LAPAROSCOPIC SURGERY FOR WEIGHT CONTROL

Questions and Answers for Patients

Laparoscopic surgery for weight control is surgery to treat severe obesity using a specialized telescope (laparoscope) resulting in a small abdominal incision. This handout will explain to you:

1. What is severe obesity?
2. Medical and surgical treatment options .for severe obesity.
3. How laparoscopic obesity surgery is performed.
4. Expected outcomes of the procedure.
5. What to expect if you choose to have laparoscopic surgery for obesity.

What is "clinically severe obesity"?

Severe obesity, sometimes known as "morbid obesity", is defined as being 100 Ibs. or 100% above ideal body weight according to the Metropolitan Life Insurance Company height and weight tables. Between 3 and 5% of the US adult population has severe obesity. This condition is associated with the development of life-threatening complications such as hypertension, diabetes, and coronary artery disease to name a few. Numerous therapeutic approaches to this problem have been advocated, including low calorie diets, drugs, behavioral modification and exercise therapy, but the only treatment proven to be effective in the long-term management of morbid obesity is surgical intervention.

What causes severe obesity?

The cause of severe obesity is poorly understood and there are probably many factors involved. In obese persons, the set point of stored energy is too high. This altered set point may result from a low metabolism with low energy expenditure, excessive caloric intake, or a combination of both disorders. There is some scientific data that suggests obesity may be an inherited characteristic. Severe obesity is most likely a result of genetic, psychological, environmental, social, and cultural influences that interact resulting in the complex disorder of both appetite regulation and energy metabolism. Severe obesity is not simply a lack of self-control.

How is severe obesity treated?

Medical Treatment

In 1992, the National Institutes of Health Conference concluded that non-surgical methods of weight loss for patients with severe obesity are not effective in the long term, except in rare instances. Data reviewed at that time showed that nearly all participants in any non-surgical weight loss program for severe obesity regained their lost weight within five years. Although prescription and non-prescription medications are available to induce weight loss, there is no role for long-term medical therapy in the management of morbid obesity. Drugs that reduce appetite can result in an 11 to 22 pound weight reduction; however, weight regain is rapid once medication is withdrawn. Various professional weight loss programs use behavior modification techniques, in conjunction with low calorie diets and increased physical activity. Weight losses of one to two pounds per week have been reported. However, nearly all weight loss is regained after five years.

Surgical Treatment

A number of weight loss operations have been devised over the past 40 years. The two operations recognized by most surgeons today include the vertical banded gastroplasty and the Roux-en-y gastric bypass. The vertical banded gastroplasty involves the construction of a small pouch with a restricted outlet to the lower stomach. The outlet may be externally reinforced to prevent disruption and dilation. The gastric bypass procedure involves constructing a small gastric pouch, which is constructed of a Y-shaped limb of small bowel of varying lengths (Roux-en-y gastric bypass). Choosing between these procedures involves the surgeons' preference and consideration of the patient's eating habits. The gastric bypass procedure generally results in greater weight loss but has a higher risk of nutritional deficiencies.

Who should be considered for obesity surgery?

The following guidelines for selecting patients for obesity surgery were established by the National Institute of Health (NIH):

1. Patients should exceed ideal body weight by at least 100 Ibs. or 100%.
2. They should have no known causative metabolic or endocrine causes for the morbid obesity.
3. They should have an objectively measurable complication (physical, psychological, social or economic) that might benefit from weight reduction.
4. They should be intelligent enough to understand the full importance of the proposed surgical procedure, including all known and unknown risks.
5. They should be willing to be observed for a prolonged period.
6. They should have attempted weight reduction using conservative treatment modalities without success. In rare circumstances, patient who are not quite 100 Ibs. or 100% above ideal body weight are candidates for surgical intervention if they have significant medical problems that might benefit from weight reduction.

How is laparoscopic obesity surgery performed?

The laparoscopic approach to obesity surgery is different from the traditional "open" approach that uses a 10 to 12 inch incision only in the method of accessing the stomach and intestines. In other words, the operations are exactly the same as the open approach, except five to six small incisions (1/4 to 1/2 inch) are used instead of the ten to twelve inch abdominal incisions. In a laparoscopic procedure, the laparoscope, which is connected to a video camera, is inserted through small abdominal incisions, giving the surgeon a magnified view of the patient's internal organs on a television monitor. The entire operation is performed "inside" the abdomen after gas has been utilized to expand the abdomen.

What are the expected results after surgery for severe obesity?

Weight Loss

The success rate for weight loss is reported as being slightly higher with the gastric bypass operation than gastroplasty. Most reports indicate a 43 to 48% loss of excess weight for the vertical banded gastroplasty and a 60 to 80% loss of excess body weight for the gastric bypass procedure. Substantial weight loss generally occurs for both procedures 18 to 24 months after surgery. Some regain of weight is common about two to five years after surgery. Regain of weight may be more common after the gastroplasty than by the gastric bypass.

