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CHOOSING THE RIGHT OPERATION

"After much discussion with my friends on the Internet, I finally decided to approach my operation in a manner that I felt was logical. To the best of my ability, I selected a surgeon who I believed was experienced and well-qualified. I looked at his program and what it had to offer me in terms of follow-up care. Once I was satisfied that I had picked someone knowledgeable and caring, I decided to let him be in the driver's seat and pick which operation he thought was best for me. I'm an architect, and a very good one. I would really resent it if some surgeon tried to tell me how to design a building."

Walter L, 42, 456 lbs pre-op; 311 lbs, 16 months post-op.

The Procedure

Since most bariatric surgeons and patients had negative experiences with the intestinal bypass procedures (such as JIB), there has been a shift toward the use of more restrictive weight loss procedures. The desire to find safer operations led to the development of the vertical banded gastroplasty and roux-en-y gastric bypass in the late 1960s and 70s. Initially, the VBG was more popular because it is simpler to perform and does not result in vitamin and mineral deficiencies. In the 1980s, approximately 75 percent of bariatric surgeons in the United States preferred the VBG, 25 percent preferred the RYGB and less than 1 percent preferred more radical procedures like the bilio-pancreatic diversion or duodenal switch.

However, over time it became apparent that VBG and other restrictive procedures are inferior to the RYGB in terms of weight loss achieved and weight regained. Thus, the pendulum has swung back toward more radical or malabsorptive weight loss procedures.

In a recent survey conducted by the American Society of Bariatric Surgery (1999), about 75 percent of surgeons preferred RYGB as their primary operation, 15 percent preferred VBG or a variation thereof, and 10 percent preferred BPD or DS. Comparing these three procedures (Table 8-1), the reasons for these preferences become clear. The VBG is the simplest procedure to perform, however it results in less weight loss, more weight regain, and has the highest incidence of technical problems, which affect postoperative eating and often require re-operation.

The BPD/DS results in the greatest weight loss and smallest regain, however it occasionally produces severe protein-calorie malnutrition requiring re-operation and lengthening of the common channel. The RYGB results in good weight loss and maintenance, close to that achieved with BPD/DS, and does not cause the severe types of nutritional deficiencies (protein, calcium) that are occasionally seen after BPD/DS. Thus, most surgeons in the US feel that overall, RYGB is the best and safest operation available - with VBG being inferior and BPD/DS having too great a risk of complications.

With the development and perfection of newer procedures, surgical treatments for severe obesity should, logically, be more specifically tailored to the health risks and needs of individual patients. For example, VBG, gastric banding, and short limb RYGB (less than 75 cm) may be best suited for individuals with the lowest BMIs (35 to 40 or 45), RYGB with longer limbs (150-250 cm) preferred for those with intermediate BMIs (40 or 45 to 55 or 60), and BPD/DS for those patients with the highest BMIs (over 55 or 60). Although intuitively this makes sense, carefully performed, long-term studies need to be done to document which operative procedures are best for which people.

Table 8-1: Comparison of Vertical Banded Gastroplasty, Roux-en-Y Gastric Bypass, Bilio-Pancreatic Diversion/Duodenal Switch

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VBGRYGBBPD/DS

Weight Loss (percent of

excess body weight lost)

40-60

60-75

70-80

Weight Regain

(percentage of excess body

weight regained)

25-40

10-15

<10

Limited Amount of

Food Intake

Yes

Types of Food

Restricted

Meat, raw fruit Simple Fats

and vegetables

Sugars

Excessive Gas/Flatus

Rare

Common

Dumping Syndrome*

Yes

Protein Malnutrition

Occasional

Vitamin Deficiency

Yes

Calcium Deficiency

Yes

Iron, Vit B12 Deficiency

Yes

Technical Ease

Easiest Intermediate Most Difficult

Need for Common Rare Unusual

Operative Revision

(weight regain, (weight regain, (malnutrition)

stricture, ulcer) stricture, ulcer)

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* Dumping syndrome is a constellation of symptoms (lightheadedness, cold sweats, abdominal cramps and diarrhea) caused by certain foods, usually simple sugars or dense fats, leaving the stomach and entering the small intestine too quickly. It can occur after any operation that changes the way food is routed during digestion. (See Chapter 12 for more information about dumping syndrome and how to avoid it.)

The Method: Laparoscopic or Open

Until recently, all abdominal operations were performed through incisions that opened the abdomen, providing exposure to the internal structures. Laparoscopy is a method by which surgical procedures can be performed through a series of small incisions using specially made instruments and guided by a video camera. Although laparoscopy has been available for decades, and has been widely used in gynecologic surgery for over 20 years, it only became popular in general surgery in the late 1980s, as a method to remove gallbladders (cholecystectomy). Since then, the equipment has improved considerably and laparoscopy has been increasingly used to perform other general surgery operations, including VBG, gastric banding, and RYGB.

