Types of surgeries

 

Sleeve Gastrectomy

Currently is the most common type of surgery performed in Australia and is gaining momentum in other countries as well. The surgery was discovered accidentally, as it was the first stage of laparoscopic duodenal switch surgery. Due to technical difficulties in patients with a BMI 60 and over, some cases of surgery were cut short after finishing the first stage, which was to sleeve the stomach. Many patient didn’t go back for the second stage as they lost enough weight and maintained it, and the idea of sleeve gastrectomy (SG) as a stand-alone procedure for weight management developed around year 2000.

Sleeve gained popularity over lap band due to higher success rate and better life style. Medium term complications are much less than lap band, currently significant number of lap band patient experience the treble effect of the band on the esophageus, severe dilatation and reflux, acid and non-acid reflux. Popularity of sleeve gastrectomy has accelerated since 2010, as it can be performed even in patients with previous multiple abdominal surgeries, as compared with gastric bypass or other surgeries which would necessitate conversion to open surgery.

The principle of SG, is to reduce the size of the stomach down to 100 – 150 ml. In practice this size goal serves only as a guideline, and is slightly different between practicing surgeons. Although the principle of the operation is consistent between different surgeons there is variation in the finer points of surgery with a SG such as the amount of stomach removed and the exact shape which will optimise outcomes. My own technique have also undergone some changes throughout my years of practicing.

Sleeve works by altering size / shape of the stomach, decreasing Ghrelin hormone and altering vagal nerve signals to the brain. This is to counteract against the second strongest signal in our brain, the hunger signal which is the main cause of diet failure. This signal together with breathing signal are vital to keep us alive. Food and oxygen are important element in energy production ( calories) which keeps our body alive and kicking. So it is our survival instinct which push us to eat.

Size

Generally 100 – 250 ml is an acceptable size. We are producing one size fits all, and have only a few pre-operative hints with some patient to lean toward smaller size stomach, but otherwise we are trying to produce same size for all comers. Too small a size might produce severe food intolerance and poor life style, although the patient could lose all the excess weight and in short period of time. It is very important to strike the balance right, which is easy to say but hard to achieve sometimes.

The size of stomach which allows you to eat close to entire size and any food you like, I think this is the ideal size. Desperation or the push to lose more weight and gain more patient satisfaction could have led some surgeon to produce excessively small stomach. The smaller the size the higher the leakage rate and other complications.

Stomach will never regrow but could stretch slowly. Nobody knows what is the maximum stretching ability our stomach has, but shouldn’t double in size. Up to 250 ml is acceptable size.

Shape

Attention to shape is gaining more interest as it plays very important role in combination with size in the determination of patient progress. The ideal shape is gradually increasing size from the cardia to the antrum. Axial rotation, angulation and narrowing at the mid stomach (the incisura) are important issues that needs special attention by the surgeon.

Leaving or retaining some fundus (the upper thin part of the stomach), could lead to weight regain as this part could stretch and allows the patient to eat more. It also affects the number of remaining Ghrelin producing glands.Leaving too much of the antrum (the lower portion of the stomach), again allows bigger portions of foods and could also stretch needing redo-surgery.

Ghrelin Hormone

Is a hunger producing hormone located in microscopic glands inside the flesh of the stomach and very concentrated at the upper part. Surgery will not remove it all but majority will go with proper sleeving of the stomach.

About 30% of patients have to remind themselves to eat due to complete loss of hunger signals, whilst the other 70% still feel hunger but no where near the intensity prior to surgery. Other non-consistent changes could be encountered, like for example losing interest in your favourite food and being unable to tolerate smoking.

Ghrelin has multiple effects on our body including bone mineralization, muscle growth, and repair of intestinal cells.

Vagus Nerve

This nerve conveys direct information to the brain about status of the esophageus, mainly the speed the food bolus travelling down to the stomach. Usually if the stomach is empty, it will take 4-8 sec for the bolus to reach the stomach once swallowed. With a sleeved stomach, the new tube like stomach is not as welcoming and fills up with a few mouthfuls, leading to significant slow down of the passage of food bolus. Signal through the nerve then will tell the brain that the stomach is full and should urge us to stop eating.

Other possible mechanism, could play part in the weight loss following sleeve gastrectomy, like producing dumping syndrome, which is not as common as in gastric bypass surgery.

