Metabolic and bariatric surgery has progressed beyond 'experimental' weight-loss surgery. As procedures have progressed over the last few decades, so has the volume of research and data demonstrating that both weight reduction and metabolic health improvement are induced.
Because of the changed gut structure and associated good metabolic benefits, metabolic surgery has become a more acceptable word for weight-loss surgery. Despite the fact that metabolic surgery is a highly refined procedure, a large portion of the world population does not have appropriate access to it.
This clinical update seeks to inform healthcare practitioners from all disciplines about the numerous benefits of metabolic surgery and equip them with the information needed to bridge the gap between patients in need of metabolic therapy and the metabolic surgery therapies accessible to them.
Metabolic/bariatric surgery is the most successful and long-term treatment for extreme obesity, resulting in considerable weight loss as well as the improvement, prevention, or remission of many associated disorders such as type 2 diabetes, heart disease, hypertension, sleep apnea, and some malignancies.
Obesity-Related Health Problems
1. Types 2 Diabetes Mellitus (T2DM):
T2DM occurs later in life than Type 1 (or juvenile) diabetes and is connected with obesity. Insulin, the hormone that regulates blood sugar, is generated; however, the tissues that typically break down and store sugar are not as responsive to insulin, resulting in high insulin levels as well as high sugar levels. Some obese children and adolescents acquire T2DM at a young age.
This is a chronic condition that worsens with time. Diabetes puts children at risk for high blood pressure, high cholesterol, and liver damage. Uncontrolled T2DM can lead to premature heart disease, renal failure, eyesight loss, and death. According to research, adolescents who undergo bariatric surgery can greatly improve or may no longer have T2DM, and bariatric surgery is significantly better than medication alone.
2. Obstructive Sleep Apnea (OSA):
Obstructive sleep apnea affects up to 22% of obese children and adolescents (OSA). This medical condition is distinguished by loud snoring or pauses in breathing while sleeping. Sleep apnea scan causes daytime tiredness, difficulty focusing at school, and behavioral issues. Tonsil removal surgery is commonly performed on children and teenagers to assist cure sleep apnea, but if obesity is not managed, it will likely recur. Obstructive sleep apnea has been observed to improve or disappear in many people following bariatric surgery when their weight improves.
3. Idiopathic Intracranial Hypertension:
Idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri, is a medical condition characterized by elevated pressure inside the skull. Headache, visual abnormalities, tinnitus, nausea, and vomiting are all possible symptoms. This syndrome typically has no evident origin, however, it has been linked to obesity, and symptoms frequently improve within months after following bariatric surgery.
4. Quality of Life:
Many obese children and adolescents believe that their weight and health difficulties are affecting their quality of life and emotional health. This might be as a result of taunting, bullying, or the physical strain of carrying additional weight. Several research studies in children and adolescents have showed a considerable increase in quality of life following metabolic and bariatric surgery.
5. Eating Disorders:
Binge eating and purging (also known as bulimia nervosa) has been observed in certain obese teens seeking bariatric surgery. There has been little study on the results of bariatric surgery in teens with eating problems. As a result, metabolic and bariatric surgery should be considered only if the kid is stable and receiving ongoing treatment for this disorder.
6. Cardiovascular Disease:
We are continuously learning about the risk factors for heart disease in obese children. Obesity in children has been linked to an increased risk of heart and vascular disease in adults, according to research. Bariatric surgery-induced weight loss has been shown to improve some of these risk variables in adults. However, measuring these impacts in children and teenagers would require several years. In this field, studies are still being conducted.
Obese children and teenagers are more likely to be depressed. Adolescents who have metabolic and bariatric surgery frequently experience improved emotional well-being. Adults, on the other hand, appear to be at slightly elevated risk of suicide following bariatric surgery, according to research. We recommend that children with depression be treated and stabilized before to surgery, and that they be closely followed for symptoms of depression after surgery.
What is Metabolic Surgery?
Metabolic, or bariatric, surgery is a surgical treatment used to aid in weight loss or cure metabolic problems. This includes a sleeve gastrectomy, which involves dividing and stapling a patient's stomach in a way that limits how much food can be consumed and absorbed by the body; and a Roux-en-Y gastric bypass, in which a surgeon greatly reduces the size of a patient's stomach and reattaches it in a way that limits calorie absorption.
Does It work?
Studies continue to suggest that metabolic surgery can assist patients in losing and maintaining weight while also lowering or controlling obesity-related health issues. Patients can lose up to 75 percent of their excess weight in a year and, on average, keep off 50 percent of their excess weight after five years.
Furthermore, according to a 2004 research published in the Journal of the American Medical Association, the majority of bariatric surgery patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea had their problems improve or disappear following surgery.
Who Can Have Metabolic Surgery?
- You are over 100 pounds over your optimal body weight.
