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Obesity

The following pages are best read in order, to give you maximum understanding of the problem.

What is morbid Obesity and how does it differ from just being overweight?

Am I Morbidly Obese?

How do we tell if someone is Morbidly Obese or just overweight?

Why resort to surgery for Weight Loss?

What are the non-surgical options for Weight Loss?

• “Bounce Medical regime”
• Bioenterics Inflatable Gastric Balloon (BIB)

What are the surgical options for Weight Loss?

• Laparoscopic Adjustable Gastric Banding
• Laparoscopic Gastric Sleeve Resection
• Open and Laparoscopic Gastric Bypass (Fobi Pouch)

An Explanation Of Fees

Which Operation

The Perioperative phase …..before and after Weight Loss Surgery

What are the goals of Bariatric Surgery?

Complications of Bariatric Surgery.

Where is the surgery performed?

Links

Who are we?

How to find us

How to make an appointment for assessment of Morbid Obesity

WHAT IS MORBID OBESITY AND HOW DOES IT DIFFER FROM JUST BEING OVERWEIGHT?

For most of us, at some time in their life, are able to stay at a steady weight form day to day, despite the amount of energy that we eat, never balances the amount of energy we burn off with activity.

The ability to do this without thinking about it, is called the Weight Homeostasis Mechanism.

It evolved in our primitive ancestors. They did not have fridges, so they could not store food, until a genetic aberration occurred, that allowed primitive man to store any excess food requirements as fat, which was used to keep them alive during the lean hunts and long winters.

We all have this mechanism, as it is/was essential for survival. However, note that the mechanism is really about storing fat….not just keeping our weight stable. So we all are genetically programmed to have a certain amount of fat present from day to day. Everyone is different, so “Ideal Weight” as quoted by many clinics and weight loss centres doesn’t really make much sense. Unfortunately, we are unable to measure this, as it is genetically determined, but our research is coming up with some answers.

For most people, being overweight is usually a simple imbalance between the food consumed, and the amount of activity. The more we eat, the heavier (more fat) we get. By eating less and exercising more, weight loss will occur.

However, at a certain size in some people, something changes in our body chemistry, and we are now unable to loose the excess weight by dieting and exercise. The changes are almost always irreversible (Less than 2% are able to lose the weight LONG TERM).

That person now becomes a patient, in that they are now “Morbidly Obese”. They are able to diet and lose weight for a short time, but weight gain is inevitable, and usually end up a little heavier than when they started the diet. In this condition, diets and exercise will never work LONG TERM.

Which means that for those who have struggled, it’s not your fault. The chemistry that has developed makes long term weight loss impossible. There is no will power in the world that can overcome this.

There are several definitions used, most commonly, a BMI >35 .

A real mouthful (excuse the pun) is “A Genetic and Neurohumoural breakdown in the weight homeostasis mechanism”

Although an awful term, it does draw attention that the amount of fat is now causing illness (Morbidity). So it is not really a description of shape. However, the definition is changing, as muscular athletes have a high BMI, no fat, and no illnesses. But it is adequate for screening those who might have a health problem.

Once morbidly obese, patients have an increased risk of early death, and a huge list of illnesses attributable to the excess fat.

The good news is that with fat loss, the illnesses attributable to excess fat will either improve substantially, or disappear.

Imagine the wonderful satisfaction and pleasure we get in curing Type II diabetes, and seeing a withdrawn poorly dressed individual blossom and play on the beach with their children….and wearing a swimsuit!

AM I MORBIDLY OBESE?

Just find your height, and move down that column to your weight. That number will give your BMI.

If your BMI is 35 or greater, you are likely to have a significant health problem, but may not, depending on your age and build.

Polynesians will have a larger muscle mass, so they may be very healthy with no risks.

Asians have low fat mass, so the BMI for morbid obesity in an Asian is 27.5.

However, you may have the problem but your BMI is 33. Give it a couple of years, and it might be 35 or greater. In that case, why wait to become diabetic?
 

BMI Classifications:

BMI Calculator

HOW CAN WE TELL IF SOMEONE IS MORBIDLY OBESE?

There is no simple test.

As it is a genetic problem (Not necessarily inherited…..damage to a gene may occur after conception), there is often a family history of obesity, with a high prevalence of diabetes, abnormal blood fats, hypertension, and heart disease occurring in the family.

