OESOPHAGUS AND STOMACH

Bariatric surgery

are far less likely to achieve enough weight loss to improve their
physical and/or mental health without surgery.
Although the short-term results of surgery are easily apparent
in copious amounts of literature, long-term data as to the benefits
of bariatric operations are also emerging. The Swedish obesity
study, the largest long-term study of bariatric surgery, not only
demonstrated a significant difference in the amount of weight
lost by patients undergoing surgery compared to those treated
medically, but also demonstrated an overall sustained weight
loss of 14e25% excess body weight loss at 10 years.6
The comorbidities associated with obesity are numerous,
therefore obesity could be considered as a spectrum of disease,
rather than an entity on its own. Table 1 shows the most common comorbidities found in obese patients, although the list is
not exhaustive; for example, increased risks of cancer have been
seen in this population.

Corinne E Owers
Roger Ackroyd

Abstract
Obesity is one of the most prevalent problems worldwide today, with the
incidence fast increasing. As such, bariatric surgery is becoming a valuable alternative solution for those who have failed to lose weight by conservative means. Alongside obesity exist multiple comorbidities, both
physical and mental, which have a significant affect upon the patient
and need to be addressed before, during and after any operative intervention. This article outlines the problems associated with obesity, and
discusses the most common operations in terms of risks and benefits.
Finally, it explores the postoperative considerations that must be taken
into account before embarking upon weight loss surgery.

Pre-surgical considerations

Keywords Bariatric surgery; obesity; operation; weight loss

No international (or often national) consensus exists as to which
patients are suitable for bariatric surgery, although a patient
should have a significantly high BMI (often above 40 kg/m2 or 35
kg/m2 with a weight related comorbidity) (Table 2).
Each case must be considered based on its individual merit,
and in some specific cases, exceptions may be made by individual
surgeons. Patients with medical comorbidities such as diabetes or
sleep apnoea may benefit from a combined restrictive and malabsorptive operation, rather than purely restrictive as weight loss
is often more significant (Table 3). Patients with psychological
comorbidities may need substantial psychological support before
considering them for surgery. Each patient should be able to
demonstrate commitment to a healthier lifestyle following surgery, as those who do not change their eating and exercise habits
may be liable to weight regain. Some centres require patients to
quit smoking or drinking alcohol before offering surgery.
In most services, the surgical team should be supported by a
dietitian, specialist nursing staff, anaesthetic doctors and psychologists, all of whom can work to maximize the weight loss
outcome for each patient. The decision as to which operation to
offer should be made in consultation between the surgeon and
the patient, as many patients have a preference as to the type of
surgery they prefer.
Operations can be classified in a number of ways, and each
operation or procedure has its own advantages and disadvantages. The risks and benefits, along with complication risks,
should be discussed thoroughly with the patient before undertaking any operative procedure.
In most circumstances each operation is performed laparoscopically, apart from the intra-gastric balloon and endobarrier, which are performed endoscopically. Patients who have
had previous abdominal surgery, or those who have abdominal
wall herniae, for example, may need to have these factors taken
into consideration when choosing their operation.

Obesity is a global health epidemic, with numbers of people

diagnosed as obese rising in both the developed and developing
world.1 In the United States (USA), obesity rates have reached
one-third of the population2; one-quarter of British people3 and
31 million Chinese are also classed as obese.4
Obesity is associated with a significant number of medical and
psychological health problems, all of which impact upon progression of the disease, and its treatment. Unfortunately, limited
resources and lack of detailed understanding of the ideal way to
treat patients who have failed to lose weight by simple lifestyle
modification contribute to the debate surrounding bariatric surgery. However, the number of patients undergoing successful
surgery is increasing, as new techniques are developed and
safety improves, particularly since the introduction of laparoscopic techniques.
Although weight reduction is known to improve or cure the
majority of weight-related physical health problems such as
obstructive sleep apnoea, type 2-diabetes, hypertension and
arthritis, it is often difficult to accomplish any meaningful weight
loss without medical assistance. The psychological associations
made with food mean that a substantial number of obese people
eat for reasons other than hunger. These may include addiction,
comfort or recreation, and these psychosocial aspects may make
lifestyle modification almost impossible.
For patients who have failed with lifestyle measures or weight
loss medications, bariatric surgery is often considered to be the
next logical step towards achieving substantial weight loss and
reducing medical comorbidities, many of which contribute to a
decreased life expectancy.5 Patients with morbid or super-obesity

Corinne E Owers MBChB, MRCS, PGDipMedEd. is a Clinical Research Fellow

and a Specialist Registrar in General Surgery at Sheffield Teaching
Hospitals NHS Foundation Trust, UK. Conflicts of interest: none
declared.

