effective treatment for severe obesity. It is safe, with mortality comparable to that of cholecystectomy, and effective in producing substantial and sustainable weight loss, along with high rates of resolution of associated comorbidities, including type 2 diabetes. For this reason, indications for bariatric surgery are being widened. In addition to volume restriction and malabsorption, bariatric surgery brings about neurohormonal changes that affect satiety and glucose homeostasis. Increased understanding of these mechanisms will help realise therapeutic benefits by pharmacological means. Bariatric surgery improves long-term mortality but can cause long-term nutritional deficiencies. The safety of pregnancy after bariatric surgery is still being elucidated.

Introduction

Obesity is a worldwide pandemic,1^–4 with the number of obese children and adolescents increasing alarmingly.5 This has serious health and socioeconomic implications due to the attendant increase in related comorbidities.1^,2^,4^,6 Obesity causes type 2 diabetes, hypertension, dyslipidaemia, cardiovascular disease, obstructive sleep apnoea, obesity hypoventilation syndrome, cancer, steatohepatitis, gastro-oesophageal reflux, gallstones, pseudotumour cerebri, osteoarthritis, infertility and urinary incontinence.1^–6 Severe obesity reduces life expectancy by 5–20 years.1

Diet, exercise and drug treatments for severe obesity have been disappointing.1^–3^,5^–12 At the present time, bariatric surgery is the only treatment that reliably produces substantial and sustainable weight loss.1^–7^,9^,13 It is indicated in people with BMI >40 kg/m² or with BMI >35 kg/m² in the presence of significant comorbidity.3^,5^,7^,14 Bariatric surgery is cost effective,3^,6^,15 achieving weight loss, as well as improvement or resolution of associated comorbidities.1^,2^,5^,6^,9^,15^,16 In the past decade, the development of centres of excellence,5^,6laparoscopic techniques,2^,5^,6 improved safety profiles2^,6^,9 and better documentation of clinical effectiveness2^,6^,15 have fuelled an increase in the number of procedures performed.

Types of surgery

Bariatric surgical procedures are traditionally classified as restrictive, malabsorptive or combined according to their mechanism of action. The procedures most commonly performed are laparoscopic adjustable gastric banding and roux-en-y gastric bypass.3^,13 Sleeve gastrectomy is increasingly performed.2^,6^,7 Biliopancreatic diversion and biliopancreatic diversion with duodenal switch are much more complex and performed infrequently.2^,5^,17^,22 Other historical procedures are no longer in common use.

In addition to restriction and malabsorption, recent evidence suggests that neurohormonal changes are an important effect of bariatric surgery.2^,6^,7^,17^,18 Bariatric surgery is only part of the management of severe obesity. Careful patient selection and preparation are extremely important, as are long-term compliance with diet, nutritional supplementation and follow up.2^,5^,6^,19

Laparoscopic adjustable gastric banding2

A purely restrictive procedure, laparoscopic adjustable gastric banding (LABG) is the least invasive procedure, is completely reversible and has the lowest mortality.19 A silicone inflatable band is placed around the stomach cardia immediately below the gastrooesophageal junction (Fig 1). This is connected to a subcutaneous port that is used for band adjustment.5^,6 The band compresses the cardia to generate a sense of satiety and reduced appetite, which is thought to be mediated via vagal afferents.2

Roux-en-Y gastric bypass (RYGB) is a combined procedure that is also performed laparoscopically. A 20–30-ml gastric pouch connected to the jejunum forms the Roux limb (Fig 2). The disconnected duodenal limb is anastomosed 75–150 cm along the Roux limb, forming a Y configuration. The distal stomach, duodenum and part of the proximal jejunum are thus bypassed.5^–7^,20 Despite the traditional classification of the this procedure, malabsorption is not significant with the standard RYGB surgery.7 In an extended gastric bypass, the Roux limb is lengthened to increase the malabsorptive component.6^,20

