Weight loss surgical procedures, in one form or another, achieve the desired effect of weight loss by altering absorption of fat, protein, and carbohydrates. This results in decreased total absorption of required calories.
An unintended consequence is the altered absorption of medications. Frequently I am asked about the specific medication. Usually the answer is vague since the information is limited on specific medications. If the desired effect is not achieved, then it is probably not being absorbed well. Specially, if the same dose of the same medication working well before surgery.
There is a summary article about the Theoretical absorption pattern of different weight loss surgical procedures.
Sleeve gastrectomy (SG) is the most commons performed weight loss surgery in the US. There is a subset of patients for which Sleeve Gastrectomy will be inefficient/ineffective. Sleeve Gastrectomy failure may be defined as inadequate weight loss or weight regain. However, in some cases this may also include non resolution of some of the co-morbidities of obesity, and/or recurrence of others.
Biertho, et. al, (Surgery for Obesity and Related Diseases 14 (2018) 1570–1580) Published a study titled “Second-stage duodenal switch for sleeve gastrectomy failure: A matched controlled trial” where 118 patients were decided in two groups. One group had the duodenal switch as a singe procedure, and the second group had the sleeve gastrectomy followup by the second stage duodenal switch. They concluded that “Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed.”
They showed that the remission rate of the obesity related co-morbidities were improved.
The weight loss rate that had stopped, or in some cases where weight gain had been noted, were both reversed where by at at average of 24 months after addition of the DS to the SG patients would experience additional 39% Mean excess weight loss.
With regards to alternative approaches they indicate “ Other forms of revisions have been described, (i.e., adjustable or nonadjustable gastric band, plication, endoscopic balloon), with limited scientific evidence on their efficacy or safety. These procedures are mostly considered investigational and should be performed under Ethical Review Board approved protocols.”
In summary, patients may be offered a number of alternative if they are experiencing weight regain, inadequate weight loss, or return of co-morbidities after sleeve gastrectomy failure. We have seen a variety of them in our office. Patients who have had band placed on the sleeve, or are scheduled to have gastric balloons placed. As I have always said, buyers beware and know your outcomes and resolution of co-morbities.
Duodenal switch operation, (not the single anastomosis look alike) results in sustained weight loss and resolution of the co-morbidities. A second stage Duodenal Switch can mean adding the intestinal procedure to an existing Sleeve Gastrectomy. Some patients have required an adjustment to their Sleeve Gastrectomy in addition to adding the Duodenal Switch intestinal portion. Finding the right balance for each patient is a crucial part of our practice.
The American Society for Metabolic and Bariatric Surgery (ASMBS) and MBSAQUIP-A on March of 2019, published and updated list of “Endorsed Procedures and Devices”
Note that any surgical procedures that does not employ two anastomosis, are not endorsed and are only recommended to be performed with an IRB (Institutional Review Board) or an IRB exemption. Duodenal Switch, Sleeve Gastrectomy, Roux en Y Gastric Bypass, Gastric Balloon, Adjustable Gastric Banding, and Nerve Blocking which are endorsed procedures.
SIPS, SADI-S, SIPS, Loop DS are all in the category of the “Non-Endorsed Procedures and Devices”. To see an anatomical comparison of these procedures to the Duodenal Switch procedure.
Patients should request that their consent be clearly defined and should explicitly outline the procedure that is being proposed to them. This is to avoid a patient having a procedure that they assumed, or are led to believe to be a Duodenal Switch operation with two anastomosis. Do your due diligence and know the procedure you want. Investigate if the surgeon you are working with performs the procedure you are interested in. Have them draw a picture of the procedure or give you a diagram of the procedure.
There are differing opinions, based on a broad set of scientific publication, wether or not gallbladder should be removed at the time of weight loss surgery. Obviously, Cholecystectomy is a stand alone general surgical procedure that is often performed due to gallstones and/or gallbladder disease with a variety of symptoms. However, the focus of this blog will deal with Bariatric Surgery and Cholecystectomy.
Rapid weight loss can increase a patients chance of forming gallstones. This rapid weight loss can be as little as 3-5 pounds per week. Weight loss surgery can increase your risk for gallstone formation. Several of the common thought processes the mechanism of this is, obesity may be linked to higher cholesterol in the bile, larger gallbladders, high fat diet and larger abdominal girth.
When a patient is having the Duodenal Switch (DS) Bariatric operation, or having a revision of a failed gastric bypass to the DS, I always remove the gallbladder. This is because there isn’t an anatomical route to utilize endoscopic procedure for an ERCP should the need rise.
In the case of a patient undergoing Vertical Sleeve Gastrectomy, if there are any indications or complaints of abdominal pain then an ultrasound is done. If there are findings of gallstones or other disease of the gallbladder, then a cholecystectomy is performed at the same time as the Sleeve Gastrectomy.
