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Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
Original Article
Surgical Management of Obesity – National University Hospital Experience
Asim Shabbir,1MMed, FRCS, FAMS, Tsuan Hao Loi,1MBBS, MRCS, Davide Lomanto,1,2MD, PhD, Thiow Kong Ti,1,2FRCSE, FRACS, FAMS,
Jimmy BY So,1,2MBChB, FRCS, FAMS
Abstract
Introduction: The Singapore National Survey of 2004 reported the prevalence of obesity to
have increased to 6.9%, thus reflecting the profound changes in our society’s lifestyle and eating
habits. Bariatric surgery has steadily been increasing to counter the ill effects of obesity. Materials
and Methods: We audited our prospective series of 31 patients who had laparoscopic adjustable
gastric banding (LABG) for morbid obesity performed by our multidisciplinary team at the
National University Hospital, Singapore, between August 2004 and December 2006. Results: The
median age at presentation was 40 years old including 6 males and 25 females. Their median
BMI was 42.35 kg/m2. At a median follow-up of 26 months, the median percentage of excess
weight loss (%EWL) was 41.95%. The positive impact of gastric banding on comorbidities are
evident whereby 15 (94%) of the diabetics had improved glycaemic control with HbA1C of 7.7%
preoperatively improving to 5.9% postoperatively, and also 8 (58%) now take smaller doses of
oral hypoglycaemic agents. Hypertension improved in 4 patients and 2 (11%) were cured. All
our patients with dyslipidaemia had their statin doses reduced with marked lowering of serum
lipid levels. We had 2 patients (6.45%) with band erosion and another 2 with reflux oesophagitis.
Our article also summarises the available surgical procedures while discussing the pros and
cons of each. Conclusion: Our results showed that a multidisciplinary programme can achieve
significant weight loss for obese patients in Singapore. To achieve long-term weight loss, a commitment of both the medical team and the patient is necessary. Laparoscopy has revolutionised
the practice of bariatric surgery worldwide. LAGB is an effective and safe procedure.
Ann Acad Med Singapore 2009;38:882-90
Key words: Laparoscopic adjustable gastric banding, Outcomes, Surgical technique review
Introduction
The Singapore National survey of 1992 reported the
prevalence of obesity to be 5.1%, increasing to 6.0% in
1998, and in the 2004 survey it had increased to 6.9%.1
The increase reflects the profound changes in our society’s
lifestyle and eating habits. Today, obesity is not only a threat
for the developed nations but is fast eating into the health
resources of developing nations. Obesity which was once
thought to have resulted from a lack of eating discipline is
now increasingly being recognised as a disease that roots
from in-born errors of metabolism thus resulting in impaired
satiety and increased conversion of calories to fats.2
Deurenberg-Yap et al studied the relation between body fat
percentage and body mass index (BMI) among Singaporean
adults. They found that in comparison to Caucasians, Asians
had a higher percentage of body fat at lower BMI. They
recommended the obesity cut-off point for Singaporeans to
be lowered from 30 kg/m2 to 27kg/m2.3,4 A re-calculation
based on a BMI of 27 kg/m2 would raise the prevalence of
obesity in Singapore from 6% to 16%.5
Obesity not only results in an increased risk of mortality
for matched age6-8 but these individuals are at a risk for
important comorbidities including diabetes, hypertension,
obstructive sleep apnoea, depression and impaired quality
of life.9,10 The economic implications in terms of cost for
treating these comorbidities are overwhelming.11 Treatment
of morbidly obese individuals with diet, exercise and
behavioural intervention results in modest and transient
weight loss, so not surprisingly the results of such studies
are poor.12,13 Although we live in hope, currently there is
no drug either commercially available or in the research
pipeline that promises to be as effective as surgery in
1
University Surgical Centre, National University Hospital, Singapore
Department of Surgery, National University of Singapore
Address for Correspondence: A/Prof Jimmy So, University Surgical Centre, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074.
