A recent edition of the Pretoria News featured an article on bariatric surgery, entitled “When diets and exercise fail, surgery can help”, written by Barbara Cole.

This article reported on how Natashua Fourie lost 34kg since last November, following keyhole laparoscopic surgery for morbid obesity. According to the report, the surgeons, who are authorised to perform such operations at St Augustine’s Hospital in Durban, have recorded even greater successes, including one patient who lost 120kg of weight after this type of operation.

As many Health24 readers also suffer from morbid obesity with BMIs exceeding 35, coupled with a variety of so-called comorbidities (other health conditions such as diabetes, sleep apnoea, painful joints, high blood pressure and impending heart disease), I decided to read up on the available scientific literature and to share my findings.

What do these operations entail?
Bariatric surgery involves a reduction in the size of the digestive tract to restrict how much food the patient can eat and absorb. Most of the present-day techniques reduce the size of the stomach.

For example, gastroplasty involves placing stainless steel staples across the top of the stomach, leaving a small opening so that only a small amount of food can pass into the stomach at any one time.

A gastric bypass, on the other hand, also entails a reduction in the size of the stomach (with the aid of staples) and connecting the part of the stomach that is still functioning to the small intestine (Krause, 2000).

Laparotomy vs. laparoscopic surgery
Initially, bariatric surgery always involved a laparotomy (surgical opening of the abdomen). But nowadays keyhole laparoscopic surgery, which only requires small incisions in the abdomen, has become more popular. The latter procedure is much less invasive and faster, thus exposing the patient to less risk during the operation.

In one study conducted at the University of California, researchers found that laparoscopic bypass surgery took less operation time, caused less blood loss, reduced the length of time that patients were in intensive care after surgery and the length of their stay in hospital (Nguyen et al, 2000).

An Italian study reports that, on average, laparoscopic procedures took 60 minutes to perporm compared to up to 3,5 hours for the more invasive, full-scale operations (Angrisani et al, 2007).

From the point of view of the patient undergoing surgery, it is evident that the more recent keyhole surgery techniques are faster and safer.

Can one expect the same weight-loss results?
A valid question is if the keyhole laparoscopic technique produces the same long-term results as the longer, more invasive surgical procedure.

A German research team, who studied 100 patients who underwent laparoscopic adjustable gastric banding, found that this procedure produced excellent results with an average weight loss of nearly 60% eight years post-operatively with reductions in BMI from 46.8 to 32.3 kg/m (Weiner et al, 2003). These researchers concluded that laparoscopic adjustable gastric banding is safe and has a lower complication rate than other bariatric operations.

Nguyen and coworkers (2000) also concluded that the keyhole technique produces the same initial weight loss as the more invasive surgical procedure.

Thanks to progress in the field of bariatric surgery, the keyhole operation appears to be faster and potentially safer than techniques that require full-scale opening of the abdomen, and this newer approach apparently also gives good weight-loss results.

According to the newspaper report, Natashua Fourie, who shed 34kg, was treated with the keyhole procedure. Her mother and a friend had the same operation and lost 29kg and 25kg, respectively.

Who qualifies for bariatric surgery?
In my reading of the scientific literature, a number of authors repeatedly stated that “bariatric surgery is NOT to be regarded as a cosmetic procedure, but as a life-saving intervention in patients who suffer from morbid obesity.”

It is very important to understand that individuals who only need to shed a few kilos or who have a BMI of less than 35 are usually not regarded as candidates for bariatric surgery. In fact, the majority of studies I investigated were treating patients with BMIs exceeding 40!

If your BMI is lower than 40, surgeons may, therefore, only consider you as a candidate for bariatric surgery if you have severe comorbidities such as diabetes mellitus, very high blood pressure or raised blood fat levels, and if you are at risk of suffering a heart attack.

In most cases, the decision to do a gastric bypass operation is determined by its effect on potentially life-threatening obesity and other risk factors.

If you do not suffer from morbid obesity and accompanying life-threatening conditions, then most surgeons would recommend that you use diet and exercise, plus medications such as Xenical, to lose your excess weight. COSMETIC BLISS NOTE: The insertion of a BIB Intragastric Balloon for candidates with a BMI which is not high enough to justify surgery is proven to give good weight loss results, and can be seen as a very useful tool in giving a six month “training period” in which eating habits and the relationship to food can be permanently changed.
Read the full story at
http://www.health24.com/dietnfood/Weight_Centre/15-51-2992-3081,41241.asp

Extremely obese people suffering from depression or anxiety tend to lose less weight after obesity surgery than mentally healthy people, researchers reported in a study that suggests such patients could benefit from treatment beforehand.

People diagnosed with mood or anxiety disorders on average lost 81 pounds six months after gastric bypass surgery compared to their counterparts who shed 86 pounds. Although both groups lost significant weight after surgery, people without mental health problems did slightly better. Researchers plan to follow patients for up to two years to determine if there’s a weight difference over time.