In sleeve gastrectomy, 60–80% of the stomach is removed along the greater curvature to leave a restricting ‘sleeve’ of stomach along the lesser curve (Fig 3).5^,20^,21 Originally the first step of the biliopancreatic diversion with duodenal switch (see below), sleeve gastrectomy has evolved into a staging procedure for super obese or high-risk patients.2^,5^–7^,20 It is also increasingly used as a standalone procedure.2^,6^,7

Biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPD/DS) are malabsorptive operations that result in bypass of most of the small intestine. With BPD/DS, a sleeve gastrectomy is performed, leaving the pylorus intact. The duodenum is then disconnected and the stomach anastomosed to the distal small bowel (the ‘duodenal switch’), creating a short alimentary limb. The long biliopancreatic limb is then anastomosed to the ileum 75–100 cm proximal to the ileocaecal valve, so digestion and absorption occurs only in the short common channel.5^,6^,20 With BPD, a partial gastrectomy leaves a 400 ml gastric pouch and the common channel is shortened to just 50 cm.5

Safety profile and complications

Bariatric surgery is safe.2^,5^,6^,9^,22^–24 High-volume centres of excellence deliver bariatric surgery with inhospital mortality of 0.14% and 90-day mortality of 0.35%, which is comparable to that for cholecystectomy.6 Acute complications, including haemorrhage, obstruction, anastomotic leak, wound infection, cardiac arrhythmias, pulmonary emboli, respiratory failure and rhabdomyolysis, occur in 5–10% of patients.5^,6^,9^,10^,25

Long-term complications include internal hernias, anastomotic stenoses, marginal ulceration, fistulae, diarrhoea, dumping syndrome, gallstones, emotional disorders and nutritional deficiencies.5^,6^,13^,15^,20^,25^–27 Patients with LAGB can experience port problems, stomal obstruction, band slippage/erosion, pouch dilation, gastro-oesophageal reflux and oesophageal dilation.5^,13^,19^,25 Malnutrition is a concern with BPD with or without DS.1^,17 Long-term risks for sleeve gastrectomy are unknown.5

The Longitudinal Assessment of Bariatric Surgery22 reported overall 30-day mortality of 0.3% for 4,610 patients having LAGB or RYGB for the first time, with 4.3% of patients having a major adverse outcome within 30 days. This was most frequent among patients having open RYGB (7.8%). A meta-analysis involving 85,048 patients reported a total 30-day mortality of 0.28% and a two-year mortality of a further 0.35%.24 The most complex malabsorptive procedures had the highest perioperative mortality at 1.11%. Mortality for gastric banding is between one in 2,000 and one in 5,700.2

Effects on weight, comorbidities and long-term mortality

After RYGB, patients lose 60–70% of their excess weight over two years, and this is largely durable.1^,2^,6^,9^,15^,16^,28 Weight loss is dependent on long-term compliance with dietary recommendations.2^,5^,6 Sugary, energy-dense foods and drinks can ‘bypass the bypass’. After gastric banding, patients lose about 50% (range 39%–59%) of their excess weight at a slower rate, often continuing into the fifth year.1^,2^,5^,6^,9^,19 Regular band adjustment is necessary.16 The Swedish Obese Subjects (SOS) study reported a reoperation or conversion rate of 31% for gastric banding and 17% for gastric bypass among patients followed for ≥10 years, excluding operations for postoperative complications.16 However, at the centre in Melbourne, only about 10% of patients after LAGB need some revisional procedure, including band replacement, in the following 10 years.2 Biliopancreatic diversion with or without DS produces excess weight loss of 70.1%9sleeve gastrectomy produces initial excess weight loss of 55%, but this may not be durable.2

Bariatric surgery also produces significant improvement in obesity-related comorbidities, with the most remarkable effect being resolution of type 2 diabetes (T2DM). A meta-analysis encompassing 22,094 patients reported complete remission of T2DM in 76.8% of patients,9 and a registry from the UK with data on 8,710 patients reported resolution of T2DM in 85.5% of patients.29 Major improvement often occurs within days after RYGB, before significant weight loss is achieved.5^–7^,17^,18 After LAGB, improvement in T2DM occurs more slowly as a result of weight loss.2^,7^,19 Combined or malabsorptive procedures produce greater improvement than purely restrictive procedures.1^,2^,5^,9^,18 Diabetes less than three years in duration, no insulin requirement, milder obesity with BMI <40 kg/m² and weight loss ≥10% predict complete resolution of T2DM.18^,19 Bariatric surgery is now advocated by some for the treatment of T2DM in patients with BMI <35 kg/m².4^,7^,30^,31