Email: jimmyso@nus.edu.sg
2
Annals Academy of Medicine
Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
controlling morbid obesity. For today and in the near future,
bariatric surgery seems to be the best means of achieving
a sustained weight loss and is also effective in reducing
associated comorbidities with prolongation of life.14,15 In a
study on gastric bypass outcomes, Pories et al16 reported an
83% cure of Type II diabetes mellitus at 14 years followup. An enormous literature on obesity surgery testifies to
improvement and, in many cases, cure of dyslipidaemia,
hypertension, obstructive sleep apnoea and joint problems
after surgery.17-19 Also, successful weight loss surgery has
been shown to normalise the risk of death and prolong life
span in morbidly obese patients.7,8
National University Hospital Experience
When compared to the solo practice model, the
multidisciplinary team model has the advantage of offering
the patient the benefit of a treatment that covers all necessary
areas by participation of members of different disciplines.
Each individual team member has an ownership and plays
a pivotal role in the patient’s long-term counselling and
behavioural modification. Sharing of information is free
within our multidisciplinary group.
On the first visit apart from obtaining a detailed medical
history and ordering the necessary investigations, patients
are reviewed by the dietician and physiotherapist. The
patients continue with medical treatment and monitoring
until a point where a decision has to be made for a change in
the management plan such as when it is deemed necessary
for surgery or medications are thought of.
As dietary changes need to be long-term, the dietician has
a fundamental role in management. Our dietician generates
and counsels patients on dietary prescriptions, adherence and
changes in lifestyle. They cater to the needs of patients who
suffer from obesity-associated comorbidities like diabetes
and who require a different composition of diet regardless
of calorie levels. Moreover, monitoring of patients’ dietary
patterns to uncover any nutritional deficiency and institute
appropriate measures also fall within their domain. Exercise
is crucial in obesity for weight loss and maintenance. In
our team, the physiotherapist assesses the patient’s baseline
fitness level, and then develops, monitors and modifies
the exercise plan while bearing in mind the impact of
obesity- related comorbidities on exercise capacity. Obesity
being the resultant of a complex interplay between various
causal factors requires the expertise of a physician for
assessment, management, counselling and coordination
of the multidisciplinary team. In our team, the physician
also conducts preliminary screening for eating and mood
disorders and is also entrusted with the task of orders for
trials of medications. Patients who fail medical management
and suitable candidates for surgery are discussed for surgical
intervention and counselled for the same. The day-to-day
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883
requirements of an obese patient can vary much from those
of the general population, and our nursing staff, besides
carrying out their traditional functions, are tasked to educate
and counsel obese patients as well.
Results
At the National University Hospital, Singapore, between
August 2004 and December 2006, we had treated 31 patients
with laparoscopic adjustable gastric banding (LAGB) for
morbid obesity. Their median age at presentation was
40 years (range, 19 to 62). In this cohort, there were 6
(20%) males and 25 (80%) females with a median BMI
(range) of 43.5 kg/m2 (36.1-54.5) and 41.2 kg/m2 (30-57),
respectively. After a median follow-up of 26 months, the
median percentage of weight loss (%EWL) was 41.95%
with 45.1% for females and 38.8% for males. In our
series, 24 patients had more than one comorbid condition.
Hypertension was noted in 18 (58%) of the 31 patients, 16
(51%) were diabetic requiring medical treatment, while 9
(29%) had dyslipidaemia. Fifteen (48%) patients each were
afflicted with obstructive sleep apnoea and osteoarthritis.
The positive effect of gastric banding on comorbidities are
evident in Table 1, Student’s t-test was used to compare the
pre- and postoperative median values with significance set at
P <0.05. We noted that 15 (94%) of the diabetics had
improved glycaemic control, their HbA1C improved from a
median of 7.7% preoperatively to 5.9% postoperatively (P =
0.001) with 8 (58%) with their dose of oral hypoglycaemic
agents reduced. About a quarter, 4 (22%) of the hypertensive
now take lesser doses of anti-hypertensive drugs and 2
(11%) were cured of their hypertension. All 9 (100%)
patients with hyperlipidaemia had their statin doses reduced
and their serum cholesterol, triglycerides and low-density
lipoprotein (LDL) were significantly lowered (Table 1).
We had 2 patients (6.45%) with band erosion. Two of our
patients also had symptoms of reflux.