Laparoscopic adjustable gastric banding (LAGB)

The laparoscopic adjustable gastric band (Figures 1 and 2) has
until recently been one of the most popular forms of weight loss
surgery, and remains in the repertoire of most bariatric surgeons.
An adjustable silicone band is placed laparoscopically around the

Roger Ackroyd MBChB, MD, FRCS is a Consultant Upper Gastrointestinal

and Bariatric Surgeon at Sheffield Teaching Hospitals NHS Foundation
Trust, UK. Conflicts of interest: none declared.

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OESOPHAGUS AND STOMACH

Laparoscopic adjustable gastric banding

Comorbidities commonly associated with obesity

Medical comorbidities

Psychological comorbidities

Hypertension
Cardiac failure
Thromboemolic disease
Hypercholesterolaemia
Type 2 diabetes
Arthritis/back pain
Infertility
Liver disease

Depression
Anxiety
Eating disorders
Social anxiety (e.g. Agoraphobia)
Suicidal ideation

Table 1

Classification of obesity
BMI

Classification

Less than 18.5

18.5e24.9
25.0e29.9
30.0e34.9
35.0e39.9
Over 40

Underweight
Normal weight
Overweight
Class 1 obesity
Class 2 obesity
Class 3 obesity

Figure 1

term complications, such as band slippage, erosion, port infections, and tubing issues.7e9
Average weight loss with the gastric band is around 50e60%.10
Resolution of type 2 diabetes is less than other operations, therefore it may not be as useful in this patient cohort as other operations. As demonstrated by Dixon et al.11 however, the gastric band
has a five fold increase in curing type 2 diabetes when compared to
medical management alone.

Table 2

fundus of the stomach and sutured in place to prevent band

slippage. The restriction of the band is adjusted with fluid via a
port, connected to the tubing and placed subcutaneously on the
anterior abdominal wall. This causes early satiety once the pouch
is full, and the amount of food is restricted until ingested foodstuff has passed through the band. A precursor to the bands in
use today, was the vertical banded gastroplasty, but this is no
longer in common use due to the high number of complications.
The band can be adjusted in the outpatient setting, either
clinically based on patient comfort with swallowing, or with
radiological assistance. Over-inflation of the band can lead to
oesophageal dysmotility or dilatation, therefore optimum tightness must allow for food to pass through in reasonable time. A
high level of patient compliance with dietary changes is required;
cheating is relatively simple by melting or pureeing food.
Although a relatively simple procedure that can be done as a
day case operation, the LAGB has a significant number of longer-

Sleeve gastrectomy (SG)

The sleeve gastrectomy is a more recent addition to the bariatric
surgeons repertoire. The stomach is stapled along its length over

One classification system for operative intervention

Restrictive
Reversible

C
C

Irreversible

C
C

Gastric band
Intra-gastric balloon
Gastric sleeve
Roux-en-y gastric
bypass
Biliopancreatic
diversion

Malabsorptive
C

Endobarrier

Roux-en-y gastric bypass

Biliopancreatic
diversion
Duodenal switch

Table 3

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Figure 2 Intra-operative laparoscopic adjustable gastric banding.

