Overview of Obesity Surgery Indications and Contraindications
In the United States, about one in three adults and nearly one in six young people are affected by obesity. This condition increases the risk of other health problems such as heart disease and type 2 diabetes. Traditional treatments for obesity, such as diet and exercise, often fail, but surgical solutions have shown significant success.
Weight loss surgery has been proven to not only help with weight loss, but also the additional health problems that often come with obesity. Research has shown that, compared to non-surgical treatments like diet and exercise, weight loss surgery has long-term benefits for people with obesity.
Anatomy and Physiology of Obesity Surgery Indications and Contraindications
To comprehend how weight loss surgery works, it’s crucial to understand the changes it makes to your digestive system. There are two main types of weight loss surgery that are most often recommended today: Laparoscopic sleeve gastrectomy (LSG) and Laparoscopic Roux-en-Y gastric bypass (LRYGB).
LSG is a simpler type of surgery. In this procedure, the surgeon removes a large portion of the stomach, leaving behind a much smaller, tube-shaped stomach, or ‘sleeve’. This new, smaller stomach means you can’t eat as much as before, so you’ll take in fewer calories. You’ll feel full after eating much smaller meals because your stomach is now significantly smaller. Plus, the surgery removes parts of your stomach that make some of the hormones that signal hunger to your brain. So, not only does the smaller stomach size help with weight loss, but changes in your hormone levels can also make you feel less hungry.
LRYGB, the second type of surgery, is more involved and changes the path that food takes through your digestive system. In this procedure, your stomach is divided into a smaller pouch. This pouch is then connected directly to a lower part of your small intestine, skipping a big portion of it. This makes a new path for your food and avoids a part of your intestine that absorbs calories. Therefore, you get fewer calories from the foods you eat.
There are also other theories about why this type of surgery can lead to weight loss. Some researchers think it might change the types of bacteria in your gut, alter the substances that help to digest your food, or change how your body uses energy. These theories are based on animal studies and more research is needed to understand exactly how these changes might contribute to weight loss. Despite much research, the complex benefits of weight loss surgery are difficult to replicate with medications alone.
Why do People Need Obesity Surgery Indications and Contraindications
If someone is considering weight loss surgery, also known as bariatric surgery, several factors need to be considered. One of these factors is a person’s body mass index (BMI). The BMI is a measure that uses your height and weight to work out if your weight is healthy.
People who have a BMI at or above 40 can be suitable candidates for weight loss surgery, even if they don’t have any other health issues. This is as long as the surgery wouldn’t put them at too high of a risk.
Individuals with a BMI equal to or more than 35 may also be eligible for weight loss surgery. This applies particularly if they suffer from serious health issues related to obesity. These can include type 2 diabetes, high blood pressure, high blood fat levels, sleep apnea, non-alcoholic fatty liver disease (a condition where fat builds up in the liver), acid reflux, asthma, venous stasis disease (a condition that affects blood flow in the legs), severe urinary incontinence, debilitating arthritis, or if their quality of life is considerably affected.
In some cases, people with a BMI between 30 to 34.9 who have diabetes or metabolic syndrome (a group of conditions that puts them at risk for heart disease and stroke) can also get weight loss surgery. However, more research is needed to show whether these individuals could experience long-term benefits from the procedure.
When a Person Should Avoid Obesity Surgery Indications and Contraindications
While there is no absolute reason why a person cannot have a bariatric surgery, there are certain conditions (referred to as relative contraindications) that can make it risky. These include severe heart failure (when the heart doesn’t pump blood properly), unstable heart artery disease (problem with major blood vessels supplying the heart), end-stage lung disease (severe lung problems), treatment for active cancer, portal hypertension (high blood pressure in a major vein called the portal vein), addiction to drugs/alcohol, and inability to understand or make decisions fully.
If a person has Crohn’s disease (a chronic inflammatory condition of the digestive tract), it might make LRYGB (a type of weight-loss surgery) more risky.
Also, these surgeries require general anesthesia (a medicine that makes people unconscious during the surgery). So, if a person can’t receive general anesthesia due to some reason, they would also have a risk associated with these surgeries.
