Types of bariatric surgery is our 2nd video in a series that looks at all aspects of weight loss surgery. In this video, Dr Leon Cohen talks about the different types of bariatric surgery, how a sleeve gastrectomy works and if a patient doesn’t have private health insurance.
Types of Bariatric Surgery
Video Transcription
So what are the different operations that are available?
Dr. Leon Cohen: There are a number of different operations available and variations in the way that they are done. Bariatric surgery is a constantly evolving practice. And over the years that it has been done, 30 or 40 years, many different operations have been designed, they have been tested, they have been evaluated, and many cases, they have been abandoned.
But currently and in Australia, there are three main types of operations done, the adjustable gastric band, the sleeve gastrectomy, and various forms of bypasses. And each of them has advantages and disadvantages. But overall, although the adjustable gastric band was immensely popular in the 10 years from 2000 to 2010, it’s largely been abandoned. And the rates now are only about 12% of bariatric operations around Australia are band, about 76% is sleeve, and a small percentage are the bypasses.
This unit has concentrated on the sleeve really for the last 10 years since I started doing it 14 years ago.
Doctor, why don’t you favor the bypass?
Dr. Leon Cohen: Look, the bypass operations, particularly the traditional Roux-en-Y gastric bypass has been a workhorse of bariatric surgery around the world for 30 years. And there’s no doubt it is a good operation.
But in America and in Australia, what we’re seeing is that more people are changing from the bypass as their primary operation to the sleeve gastrectomy. And I rather view the bypasses and I used to do them when I started surgery, I rather view the bypasses as a little bit like bringing a bazooka to a gun fight when a Colt 45 is going to do the job. There’s no doubt it’s a very powerful operation but you’ve got to expect some collateral damage.
The bypass is bringing an element of malabsorption particularly to elements like iron and calcium, which the sleeve does not do. With the sleeve, what you eat is what you get. And down the track, if patients aren’t taking their multivitamins assiduously, they will get deficient, and that’s a problem.
Also, there are some particular longer term complications from the bypass like ulcers of the joint and obstruction of the bowel that at times can be life-threatening. But the main reason why I don’t favor the bypass is rule number one, which is that all obesity surgery will eventually fail to some degree.
And the problem with the bypass is that when people start to regain weight with the bypass five, ten years down the track, there really is no effective, safe, easy revision option to make that pouch smaller. And although there have been lots of things tried, they’re just not uniformly successful in the way they are with the sleeve.
So with the sleeve, as I’ve said, you can re-sleeve. You can convert it to a bypass. So you got lots of revision options. And so for us, we reserve a bypass surgery for some unusual circumstances and particularly circumstances where the sleeve is just not appropriate.
What if the patient doesn’t have private insurance?
Dr. Leon Cohen: The bariatric surgery in the public centre at the moment is very limited. So Joondalup Hospital has a modest bariatric program and I think they’re allowed to do two or three hundred cases a year.
A lot of the case load is swamped by patients who previously had bands and have had complications with the bands and they’re trying to then fix those problems up.
In practical terms, you’re probably going to wait two or three years just to be seen in one of their clinics and another period of waiting a year or two just to get on their waiting list. So if patients don’t carry private insurance, we recommend a number of things.
The first is, take out private insurance. Wait a year and then you will be ready to have your surgery.
The second is that it is actually possible to access your superannuation account if you have money in that account, sufficient money, which can pay for the whole surgery or for the gap which is for us, around $6,000 to $7,000 on top of any private insurance that you have. Read more about costs and finance options.
Why do you favor the sleeve?
Dr. Leon Cohen: I’ve been doing the sleeve for 14 years. And over that time, there is nothing I’ve seen about it that hasn’t firmed up my view that the gastric sleeve is a fantastic operation. It is well-tolerated by patients. It’s durable. The quality of eating and the absence of long-term side effects I believe are superior to any of the other operations.
How does the sleeve work?
