Bands, Bypasses and Balloons

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It will come as no surprise to most readers that I spend a great deal of my working life talking about weight issues or their consequences, and as we continue to career headlong further into our obesity epidemic I can only assume that this aspect of my work is, sadly, only going to increase. Most of the time I am dealing with the consequences of being overweight like high blood pressure, heart disease, depression (which can also be the cause of the problem and it can be interesting to sort this out in a ‘chicken and egg’ kind of way), arthritis, diabetes and many more, and often suggesting to a patient that they could help themselves out of their predicament with healthy eating and exercise does not always make me popular. And it may not even be the right advice; mounting evidence is suggesting that the situation is a lot more complex, and while healthy eating and exercise should enable anyone sticking to a sensible regime to lose weight, the problem is that of keeping it off in the long term, and very few things have been shown to work.

Some of my patients seem very keen on instant, painless results (who can blame them!) and I frequently find myself organising yet another thyroid test in the hope that this particular overweight person has a simple explanation for their problems and just needs some levothyroxine – and it is wonderful on the few occasions when this does turn out to be the case – and fielding questions along the lines of ‘Can’t you just give me a pill?’ or ‘Can’t I just have surgery/lipo?’The answer to both these questions is ‘Yes’, I can give certain people Xenical, and weight loss or ‘bariatric’ surgery is available, albeit very rarely via the NHS, although the numbers of operations are increasing rapidly and there is something of a postcode lottery. But it is certainly available for a (high) price, and private bariatric surgery is big business.

For the record, Xenical is the only weight loss pill available on prescription these days and it is fairly effective, but it does not address the underlying reasons for a person being overweight in the first place, so while I do recommend it to some people it is not magic and it is certainly not enough on its own. I do not intend to cover this in any detail here, but if you are obese or overweight with other health problems then it may be worth discussing this with your GP. However, given the huge increase in surgical weight loss procedures in the last few years I thought a brief run through all things bariatric would be in order.

The first thing to clear up is who should be even considering these options! According to NICE (National Institute for Clinical Excellence), a bariatric surgeon can only offer a procedure if you:

  • Have a body mass index of more than 40, or more than 30 with an obesity related health problem
  • Are between the ages of 18 and 60, although older people can be considered in exceptional circumstances
  • Have been in the qualifying weight range for at least 5 years and have tried all other options including diet, exercise and medication, and you can demonstrate that these were either completely unsuccessful or that you could not maintain the weight loss long term
  • Are fit enough to undergo the procedure
  • Have a substantial obesity related risk to your health now, or are thought to be at substantial risk in the near future
  • Are fully committed to the aftercare programme including a complete change of diet, exercise, follow up sessions with your chosen clinic and nutritional supplements as required

There are currently two types of surgical procedures designed to aid weight loss in the UK and they are classified as ‘restrictive’ or ‘malabsorptive’. Restrictive procedures reduce the amount of food that it is possible to consume at a time, the most common being the gastric band, while malabsorptive procedures both reduce the amount of food eaten and the number of calories it is possible to absorb from that food, an example of this would be the gastric bypass. Both have pros and cons, which is why both still exist – after all if there was one procedure that was completely safe and totally effective while being acceptable to all patients then that would rapidly become the only one available. Essentially, gastric banding comes with fewer complications but results in less weight loss on average, while gastric bypass results in slightly more weight loss but comes with a higher associated risk.

Gastric Banding

Essentially a band is placed around the top portion of your stomach which makes it much smaller and able to hold much less food at any one time. It is performed under general anaesthetic using keyhole surgery techniques, and takes about 30-60 minutes to complete. The band will need to be tightened a few weeks after the original surgery when all the initial swelling has settled, and this happens through a ‘port’, a small tube running from the band itself to a site just under the skin on your chest or abdomen.Following the band fitting your ability to take in food will be dramatically reduced and you may find that you suffer with nausea or vomiting as a result in the early days. There are potential complications such as infection to be wary of, but in general gastric banding is considered to be a fairly safe procedure. Gastric balloons work on similar principles but are fitted inside your stomach rather than around the outside.

Gastric Bypass

This is a bigger surgical undertaking and involves making your stomach smaller (commonly known as stomach stapling) along with bypassing a portion of your intestines and can be performed using either keyhole or traditional surgical techniques. This means that you will be able to eat less at any given time, and that less of what you eat can be absorbed. The side effects are similar to those for gastric banding but you can also get a symptom known as ‘dumping’ (every bit as unpleasant as it sounds) if you do not follow the diet plan strictly. While complications are more likely with bypass rather than banding, bypass is still also considered to be a fairly safe procedure.

Now for the good news! There have not been many long term trials monitoring what happens to patients in the 5-10 years following surgery but I was able to unearth a few. From reading these it seems that most people lose most of their excess weight and while a proportion do regain some of their weight, on the whole they keep most of it off. And, as expected, these people do have a much lower risk of diabetes, heart disease and some types of obesity related cancer as a result

So what’s the problem then? Surely we can all eat and drink whatever we want and then check in with our local friendly bariatric guy when the time comes, can’t we? Well we could –if we could all afford it, and for those of us who are Christians, we thought it appropriate (unlikely on so many levels!) – but there are definite down sides to this approach. Firstly, the sad fact that puts most of my patients off: a significant number of people who have these procedures die within a month of having them done, usually as a result of complications arising from the anaesthetic or surgery. And while the actual numbers of people who die are small, for those involved this is obviously a tragedy when there was an alternative to surgery. And for some reason yet to be explained, people are far more likely to die from accident or suicide in the first few years following banding or bypass, although the death rates from obesity related problems drops substantially, so overall your chances of survival do increase rather than decrease following the procedure. In fact, to date bariatric surgery is the most effective way of increasing your chances of survival if you are very obese.

There are other concerns; bariatric surgery does not always work, sometimes because of technical problems like the band slipping out of place, but more often because people find it so hard to live the new lifestyle associated with bands and bypasses. It is not the easy option by any means and requires a large amount of motivation and self control to see significant results, and while many people see dramatic weight changes it strikes me that most individuals who have found themselves in a position of having a bariatric procedure have got there precisely because, for whatever reason, they had motivation and self control issues to begin with, combined with living in our ‘obesogenic’ (fattening) environment which means that weight gain is almost inevitable for even the most disciplined of people!

Experts define this type of surgery as ‘failed’ if your body mass index (BMI) returns to more than 35 if you started at a BMI of 40-50, and more than 40 if you started with a BMI of more than 50. The studies I read found that approximately 20% of procedures had failed 5 years later, and 35% had failed 10 years later. I was also slightly concerned by the fact that by these criteria you can have a BMI of 39 and be considered a success! It does undoubtedly lead to significant health benefits in terms of reduced risk of heart disease, diabetes and other related conditions if you started with a BMI of more than 50, but living with a BMI of 39 is still pretty hard work.

So would I recommend gastric banding/bypass? It is clear from the evidence I have read that there are obvious benefits if the right person has the right procedure at the right time, but I would urge anyone out there considering bariatric procedures to make it an absolute last resort, which is exactly what almost any bariatric surgeon would be the first to agree with. Before you undertake something that drastic, finding out the reasons why you have overeaten in the first place and dealing with those will allow you to achieve great results while still living a normal life and may even be more effective in the long term.

I will give the last word to a woman who was quoted on one of the websites I read while researching this article: ‘Gastric banding relieves physical hunger but no operation can undo a lifetime of emotional eating’. Food for thought, isn’t it…

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