Discussion
In our series, 1 patient failed to comply with lifestyle
modifications and had a %EWL of only 0.23% that has
skewed the data analysis. If his data point is excluded
from analysis, the median EWL for males would be 46.0%.
However, the median %EWL was 41.95% in our series which
is in keeping with those reported in literature of 45% at 24
months median follow-up.20 In our series, 24 patients had
more than one comorbid condition. Obesity is known to be
associated with comorbid conditions such as hypertension,
diabetes and dyslipidaemia. Not surprisingly, the figures for
obesity-related comorbidities of our series are prominently
different from the general Singapore population. In the
2004 National Health survey, diabetes, hypertension and
dyslipidaemia were reported to be 8.2%, 20.1% and 19.8%21
versus our obesity related figures of 51%, 58% and 29%,
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Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
Table 1. Effect of Laparoscopic Adjustable Gastric Banding on Comorbidities
Comorbidity
n
Parameter
Pre-LAGB
Post-LAGB
P value
Diabetes
16
HbA1C (%)
7.7 (5.5-11.4)
5.9 (5.2-9)
0.001
Hyperlipidaemia
9
S. Cholesterol (mmol/L)
5.42 (4.36-6.3)
4.3 (3.6-4.9)
0.001
S. Triglyceride (mmol/L)
1.7 (0.8-3.1)
1.3 (0.5-1.7)
0.021
S. LDL (mmol/L)
3.47 (3.08-4.36)
2.50 (2.05-3.24)
0.022
Number of medications
2 (1-4)
1 (1-3)
Hypertension
18
All values are reported as median (range)
respectively. The positive effect of gastric banding on
comorbidities are evident from this study and our results
are akin to those in a meta-analysis by Buchwald et al22
who reported improvements in 80.8% of diabetics, 71.1% of
hyperlipidaemics and 70.8% of hypertensives after LAGB.
If weight loss and improvement in comorbid conditions are
added up, it would not be wrong to say that weight loss
surgery has led to a cut in the total cost that could have been
spent on lifelong management of our patient’s obesity and
its related problems. LAGB is deemed a safer procedure
with overall mortality of 0.05%.23 In their series of 1120
patients undergoing Lap banding, O’Brien and Dixon24
reported an overall complication of 1.5%. However, the
figures for morbidity vary ranging from 3.9% to 11.3% in
other series.25,26 The commonly encountered preoperative
complications include injuries to structures such as liver
and stomach, atelectasis and wound/port site infections. We
have no operative adverse events or mortalities to report.
The incidence of band slippage which is a late complication
has been reported to be 4% to 16%, but there is none in our
series. We routinely use the pars flaccida technique which
has been shown to have resulted in lowering the incidence of
band slippage.27 Another long-term complication of LAGB
is the band eroding into the stomach cavity. The incidence
of band erosion ranges from 7.5% to 11.1%.28,29 We had 2
patients (6.45%) who presented at 7 and 12 months with
port site infection and on endoscopy found to have band
erosion. These patients complained of mild pain over the
port site with associated tenderness and were noted to have
increasing weight. The 2 cases had stable band volumes
and none went for recent tightening of the band to suggest
a source of infection. A computed tomography scan
was performed in both cases and these showed fat
stranding along the abdominal wall next to the tubing
to the reservoir port. Both cases were later confirmed
on oesophagoduodenoscopy to have band erosions.
Their bands were taken out laparoscopically with an
uneventful postoperative course. Two of our patients
also had symptoms of reflux. They had oesophagogastroduodenoscopy that confirmed them to have reflux
oesophagitis, which was treated successfully with proton
pump inhibitors and dietary modifications without
the necessity of loosening the band. The incidence of
reflux oesophagitis has been reported to be high in some
LAGB series due to its restrictive nature. The general
recommendation has been to deflate the band and dietary
modification. However, loosening of the band is associated
with an increase in weight.30,31
Conclusion
Our results showed that a multidisciplinary programme
involving surgeons, physicians and paramedical therapists
can achieve significant weight loss for obese patients in
Singapore. The advent of laparoscopy has revolutionised
the practice of bariatric surgery worldwide. LAGB is an
effective and safe procedure. To achieve long-term weight
loss, a commitment of both the medical team and the patient
is necessary.