The weight problem can be present from birth, or later in life. The risk times for females are puberty, childbirth, and to a lesser degree, approaching menopause.

Typically, a person is able to lose weight for a while, but then the loss plateaus, and despite the best intentions in the world, there is regaining of all that weight loss, and usually end up a little heavier than when they started, i.e. a stepwise weight gain over the years. This happens repeatedly, so it becomes incredibly demoralizing and depressing.

A screen of blood tests are done, to see if there are any other causes for obesity present, (Such as an under active thyroid) as well as look for undiagnosed illnesses. In particular, insulin resistance is commonly found. This appears to be the first step towards diabetes.

One important investigation that we do is a body composition study, which tells us how much fat is present, and how much of the weight is due to muscle bulk or water. Our research in this field has been internationally acknowledged

If we are not sure, we have a variety of options available for patients that might be worth pursuing that we will discuss with them.

WHY RESORT TO SURGERY?

When the weight control mechanism goes wrong, it’s as if the part in the brain controlling this amazingly complex mechanism, has been re-set. It thinks that the normal amount of fat for that person should be say 50%, rather than say 21%, which would be their normal fat. So weight is able to be lost for a while, then the control center gets alarmed, as it thinks there is not enough fat to survive the next poor hunt or lean winter. So a whole series of body chemistry is set into motion to regain that fat, in order to survive. These body chemistry changes occur without us knowing, and are beyond our control, just like heart beats and breathing. We can influence them for a while, but we cannot stop them.

We have very limited medical ability to control this system. Long term drug use is very unlikely to loose more than 10% of body weight, and there are side effects for many people.

And thus we resort to surgery, as it is the only available treatment for maintaining long-term weight loss. It is vital to understand that surgery is done to improve health and cure or improve illness. To do that, we have to get rid of fat.

It is not a purely cosmetic option.

If you have read all of this so far, take a break as it gets a bit more complex from here on!



WHAT ARE THE NON-SURGICAL OPTIONS?

Patients must have had multiple attempts at weight loss before coming to see us. We would not consider anything more aggressive unless that has been attempted.

a. Our medical treatment or “Bounce Treatment”

This is something that has been formulated by our clinic a few years ago.

It involves medical suppression of the appetite (utilizing a drug called Sibutramine, or known as Reductil.) for about 3 months, then a month or two of sensible eating, then 2 or more weeks of a special VLCD (Up to now we have used Optifast, but because of several problems have recently switched to another brand). Then normal food for a month, then back to reductil. It does mean followup (as do weight clinics such as Jenny Craig or Weight Watchers). It is used in special cases where surgery might not be an option)

b. The Bioenterics Intragastric Balloon (BIB)

This is done under sedation. A special balloon is gently passed down through the mouth into the stomach, and inflated under direct vision with a camera in the stomach (Gastroscope)

By filling the stomach, the appetite is suppressed, and patients feel full. However, it must be removed after 6 months, so it has some limitations to being used in:-.

1. In adolescents

2. In those who are massively obese, whereby reducing their size pre-operatively would make the operation safer.

3. Those who have a BMI <35, or who might not have the biochemical abnormalities

Intragastric Balloon in place in stomach.

WHAT ARE THE SURGICAL OPTIONS?

There is no “Best” operation. If there was, despite the claims, then every surgeon in the world would be doing it. We have always maintained that there is not just one operation that suits everyone, so we offer a variety, all of them working in different ways. But be aware that all procedures have failure rates, and none of them is perfect.

Morbid obesity is now regarded a bit like hypertension. There are a variety of medications, and patients may need to be changed, or might need the addition of a second or even a third medication. Obviously no-one wants a second or third operation, but unfortunately that it is occasionally required.

Therefore we offer three operations (beyond the BIB). All 3 are done laparoscopically:-

• Gastric Banding (Midband and Gastric Band)
• Gastric Sleeve resection
• Gastric bypass (Fobi Pouch, Banded Roux-en-Y)

Lifestyle changes and follow up is essential after any procedure.

a. Eat small meals

b. Don’t drink with meals (food will empty more quickly)

c. Eat slowly (15 – 20 mins for a meal)

d. Don’t skip meals

e. Exercise

1. Laparoscopic Gastric Banding:-

An inflatable silastic band is placed around the upper stomach to create an hourglass stomach. The upper pouch is only golf ball sized, with a narrow exit created by the band. Thus a small meal fills this pouch quickly. There is probably no significant difference between the Midband and the Gastric Band in its effect.

