Over the past few years, with TV shows such as Extreme Makeover, Botched and Dr 90210, the obscure world of plastic surgery is not as unknown as it was a few years ago. We were welcomed into the operating room, where confusing, oftentimes life-threatening surgeries, was a bit more generalized.

One of those surgeries is gastric bypass.

Alternative names for the surgery are: Bariatric surgery, Roux-en-Y gastric bypass, weight-loss surgery, and obesity surgery.

Broadly defined, it is surgery on the stomach and intestines to help reduce obesity and obesity-related conditions. Obesity has been identified as a major health concern affecting both genders of all ages, not only in South Africa but globally.

Obesity is also linked to various other conditions (co-morbidities), such as:

  • sleep apnoea
  • obesity-associated hypoventilation
  • glucose intolerance
  • diabetes mellitus
  • hypertension
  • serum lipid abnormalities

Risks

Gastric bypass is major surgery and it has many dangers. Some of these risks are very serious and should not be taken lightly.

Any operation that requires an anaesthetic, which takes between 1 and 3 ½ hours to complete, is potentially dangerous. Keeping in mind that there are various other associated diseases (respiratory disorders, diabetes and heart disease) the risks of complications may be even more severe.

The following risks are associated with the surgery:

Pre-operation (or shortly after):

  • Pulmonary embolism (a blood clot in the lungs)
  • It accounts for up to 70% of deaths that occur during or immediately after surgery
  • Infections
  • Peritonitis (inflammation of the membrane of the abdominal cavity)
  • Abscesses
  • Slippage of the gastric band or staples, which then require re-operation

Post-operation:

  • Vomiting
  • Dysphagia (inability to eat)
  • Hernia
  • Heartburn
  • Diarrhoea
  • Dumping syndrome (see below)
  • Malnutrition
  • Vitamin and mineral deficiencies (see below)
  • Regaining of weight that has been lost

The financial impact that this surgery will make is also immense. A bariatric operation can cost R80 000 or more, depending on the length of your stay in hospital and any complications that may occur. At the moment, most South African medical aids don’t cover bariatric surgery.

Dumping syndrome

This syndrome occurs because suddenly larger than normal amounts of food and liquid reach the upper part of the small intestine (usually it would’ve gone through the stomach). This might seem insignificant, but it has severe consequences.

The symptoms associated with dumping syndrome start with mild effects that include a feeling of satiety and nausea 10 to 20 minutes after eating. Patients may also experience flushing, heart palpitations, fainting, sweating and the need to sit or lie down.

Roughly one hour after eating, patients may experience abdominal bloating, winds, cramps and abdominal pain and diarrhoea.

Lastly, the most extreme stage can cause hypoglycaemia (low blood sugar). Patients may perspire, feel anxiety, weakness, shakiness, or hunger, and the inability to concentrate.

Now try experiencing these symptoms every time after you eat (personally, this would’ve taken all my enjoyment out of eating). Paradoxically, the fact that these symptoms are so severe, acts as a strong motivation for patients to stick to the dietary rules that they will need to follow for the rest of their lives.

Vitamin and mineral deficiencies

Post-operative vitamin and mineral deficiencies are characteristic in patients who have undergone bariatric surgery, namely:

  • Iron deficiency (risk: anaemia)
  • Vitamin B12 deficiency (risk: pernicious or megaloblastic anaemia)
  • Calcium deficiency (risk: osteoporosis later in life)
  • Folic acid deficiency (risk: megaloblastic anaemia)

Bariatric surgery patients need to take vitamin and mineral supplements for the rest of their lives. Regular monitoring of vitamin and mineral levels in the blood is suggested as a precaution to identify potential deficiencies.

Advantages of bariatric surgery

Even with all the risks mentioned, there are certainly advantages to bariatric surgery.

  • The greatest benefit of bariatric surgery is, of course, the significant weight loss that patients achieve. Losses of up to 120kg have been reported. Better still, as these patients lose weight, their co-morbidities improve dramatically.
  • Improvements are seen in: hypertension, sleep apnoea, obesity hyperventilation syndrome, gastro-oesophageal reflux, venous stasis, urinary incontinence and degenerative joint disease.
  • Any patient who has lost a third to half of his/her body weight will naturally be more mobile and active.
  • Patients also experience a great increase in self-esteem, less depression and anxiety, and feel much more self-confident.

Who is eligible for bariatric surgery?

Various criteria are taken into consideration before a patient is accepted for bariatric surgery:

  • Patients between 18 and 65 years, with a body mass index (BMI) score of 40 or more.
  • Patients with a BMI of or 35 or more would qualify, if they have at least two serious co-morbid conditions.
  • Patients should fully comprehend what the procedure will involve, the implications thereof, and be committed to a long-term lifestyle change and medical follow-ups.
  • Potential candidates for weight loss surgery must have made multiple efforts, in good faith, to achieve weight loss through conservative means such as dietary or pharmacological weight loss programmes.

Types of bariatric procedures

  • The Roux-en-Y gastric bypass procedure (GBP)
  • Biliopancreatic diversion with duodenal switch (BPD)

Both of these surgical procedures are approved by two international regulatory bodies, namely the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), and the World Obesity Federation.

Preparation process

There is an extensive process that needs to be followed to evaluate and treat candidates before bariatric surgery will be done. A multi-disciplinary team is involved in this evaluation:

Patient will meet with the psychologist for an evaluation. Where appropriate, the psychologist will refer the patient to a psychiatrist for treatment. Family sessions are an essential part of this process.

The dietician will evaluate the dieting history, dietary requirements, post-op adjustment and prevention of adverse symptoms. This is an essential step to create some of the routines that will have to be adhered to after surgery, for improving the patient’s physical health and nutritional education.

The specialist endocrinologist will complete an evaluation and initiate treatment protocol before the patient’s eligibility for surgery is confirmed.

Finally, the patient consults with the surgeon, and many investigative tests are done as recommended by the endocrinologist. These might include a gastroscopy, relevant blood tests, a lung function test and echocardiogram.

Conclusion

Gastric bypass surgery is not a quick fix for obesity. There are many risks involved, it will greatly affect your lifestyle and is a life-long commitment. After this surgery, you must eat healthy foods, control the portion sizes of what you eat, and exercise. If you do not follow these measures, you may have complications, various negative symptoms (dumping syndrome) and poor weight loss.

Retha Booyens (RD) SA

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