Equipment used for Obesity Surgery Indications and Contraindications
Both the LSG (Laparoscopic Sleeve Gastrectomy) and LRYGB (Laparoscopic Roux-en-Y Gastric Bypass) surgeries require a variety of surgical tools and instruments. These surgeries are almost always performed using a method called laparoscopy, which is a minimally invasive surgery that uses a small camera and thin instruments. This process requires standard tools for laparoscopic surgery such as a device for inflating the abdomen with CO2 gas, portals called trocars for inserting the instruments, cameras, and TV monitors to visualize inside the body.
Various laparoscopic tools are used, including needle drivers for handling sutures, non-traumatic bowel graspers for handling delicate tissue, cautery devices for cutting and sealing tissues, a liver retractor for safely moving the liver, a disposable bag for collecting tissue samples, suturing devices for stitching, shears, and other tools designed for handling tissue within the abdomen.
In addition, either the anesthesiologist or an assistant will stand near the patient’s head and introduce an instrument like a bougie or an endoscope to define the areas where the stomach and intestine need to be cut and sealed. This ensures that the newly-created channels are not too narrow for food and liquid to pass through. The endoscope also allows the doctor to inspect the digestive tract from the inside to ensure that everything is in order and perform a leak test, in which air is blown into the new stomach or pouch to confirm they are sealed properly.
After the stomach reduction or bypass surgery is complete, the trocars (usually 5-6 small access points) are removed. An absorbable type of thread or suture is used to close the different layers of the surgery site, from the innermost draft layer (the fascia) to the outermost layer (the skin). The skin incisions themselves usually range between 5 and 12 millimeters, and a skin adhesive or steri strip is used to seal the skin.
Who is needed to perform Obesity Surgery Indications and Contraindications?
The operation will involve the usual team found in an operating room. This team includes a nurse who moves to different areas (circulates) in the room to coordinate the operation, a scrub tech (person who arranges the surgical tools), an anesthesiologist (doctor who gives medication to make patients sleep and not feel any pain during surgery), a surgeon, and 1 or 2 surgical assistants. These assistants could be other doctors in training (residents), physician assistants, or students.
For this operation, one person will handle the camera that allows for viewing inside your body while the surgeon and an assistant will conduct the actual surgery.
There is also a nurse dedicated to caring for you before the surgery (pre-operative) in the holding area and another nurse will be there for you after surgery (postoperative) in the recovery area. Most patients who undergo this procedure typically need to stay in the hospital for 1 to 2 days after surgery. This duration can depend on the kind of surgery done and how well the patient is recovering.
Preparing for Obesity Surgery Indications and Contraindications
Obesity surgery, like any other surgical procedure, requires significant preparation to ensure the best possible results. Such preparation involves several healthcare professionals such as psychiatrists or psychologists, nutritionists, doctors, and social workers. They all play crucial roles in getting the patient ready for the surgery. Many patients also attend group classes where they learn about the lifestyle adjustments they’ll need to make and what to expect before, during, and after surgery.
The attention given to mental and nutritional readiness for the surgery is just as important as understanding the physical changes and surgical procedures. This preparation process, which often takes around six months, is standard procedure that patients should anticipate when considering obesity surgery. It’s a team effort with each healthcare professional working together to ensure the patient’s health and success in their journey towards overcoming obesity.
How is Obesity Surgery Indications and Contraindications performed
There are two types of surgeries – LRYGB and LSG – that surgeons use to help people lose weight. While the specifics can vary slightly depending on the surgeon’s training and preference, the overall goals of these surgeries are the same.
Both surgeries start in a similar way. The surgeon first pumps a harmless gas called Carbon Dioxide (CO2) into your belly to make the space inside your abdomen larger, kind of like inflating a balloon. This can be done using either a special needle (Veress needle) or a trocar (a medical device used to access cavities in the body) . This helps to give the surgeon a clearer view of your stomach and the organs around it. Then, small cuts (5 to 12 mm in length) are made in your belly, and instruments are inserted through these small openings (called “ports”). This is how the surgeon can operate inside your abdomen without making a big cut. A device is then placed through one of these openings to lift the liver and expose the stomach and its surroundings. The arteries supplying blood to the stomach are divided with an instrument that both seals and cuts tissue.