Interestingly, gastric banding appears to alter the abnormal body chemistry that was preventing weight loss previously, so diets and exercise will now work.

Patients are immediately not hungry, but also their attitude is immediately changed…they are not interested in food, nor do they miss it. So it is easier to say “No”. But the band does not stop people from eating junk food, nor does it make them exercise. The band always works, but it is the mind that determines the result. It is important to realize that the band does not cause weight loss by itself…..it is an aid, and now exercise and appropriate eating will burn off excess fat.

After a while after placement, the appetite gradually returns, as does the interest in food. Then it’s time to inflate the band, which is done in the office. Instantly, the hunger and interest disappears, and the weight loss resumes.

If a patient becomes pregnant, we can adjust the weight gain, which is necessary for a healthy baby, and then reinflate again after delivery!

The advantages of the gastric band are:-

1. There are no nutritional deficiencies

2. Food still passes down the normal route so there is no malabsorbtion (although extra vitamins are recommended)

3. It is removable (and food still passes down the normal route after removal)

4. It is adjustable, so the weight gain of pregnancy can be regulated for the babies sake, then re-inflate the band after delivery.

5. All foods are able to be eaten in nearly all cases (common exceptions are red meat, bread, and carrots) Problems with certain foods is nearly always an indication of eating incorrectly. (Too fast, or too big a mouthful, or not chewing enough)

6. The stomach can still be examined after placement of a Gastric Band.

Lifestyle changes and follow up is essential after Banding

a. Eat small meals

b. Don’t drink with meals (food will empty more quickly)

c. Eat slowly (15 – 20 mins for a meal)

d. Don’t skip meals

e. Exercise

However, a small group of patients do not have a satisfactory result. It proves that there is not one operation that suits everybody.

2. Laparoscopic Gastric Sleeve Resection

This works differently than either gastric banding or gastric bypass. The stomach is reduced in size, so it becomes a narrow tube. There is no restricting band, so there are no food restrictions. Appetite is immediately gone, a small meal fills quickly i.e. satisfies, and the initial results are very promising.

Initial reports report a 40 – 60% excess weight loss, with an excellent safety profile (Nearly as good as Gastric Banding). However, it is early days, and we do not know the optimum sleeve size, nor do we know the long-term weight loss results.

It initially was used in the super-obese, to get their size down to a safer weight prior to proceeding to gastric bypass. The sleeve resection was safer, and 1/2 the bypass operation had been done by the sleeve operation. We found that in many cases, there was no need for a bypass as the patients did so well.

At the present time, the indications are:-

a. Reducing the size of the super-obese as the first stage of gastric bypass or gastric banding.

b. Patients with a less than desired result from gastric banding, but don’t wish to proceed to gastric bypass.

c. Those patients who do not want gastric bypass or gastric banding as their first procedure.

3. Gastric Bypass

A small pouch is made from the upper stomach, and the food by-passes a segment of small bowel, so there is less absorption….a bit of a double whammy, by combining restriction with malabsorbtion. It does involve rearranging normal anatomy, and is by far the more aggressive procedure. The initial weight loss however, is almost inevitable and easily achieved, and the desired weight is reached more quickly. However, after 3 – 4 years, the evidence is that there is no, or little, difference in weight loss compared to gastric banding. There are also significant dietary problems and life long nutritional problems, but these are generally easily overcome.

THE PERIOPERATIVE PHASE

In Morbid Obesity, the liver is enlarged and congested with fat. This enlargement obscures the view and can make the operation dangerous or impossible to complete laparoscopically. Because it is so heavy, it can fracture and bleed horrendously, which is a dangerous situation. The diagram below shows fat dripping out of the liver in a patient who did not follow instructions.

Therefore, all patients undergoing surgery go on a 2 week preoperative liver shrinkage regime. This utilizes a commercial VLCD (Very Low Calorie Diet). A sachet of powder is mixed with water, and substituted for every meal. If there is no appropriate weight loss after 2 weeks, the surgery might need to be cancelled (postponed). This stage is very difficult, but it is for a short and defined time, with a very important objective.

