Bariatric Surgery: Pros vs. Cons

Introduction:

Obesity is an epidemic in many developed nations and is becoming a growing worry in developing countries that have traditionally dealt with the burden of malnutrition.(1) Obesity is a major public health concern due to its serious health implications, increased mortality risk, and associated social, psychological, and economic costs. Bariatric surgery is now the only effective treatment for morbid obesity that reliably achieves and maintains significant weight loss, reduces the incidence and severity of obesity-related comorbidities, and improves overall quality of life and survival.(2)

Kremen performed the first metabolic surgery, the jejuno-ileal bypass, in 1954.(3) It comprised of an anastomosis between the proximal jejunum and distal ileum, bypassing much of the small intestine, and was designed to treat severe dyslipidemias. This was a surgery with significant metabolic effects, thus most patients experienced severe diarrhoea and dehydration, and hence it was not yet ready for widespread use. Henry Buchwald later established that ileal bypass (with a jejuno-colic anastomosis) had an effect on decreasing lipid levels in individuals with known hypercholesterolemia, and that this benefit was sustained for several years.(4) Several improvements to these intestinal bypass procedures were reported in the 1960s and 1970s, but none of them were widely adopted.

The most commonly performed bariatric operations at present are the Roux-en-Y gastric bypass and the adjustable gastric band. Other bariatric operations include the vertical sleeve gastrectomy, which seems to be gaining in popularity recently, and the biliopancreatic diversion with or without a duodenal switch, an operation generally reserved for the most severely obese patient. Although the mechanism of weight loss with these operations tends to rely on restriction of food intake, malabsorption of ingested food, or a combination of the two, the exact mechanism(s) appears to be far more complex, implicating hormonal, inflammatory, central nervous system and gut microbial factors.(5)

Bariatric surgery was performed infrequently until the mid-1990s, once laparoscopic technique was introduced.(6) Laparoscopy allows surgery to be conducted through small incisions, reducing the pain and wound issues associated with traditional open procedures. With the growing obesity epidemic, the implementation of patient selection guidelines, and the increased use of laparoscopy, the stage was set for a significant increase in the rate of performance of bariatric operations, as evidenced by the jump from 13,000 procedures in 1998 to over 220,000 by 2008.

Types of bariatric surgery:

The initial advancements in surgical approaches to obesity management were documented in Sweden in 1952. Over time, these procedures have undergone considerable refinement, resulting in the emergence of three primary techniques: Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and laparoscopic adjustable gastric banding (LAGB).

Roux-en-Y gastric bypass (RYGB) is a surgical procedure primarily utilized for weight loss, also known as bariatric surgery. And has long been regarded the gold standard bariatric treatment.

 It is commonly performed laparoscopically, involving small incisions in the abdominal area. During RYGB, the surgeon reduces the size of the upper stomach, creating a smaller pouch akin to the size of an egg. This is achieved by stapling off the upper portion of the stomach. The resultant pouch is then directly connected to a segment of the small intestine known as the Roux limb, forming a distinctive "Y" shape. Consequently, food intake is restricted as it bypasses a significant portion of the stomach and the upper section of the small intestine.(7)

A vertical sleeve gastrectomy (VSG) is a minimally invasive surgical intervention aimed at reducing the size of the stomach to approximately three or four ounces. This reduction in stomach capacity restricts the amount of food intake, facilitating weight loss. Additionally, following VSG, there is a decrease in levels of ghrelin, a hormone associated with hunger, leading to an initial reduction in appetite. Patients undergoing VSG can typically anticipate losing up to 60 percent of their excess body weight.

Post-operatively, VSG is typically associated with minimal pain. The procedure involves making four to five small incisions, each approximately the width of a fingertip, through which small surgical instruments are inserted to decrease stomach size. Hospitalization for recovery typically lasts one to two days following the procedure.(8)

Laparoscopic adjustable gastric banding (LAGB) is a form of bariatric surgery aimed at promoting weight loss. This minimally invasive procedure involves creating small incisions in the upper abdomen to insert surgical instruments. The surgeon then places an adjustable band around the upper portion of the stomach, forming a small stomach pouch. This reduction in stomach size results in a sensation of fullness after consuming smaller amounts of food, facilitating weight loss.

The adjustability of the band is a key feature of LAGB. This is achieved by adding or removing fluid from a balloon surrounding the band, which can be accessed through a port implanted under the skin of the abdomen. A tube connects the port to the band around the stomach. During follow-up appointments post-surgery, the physician utilizes a needle to access the port and inject or remove fluid. This process aims to regulate the tightness of the band to optimize weight loss. Incremental adjustments are made based on the individual's progress, with careful monitoring of weight loss outcomes. If the band is overly restrictive, fluid may be extracted to alleviate discomfort and facilitate proper food intake.(9)

Pros and cons:

Considering the advantageous outcomes of the delineated bariatric procedures, juxtaposed with the limited efficacy of behavioral (e.g., dietary and exercise modifications) and pharmacological interventions in achieving substantial and enduring weight loss and improvement in comorbidities, what factors impede a broader adoption of bariatric surgery among individuals with morbid obesity? Despite the merits associated with bariatric surgery, it is imperative to acknowledge the attendant limitations and potential drawbacks.