Literature Review
Multidisciplinary Approach
Bariatric surgery should not be staged as a cosmetic
procedure but offered to obese patients as a therapeutic
procedure that aims at prolonging life by reducing the
chances of premature death.32 It can never be stressed
enough that surgery by itself does not produce long-term
favourable results. It has to be coupled with modification
in lifestyle to obtain the best outcomes. Thus, management
of obesity has to be the domain of a multidisciplinary team.
This team can tailor and cater to the needs of individual
patients. The essentials of this multidisciplinary team would
be a physiotherapist, dietician, physician, bariatric surgeon,
anaesthetist, radiologist and dedicated nursing staff.
Goals of Surgery
The goals of surgery in obesity are to achieve a sustained
weight loss over a prolonged period of time with least
complications and to improve the outcomes of associated
comorbid conditions.
Eligibility Criteria
The criteria for eligibility of adult bariatric surgery as per
Annals Academy of Medicine
Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
the National Institute of Heath guidelines are33
1. Young patients who are 18 to 55 years old, who are fit
for surgery
2. BMI >40 or 35-39 with comorbidities that can be
improved with surgery
3. Agreeable to lifelong follow-up
4. Failed conservative treatment
Surgery is contraindicated in patients suffering
from major psychiatric illnesses such as depression,
psychosis, drug/alcohol dependence and those with
prohibitive anaesthetic risk.
Perioperative Management
Prior to surgery, patients need to be educated on what
surgery can achieve for them, so that they have realistic
expectations. It is important for the patients to understand
their commitment to lifelong follow-up, adherence to dietary
restrictions and exercise. The anaesthetic risk of surgery
is less objective and decisions are usually on ad hoc basis
after weighing the risks and benefits of weight reduction.
However, this does not go without saying that it is prudent
for all patients to be optimised to the maximum prior to
surgery. In the postoperative period, patients may need
to be nursed in high dependency or intensive care units,
antibiotics are advisable and anti-thrombosis prophylaxis
is mandatory.34 Surgery, ideally, should be performed in a
high volume centre that not only has the expertise but is
also equipped to look after the needs of this special group of
patients. This approach has been shown to reduce morbidity
and mortality and results in better outcomes.35
Open versus Laparoscopic Bariatric Surgery
Interest in bariatric surgery has waxed and waned over the
years. The first bariatric procedure, that is, the jejunoileal
bypass was performed in 1954 by Kerman.36 The migration
of bariatric procedures from open to laparoscopy technique
has been a big step forward in the struggle to decrease
postoperative complication rates. Advantages of the
laparoscopic approach including decreased postoperative
pain, shorter length of hospital stay and early return to
work are well established. Open surgery especially in obese
patients is known to be associated with an increased risk of
wound infection, pulmonary complications and incisional
hernias, yet the occurrence of these complications is
remarkably low if bariatric surgery is done laparoscopically.37
Bariatric Surgical Procedures
Bariatic surgical procedures are broadly divided into
restrictive and malabsorbtive procedures based on the
primary mechanism by which they accomplish weight
loss. Some procedures such as gastric bypass effectively
utilise the benefits of both components. While restriction of
calorie intake and malabsorbtion are important mechanisms
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in bariatric surgery, postoperative alterations in the
neuroendocrine hormones that regulate appetite, satiety and
energy expenditure have been shown to be instrumental in
augmenting weight loss.38,39
Restrictive Procedures
The pure restrictive procedures are vertical banded
gastroplasty and gastric banding. They achieve weight
loss by restricting the volume of intake as a result of
reduced stomach reservoir capacity after surgery. They
are relatively easy to perform as compared to their more
complex malabsorbtive counterparts and are associated
with fewer complications. After restrictive procedures,
strict dietary discipline is prudent for a successful sustained
excess weight loss. Patients who consume liquid and semisolid high calorie diets have high procedural failure rates as
these foods easily flow into the remnant stomach without
achieving much satiety.