The rest of the procedure varies depending on whether the surgeon is performing an LRYGB or an LSG. The LRYGB is a bit more complex. First, the surgeon marks a certain distance from the beginning of the small intestine. This portion of the intestine is cut with a stapling device. The severed lower part of the intestine is then stitched up to a newly created, smaller stomach pouch. This creates a new pathway for food to pass directly from this mini stomach to the small intestine, bypassing a portion of it. Then, the upper part of the cut intestine is attached to another part of the small intestine, farther downstream, allowing digestive juices to join the food. This ensures that the digested food continues to move in the right direction.
The LSG procedure is generally simpler. The lower part of the stomach is cut and removed using a stapler. The surgeon checks to make sure the staple line is intact and that there is no leaking. Unlike in the LRYGB, no new pathways or bypasses are created during an LSG.
After both types of surgeries, the gas used to inflate the abdomen is removed, and the small openings in the abdomen are closed. The patient then wakes up from anesthesia. The type of staplers used, the technique of sewing, and other details might differ from surgeon to surgeon, but, overall, the effects and changes inside your body after the surgeries are pretty much the same no matter where you have the surgery.
Possible Complications of Obesity Surgery Indications and Contraindications
Weight loss surgery, like any surgery, can come with complications. These can happen during the surgery, right after the operation, or even years later. Complications during surgery are rare, but can include problems due to anesthesia, injuries to organs like the bowels, spleen, or liver, or harm to major blood vessels. These injuries could be caused by the surgical instruments used, mistakes made during surgery, or complications related to the patient’s body shape. The risk is usually the same as other similar types of surgeries; but those having weight loss surgery may have a slightly higher risk because of their existing health conditions.
Problems during surgery occur very infrequently, in about 1% of cases. Serious issues like heart attacks, blood clots in the veins or lungs, and heavy bleeding are extremely rare, but can occur. A certain type of weight loss surgery, known as LRYGB, carries a slightly higher risk for these complications.
The most common issue after surgery is something called an anastomotic leak. This happens when there’s a leak around the region where the bowel or stomach has been stitched or stapled. It usually happens in the first week after surgery and can cause symptoms like a fast heart rate, fever, difficulty breathing, and abdominal pain. If it’s not treated quickly, it can lead to very serious problems, such as severe infection or even death. These leaks must be treated with surgery to repair the leak, antibiotics, and not eating anything by mouth for a while.
Another potential problem after surgery is an infection at the surgical site, which happens in about 1% of cases. Using antibiotics reduces this risk. Another severe but rare issue is a blood clot in the lungs, which is the most common cause of death after surgery. Many doctors will give patients medication to prevent blood clots for up to a month after surgery to reduce this risk.
Other complications can occur years after the surgery. There could be internal hernias, which happen when the bowels move into a unintended space in the belly created during surgery. This could cause the bowel to get blocked or have blood supply cut off, and needs to be treated urgently with surgery. Another issue is marginal ulcers, which are sores that form where the small intestine is joined to the stomach pouch. If these ulcers go through the entire wall of the stomach or intestine, it’s a medical emergency and needs to be treated like a leak.
These are serious risks, and both the doctor and patient need to be aware of them when considering weight loss surgery. However, well-established weight loss surgery centers report less than 5% complication rates. Surgeons at these centers follow strict protocols and techniques to repeatedly achieve successful results.
What Else Should I Know About Obesity Surgery Indications and Contraindications?
Obesity is now considered a major health problem and is becoming increasingly common. Fortunately, advancements in medical technology, particularly in the field of weight-loss surgery, offer potential solutions to this issue. Two types of weight-loss surgeries – Sleeve Gastrectomy (LSG) and Gastric Bypass (LRYGB) – have been shown to consistently help people lose weight and improve their health.
However, it’s important to understand that not everyone who is overweight is a suitable candidate for these surgeries. Various factors need to be taken into account before deciding to go ahead with such a procedure. While there’s a risk of complications, most patients do well after the surgery. Moreover, for many, it helps them not only to lose weight but also to overcome other obesity-related health issues.
Anyone considering this option should be fully educated about it. It is the role of doctors to ensure their patients are aware that this treatment is available. The strides that have been made in this area of medicine over the past few years are certainly promising.