Bariatic surgery effectively treats all other associated comorbidities: from steatohepatitis and pseudotumour cerebri to urinary incontinence.1^–3^,5^,6^,15 Meta-analysis showed that hyperlipidaemia improved in ≥70% of patients, hypertension resolved in 61.7% (and resolved or improved in 78.5%) and obstructive sleep apnoea resolved in 83.6%.9 At five years, the risk of cardiovascular disease had decreased by 72%.3 The incidence of cancer also reduced markedly,6^,15^,16 as did the risk of developing new comorbid conditions.15 Long-term efficacy is well documented.5^,6^,28

At follow up after 10 years, the Swedish Obese Subjects (SOS) study showed a 29% reduction in adjusted all-cause mortality, primarily because of decreases in cancer and myocardial infarction.16A retrospective cohort study of 7,925 patients after RYGB reported a 40% reduction in all-cause mortality during mean follow up of 7.1 years.23 Specific mortality decreased by 56% for coronary artery disease, by 92% for diabetes and by 60% for cancer. A large observational study, in which the vast majority of patients had undergone RYGB, reported an 89% risk reduction in five-year mortality.15

Energy homeostasis and hormonal changes

Weight loss after bariatric surgery is not explained by volume restriction and malabsorption alone.17 Indeed malabsorption is estimated to account for only 5% of the weight loss following standard RYGB.17 Bariatric surgery causes significant changes in the neurohormonal profile, which contributes to sustained weight loss through changes in appetite, satiety, food preferences and eating patterns and explains the remarkable effect on T2DM.2^,5^–7^,17^,18

The hypothalamus32

Hormonal signals provide information about energy status to the hypothalamus. Adipokines are secreted by adipose tissue and enterokines by the gut. Incretins are enterokines that stimulate release of insulin after food intake.18 Two hypothalamic circuits influence food intake, and both contribute to acquisition and storage of nutrient energy. The homeostatic circuit increases appetite and locomotion in response to energy shortage. The hedonic circuit is engaged at stable weight plateaus in association with increases in body fat. It heightens finickiness to taste of food. Obese animals overeat palatable food but undereat bland foods and lose weight. In our current obesogenic environment, the hedonic circuit facilitates the seeking of energy-dense foods uncoupled from energy status.

Enterokines

Ghrelin,33 which is mostly synthesised in the stomach, is a potent appetite stimulator involved in hunger and meal initiation. Circulating levels are inversely proportional to BMI and respond to changes in body weight. Ghrelin enhances gut motility and speeds gastric emptying.17 It promotes lipid accumulation and weight gain, favouring glucose utilisation. It also inhibits insulin secretion and impairs glucose tolerance.18 Levels of ghrelin reported after bariatric surgery have been variable, which may be due to differences in surgical techniques and research methods.7^,18Overall, the trend is for a decrease in ghrelin levels after RYGB and an increase after gastric banding.7^,17 Sleeve gastrectomy, which removes most of the ghrelin-producing stomach, reduces levels of ghrelin.

Peptide YY (PYY)34 is secreted postprandially by L cells in the pancreas, small intestine and colon. It suppresses appetite and promotes satiety via signalling actions in the brain. It also delays gastric emptying (the ileal brake) and enhances insulin sensitivity.7 Secretion of PYY generally corresponds to the energy ingested, although it may vary depending on the macronutrient content.17Interestingly, levels also correlate positively with exercise intensity, with resulting decreases in food intake.

Glucagon-like peptide 1 (GLP-1) is co-secreted postprandially with PYY in the distal intestine.17 A powerful incretin, GLP-1 potentiates glucose-stimulated insulin secretion, enhances β-cell growth and survival, inhibits glucagon release and enhances all steps of insulin biosynthesis.7^,17 It also slows gastric emptying to produce greater gastric distension and helps regulate appetite and body weight.7^,17 Obese individuals have lower levels of PYY and GLP-1, and levels are decreased further in patients with diabetes.5^,17^,18

Two hypotheses exist to explain the hormonal and metabolic effects of the RYGB:

• the hindgut hypothesis
• the foregut exclusion theory.