The operation performed laparoscopically, (keyhole surgery) almost all the time, with few exceptions like patients with previous multiple complex open surgeries.

Pre-operative preparation

Patient should be assessed for suitability for bariatric surgery and anaesthetic risks:

  • We will need to know every single details of your general health, medications, previous surgeries, allergies — etc.
  • Blood tests, ECG and other investigations as needed
  • Medication review and adjustment might be needed. blood thinning medications should be dealt with properly depending on the individual patient circumstances
  • Diet prior to surgery is important to plan, some patient might not even need any diet while others might not proceed unless planned % of weight loss prior to surgery achieved. All these plans will be decided upon during the consultation. Aim of diet is to make the surgery safer, by softening the liver, improving heart and lung functions — etc.
  • Planning your work, family and social commitments
  • Psychological issues should be discussed, medication management pre and post surgery is important.
  • Setting plans about managing diabetic medication
  • Cardiac and blood pressure medication should be continued, you could even have them at the day of surgery with small sips of water.
  • Cardiac stents, and management of aspirin and plavix should be discussed.
  • Fasting before surgery, for patient on morning list, should fast from midnight the night before surgery. For patient in the afternoon, could have liquid in the morning and water up to 4 hours before surgery, unless issues with lap band and oesophageal dilation is contemplated.
  • Diabetic medication should be omitted on the day of the surgery
  • Brisk walking for few hours every day before surgery will improve recovery post surgery.
  • Smokers should attempt quitting few weeks before surgery, otherwise should expect breathing difficulties and frequent coughing which is quite painful following surgery.
  • Alcohol together with weight put more burden on liver and increases the severity of fatty changes.
  • Should inform us of any significant previous anaesthetic reactions or any significant allergies.
Pre-operative preparation

  • Hospital will contact you about your approximate time of surgery
  • Formal paper works and nursing check
  • In the operating theatre, few formal check ups and anaesthetic review
  • Positioning on operating table, intravenous cannula inserted, O2 by mask, and other preparation
  • Once anaesthetic medication given, it will be a matter of 30 – 40 sec and you will be fully anaesthetised.
The procedure

  • Position on the table and proper strapping ensured
  • Operation site cleaned with antiseptic and proper drapes used
  • The first incision for camera insertion is just under the left rib cage (anterior axillary line)
  • Other working ports inserted under direct vision and the anatomy checked as below
The yellow fatty tissue in the bottom of the picture is the greater omentum (abdominal policeman or lady), will be dissected off the stomach as you could see were the arrows are in the next picture. This will allow the resection of the lateral border of the stomach following the insertion of calibration tube (Bogie)
Next Bogie in black / blue inserted by the anaesthetist

Resect the eft lateral border

Next step of the surgery is to resect the left lateral border of the stomach using stapler device and trying to leave stomach of 100 – 150 ml size, apart from experience there are no other definitive ways to measure the size at the time of surgery, so surgeon’s experience will play important part in this surgery.

The other important point is the shape of stomach, this area is the current interest as we think it has a lot of influence in weight lost, quality of life and complications.

As you could see above in the dark lined shape, this is the final shape of the remaining stomach. Nice and narrow at the top and slowly curving and increasing in size as we go towards the lower end. I also fold and stitch the lower end using non-absorbable stitches to prevent future stretching / dilatation and possible weight regain.

Once the stapling finished, the next step will be the re-enforcement of staple line by bringing back the fat layer, (omentum) and stitching it to the staple line. This process will also stabilize the new stomach prevent twisting and bleeding from the staple line. The last quarter of the staple line will be folded to re-shape the lower part of the stomach were stapling is difficult and could lead to complications.

By finishing this step the operation is almost finished. Final inspection, instillation of local anaesthetic and retrieval of the excised stomach through the largest port site are the remaining steps. Wound cleaning and closure using dissolvable stitches under the skin. Steristrips and water proof dressing are applied.The anaesthetist will slowly reverse the anaesthetic and will remove the breathing tube once the patient is wake enough. You wouldn’t remember or recall any of these events, due to the heavy sedation on board at the time.

Rest of the recovery will be at the recovery unit and once awake enough you will be transferred to surgical word or high dependency depending on individual cases.