Like all methods, laparoscopy has certain advantages and disadvantages. The major advantage of laparoscopy in WLS is related to the size of the incision. Rather than a formal incision in the midline, laparoscopy uses a series of 5 or 6 small incisions through which the camera and instruments are inserted. The disadvantages of laparoscopy include a considerably longer operating time, significant technical difficulties in performing the procedure that frequently lead to compromises in technique, and increased cost of equipment and personnel.

Based on experience with gallbladder surgery, the laparoscopic approach to WLS should result in less pain after surgery, fewer wound infections, fewer incisional hernias, shorter hospitalizations, and faster return to work. In fact, these advantages have only partly been realized.

Postoperative pain is highly variable. The discomfort that patients experience spans a wide spectrum, with some having a great deal of pain and others having minimal pain. This is true of both the open and laparoscopic methods. Wound infections and incisional hernias (defects in the abdominal wall through which intestines or other parts can protrude) can and do occur after laparoscopy, although the incidence of hernias is most likely lower than after open surgery. However, hernias in small incisions are more dangerous than hernias in large incisions as the affected organs have a greater tendency to become trapped and die (develop gangrene). Even a low incidence of "strangulated" hernias after laparoscopy, which require emergency surgery to remove portions of dead bowel that could possibly cause death might be sufficient to offset any benefit of laparoscopy over open surgery.

The length of hospitalization with laparoscopic RYGB is usually 3 to 4 days: Patients undergo surgery on the first day, begin liquids on the second day and are discharged on the third day. In my practice of open RYGBs, I have replicated this routine and have been able to send the majority of my patients home on an identical schedule. Similarly, patients that do not have physically demanding jobs can often return to work after 1 to 2 weeks as they do after laparoscopy. It is unlikely that individuals with very physically demanding occupations will be back to work at full capacity much before 4 weeks with either technique.

On the other hand, several serious complications usually requiring surgical treatment, such as leaks and internal hernias, occur more frequently after laparoscopic than open surgery. In general, about 1 to 2 percent of patients having open VBG or RYGB report an incidence of leak. Early experience with the laparoscopic technique has shown a leak rate as high as 4 percent.

Internal hernias are hernias that occur within the abdomen when the intestine gets caught or twisted, causing a bowel obstruction. These hernias often result when the intestine is moved around during surgery and the openings created are not closed with stitches. With the open technique, it is routine to close these openings, thus preventing internal hernias from occurring. However, many surgeons performing laparoscopy do not routinely do so because it is technically challenging.

Some surgeons also make other modifications in gastric bypass technique when the procedure is done laparoscopically. For instance, they may alter the size of the anastomoses (opening between the stomach and the intestine through which food passes), and the route taken by the bowel. Only time and close follow-up will tell whether these changes affect the overall outcome and results.

Laparoscopic VBG and RYGB take much longer to perform than open procedures. In the hands of an experienced surgeon, an open VBG or RYGB should take between 45 and 90 minutes. BPD and DS are more complex procedures and require, on average, 2 to 3 hours. Laparoscopic procedures take considerably longer to accomplish than open procedures, with the operative time directly related to the skill and experience of the surgeon. A laparoscopic VBG takes between 90 minutes and 3 hours to perform and a laparoscopic RYGB between 2 and 6 hours. At present, the shortest operative times with laparoscopy (when everything goes perfectly) are closest to the slowest times when done open (when complications are encountered). Numerous studies involving open surgery have documented that longer operative times are associated with a higher incidence of infectious complications. Whether this is true with laparoscopy is not yet known.

Laparoscopic procedures are also considerably more expensive. In addition to increased operating time, the costs are related to the video equipment required, the large number of expensive disposable staplers and laparoscopic instruments and the need for an additional assistant in order to perform the procedure. In the case of gallbladder removal, where patients are usually discharged within 24 hours of surgery, the shorter length of hospitalization offsets the additional expenses in the operating room. However, if the length of stay is the same, then laparoscopy simply costs much more.

As is the case with all new technologies, laparoscopy must be carefully evaluated and compared to the existing standard treatment, which is the "open" technique. This is especially true in the area of WLS, where serious complications and poor results 30 years ago continue to tarnish this procedure's reputation and are responsible for much of the resistance and negativism patients and surgeons face within the lay and medical communities. Laparoscopic VBG and RYGB are new and the techniques being employed are constantly evolving. Technical changes in the performance of the operations are being made to make the procedure easier to perform through the laparoscope. Long-term follow-up is not yet available to compare the results of these modifications on weight loss or on the incidence of complications.

In a recent survey conducted by the American Society of Bariatric Surgery, about 90 percent of surgeons were performing these procedures via the "open" techniques, and 10 percent were using laparoscopy. Although laparoscopy may ultimately be here to stay, I am not yet convinced that just because something can be done, it should be done. More studies are needed before the laparoscopic approach can be endorsed.