- You have a Body Mass Index (BMI) more than 40.
- You have a BMI more than 35 and are suffering from serious health issues as a result of being excessively overweight, such as high blood pressure or diabetes.
- Even with medical supervision, it is difficult to maintain a healthy body weight for an extended period of time.
Diabetes treatment with bariatric surgery:
- If you have a BMI of 35 or above, type 2 diabetes, and/or other conditions associated with excess weight, and you haven't been able to reach normal fasting blood sugar (less than 125 mg/dl or HbA1c less than 7%), you may be a candidate for diabetes surgery.
- In some cases of inadequately controlled diabetes, patients may be eligible for bariatric surgery even if they have a BMI of less than 35.
Benefits of Metabolic Surgery
Losing and regaining weight has little effect on the possible health risks associated with obesity. To consider the weight reduction a success and one that can result in a happier, healthier you, you must keep it off for a minimum of five years.
The advantages of bariatric surgery extend beyond simply decreasing weight:
- Long-term remission of type 2 diabetes. According to one research, bariatric surgery leads to long-term remission of type 2 diabetes. The findings of this study suggest that the operation is very beneficial for obese individuals with type 2 diabetes, with virtually all patients being free of insulin and other associated drugs for at least three years following surgery.
- Cardiovascular health has improved. A person's risk of coronary heart disease, stroke, and peripheral heart disease is reduced with weight loss surgery. Furthermore, one research found that the weight reduction after the operation can help reduce the risk of mortality related with stroke, hypertension, and myocardial infarction. After surgery, blood pressure and cholesterol levels can recover to normal or near-normal levels, lowering these risks and increasing general well-being.
- Depression relief. Many obese persons are sad as a result of their negative body image and social stigma. Even younger individuals who are significantly overweight find it difficult to engage in activities that they might normally like, leading to social isolation and depression.
- Get rid of obstructive sleep apnea. Getting and keeping a normal weight helps patients with sleep apnea to quit using a CPAP machine at night. One year following surgery, around 80 to 85 percent of patients have remission of their sleep apnea.
- Joint pain relief. Excess weight puts a lot of strain on your weight-bearing joints, which can lead to persistent discomfort and joint deterioration. Significant and sustained weight reduction after bariatric surgery lowers joint stress and typically allows individuals to discontinue pain medicines and experience considerably greater mobility.
- Increase fertility. Weight loss surgery can also increase fertility during pregnancy. One research found that bariatric surgery reduces the chance of miscarriage and improves menstrual cycles in women who don't ovulate.
- Other medical issues can be alleviated. Weight reduction surgery can also help with metabolic syndrome, pregnancy issues, gallbladder disease, and other health problems.
What About Type 1 Diabetes Patients?
Metabolic surgery is intended to help individuals with type 2 diabetes, in which obesity is frequently a major contributing factor. Obesity, on the other hand, is becoming more of an issue with type 1 diabetes, with recent research finding that, even at the age of 18, one-third of type 1 diabetes patients are overweight or obese.
Although no randomized trial has yet addressed the benefits of surgery in type 1 diabetes patients, a number of case series and case reports have been published, with the majority reporting a significant reduction in patients' insulin needs after surgery; however, it remains to be determined whether this alone is sufficient justification for surgery in patients who do not have other obesity-related comorbidity.
Which Patients Might Gain The Most Benefit?
Patients with shorter diabetes duration (8 years) had a fourfold increased likelihood of achieving the primary outcome, the largest metabolic surgery trial to report 5-year outcomes, leading the investigators to emphasize the importance of early intervention to achieve glycemic control in diabetes patients. Their findings are consistent with prior bariatric surgery research findings, which reveal a similar pattern for long-term outcomes, including microvascular problems.
Preparation Before Surgery
A comprehensive consultation will be conducted to determine which metabolic surgery method is appropriate for you. Blood tests, abdominal ultrasound, and gastroscopy will also be performed to confirm that you are a good candidate for metabolic surgery. To ensure that any related medical concerns are handled throughout the perioperative period, your surgeon will lead a multidisciplinary team of dieticians, physiotherapists, and other medical professionals.
Surgical Options of Metabolic Surgery
The Laparoscopic Sleeve Gastrectomy, sometimes known as the "sleeve," involves removing around 80 percent of the stomach. The stomach that remains is the size and shape of a banana.
- The Procedure:
The stomach is freed from organs around it. Surgical staplers are used to remove 80% of the stomach, making it much smaller.
- How it Works:
The new stomach holds less food and fluids, allowing you to consume less food (and calories). The procedure affects metabolism by eliminating the region of the stomach that generates the majority of the "hunger hormone." It reduces appetite, enhances fullness, and assists the body to achieve and maintain a healthy weight while also controlling blood sugar levels. The operation is highly safe due to its simplicity, since it avoids the risks associated with small intestinal surgery.