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OESOPHAGUS AND STOMACH

a bougie (usually 34e36 Fr). The majority of the stomach is

removed, leaving a thin tube of lesser curve (Figures 3 and 4).
This primarily acts as a restrictive operation, limiting oral intake.
Although the staple line can leak or bleed, and strictures can
form which require endoscopic dilatation, there are few longterm complications associated with this operation. In cases
where people have undergone previous abdominal surgery, the
sleeve is often the preferred option as adhesions may make the
gastric bypass unfeasible.
Weight loss is similar to the gastric bypass in the long term,
and can be as high as 84.5% at 3 years12 although more
commonly 45e60% excess body weight loss is seen at 5
years.13,14 Patients still require a high level of compliance as
liquid or soft foods and alcohol can pass easily and quickly
through the sleeve, preventing maximum weight loss, or
contributing to weight regain. Although the sleeve does not
cause a large degree of malabsorption, due to the decreased
secretion of intrinsic factor from the remaining stomach,
vitamin B12 deficiencies are more likely than following the
gastric band.

Figure 4 Intraoperative sleeve gastrectomy.

Newer versions of the gastric bypass such as the mini gastric

bypass are gaining in popularity as they involve only one anastomosis, although long-term results are not yet available, and
there are sometimes problems with excessive bile reflux.

Roux-en-Y gastric bypass (RYGB)

The Roux-en-Y gastric bypass works as both a malabsorptive and
restrictive operation. The stomach is divided to create a small
pouch distal to the oesophagus, which is joined to a loop of
jejunum around one metre distal to the duodenal-jejunal flexure.
The redundant stomach and jejunum is then re-anastomosed to
the jejunum at a variable distance downstream (Figure 5 and 6),
where digestive juices join food, which has passed through the
pouch and proximal jejunum. Prior to this point, food is not
absorbed, and the amount of food is restricted by the limited size
of gastric pouch.

Roux-en-Y gastric bypass

Sleeve gastrectomy

Figure 3

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Figure 5

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OESOPHAGUS AND STOMACH

endoscopically, a balloon is inflated within the fundus and left

for up to 6 months. This helps the patient feel satiated more
quickly and reduce appetite. Weight loss is usually modest
compared to other operations, and weight regain commonly occurs once the balloon is removed. Average weight loss of 10e15
kg can be seen,18,19 and this procedure is often used in morbidly
or super obese patients prior to definitive surgery, in order to
help them lose weight and reduce their operative risk.20,21
Complications are mainly related to the endoscopic procedure
required to place or remove the balloon, such as pharyngeal
trauma or perforation, although vomiting, gastric reflux and
balloon rupture are not uncommon. In rare cases, gastric or intestinal obstruction has been seen as a result of the gastric
balloon.22,23

Endobarrier
The endobarrier is a further endoscopic procedure, although a
general anaesthetic is usually required. The barrier sits in the first
part of the duodenum, extending through the proximal jejunum
and preventing absorption of food for approximately the first
metre. The endobarrier is licenced for use for up to 1 year, after
which it is removed in the same manner. A mean weight loss of
19% has been demonstrated, although long-term results are
required to see if it is successful after removal.24 The endobarrier
is marketed primarily as a cure for type 2-diabetes rather than a
method for pure weight loss; therefore it is most useful in obese
patients with type 2-diabetes who need to lose weight in order to
improve their glycaemic control.

Figure 6 Intra-operative gastro-jejunal anastomosis.

The gastric bypass is often considered the gold standard and

is the most commonly performed procedure in the USA and UK.
Weight loss is 60e70%15 and diabetes remission is as high as
80% at 3 years. With a mortality of 0.25% and a low long-term
complication rate, the gastric bypass is often an ideal operation
for patients with a larger BMI as it has a duel action of restriction
and malabsorption. Complications include anastomotic leak,
bleed or stricture, but nutritional abnormalities are less common
than in other malabsorptive operations such as the biliopancreatic diversion and duodenal switch.
Evidence suggests that the RYGB may be a preferable option
in patients with a sweet tooth as the desire for sweets is often
reduced following this operation.16 This may be related to
dumping syndrome.17 However, it may be that taste preferences
change, and therefore the RYGB may be a more suitable option
for patients who feel that a substantial amount of their daily
calorie intake is related to sweet foods.