On the day of surgery, you will be nil by mouth, feeling some pain and discomfort. The pain response following surgery is different with different patients, and is dependent on a vast range of factors including age, comorbidities, social demographics and also psychological factors. Generally laparoscopic or keyhole surgery is much less painful than traditional surgery. Fluid is introduced through intravenous cannula and oxygen is given through mask or nasal tube.

Day one post surgery, you will be assessed in the morning checking your suitability to start water trial and progression to liquid. Should be able to come off the bed and move around.

Medication will need special attention:

Diabetic medication: during pre-operative diet period, usually you will need half of the dose; you should stop all diabetic medication on the day of the surgery; your blood sugar will be monitored post-surgery and we could give you small frequent doses of rapidly acting insulin for short period of time if needed. Majority of patients will not need medication, as the amount of calories ingested is very small. If you are on long acting insulin, the dose will be slowly decreased aiming at stopping them once suitable. Your individual plans will we discussed with you. If you are on a combination of oral medications and subcutaneous insulin, we will try to get you off insulin first whilst keeping oral medications until ready to stop all medication if suitable.

Blood thinners / anticoagulant: scenarios are different depending on individual patients circumstances and plans will be set before surgery. Almost every patient will have Clexane injection, to prevent clots. Some will need to have it for few weeks if previous history of deep venous thrombosis.

Blood pressure medication: depending the blood pressure, as some will go the other way, low pressure. If needed majority of blood pressure medication could be swallowed.

Antidepressant, and other psychiatric medication: most of these medication could be used on the first day, but if suitable we will try to delay the use for few days, or if liquid alternative present, some could be crushed. All medications are designed to dissolve, so even if the tablet stuck in the middle of new stomach, should eventually dissolve and pass down.

Arthritis medication: it is very important to stop these medication until full diet allowed. Using alternatives and suppositives might be needed

Cholesterol medication: no need to restart these medication , and if needed might be started few weeks later.

Other medication should be discussed and stopped or restarts as needed.

Herbal medications should be stopped, as we don’t completely understand their effect if any.

Oral intake:

Usually by midday day one post surgery, trial of water starts, you will put to plan, 20 ml of water to drink every hour, for few times and if you passed the test with no vomiting or excess nausea then you will progress to clear fluid diet and will continued for five days.

Examples of clear fluid:- ( water, juice, electrolyte drinks, sport rehydration drinks like powerade, clear broth of meat and chicken, will try to avoid jelly)

How much you will need depends on many factors, difference between individuals and seasons. Basically the gauge will be the level of your thirst and the colour of urine. If dark, then you will need to increase your oral intake.

Will need to drink slowly, chest pain and discomfort is good sign that indicate difficulties of smooth passage of liquid through, so you should slow down and swallow even smaller mouth full at a time.

If you couldn’t tolerate liquids and urine is becoming darker or you are feeling lethargic, you will need to contact us or the hospital to arrange hydration.

Diet will be progressed slowly, with gradual increasing of thickness of fluid until four weeks when soft diet could be started. Basically no food that needs chewing should be consumed in the first four weeks post surgery.

Day 1 – day 5 – week 1: water trial, if successful will proceed to clear fluid ( no Jelly), which includes, tea, coffee, clear broth, powerade, — by day 5 should be able to have shakes, like optifast, protein shakes / drink up to week one

Week 2: puree diet could be started, but very thin to start with, and mostly vegetable legume. Basically could boil small amount of rice, lentils, and others and once ready cooked turn off the fire and add vegetable and blend in few minutes time.

Week 3: Puree diet with addition of meat or chicken to the blend

Week 4: thicker puree with more consistency closing up to mashed food.

Subsequently soft food could be started, like casserole, steamed fish, boiled egg — for one week and then to full diet by about week 6.

Oral intake

Vitamins and protein supplements

Daily multivitamins is very important to cater for our body needs. Even people with a full stomach might need vitamin supplements as our current food is very poor in vitamins due to fruit harvesting and current storing practices. Wide variety of products are available and our dietician will advise you about good brands.

Vitamin B12, usually injectable preparation is needed. The absorption of this vitamin needs a special protein produced by the stomach, and since the stomach is smaller, less protein is produced leading to less vitamin B12 absorption.

Vitamin D, majority of us have low levels which becoming an epidemic. This vitamin very important for bone mineralization, immune system and over all wellbeing. Adequate level is needed to prevent hair loss

Calcium, adequate calcium especially in pre and post menopausal ladies is very important to avoid early osteoporosis..