Many hospitals and insurers require surgery candidates to go through a psychological evaluation before obesity surgery to make sure they are mentally fit for the operation and the lifestyle change afterward. Depressed people aren’t automatically disqualified for surgery, but those who are suicidal or abusing drugs and alcohol are usually ruled out.

How depression and other mental health disorders are handled before obesity surgery vary widely by medical center.

Those with serious problems are usually treated before surgery. That could include antidepressants, psychotherapy or more family involvement, said the center’s director William Perry.

In the new study, Pittsburgh researchers interviewed 207 surgery candidates and found two-thirds had a history of depression, bipolar disorder, post-traumatic stress syndrome or panic attacks. The vast majority were women with an average body-mass index of 51. A person with a BMI of over 40 is considered morbidly obese.

After adjusting for age, gender and race, researchers compared weight loss six months after surgery. Patients with a history of depression on average weighed 322 pounds before surgery and 241 afterward. Those with no mental health problems weighed 303 pounds before the operation and 217 pounds afterward.

Having a history of mental health problems should not prevent people from getting obesity surgery, even though they may not lose quite as much weight as mentally healthy people, said Dr Philip Schauer, president of the American Society for Bariatric Surgery.

By David Hurst -  Daily Mail  19th June 2007

Many patients are being denied surgery, including joint replacements, because they are overweight. John May, 68, a retired Army corporal from Manchester, underwent stomach balloon surgery privately in order to lose weight for his NHS operation.
Here he talks to DAVID HURST about his experience and his surgeon explains the procedure:
THE PATIENT
My problems started when I left the Army in 1980. I’ve always been heavy – I’m 5ft 8in and back then weighed 15st – but at that point I was very fit. Then I took a job as a night attendant at Manchester City Council.
After driving to work, I’d sit down all night, and sleep during the day. I also ate a lot of takeaways and my weight increased by a stone a year. By the mid-1990s I was 28st.
Nine years ago I developed problems in my hips and knees, especially my right hip and left knee – it was painful standing up for any length of time. The doctors told me both joints needed replacing.
However, a year later, I was informed that the NHS would not perform these operations because my weight would place too much stress on my new joints, and before long they’d need replacing again. I was told I’d have to get down to 17st before they’d operate.
I tried various diets over the next five years. In 2000, after a few months on a liquid-only diet, I got down to the required weight. But as soon as I came off the diet my weight shot back up to 25st. Looking back, I can see I was eating to cheer myself up.
By 2005 I could only get about using crutches. I couldn’t work and felt desperately unhappy. Last June, a friend told me about an operation to help obese people by inserting a balloon into the stomach via the throat. This is then filled with liquid, making you feel fuller quicker. I’d only need to eat a quarter of what I did before to feel full.
Then, by the time the balloon was removed, six months later, I would be in the habit of eating healthily.
Having the balloon inserted meant I could lose 5st in six months. Then, under weekly supervision, I would continue my new diet. Within a year I could be in line for hip and knee replacements. The cost was just under £5,000 including consultations, supervision and counselling.
I wanted to try it as soon as possible. So, last summer, Phil Thomas, director of a specialist centre, agreed to insert my balloon – provided I was prepared to alter my diet and keep a journal of my eating and exercise. Two weeks later I was at Manchester’s Trafford General Hospital.
First, a spray numbed the back of my throat. Then a tiny camera on the end of a tube was used to see that everything was OK.
After removing that, I had another tube down my throat, with the deflated balloon – about the size of a party balloon – attached. I could feel it going down, but it only took a few minutes.
When they filled the balloon I didn’t feel a thing. That took just a few minutes – the entire procedure took less than an hour. I was warned I might feel sick for a few days, but didn’t.
I was able to eat within hours, but my diet was vastly different – fruit for breakfast, tuna and tomato on Ryvita at noon, and in the evening I’d have something like minced beef with vegetables. Even though it was much less than I wanted to, I still felt full, and my cravings disappeared. In six months I lost 5st.
The procedure to remove the balloon was just the reverse of how they inserted it and not painful. That was in January, and I’ve continued to eat healthily. In the months since the balloon was removed, my weight has continued to drop. I now weigh under 20st and still lose a couple of pounds a week.
Not only does everyone tell me I look better, I feel far better due to my improved diet, and my sleeping has improved. I can get about without crutches for the first time in years.
I’m now having my knee operation in July and the hip two months later. I couldn’t be happier.
Having the stomach balloon fitted has transformed my life. It was worth every penny.

Read the full Daily Mail article at: http://www.dailymail.co.uk/pages/live/articles/health/myoperation.html?in_article_id=462993&in_page_id=1989&in_a_source=