- Surgery is technically straightforward and takes less time.
- Certain people with high-risk medical problems may be candidates for this procedure.
- For people with extreme obesity, this might be the initial step.
- It can be used as a stopgap between gastric bypass or SADI-S surgeries.
- Effective weight loss and improvement of obesity-related disorders.
- The surgery is permanent.
- Reflux and heartburn may worsen or occur for the first time.
- When compared to bypass surgeries, there is less influence on metabolism.
The Roux-en-Y Gastric Bypass, sometimes known as the "gastric bypass," has been performed for over 50 years, with the laparoscopic method developed since 1993. It is a frequent procedure that is highly helpful in treating obesity and obesity-related disorders. The name is a French expression that means "in the shape of a Y."
- The Procedure:
The stomach is first separated into a smaller upper section (pouch) about the size of an egg. The majority of the stomach is skipped, and food is no longer stored or digested.
To allow food to pass, the small intestine is split and joined to the new stomach pouch. The small bowel segment that empties the bypassed or enlarged stomach is joined into the small bowel around 3-4 feet downstream, resulting in a bowel connection that resembles the letter Y.
The stomach acids and digestive enzymes from the skipped stomach and first segment of the small intestine will eventually mix with the food eaten.
- How it Works:
The gastric bypass works in a variety of ways. As with many bariatric surgeries, the recently constructed stomach pouch is smaller and can retain less food, resulting in fewer calories consumed. Furthermore, because the meal does not come into touch with the initial region of the small bowel, absorption is reduced. Most significantly, altering the meal path through the gastrointestinal tract has a significant impact on decreasing appetite, increasing fullness, and allowing the body to achieve and maintain a healthy weight.
The effect on hormones and metabolic health frequently leads to an improvement in adult-onset diabetes even before any weight reduction occurs. The procedure also helps patients with reflux (heartburn), and the symptoms frequently resolve fast. Patients must avoid tobacco products and nonsteroidal anti-inflammatory medications (NSAIDs) such as ibuprofen and naproxen, in addition to adopting suitable eating choices.
- Reliable and long-lasting weight loss.
- Effective for remission of obesity-associated conditions.
- Refined and standardized technique.
- Technically more difficult than sleeve gastrectomy or gastric band.
- More vitamin and mineral deficiencies than gastric banding or sleeve gastrectomy.
- Small bowel problems and blockage are possible.
- Ulcers are a possibility, especially if you use NSAIDs or smoke.
- Can result in "dumping syndrome," a sense of illness after eating or drinking, particularly sweets.
Adjustable Gastric Band (AGB)
The Adjustable Gastric Band is a silicone band that is wrapped around the top of the stomach to restrict the amount of food a person may eat. Since 2001, it has been sold in the United States. The impact on obesity-related comorbidities and long-term weight loss is less significant than with other operations. As a result, its use has decreased during the last decade.
- The Procedure:
This device is placed and secured around the top part of the stomach creating a small pouch above the band.
- How it Works:
The size of the opening between the pouch and the rest of the stomach influences the feeling of fullness. Fluid injections through a port beneath the skin can be used to modify the opening size. Food passes through the stomach properly, but the narrower hole of the band limits its passage. It is less effective against type 2 diabetes and has very minor effects on metabolism.
- Early complications following surgery had the lowest rate.
- There is no stomach or intestinal division.
- On the day of operation, patients can go home.
- The band is removable if necessary and offers the least risk of vitamin and mineral shortages.
- Several modifications and monthly office visits may be required over the first year.
- Weight reduction is slower and less dramatic than with other surgical treatments.
- Over time, there is a risk of band movement (slippage) or stomach injury (erosion)
- It is necessary for a foreign implant to remain in the body.
- Has a high re-operation rate
- Can cause swallowing difficulties and esophageal enlargement.
Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
The Biliopancreatic Diversion with Duodenal Switch, or BPD-DS, the procedure starts with the formation of a tube-shaped stomach pouch, similar to a sleeve gastrectomy. It is similar to a gastric bypass in that more of the small intestine is not utilized.
- The Procedure:
The first segment of the small intestine is split from the stomach when the sleeve-like stomach is formed.
When the patient eats, the food passes through the sleeve pouch and into the later section of the small intestine because a portion of the small intestine has been pulled up and attached to the outlet of the newly constructed stomach.
- How it Works:
Patients may consume less food since their stomach is shaped like a banana. The food stream skips nearly 75% of the small intestine, the highest percentage of any routinely done approved treatment. As a result, calorie and nutrient absorption is significantly reduced. Following surgery, patients must take vitamin and mineral supplements. The BPD-DS affects intestinal hormones in a way that lowers appetite, enhances fullness, and improves blood sugar management even more than gastric bypass and sleeve gastrectomy. The BPD-DS is widely regarded as the most effective approved metabolic procedure for the treatment of type 2 diabetes.