Silica and other hair and nail preparations: supplement helps to stabilize and prevent excess hair loss.

Protein, average of 60 – 70 gm of protein needed daily, to keep lean body weight, sense of well being and help to prevent hair loss.

Iron, iron usually in the best circumstances is difficult to absorb and needs adequate acid to facilitate absorption. Smaller stomach, less acid and eventually less iron absorption. Supplement could be oral or through infusion if severe deficiency encountered.

Fibre, good % of patients suffer from constipation due to insufficient fibre from inadequate fruit and vegetable intake. We usually recommend benefiber to help with bowel movement.

Pain relief

Pain is not a big issue and majority of our patients are pleasantly surprised, saying “we expected much more pain than this, did you actually operate on us”

Injectable pain relief used during hospital stay and script will be given when discharged home. Majority won’t need more than dissolvable panadol. Endone and targin are stronger pain relief medication options.

Lower front chest wall pain could be related to fast eating and drinking very quickly. Pain around the wound usually due to muscle stretching and bruising from the surgery. Shoulder tip pain might be significant in patient whom had hiatus hernia repair.

Excessive pain with other symptoms should prompt you to contact us for advice.

Unusual pain in the chest, leg should be investigated for possibility of deep venous clotting and pulmonary embolism ( clot going to lung).

Acid medication

Acid medication is administered through the drip whilst you are in hospital. On discharge, you will be given a script for pariet tab 20 for 2 weeks, mainly to help you stomach wound to heal, and will help if you had acid reflux.

Acid reflux might persist with majority setting down in about 3 month. If it persists a for long period and is not responding to medication then formal assessment and investigation is needed. Some might need surgical intervention.

During initial surgery we try to make sure a few boxes are ticked to prevent or lessen the impact of possible post-operative acid reflux. Difficulties encountered may include a very large fatty liver which obscures the hiatus making it difficult to assess or repair hernia during the initial surgery. Although it is not ideal, some do come back for second surgery but it is much safer once some weight is lost.

Dressing and wound management

You will have water proof dressing covering the wound. It could stay up to 7 – 10 days. Some bruising in and around the wound is expected in some patients. Minor blood oozing might happen too, only excessive bleeding leaking through the dressing needs attention.

Infection is not very common and not very troublesome as we don’t have foreign body inside to worry about. Occasionally some of the stitches might poke through before they are completely dissolved. It will eventually dissolve and shouldn’t be too much of a bother.

You may shower from the first day, but you do need to pat the wound dry.

Level of physical activities and daily living

You will need to take it easy in the first 5 – 7 days. Some could go back to office type of duties one week post surgery, but some might feel week, depending on how much initial restriction they had. If calories are too restricted the body will switch into severe starvation mode to decrease energy expenditure making you feel like you have no power even to move around. The body eventually will let stored energy out ( stored fat) to supply the body.

Should be able to drive after 5 – 7 days, and could return to office type of duties 1 – 3 weeks post surgery depending on overall recovery. From 3 – 6 weeks post surgery, could go back to work on light duties, meaning not pulling or pushing hard and not lifting over 5 kg.

In term of exercise, normal walking is allowed for up to 2 weeks. On the 3rd week you may start brisk walking and gentle jogging. Full sport activities could be started 6 weeks post surgery.

Could start physical intimacy roughly by 3 weeks, but do be gentle to start off with. If you have children at the age where you need to lift them and change nappies, you may need help for few weeks.

Heavy lifting or physical activities of any sort could lead to the development of abdominal wall hernia, but no untoward effect on the actual sleeved stomach unless extreme activities or direct accidents.

When to call / what are the signs of concern / complication

Although there are great variation between different patients experience, but few points should raise concerns if happened.

– ( STAPLE LINE LEAKAGE)

Rate of leakage of %1 or less depending on the unit. Usually causes temperature and Severe sudden pain, following food especially if you were not following diet instruction. If you start eating solid food early, it will be like poking your finger through the staple line trying to break it. You might get away with it, but if leakage happened you should remember that your life is at stake. It can be quite a painful experience . At best you will be in hospital for a few months with multiple surgical procedures. Outcome depends on clinical situation.