Vertical Band Gastroplasty (VBG)
The VBG involves the creation of a 20 mL proximal gastric
pouch. A Gortex mesh is used to create a collar to restrict
out flow from the pouch (Fig. 1). The ends of the mesh
are overlapped for 1 cm so that in future should dilatation
be required, the sutures will give way during dilatation
without the need for surgery. VBG is now less commonly
performed and this is largely because it is technically more
challenging with a higher incidence of complications when
compared to gastric banding.
Laparoscopic Adjustable Gastric Banding
The number of gastric banding cases has been steadily
rising worldwide. There are many types of bands available
for commercial use; all of them have an infusion reservoir,
tubing and an adjustable silicone band with a bladder. On the
operating table, the patient is placed in Lloyd-Davis position
with the upper abdomen upright and the leg fitted with
intermittent pneumatic compression devices. The patient
is strapped to the table to prevent a fall. A 10-mm port is
Fig. 1. Vertical band gastroplasty.
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Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
Fig. 2. Laparoscopic adjustable gastric banding port placement.
inserted midway between the xyphoid and the umbilicus
with the aid of the optiview trocar. Pneumoperitonium is
created and the remaining ports as shown in Figure 2 are
inserted under direct vision. A snake liver or Nathanson’s
liver retractor is used to elevate the liver through the subxyphoid port. We use the pars flaccida technique for the
creation of a retrogastric tunnel. Starting at the angle of
His the gastrophrenic attachments to the left crus are taken
down. The pars flaccida of lesser omentum is entered and
the right crus identified. The peritoneum over the base
of the right crus is divided for a short distance and the
dissection deepened. Using a grasper, a retrogastric tunnel
is dissected from right to left emerging at angle of His
staying as close to the stomach as possible. A Gold finger
(Obtech Medical GMBH, Germany) is threaded through
this tunnel. The gastric band is inserted through the 15
mm port and retrieved through the retrogastric tunnel after
mounting a retrieving suture on the Gold finger’s tip. Care
needs to be taken to orientate the band so that the bladder
faces the stomach and then the buckle is fastened. Four
interrupted intracorporeal gastrogastric sutures are placed
to cover the band taking care to avoid covering the buckle
(Fig. 3). The tubing is retrieved through one of the port
and fixed to the reservoir which itself is anchored to the
anterior rectus sheath over distal sternum. The patient is
allowed to recover and is started on a low calorie liquid
diet. The band is adjusted to provide adequate restriction
6 to 8 weeks after surgery. A few sessions may be required
before an adequate adjustment is possible.
Malabsorbtive Procedures
The weight loss observed after malabsorbtive surgery
results from the minimal contact of digested food with
secretions from the liver, pancreas and intestine along with
impaired nutrient absorption from the shortened length of
the functional small intestine. The malabsorbtive procedures
suit people with a sweet tooth well. After consumption
of a high sugar meal, the altered anatomy results in a
dumping syndrome characterised by light-headedness,
Fig. 3. Laparoscopic adjustable gastric band.
nausea, perspiration, abdominal pain and diarrhoea. These
unpleasant symptoms generate a negative conditioning
bio-feedback.
The length of the common channel has significant
bearing on the mixing of ingested food with digestive juices
and also on the absorptive surface area. So a shorter common
channel will have a shorter contact time for digestion and
lesser surface area of absorption. This will translate into
greater weight loss with a higher risk of malnutrition.
Commonly performed malabsorbtive procedures are
1. Gastric bypass or more commonly termed Roux en Y
gastric bypass (RYGB)
2. Biliopancreatic diversion (BPD)
3. Duodenal switch (DS)
These procedures are more suited for patients with
gastroesophageal reflux disease, for diabetics and people
who like to eat sweet food.
Jejunoileal bypass was fraught with multiple severe
complications such as liver failure, renal stone formation,
nutritional deficiencies and high mortality.40,41 Its importance
lies in the caring of those who had undergone jejunoileal
bypass and survive to date.
