Bariatric surgeries: which are the main ones and how they work
Bariatric surgeries: which are performed laparoscopically through 4 small incisions
Bariatric surgeries can be classified into
- restrictive: vertical gastroplasty, gastric banding, sleeve gastrectomy, bariclip, they are based on the reduction of gastric volume;
- mixed: gastric bypass, which reduces the volume of the stomach pouch and the intestinal surface area for absorption;
- malabsorptive: biliopancreatic diversion and mini gastric bypass, are aimed at reducing the size of the stomach by modifying the digestive process.
Sleeve Gastrectomy and Sleeve Gastrectomy with fundoplication
Sleeve Gastrectomy surgery consists of a partial vertical resection of the stomach (vertical partial gastrectomy).
The stomach is divided into 2 parts vertically using special mechanical sutures.
The left part of the stomach, which corresponds to about 80% of the whole stomach, is then removed.
The stomach that remains in place takes the form of a ‘sleeve’.
The remaining part of the stomach will have the same functions as before the operation.
This, in fact, does not change the physiological transit of food that is ingested, although accelerated gastric emptying is observed.
The operation is irreversible.
The Sleeve Gastrectomy variant with fundoplication, or Rossetti Sleeve or Modified Sleeve, developed by our team, differs from Sleeve Gastrectomy in the presence of an anti-reflux plastic (fundoplication).
In the years following sleeve gastrectomy surgery, the following complications may occur
- overeating, which can dilate the stomach, causing a continuous increase in pressure inside the gastric pouch: this results in the ability to introduce progressively more food, and thus a cessation of weight loss or recovery. Correction of the dilatation requires surgery again;
- post-operative bleeding, which may require reoperation;
- gastro-oesophageal reflux episodes up to actual reflux disease with the need to convert sleeve gastrectomy to a by-pass;
- functional disorders such as nausea, vomiting, intolerance to solid foods, which tend to self-limit with adequate nutritional advice and appropriate medical therapy;
- gastric fistula (early or distant), i.e. a small opening of the gastric suture: the fistula can be treated with an endoscopic approach (endogastric prosthesis or pigtail) or require reoperation.
Gastric plication in bariatric surgery
Plication represents a less invasive evolution of Sleeve Gastrectomy.
The restriction of the stomach is achieved by folding it in on itself and suturing a part of it.
In this way, an 80% reduction of the stomach’s initial capacity is achieved.
As with sleeve gastrectomy, the functions of the stomach, of which only the volume is reduced, are preserved and the physiological transit of the food that is ingested is not altered.
This type of operation is completely reversible.
The main complications due to gastric plication are:
- post-operative bleeding, which may require reoperation;
- laxity of the gastric suture, resulting in the ability to progressively introduce more food and thus a halt or recovery of weight loss. Correction requires reoperation.
Gastric bypass over a Roux loop
The classic operation consists of creating a small gastric pouch that does not communicate with the rest of the stomach, but is directly connected to the small intestine at a variable distance from the duodenum.
In this way, most of the stomach and the duodenum are completely excluded from the transit of food.
The effect of gastric bypass results in
- reduction in the amount of food introduced, whereby only a small amount of food needs to be introduced to achieve satiety;
- reduction of appetite, due to the arrival of freshly chewed food in a tract of the intestine that was not used to receiving it in this form;
- premature satiety of varying degrees;
- failure to absorb much of the food that remains undigested.
In the months and years following the operation, complications that may occur are:
- iron and/or vitamin B12 and/or folic acid deficiency anaemia: this is mainly linked to the exclusion of most of the stomach and the entire duodenum from food transit. This complication can be prevented or corrected by oral, intramuscular or intravenous administration of the deficient substances;
- calcium-deficiency osteoporosis, also due to the fact that food no longer passes through the duodenum, the main site of its absorption. Oral supplementation may be necessary;
- ulcer at the point where the stomach joins the intestine (anastomotic ulcer): this rare complication, more frequent in smokers and drinkers, is usually prevented or corrected with medical therapy, but may require surgery again;
- intolerance to the intake of certain foods, especially liquids with a high concentration of sugars, which manifests itself with sweating, a sense of exhaustion, palpitations and possible fainting (dumping syndrome). This symptomatology is transitory and subjective: it resolves itself by following the dietary-behavioural rules indicated by the team;
- internal hernia that leads to intestinal blockage and often requires surgery.
Bariatric surgery: the Mini Gastric Bypass
The operation consists of the creation of a small vertical gastric pouch, designed to receive food and no longer communicating with the rest of the stomach, which is however left in place.
Similar to the gastric bypass, in the mini gastric bypass the stomach and duodenum are completely excluded from the transit of food.
The decrease in body weight is brought about by the mechanism of reducing the amount of food introduced and by an early feeling of satiety of varying degrees.
In the course of the months and years following the operation, in addition to the side effects common to By pass, biliary reflux gastritis may occur, which can be corrected with medical therapy, but in exceptional cases may require surgery again.
Gastroplasty with Clip (BariClip)
Gastroplasty with a Clip (BariClip) is a very recent reversible surgical technique with a laparoscopic approach that consists of placing a titanium, silicone-coated clip on the stomach.
The clip divides the stomach into 2 vertical portions and, once closed, acts by creating a gastric pouch, through which food can pass, and ‘excluding’ the rest of the stomach.
There is therefore, as in sleeve gastrectomy, no removal of part of the stomach: the clip is placed with sufficient pressure on the gastric walls to keep the formed gastric pouch closed, without causing ischaemia, ulceration or injury to the treated region.
The aim, as with the sleeve, is to promote an early feeling of satiety, thus decreasing the desire for food and limiting the volume of food consumed.
The data from the studies carried out so far in the medium term are encouraging: at more than 3 years, more than 92% of patients have improved their quality of life as a result of the weight loss following the intervention.
Some data also seem to indicate a lower risk of developing gastric reflux problems post-surgery. Finally, complications in the immediate postoperative period, such as fistula, are reduced to zero.
Precisely because of the experimental nature of the procedure, there are particular indications for this type of treatment.
In particular, the following are eligible for this procedure
- patients with a higher risk of fistulas, such as diabetics, dialysis patients;
- those who have been on corticosteroid therapy for a long time;
- those who have a BMI between 30 and 40 and who do not need a major weight loss;
- those who do not want to undergo an irreversible procedure.
The follow-up of bariatric surgery
The follow-up, i.e. the period after surgery in which patients undergo regular check-ups, is as important as the surgery itself for achieving the goals of bariatric surgery.
The follow-up visit consists of an interview with the surgeon, the dietician and possibly the psychologist.
Visits are scheduled at 1 month after surgery, at 3 months, at 6 months, at 1 year and from the first year onwards, every year.
Through interviews and the evaluation of blood tests it is possible to
- follow the progress of weight loss
- make corrections in eating habits
- correct any treatment;
- prevent, identify and treat the occurrence of any long-term complications of surgery.
A patient who does not scrupulously adhere to check-ups exposes himself to the risk of developing even severe complications that could have been avoided with the surgeon’s or dietician’s instructions.
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