Effect of surgery on associated medical conditions

Weight-reduction surgery has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure, and high cholesterol. Many patients report an improvement in mood and other aspects of psychosocial functioning after surgery .
Because the laparoscopic approach is performed in a similar manner to the open approach, the long-term results are comparable. Advantages of the laparoscopic approach include, reduced postoperative pain, shorter hospital stay (1-3 days), a faster return to work (5-10 days) and improved cosmesis.

What are the risks of obesity surgery?

The immediate operative mortality rate for the conventional operations, vertical banded gastroplasty and gastric bypass has been relatively low in the reported case series (less than 1%). On the other hand, complications such as wound infection, wound breakdown, leaks from staple- line breakdown, stomal stenosis, marginal ulcers, various pulmonary problems, and blood clots in the legs, may be as high as 10% or more. In the latter postoperative period, other problems may arise that may require re-operative surgery. These problems may include pouch dilatation, persistent vomiting, gallstones, or failure to lose weight. Complication rates with re-operative surgery are higher than with primary operations.

In the long term, nutritional deficiencies such as vitamin 8-12, folate, and iron are common after gastric bypass and must be sough and treated. Another potential results of this operation is the so-called “dumping syndrome”, which is characterized by abdominal pain, diarrhea and light-headedness. Sometimes these symptoms do not respond to conservative measure and may be troublesome to the patient. Women who become pregnant after these surgical procedures need special attention from the clinical care team.

Data suggests that complication rates of the laparoscopic approach are equal to or less than the conventional approach. Following obesity surgery, patients must reorient themselves and adjust to the effect of a changing body image.

What happens if the operation cannot be performed by the laparoscopic method?

The laparoscopic method is a fairly new approach to obesity surgery. The overall risks of conversion to the "open" procedure are unknown at this time. Reasons for the surgeon to elect to convert to the open procedure include bleeding problems during the operation or inability to visualize adequately. The decision to perform the open procedure is a decision made by the surgeon either before or during the actual operation. The decision to convert to the open procedure is strictly based on the patient's safety.

What to expect if you choose to have laparoscopic obesity surgery.

Before surgery

To determine if you are a candidate for laparoscopic obesity surgery a thorough medical evaluation by your physician is necessary. In addition, supplemental diagnostic tests may be necessary. Patients will undergo a nutritional evaluation prior to surgery .A psychological evaluation is performed to determine the patient's ability to adjust to changes after the operation. Some patients require consultation from specialists such as cardiologists or pulmonologists.

After the surgeon reviews the potential risks and benefits of the operation, written consent for surgery must be provided. The day prior to the surgery, the patient will begin a clear liquid diet with no food or liquids after midnight. A bowel prep will also be necessary to decrease infection rate.

Day of surgery

You will arrive at the hospital the morning of the operation. Preparation before surgery often includes changing into a hospital gown and placement of a catheter in your vein (IV). Preoperative medications are often necessary. You will meet the anesthesiologist and discuss the anesthesia. You will be under general anesthesia during the operation, which may last for several hours. Following the operation you will go to the recovery room until you are fully awake. Then you will be sent to your hospital room.

In the hospital after the operation

You will be in the hospital approximately 2 to 3 days following the laparoscopic procedure, or 5 to 7 days if an open procedure is required. You may have a tube through your nose and you will not be permitted to eat or drink anything until it is removed. You should be up and walking the night of surgery and participating in breathing exercises. You will receive fluids and pain medication through the IV. Usually on the first or second day after surgery you will have an x-ray of your stomach to test for leaks. If no leaks are present (the usual case) then you will begin the staged diet. The volume of liquid you intake will gradually increase. You will remain on a liquid diet until you are evaluated by your doctor approximately 7 to 10 days after you return home.

At home during recovery

Patients are encouraged to engage in light activity and continue breathing exercises while at home after surgery. Pain after laparoscopic surgery is generally mild although some patients may require pain medication. At the first follow-up visit, the surgeon will discuss with you any dietary changes.

Your wounds

After laparoscopic surgery, the small incisions on your abdomen are closed with stitches on the inside and dissolve in 4 to 6 weeks. The steri-strips {special pieces of tape) covering the incisions will fall off after approximately two weeks. You may shower three days after surgery. If you require an open incision, staples will be used for closure. The staples will be removed by the surgeon prior to discharge from the hospital or on the first postoperative visit.

When to call your doctor

Be sure to call your doctor if you develop any of the following:

• Persistent fever (over 101 F)
• Bleeding
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough and shortness of breath
• Difficulty swallowing that doesn't go away within a few weeks