Gastric Bypass
RYGB is technically considered the simplest of the
malabsorbtive procedures. The procedure involves creating
a 30 mL proximal gastric pouch using a linear cutting
stapler leaving the distal gastric remnant separate from
the pouch. Then 50 to 100 cm away from the ligament of
Trietz, the jejunum is divided and this creates a proximal
biliopancreatic limb. Jejunum 150 cm distal from the
divided end is anastomosed to the biliopancreatic limb, thus
forming a distal common channel and proximal alimentary
limb called the “Roux limb”. The proximal end of the Roux
limb is anastamosed to the gastric pouch creating a tight
gastrojejunostomy (Fig. 4). The lengths of the Roux limb
and common channel vary depending on the surgeon’s
choice and patients’ BMI.
Annals Academy of Medicine
Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
887
Fig. 5. Biliopancreatic diversion.
Fig. 4. Roux en Y gastric bypass.
Biliopancreatic Diversion
BPD was pioneered by Scopinaro to address some of the
shortcomings of the jejunoileal bypass.42 The anatomy postsurgery is much like that of RYGB with a few differences
(Fig. 5):
1. The gastric pouch has a capacity of about 150 mL.
This bigger pouch inherits with it an increased risk of
developing stomal ulcers at the gastrojejunostomy site.
2. The remnant stomach is re-sected, which obviates the
need for surveillance of the remaining stomach as in
RYGB.
3. A longer alimentary limb of 200 cm results in greater
weight loss.
4. The common channel is shorter and predisposes patients
to severe protein and calorie malnutrition which requires
chronic dietary supplements.
This procedure is highly effective but may have higher
risks. Considering the challenges posed to surgeons
and patients, the role of BPD as a primary procedure
for morbid obesity has to be carefully thought out prior
to recommending it to patients. However, its place in
revisional obesity surgery for those who failed other surgical
procedures might be more appropriate.
Biliopancreatic Diversion with Duodenal Switch
Technically, this is the most demanding and complex
bariatric procedure with greater perceived preoperative and
malnutrition risk in comparison to others.43 It was designed
to overcome nutritional problems associated with BPD.
The first step is to perform a sleeve gastrectomy, the
technique of which is described further in the text
under discussion of sleeve gastrectomy. Following a
sleeve gastrectomy, the duodenum is mobilised and
transected with a cutting stapler 3 to 5 cm distal to the pylorus;
250 cm from the ileocaecal valve, the ileum is divided
with a cutting stapler. The distal ileal loop is anastamosed
October 2009, Vol. 38 No. 10
end to end to the gastroduoenal stump creating the alimentary
loop and, 50 to 100 cm from the ileocaecal valve, the
proximal ileal loop is anastamosed to the ileum creating
a common channel distally. The proximal loop forms the
biliopancreatic loop with an oversewn duodenal stump
(Fig. 6).
Miscellaneous Procedures
Sleeve Gastrectomy
In super obese patients with life threatening comorbidities,
poor quality of life and high risk for surgery, sleeve
gastrectomy offers a safer and less invasive procedure for
initial weight loss.44 Following this when the patient is more
stable, a completion procedure can be done as a stage II. The
use of sleeve gastrectomy as a definitive restrictive bariatric
procedure is increasingly being studied and practiced, but
long-term results are still pending.45 In this procedure, the
greater curve of the stomach starting at appoint 6 to 10 cm
proximal to the pylorus all the way to the angle of His is freed
of greater omentum and vessel secured. Over a 36 French
orogastric bougie, a gastric tube is created by resecting the
greater curve of the stomach using a cutting stapler along
a line joining the initial point of dissection and the angle
of His. The reservoir capacity of the stomach is reduced
to 200 mLs with the advantage of preserving most of the
normal digestive stomach function (Fig. 7).
Results of Bariatic Surgical Procedures
Bariatric procedures are no longer only assessed by
the %EWL and complications but, increasingly, the
improvement in comorbidities is being recognised as an
indicator of success.
Percentage of Excess Weight Loss
Dietel et al46 reported VGB to achieve 58% EWL at 5
years. In a study by Zinzindohoue et al, 47 the EWL at 3
years follow-up for LAGB was 54.8% which is comparable
to VGB. However VGB has fallen in favour of gastric
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Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
Fig. 7. Sleeve gastrectomy.