Postoperative considerations
Following bariatric surgery, patients require a significant amount
of input from the multidisciplinary team. Although they will have
been educated regarding their postoperative diet prior to surgery,
most patients will see the dietitian postoperatively to discuss this
further. Although different centres have their own practices, in
most cases patients are able to sip fluids on day 1 following their
operation, gradually building up their oral intake. Patients usually follow a staged diet, progressing from liquid foods, through a
sloppy and mushy stage, until they are able to tolerate solid
foods, often a few weeks to months postoperatively. In the case of
the gastric band, this staged diet needs to be revisited after every
adjustment in order to avoid complications.
Most patients are encouraged to take daily multivitamins
following surgery; this is especially important following the
larger operations, most notably the sleeve, bypass and BPD/DS.
The malabsorption of nutrients and minerals following surgery
mean that bariatric patients are at risk of nutritional deficiencies,
and they should engage with their general practitioner in the
long-term, ensuring that routine nutritional markers are taken at
least annually and any malnourishment or deficiencies corrected.
Rarely, these nutritional abnormalities or malnutrition become
severe enough to warrant revisional surgery, and even reversal
of the malabsorptive component, although this is usually only
after the BPD/DS or gastric bypass.
In many cases, surgery has an almost immediate affect upon
glycaemic control. Due to a combination of factors including
limited oral intake and liquid diet, blood glucose is often low
following surgery and glycaemic medications are not required.

Biliopancreatic diversion and duodenal switch (BPDDDS)

Both operations are restrictive and malabsorptive, in that they
reduce the amount a patient can eat, and involve bypassing a
proportion of the small bowel in a similar manner to the gastric
bypass. The BPD and DS operations are less commonly performed due to the high risk of nutritional abnormalities following
surgery. Although more successful in the super-obese patient,
care must be taken to ensure they receive an adequate supply of
vitamins and minerals, as the greater length of bypassed small
bowel contributes to a high degree of malabsorption. In many
cases, these operations are reserved for patients who have failed
to lose weight following the gastric bypass.

Intra-gastric balloon
Not strictly an operation, the intragastric balloon is a relatively
cheap and simple adjunct to weight loss. Performed

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Significant reductions in blood glucose have been seen 6 days

following surgery,25 and in many cases, patient can be discharged without the need to use their insulin or oral glycaemic
medications. They should be advised to monitor their blood
glucose and contact their dietitian or general practitioner if
further advice is required.
Although bariatric surgery can often help patients to lose
weight and improve their body image, loose skin is a common
issue, and unfortunately many patients feel this significantly
impacts of their self perception. Further surgery can be undertaken to reduce this excess skin, but cost of plastic surgery can
often be substantial and many patients are not able to afford
further surgery. Patients who suffered with psychological problems preoperatively may find it difficult to adjust to their new
lifestyle particularly if their coping mechanism were previously
related to food. The addition of a trained bariatric psychologist to
the multidisciplinary team can be a useful adjunct, particularly in
cases such as these.
Dumping syndrome can be a common occurrence following
bariatric surgery, particularly the bypass, biliopancreatic diversion or duodenal switch, and to some extent the sleeve gastrectomy. Characterized by symptoms of hypovolaemia, tremor,
confusion and gastrointestinal disturbance, early dumping is
caused by the rapid expansion of the duodenum as food passes
through the remaining stomach, causing rapid osmosis. As fluid
passes into the small bowel so rapidly, the patient may become
significantly hypotensive and even lose consciousness. Late
dumping is caused by the massive secretion of insulin from the
pancreas, leading to hypoglycaemia. Both forms of dumping
syndrome can be distressing to the patient, and are more common following carbohydrate or glucose injection. The patient
often has to learn which foods to avoid in order to control their
dumping syndrome, as there is often no alternative.

Conclusion
Bariatric surgery is increasingly employed to help patients with
weight loss, reduce physical health issues and increase life expectancy. Previously considered a high-risk weight reduction
strategy, surgery is today a safe and viable alternative to medical
and life-style weight loss interventions. There are significant
considerations both for patient and the multidisciplinary team
before and after the patient undergoes surgery, but by working
with the patient, weight loss can be optimized and health gains
can be substantial. Bariatric surgery should therefore be
considered as a worthwhile option for any patient who needs to
lose weight in order to maintain or adopt a healthy lifestyle. A

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