The hindgut hypothesis postulates that after RYGB and malabsorptive procedures, rapid nutrient delivery to the distal gut L cells and their increased exposure to incompletely digested nutrients lead to an early and exaggerated PYY and GLP-1 response, contributing to early satiety, reduced meal size and early resolution of T2DM.7^,17^,18 Ileal transposition studies provide strong evidence for this. Interposition of an ileal segment into the proximal gut in rodents produced exaggerated PYY, GLP-1 and enteroglucagon responses, reduced food intake, weight loss, improved insulin sensitivity and overall improved glucose homeostasis.7

The foregut exclusion theory proposes that exclusion of the duodenum and proximal jejunum after RYGB is the mechanism that mediates the effects of bariatric surgery.7^,18 However, duodenal–jejunal bypass experiments in rats supporting this theory are compounded by the accompanying pyloric disruption that results in accelerated gastric emptying and rapid nutrient delivery to the hindgut.7 The endoluminal duodenal–jejunal sleeve also accelerates gastric emptying by abolishing duodenal osmoreceptor control of pyloric contraction.7 This 60 cm-long sleeve prevents nutrient contact with the duodenum and proximal jejunum, while biliary and pancreatic secretions flow outside the sleeve, delaying digestion.35

A possible mediator of the foregut exclusion theory is the gastric inhibitory polypeptide or glucose-dependent insulinotropic polypeptide (GIP), which is secreted by K cells in the duodenum in response to nutrient absorption.18^,39^,40 In addition to its incretin action, GIP promotes lipogenesis,41 with GIP receptor knockout mice protected against diet-induced obesity and insulin resistance,39 while antagonism of the GIP receptor improves glucose tolerance and insulin sensitivity and partially corrects pancreatic islet hypertrophy and β-cell hyperplasia.40 Levels of GIP are suppressed after malabsorptive procedures.18^,41

Adipokines

Adiponectin17^,36^,37 is synthesised primarily in adipose tissue, with levels inversely correlated with BMI. It is an important insulin sensitiser, and hypoadiponectinaemia causes insulin resistance and T2DM. Adiponectin also possesses antiatherogenic, anti-inflammatory and cardioprotective properties and may act centrally to modulate food intake and energy expenditure. Weight loss following bariatic surgery increases levels of adiponectin.

Leptin38^,32 is secreted by adipose tissue and regulates body weight via its action on the hypothalamus. It increases nocturnally to stimulate lipolysis but also increases postprandially to induce anorexia. In addition, leptin plays an important role in glucose homeostasis. Levels of leptin are proportional to body fat, with starvation or energy shortage activating the homeostatic mechanism in the hypothalamus to restore energy balance. However, leptin resistance develops in obesity. Weight loss from bariatic surgery reduces leptin levels.17

Many other enterokines and adipokines exist, some of which may also play a part in producing and sustaining weight loss or diabetes remission after bariatric surgery.17^,18 Understanding the mechanisms of action of bariatric surgery will help realise therapeutic benefits by pharmacological means.6^,7^,19

Nutritional deficiencies

Nutritional deficiency is common after bariatric surgery and the risk increases from LAGB through SG and RYGB to BPD with or without DS.20^,26^,31 The problem is heightened by the fact that micronutrient deficiencies are already highly prevalent in obese patients before surgery.21 After surgery, patients are at particular risk of deficiencies in Vitamins B₁, B₁₂, C, A and D and folic acid, as well as Iron, Calcium and Protein.20^,26 Lifelong prophylactic supplementation is often necessary, and regular monitoring is essential.26 Investigation of clinical syndromes resulting from malnutrition can be challenging.