Fig. 6. Biliopancreatic diversion with duodenal switch.
banding not only because it is technically simple, but because
LAGB has a lower mortality, is adjustable, reversible,
and able to achieve good EWL with improvement in
comorbidities.15,48-51 A series from O’Brien and Dixon et
al23 had a 50% EWL up to 6 years follow-up after LAGB.
The percentage EWL after malabsorbtive procedure is
higher; EWL after gastric bypass is reported to be 68% at
5 years.52 EWL for BPD and BPD with DS at 8 years are
77% and 70%, respectively.53,54 Ti et al55 in their series of
26 patients undergoing VBG or RYGB reported EWL of
56.3% and 48.3% at 4 and 8 years, respectively. The use
of laparoscopic sleeve gastrectomy as a primary bariatric
surgical procedure is a relative new concept with paucity
in literature of long-term follow-up. In a prospective trial
of 163 patients, Nocca et al56 reported 61.25% EWL at
2 years follow-up. They proposed to use the technique
for volume-eaters and as a bridging procedure to definite
surgery like BPD or DS.
Improvement in Comorbidities
Bariatric surgery is associated with improvements in
associated comorbid conditions. In a meta-analysis by
Buchwald et al,22 it was reported that there was improvement
in 80.8% of diabetics, 71.1% of hyperlipidaemics and 70.8%
of hypertensives after LAGB. The results of malabsorbtive
procedures in this meta-analysis were even better with 98.9%
and 83.4% having resolution of DM and hypertension,
respectively.
Complications
Higher incidence of complications after VGB surgery
such as staple line disruption, stomal stenosis, mesh erosion,
reflux disease and vomiting had called for revisional surgery
in 20% to 56% of patients.57-59 In a local series of 22 patients
undergoing VBG in Singapore, Ti et al55 reported 1 patient
to have had a wound infection and 3 patients complained of
vomiting but none of them required any surgical intervention
at 10 years’ follow-up.
In the initial phase, the general complications associated
with malabsorbtive surgery are no different from those
seen in obese patients undergoing other forms of surgeries.
The construction of multiple anatomises in malabsorbtive
procedure increases the potential risk of leak. Anastamotic
leak have been reported to occur in 2.2% and 1.8% of patients
after RYGB and BPD60 surgeries, respectively. As RYGB
incorporates a restrictive procedure with the creation of a
small gastrojejunostomy stoma, it exposes the patient to a
risk of stenosis. Irrespective of technique of anastomosis, that
is hand-sewn or stapled, the incidence of gastrojejunostomy
stenosis has been reported to be as high as 5%.61 The dramatic
differences in EWL and improvement in comorbidities
between restrictive and malabsorbtive procedures cannot
go without notice in Buchwald et al’s report.22 What one
needs to understand also are the long-term implications of
these procedures. Altering the gastrointestinal anatomy to
achieve weight loss predisposes patients in the long term
to increased risk of nutritional deficiencies. In particular,
the common deficiencies seen are those of iron, vitamin
B12, Vitamin D, calcium and thiamine. Hypocalcaemia is
the result of decreased intestinal absorption and deficiency
of Vitamin D.62 In the meta-analysis by Maggand et al
which analysed 70 RYGB, 41 LAGB and 7 BPD trials,
postoperative gastrointestinal side effects were significantly
higher in the malabsorbtive group when compared to the
restrictive surgery group with reports of 7%, 16.9%, and
37.7% after LAGB, RYGB and BPD/Ds, respectively.60
Also, in the RYGB group, 16.9% patients were diagnosed
to have nutritional complications while 5.9% patients
presented with ongoing vomiting after BPD. These are longterm complications that require continuous monitoring and
intervention. The overall perioperative complication rate of
sleeve gastrectomy is 7.36%. The classical complications are
haemorrhage of staple line, gastric stenosis and staple line
failure leading to leak and fistula formation postoperatively.
Also reported is a high incidence of reflux oesophagitis of
11.8% to 21.8%, making sleeve gastrectomy a less attractive
procedure for this group of patients.63
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Obesity Surgery NUH Experience & Overview— Asim Shabbir et al
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1. Ministry of Health. National health survey 2004, Singapore;
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