In my opinion, every patient having the Gastric Bypass (RNY) should also have the gallbladder removed because of the anatomical limitations after surgery that prevents the use of ERCP if needed. Some clinicians will place the patient on a long term medications to reduce the chance of gladstone formation after surgery, which themselves have side effects limiting the compliance in most patients.
Further information on Common Bile Duct Dilatation and ERCP
PolyCystic Ovarian Syndrome PCOS is a complex condition. The exact cause of PCOS is unknown however, it involves hormones imbalance and multiple ovarian cysts, irregular menses, and infertility. In some cases, PCOS can be compounded by diabetes, hypertension and other metabolic conditions. PCOS has been shown to effect approximately 10% of women of childbearing age with symptoms of menstrual abnormalities, poly cystic ovaries, and excess androgen (male sex hormone). PCOS should be diagnosed by ensuring there are no other underlying endocrine issues. There are several associated disease processes that seem to be related to PCOS. These related disease processes are Type 2 Diabetes, higher depression and anxiety, increased cardiovascular risks, stroke, hyperlipidemia, sleep apnea, overall inflammation, and endometrial cancer.
Anatomically, numerous cysts are found on the ovaries. These are usually diagnosed by ultrasound, blood levels of hormones, and symptoms described above.
Bariatric Surgery and PolyCystic Ovarian Syndrome PCOS
Bariatric Surgery can improve PCOS in those individuals with Type 2 Diabetes Mellitus. Further information on weight loss surgery and its effect on PCOS here.
A few times a month during consultation for weight loss surgery , I’m ask as to why I do not offer the adjustable gastric banding as an alternative to the patients. As I have said over the years when a patient considers an weight loss surgery the totality of the risk should be considered. This includes the operative, immediate postoperative course, the maintenance and the follow-ups needed. The potential complications of the procedure in addition to the long-term success off each operation should also be taken into account.
Unfortunately, some patients are led to believe that any perceived benefit in the short operative time and the ease of the adjustable gastric banding also translates to a better outcome. This is in fact the opposite of what the published data have shown, a recent study published in April 2017 by Vinzes et.al, shows that 71% of patient lost their band by 10 years out.
More importantly, The patients who underwent a revision from failed AGB to the duodenal switch operation had the best long term results of all patients (Fig 2.) note the “rBPD” line that is the highest of %EBMIL.
Complication’s were broad and frequent (Table 3.)
Further information on revision from failed AGB to Duodenal Switch or other failed weight loss surgeries can be found here.
It is interesting to encounter patients who are still being recommended for Lap Band placement to treat morbid obesity. There is a vast body of scientific evidence supporting that Lap Band not only does not result in a sustained weight loss for majority of the patients, but that it results in significant long term complications for some.
One of the complications is a significant stricture (narrowing) where the band is located even when it is completely empty. This is cause by:
1- either scarring of the tissue around that band causing a “belt” effect around the stomach, or
There are numerous other complications that are associated with Adjustable Gastric Bands that encompass a wide range of areas that are not discussed in this blog. This recent article (yes another one) outlines the dismal long term outcome of the Adjustable Gastric banding- Buyer Beware.
For years, we have seen patients who have had Adjustable gastric bands placed and continue to suffer from the complications associated with it. Gastric Band complications include erosion, persistent nausea, vomiting abdominal pain, inadequate weight loss and weight regain, etc. . Unfortunately, when seeking help, they are often told that this never happens to others and that complications are a rare occurrence. Let’s remember that the Adjustable Gastric Band was promoted and sold as a procedure with almost no down side, low risk and easily revisable!
There is an unfounded expectation that the band can be deflated and all the Gastric Band complications will resolve. This could not be any further from the truth. The reality is that there are patients whose symptoms may somewhat improve but will continue to have the abdominal pain, the nausea and or vomiting-albreit, not to the same intensity. There are several Gastric Band complications that are considered emergency situations that require immediate attention by a physician.
Our position has always been, and continues to be, that all Adjustable Gastric Bands should be removed by a surgeon who is experienced with the Gastric Band complications and revisions.
A slipped Band emergency
This patient had a Adjustable Gastric Band (AGB) or LapBand place approximately 7 years ago. The last time this patients had a follow up with the surgeon who placed the AGB was 5 years ago. The patients has been having reflux, episodes of Nausea and vomiting on and off for about 2 years requiring multiple medical visits and procedures. He/she has had upper endoscopies, not by the surgical team and was diagnosed with esophagitis.
This patient presented in the Emergency Room with projective vomiting for 24 hours, bloody emesis, and significant dehydration. After obtaining the necessary tests and X-ray studies a plan was constructed. At this time, due to the continuous and significant nature of the symptoms this patient was taken to the Operating Room for emergency AGB removal.
The abdominal X ray showed a slipped band. Following a complicated surgical procedure, the band was removed and a segment of the stomach that had eroded into the stomach was removed. The photograph below shows the end result with a portion of the stomach removed due to the band’s erosion into the stomach.
Additional information regarding complications of Adjustable Gastric Banding here.