Surgical weight loss is on the rise


The number of Aussies admitted to hospital for weight loss surgery has more than doubled in a decade.


With so many non-surgical weight loss options available, why is this on the rise?


Ed Phillips spoke with Dr Steven Leibman who is a General, Upper Gastrointestinal & Weight Loss Surgeon to find out more.


 What is weight loss surgery?


Weight loss surgery refers to undergoing an operation designed to achieve substantial weight loss for patients who have a degree of obesity that is clinically harmful. There is extensive evidence now showing a relationship between being overweight and having multiple health conditions (referred to as comorbidities). These include but are by no means limited to type 2 diabetes, sleep apnoea, asthma, hypertension (high blood pressure), arthritis, depression, and a number of cancers. The level of obesity at which health problems begin to occur is most commonly defined based on the body mass index (BMI) which is a calculation based on someone’s height and weight. Once the BMI exceeds around 35, the risk of developing or successfully treating obesity related comorbidities becomes increasing difficult. There is also extremely reliable evidence that suggests the ability to lose and maintain weight loss for patients who already have a BMI at this level is extremely difficult to achieve.


Will weight loss surgery work long-term?


The long-term management of these health conditions involves the individual being able to lose sufficient weight and to sustain that weight loss long term (durability). It is for these patients therefore that surgery may be considered as an appropriate treatment for the weight condition. While most non-surgical techniques such as diet, exercise and some mental or medical therapies tend to achieve a weight loss of around 10% with the usual pattern of weight regain in the following months, surgery aims to achieve a weight loss of 70% excess weight with long term maintenance of this weight loss.


Who are good candidates for weight loss surgery?


Good candidates for weight loss surgery are those with a BMI above 35 who have tried to achieve weight loss by non-surgical means and have either had limited success or short-term success only. Patients who already have established comorbidities (such as type 2 diabetes) are excellent candidates as weight loss surgery is primarily designed to achieve health improvements rather than just weight loss measured in kilograms. The best candidates for weight loss surgery are those who have given it careful thought and are committed to a combination of lifestyle changes including food choice and exercise in combination with the effects of surgery.


What options are available?


There are various different choices of operation designed to achieve weight loss and while none are perfect, most comprehensive weight loss surgeons will tailor an operation to the patient based on their unique medical situation. The most common procedures performed for weight loss today are the sleeve gastrectomy, the gastric bypass, and the gastric band operation. The gastric band has  been the most popular operation in Australia in the past, but over recent years has been decreasing in popularity both by patients and surgeons because of a number of factors including cumulative long-term complications, less successful long term weight loss compared to some of the alternative procedures, the impact on quality of life for many patients and the need for ongoing frequent medical follow-up and band adjustments. The gastric band is the only common procedure where an artificial device is actually placed inside the body and expected to stay there for the rest of the patients’ life without any problems. This device is prone to a number of long-term problems such as infection, change in position, or erosion into the stomach as well as wear and tear with leakage and loss of effectiveness. Many surgeons have now chosen to stop performing gastric band surgery unless there is a specific indication for it. Many patients who have had gastric band surgery are seeking revisional surgery because of either limited success or a complication related to the band.


What is the most popular weight loss option?


The sleeve gastrectomy is the most popular choice for operations at the moment in Australia. This operation involves reducing the size of the stomach by approximately 70- 80% and permanently removing most of the stomach leaving behind a narrow “sleeve” of stomach approximately the size of a banana. This obviously limits the capacity of the stomach so meals are significantly smaller, but it also has a powerful and profound hormonal effect on hunger, the desire to eat, and food choices which is biologically driven. It also has excellent results for most people in terms of weight loss and health improvements.


What is gastric bypass surgery?


The gastric bypass (of which there are some varieties) involves reducing the size of the stomach without removing any of it, as well as joining part of the intestine back onto the smaller stomach so that food is diverted away from the top part of the intestine. This adds an element of “malabsorption” to the restrictive component of the operation and for a long time has been considered the gold standard weight loss operation against which others have been compared. While it is a larger and technically more challenging procedure, the weight loss results are excellent and the health improvements very significant. It is however more likely to be associated with the possibility of long term nutritional deficiencies if close attention to diet and vitamin replacement are not adhered to.



How do these weight loss surgeries work?


All weight loss operations essentially attempt to address a combination of food choices and portion size and are designed to work in conjunction with lifestyle changes. Portion size is altered by restrictive operations that either artificially (gastric band) or actually (sleeve or bypass) reduce the capacity of the stomach. The food choice and hunger components are biologically driven due to change in hormonal communications between the gastrointestinal tract, the stored fat and muscle cells, the brain, and the digestive organs such as the liver and pancreas.


Is key-hole weight loss surgery a good option?


Modern key-hole weight loss surgery is very successful and very low risk. There are identified and acceptable risks associated with surgery that your surgeon will discuss with you but these are very low. The operations are all minimally invasive keyhole operations with a recovery in hospital of only 2-3 days. Most people would expect to lose about 70% of their excess weight which can be calculated with your clinician during a consultation. Studies show sustained weight loss of up to ten years or more in large proportions of patients who undergo surgery.


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