In practice, given the large number of people who are prospective candidates for surgery, there aren't enough surgeons with the necessary expertise to execute the operations. There are additional patient-related factors that, if not addressed, may rule them out of consideration for surgery.(10) Patients suffering from binge eating disorder, for example, may maintain their problematic eating behaviour after surgery, resulting in surgical failure or weight regain. Active depression or other serious psychological disorders may produce similar negative results.(11)

Undoubtedly, the most triumphant outcomes in bariatric surgery are observed in patients who exhibit proactive adjustments to their lifestyle, encompassing enhancements in dietary habits and increased physical activity [2]. Nonetheless, apprehensions regarding potential unforeseen long-term ramifications of certain surgical interventions persist, especially given that a considerable portion of bariatric surgery recipients are relatively young and therefore possess a prolonged life expectancy. Certainly, the prospect of encountering challenges akin to those associated with the discontinued jejunoileal bypass procedure is a scenario that no one wishes to confront.(2)

The emergence of enduring and thoroughly delineated adverse surgical events, such as symptomatic cholelithiasis, complications associated with gastric bands, anastomotic strictures, leaks, and bowel obstructions, presents additional long-term apprehensions. Furthermore, gastrointestinal issues, including bleeding, small bowel bacterial overgrowth, and a spectrum of upper and lower gastrointestinal symptoms, along with nutritional challenges such as steatorrhea, protein-calorie malnutrition, and micronutrient deficiencies, compound the complexity of post-bariatric surgery care.(12) These metabolic and nutritional sequelae necessitate ongoing surveillance and supplementation with micronutrients throughout the patient's lifetime.(13)

For obese individuals grappling with numerous medical comorbidities and consequent diminished quality of life and shortened life expectancy, the potential adverse outcomes associated with bariatric surgery, as outlined previously, may be outweighed by the prospective benefits. No alternative treatment modality less invasive than bariatric surgery offers comparable effectiveness across multiple dimensions and over the long term, particularly for individuals who are motivated to pursue such interventions (depending on the specific procedure undertaken). Moreover, notwithstanding the initial costs associated with surgery, the economic considerations surrounding this form of therapy appear to favor bariatric surgery (contingent upon the success of the procedure and the necessity for any subsequent medical or surgical interventions to address complications that may arise).(14)

Discussion:

Bariatric surgery has emerged as a critical strategy in the treatment of morbid obesity, providing significant and long-term weight loss while also improving metabolic health and overall quality of life. Regardless of its effectiveness, the choice to have bariatric surgery involves a thorough assessment of both the possible benefits and cons.(15)

One of the primary benefits of bariatric surgery is its unrivaled ability to achieve significant weight loss and alleviate obesity-related comorbidities. Roux-en-Y gastric bypass and vertical sleeve gastrectomy are two procedures that have proven excellent success rates in terms of long-term weight loss and metabolic benefits. This weight loss frequently leads to increased physical mobility, less dependency on drugs, and a lower risk of obesity-related comorbidities like type 2 diabetes and cardiovascular disease.(16) The findings from Batsis et al. provide compelling evidence supporting the discussion on the benefits of bariatric surgery in improving metabolic health and reducing obesity-related comorbidities. Their study demonstrated significant reductions in the prevalence of diabetes, hypertension (HTN), dyslipidemia, sleep apnea, and metabolic syndrome (MeS) one year following bariatric surgery.(17)

Furthermore, bariatric surgery provides benefits beyond only weight loss. Many patients report increased psychosocial well-being, including higher self-esteem and less stigma associated with obesity. With a focus on depression, De Zwaan and colleagues used in-person interviews done prior to surgery and afterward at 6–12 months and 24–36 months to examine the course of anxiety and depressive disorders in 107 severely obese bariatric surgery patients. Participants with both anxiety and depression disorders at baseline lost significantly less weight following surgery, even though the prevalence of depressive disorders in their cohort fell dramatically after surgery. Furthermore, at the 24- to 36-month follow-up, there was a negative correlation between weight loss and postoperative depression condition. Also, the metabolic changes caused by specific bariatric surgeries, such as changes in gut hormones and bacteria, may provide long-term metabolic benefits unrelated to weight loss.(18)

However, it is imperative to acknowledge the potential risks and challenges associated with bariatric surgery. Long-term consequences, including nutritional deficiencies, gastrointestinal issues, and surgical complications such as anastomotic strictures and leaks, underscore the importance of sustained postoperative care and vigilant monitoring (19). Without appropriate supplementation, deficiencies in essential nutrients such as iron, calcium, copper, vitamin D, thiamine (vitamin B1), and vitamin B12 are common (20). A retrospective study revealed that 25% of patients exhibited low serum levels of zinc, selenium, and vitamin A, although most patients demonstrated improvement in these areas after receiving supplementation within two years post-surgery (21).

Recent retrospective analyses have shown that within a year following laparoscopic Roux-en-Y gastric bypass (RNYGBP), approximately 51.3% and 22.7% of patients experienced iron deficiency and iron deficiency anemia, respectively. Factors contributing to iron insufficiency include inadequate food intake, reduced absorption, and physiological or pathological losses (22). To mitigate these risks and optimize outcomes, patients undergoing bariatric surgery must commit to lifelong adherence to prescribed dietary and supplement regimens.

Furthermore, bariatric surgery has psychological and social effects. Some individuals may have difficulty adapting to postoperative dietary limitations or dealing with changes in body image.(23) In addition, concerns about the long-term viability of weight loss and the possibility of revisional procedures highlight the significance of comprehensive preoperative counselling and ongoing support from multidisciplinary care teams.

Conclusion:

To summarise, bariatric surgery is an effective strategy in the treatment of morbid obesity, providing significant benefits in terms of weight loss, metabolic improvement, and quality of life. However, the choice to have bariatric surgery should be carefully considered, taking into account the potential risks, benefits, and unique patient variables. Continued research and innovation in bariatric surgery are critical to improving results and increasing access to this life-changing procedure.

Reference:

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