There is no hunger immediately after surgery, so it is easier to follow the instructions. They are the same for all procedures. Failure to follow these instructions can lead to serious complications including death.

Patients stay on a liquid blenderised diet for two weeks, then week by week, increase the consistency until they are back onto normal food after a month. It sounds a bit complicated, but we take patients through these stages …..we don’t just leave them to it to fend for themselves!

After a month, an exercise regime is worked out for them, and it is easy to achieve as it is based on the individual’s heart rate and respiratory rate.

Follow up timings varies somewhat between the procedures, but is essentially forever as there may be unknown problems in the future that haven’t occurred yet. We also need to ensure that there are no dietary deficiencies occurring. Gastric bandings need a tiny “top-up” every year or two as there is a slow loss of fluid from the band.

WHAT ARE THE GOALS

There are many definitions of success, based on either weight, BMI, % loss of excess weight, and quality of life.

Several years ago we abandoned these, as it became obvious that none of these definitions of success were suited to everybody.

Remember we are performing surgery to correct or improve illnesses. So our goal is to improve health as much as is possible, and down to a size that the patient is happy with. Patients are usually still a little “cuddly”, but they are content. AS we frequently quote:-

“What’s the point of being skinny if you are unhappy?”

We indicate a likely weight that could be achieved, but do not put any pressure on patients to achieve this, and are not obsessed by WEIGHT loss. We let the patient decide.

COMPLICATIONS OF SURGERY

Unfortunately, complications do occur despite every effort to avoid them.

But what else is there besides surgery? You have already tried everything else without success.

Below is a list of complications that are more common for the different procedures. They are not the full list, and it is important to know that there may yet be complications in the future that we are unaware of at this point in time.

There are anaesthetic risks and risks peculiar to each particular procedure. Any weight loss surgery can cause gallstones to become symptomatic and subsequent removal of the gallbladder.

All patients who are morbidly obese are immediately classed as high anaesthetic risk, due to the nature of the illness and the morbidities.

General surgical complications include, but are not limited, to DVT (Dangerous blood clots in the leg veins), Pulmonary embolus, wound infection, bladder infection, chest infection, and intra-operative damage to organs. These can occur as a result of traction, slippage of tissues during retraction, thermal injuries, perforation of the stomach, bowel, or adjacent organ, bleeding from major vessel….the list goes on, but fortunately they are uncommon. There may in fact even be complications in the future that we are unaware of at this early phase in the history of Weight Loss Surgery.

1. BIB (Bioenterics Intragastric Balloon)

a. Pressure necrosis of gastric wall

b. Bleeding from stomach

c. Migration and intestinal obstruction or impaction.

d. Migration and aspiration

e. Intolerance needing removal

2. Gastric Banding

a. Slippage, which might cause obstruction and urgent surgery.

b. Erosion into the stomach.

c. Perforation of stomach during surgery, which might be unrecognized at the time.

d. Leakage, usually from difficulty in inflating the port and damaging the tubing.

e. Wound infection that might need removal of port and replacement 3 months later.

f. Further surgery (~5%)

g. Mortality <1%

a. Leak from staple line (<1%)

b. Necrosis of remaining stomach (Not reported yet)

c. Damage to spleen or bowel, requiring removal or repair

d. Bowel obstruction

e. Mortality (Not known in 2005)

a. Staple line leak

b. Anastamotic leak

c. Damage to spleen or bowel, requiring removal

d. Nutritional deficiencies ( ~ 30%)

e. Dumping syndrome

f. Further surgery (10 – 20%)

g. Bowel obstruction.

h. Mortality 0.3 – 5%

WHERE IS THE SURGERY PERFORMED?

Either at The Northern Clinic, or next door at Southern Cross Hospital.

The Northern Clinic do not charge for any early returns to theatre for their patients, except for any disposables used, and there is no additional surgical fee, and usually a reduced or zero anaesthetic fee. Thus there is the added security of not having to worry about a second expensive bill for unexpected surgery at The Northern Surgical Centre.

This means the clinical staff are on site every day while you are in hospital.
 

© New Zealand Obesity Surgery Centre- Auckland, New Zealand.