Anaemia20^,27

After bariatric surgery, patients are prone to Iron deficiency because of intestinal bypass, pouch hypoacidity and intolerance of red meat. Obesity creates a state of chronic inflammation that can contribute to anaemia. Anaemia can also be caused by deficiencies in folate, Vitamin B₁₂, Vitamin E (haemolytic anaemia), copper (anaemia and neutropenia), Vitamin A and zinc. In refractory anaemia, gastrointestinal blood loss must be considered. Bleeding in the excluded stomach, duodenum or biliopancreatic limb is problematic as the usual endoscopic access route is no longer available.

Neurological problems6^,20

Neurological symptoms can result from deficiencies in thiamine, vitamin B₁₂, niacin, vitamin E and copper or from hypocalcaemia secondary to Vitamin D deficiency. Clinical syndromes includes Wernicke's encephalopathy, peripheral neuropathy, dry beriberi, neuropsychiatric beriberi, pellagra, ataxia, spasticity, myelopathy, muscle weakness, posterior column signs and ptosis.

Oedema6^,20

Patients with oedema may have underlying heart failure, which can also be due to wet beriberi (thiamine deficiency) or selenium deficiency. Hypoalbuminaemia may be caused by liver cirrhosis secondary to steatohepatitis; severe protein/calorie malnutrition; kwashiorkor; and diarrhoea secondary to bacterial overgrowth, malabsorption of bile salts and niacin deficiency.

Eye, skin and hair problems20

Vitamin A deficiency causes difficulties with nocturnal vision and reduced visual acuity. Vitamin E deficiency can cause retinopathy. Thiamine deficiency can present with blurred or double vision. Dry skin, pruritus and rash can be caused by deficiencies in Vitamin A, niacin, riboflavin, zinc and essential fatty acids. hair changes can be due to zinc deficiency or Protein malnutrition.

Pregnancy after bariatric surgery

About half of patients undergoing bariatric surgery are women of childbearing age,8 which introduces specific concerns. Obesity is strongly associated with infertility8 and increases the risk of obstetric complications.8 Yet the effects of rapid weight loss and potential malnutrition in pregnant patients are of concern.

Bariatric surgery improves fertility42^,43 and reduces the incidence of obesity-related complications such as gestational hypertension, gestational diabetes, pre-eclampsia and foetal macrosomia when compared with obese controls. The effect on premature delivery, miscarriage, intrauterine growth retardation, low birth weight and neural tube defects and the need for caesarean section are unclear.8^,43 Maternal surgical weight loss reduces the prevalence of obesity and cardiometabolic risk factors in offspring until the adolescent years.42

Pregnancy seems to have little effect on the surgically induced weight loss.8 Patients are generally advised to delay pregnancy until after the period of maximal weight loss (12–18 months).8 Extra vigilance in preconception, antenatal and obstetric care is required.

Conclusion

In summary, bariatric surgery is a safe and effective treatment for severe obesity and its associated comorbidities. It is particularly effective in the treatment of T2DM. Neurohormonal changes that affect appetite, satiety, glucose homeostasis and long-term energy balance contribute to its long-term efficacy. Two hypotheses exist to explain how hormonal changes produce these effects, and both may contribute. Patient adherence to postsurgical aspects of management is very important. Pregnancy after bariatric surgery brings additional considerations. Finally, the indications for bariatric surgery are being widened.

Acknowledgements

Dr Keng Ngee Hng is a specialty registrar in gastroenterology and has previously submitted part of this work for her Master of Science in gastroenterology (Salford University). Dr Yeng S Ang is the educational supervisor for Dr Hng and has refined the ideas, concepts and layout of the previous work. Recent updates are also included within this paper.

• © 2012 Royal College of Physicians

[Madam Reverie 2,958]

The system wouldn't accept the reference list attached to the rest of it - so here it is.

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[Sydney Susan 333]

Excellent article - thank you. Should be compulsory reading... I've never understood so many of the mechanisms, and that really helps me. We ought to post this on a lot of threads...

[Madam Reverie 2,958]

Excellent article - thank you. Should be compulsory reading... I've never understood so many of the mechanisms, and that really helps me. We ought to post this on a lot of threads...

You're more than welcome, Susan, happy to help. If there's anything else you'd like to know, please just shout x