- Among the best results for improving obesity
- Affects bowel hormones to cause less hunger and more fullness after eating
- It is the most effective procedure for the treatment of type 2 diabetes
- Complication rates are somewhat greater than for other operations.
- Highest malabsorption and a higher risk of vitamin and micronutrient deficiencies
- Reflux and heartburn might occur or worsen.
- The possibility of looser and more frequent bowel motions
- More difficult surgery necessitates more operative time.
Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S).
The SADI-S, or Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, is the most current treatment to be approved by the American Society for Metabolic and Bariatric Surgery. The SADI-S, while comparable to the BPD-DS, is easier and takes less time to perform since there is only one surgical bowel connection.
- The Procedure:
The procedure begins in the same manner as a sleeve gastrectomy, with the creation of a smaller tube-shaped stomach. Just after the stomach, the first section of the small intestine is divided.
The length of an intestinal loop is measured from end to end and then linked to the stomach. In this surgery, only one intestine connection is made.
- How it Works:
When the patient eats, food passes through the pouch and directly into the small intestine. The meal next comes into contact with digestive fluids from the first section of the small intestine. This provides for adequate absorption of vitamins and minerals to maintain optimum nutritional levels. This operation promotes weight loss while also improving blood sugar control and diabetes management.
- Highly successful for long-term weight reduction and type 2 diabetes remission.
- It is less complicated and faster to conduct (just one intestine connection) than gastric bypass or BPD-DS.
- Excellent choice for a patient who has already had a sleeve gastrectomy and wants to lose more weight.
- Vitamins and minerals are not absorbed as efficiently as they are with a sleeve gastrectomy or a gastric band.
- Newer surgery with just short-term outcome data.
- The possibility of worsening or developing new-onset reflux.
- Possibility of looser and more frequent bowel motions.
Metabolic Surgery Recovery
The procedure takes roughly 2 hours and is performed under general anesthesia. For a few days, you will be on a liquid diet before progressing to soft meals. The majority of patients will be hospitalized for 3 to 5 days. You can start moving around the day following surgery, and most patients can resume their daily habits and exercise within approximately two weeks.
Risks & Complications of Weight-loss Surgery
These operations may have the following risks:
- Poor anesthetic response.
- During surgery, adjacent organs are damaged.
- Formation of a blood clot (DVT).
- Peritonitis is an inflammation of the peritoneum, which covers and supports the organs in the abdomen.
- Other concerns include intestinal blockages.
- Gallstones and kidney stones can form.
- Anastomotic stenosis is a narrowing of the junction between the stomach and the intestine.
- Dumping syndrome (early and late) is characterized by nausea, stomach discomfort, and vomiting after eating.
Metabolic Surgery Results In Diabetic Patients
Blood glucose levels may improve immediately following surgery. You should be able to lower the dosage of your diabetic medication. You may even be able to discontinue all drugs. You will have a lower risk of heart attack, stroke, and heart and kidney failure. You may be able to discontinue your prescriptions for such diseases as well. Sleep apnea and fatty liver should be less of an issue.
If you follow the guidelines on when to eat, what to eat, and how much to eat, you will lose weight in the short and long term. You will first be on a liquid diet. With the assistance of your dietician, the diet will move to solid food over the first month.
Depending on the type of surgery and how fast you recover, you should be able to return to work in 3-4 weeks.
You will be required to attend the planned appointments following the procedure.
After-surgery follow-up (generally 1 week, 1 month, and then once a year)
Laboratory work (at 6 months, one year, and then once a year).
Nutritional advice (at one month, 3 months and then as needed).
Psychological treatment (once a month for the first month, then as required) and exercise counseling (at one month and then as needed).
Routine treatment with your primary care physician (as needed).
Attendance at a monthly support group.
The term "metabolic syndrome" refers to a collection of risk factors that raise the likelihood of getting heart disease, diabetes, and stroke.
Metabolic Surgery is now used to describe weight reduction therapies and operations used to manage metabolic conditions, particularly type 2 diabetes.
While all surgeries include some risk, bariatric procedures performed in accredited facilities are safe and have a minimal risk of complications. A team-based approach is required for successful bariatric surgery, which includes your surgeon, dietician, psychologist, nurse case manager, and obesity medicine expert who will focus on guiding you through each stage of the process.
Patients will do better if they continue to eat well, exercise regularly, maintain their appointments with obesity medicine experts, and take vitamins and minerals as prescribed. Your bariatric care team will help you for the rest of your life in order to achieve and maintain a permanent healthy lifestyle that includes dietary adjustments and frequent physical activity. Most patients require routine blood work to monitor vitamin and mineral levels, as well as annual checks at their comprehensive metabolic and bariatric surgery care facility.