Dr. Leon Cohen: So I like to think of the sleeve as a reductive operation rather than a restrictive operation which is what the band is or a malabsorptive operation which is what the bypasses deliver as well.
And by reductive, I mean that and I’ve got a model I can show this, so this is about the size and shape of a typical stomach. By reductive, I mean that by keyhole surgery, laparoscopic surgery, we can staple off and permanently remove about 90% of the stomach. And that converts you from what is typically a one and a half liter stomach sack to about 100 ml stomach tube.
So your stomach is going to start off looking a little bit like that in shape and size. The outlet of your now skinny stomach is still the normal pyloric valve or sphincter that opens and closes rhythmically. And that means that unlike a band, which is a ring that sits around the top part of the stomach and produces a restriction to flow, this is a dynamic system. It opens and closes. And that means that unlike a band, patients are able to tolerate all the foods which a band patient struggles with.
Dennis: So it works like normally.
Dr. Leon Cohen: It is much more physiological. So, they’re better able to tolerate things like sandwiches, bread, chicken and steak. All the foods that the band patients typically struggle with, a sleeve patient is able to eat.
But here’s the beauty of it, in a much smaller amount. And typically, that will be an entrée size portion and that entrée will feel like a banquet. But the sleeve does a lot more than reduce the amount that a person can eat at one time. Because you now have a much smaller volume stomach, there is actually an absolute volume reduction even to liquids.
And so, patients get to half a mug of coffee to begin with and they feel full. And the coffee is getting cool by the time they finish. Unlike a band patient for whom there is very little restriction to flow of fluids, and so because they can’t eat good quality solids, they slip into bad behavior and they drink the high-calorie liquids because they can and they end up gaining weight or not losing as much.
The other way in which the sleeve works which is very different to the band and the bypass is that by removing this much stomach, we get rid of a lot of the area of the stomach that makes a particular hunger hormone called ghrelin. And so, patients after a sleeve almost universally report and experience that they just don’t feel hungry like they used to. They’ll often say to me, “I have to remind myself to eat.” And they’re not being driven by the same constant hunger and appetite that characterized their life beforehand.
Now, ghrelin is still made from this part of the stomach which is retained but in much smaller amounts and the levels only rise very slowly of months and years after surgery. And patients generally don’t return to that same drive of hunger as they used to have.
There are some other ways in which the sleeve works. And so for example, because you now have a very small volume stomach, it actually empties more rapidly than a normal stomach. There’s no time for the food to get diluted and to be released slowly.
But that has a consequence. So if for example, you choose the wrong food particularly very sweet foods like chocolate lollies and milkshake, those high-calorie carbohydrates hit the small bowel in a rush. The small bowel doesn’t like that. It wants to draw water in to dilute those things out. Your blood sugar might go very high and then plummet very low.
And about 20 minutes after you have a row of chocolate, patients will often experience something called diarrhea and dumping where they feel shivery and shaky and sweaty and they have a fast pulse rate and they may end up with runs and with cramp. And they very quickly learn not to do that.
So, patients that used to have a sweet tooth say to me, “I used to enjoy chocolate, now I can’t stand it.” The same thing happens with alcohol to an extent too. And so, not only aren’t you able to drink the same volume of alcohol but the alcohol passes through very quickly. It gets absorbed very quickly and you will get twice as drunk twice as quickly on the same amount of alcohol.
Now of course, that has an implication for people who are driving. Whereas before, they may have had four or five drinks in a night and been fine, they can be over their limit with two or three drinks.
Dennis: That’s interesting, isn’t it? Also, the beer would have a lot of sugar in it as well. Wouldn’t that spike it?
Dr. Leon Cohen: Yes, it does. But also, if you try and drink fizzy drinks like beer and champagne, you’re going to bubble up and burp. So they have to go back to sipping on Chardonnay.
Mercy Bariatrics Perth
For all inquiries or to make an appointment please contact us.
Watch Video 3: Risks, Benefits & Outcomes of Bariatric Surgery
See all our videos.