Us perfecting the procedure and you following instructions will minimize leakage, but unlikely to reduce it to zero. If it happens, it should be managed by us, because we understand the procedure you have had and can manage its complications. Nobody should operate on you or do anything without consulting us.

Most of the time when patient call in worried about leakage, they don’t have it. We don’t mind you calling us. We would rather know of issues early, because it allows us to make treatment decisions early before you deteriorate further. If you have any concerns – even if it turns out to be a completely benign issue we are very happy to offer advice and reassurance.

Other more common causes of pain include localized bleeding, normal post-operative pain but in patient with low pain threshold, psychological issues, lung clots, infection, splenic infarction ( sharp decrease In blood supply to the spleen), lung collapse, back related pain if you already suffer from chronic back pain, severe acid reflux and inflammation of the lower esophageus, and multiple other related and incidental non-related causes.

– (severe acid reflux)

One of the areas of great interest is in understanding the causes of acid reflux following surgery and whether changing our technique may stop or at least decrease the severity of reflux. Most of the acid reflux is manageable at home with acid medication. Only in extreme cases when the sleeved stomach is pulled up into the chest where semi-urgent surgical intervention is needed. Again with proper stitching and plication this shouldn’t happen. Other causes like severe narrowing in the mid portion of the stomach, like hour glass deformity also may contribute. Thankfully most of the time it is due to much simpler causes.

– (recurrent vomiting and dehydration)

Vomiting is not uncommon following sleeve gastrectomy, and causes of vomiting are many. Vast majority will settle down, although some going on for a few days may even need readmission for hydration. The most common cause of prolonged vomiting is usually due to severe inflammation and oedema of the newly sleeved stomach as shown in the picture below. If there is some unavoidable angulation in the gastric tube, it might lead to complete blockage .

Bleeding

To counteract and decrease the oedema and the inflammation we usually use Dexamethasone which is strong steroid to help and usually suffice.

– Bleeding

Some blood loss is unavoidable. It could range from negligible to a level that we might need blood transfusion. Thankfully the rate of significant bleeding is low. Bleeding is usually from the newly formed staple line, and stitching usually is the best way to control it, which we routinely do. But bleeding from other sites is also possible including, liver, spleen, greater omentum and from the port sites. Routine blood check is done after surgery to check for significant drop in the blood level.

– Deep venous thrombosis

Obesity is one of factors which encourages clotting of the blood in the deep veins. We do take due precautions, like routinely inject clexane and putting on stocking and pneumatic calf compressors during surgery. For higher risk patient we might need about 2 weeks of clexane injection, which the patient could inject themselves at home. The risk of clotting is the highest in the first 3 weeks and fades away gradually. Long distance travelling obviously not advisable if possible in the first 4 weeks.

– Hypoglycaemia

Occasional severe attack which could lead to fainting. This is usually due to a much higher level of insulin production in an insulin resistant individual. Once weight lost occurs, the insulin sensitivity improves but the level of secretions still the same and will lead to severe hypoglycaemia if the oral intake was inadequate. It could take a few weeks until sugar level stabilizes. One of the best way to prevent these attacks is pre-operative dieting and weight loss which is basically training your body and getting it ready for the post-operative period.

Diet, vitamin and mineral sufficiency or deficiency

Balanced diet with enough protein, essential elements and vitamins is important to maintain long term healthy body. Good recipe books specifically put together for bariatric patient are available, like the example below is important to have.

Your Guide

Consulting an experienced dietician is essential and will help preventing long term nutritional deficiencies. Self education about food, calories, additives and chemicals added can be helpful . Your stomach is not just smaller but its function is affected, less acid affecting calcium and iron absorption, quicker stomach emptying in some patient leading to dumping syndrome. This is not as significant compared with bypass surgery . Vitamin B12, deficiency is common, mainly due to a decrease in protein produced by the stomach to facilitate the uptake of the vitamin in the small bowel. Vitamin D, deficiency is quite common amount the public , and it is worse with obesity, as higher doses of inactive Vitamin D needed to produced enough active Vit D compare to none obese person. Once weight loss is achieved this becomes less an issue.

Eating and chewing technique effect on the long term health of the esophageus.

Sleeve produces resistance to food passage although not as severe as lap band surgery, but it is important to consider. Basically you will need to chew your food properly and not to push it too hard or too quickly even if you feel hungry.. This behaviour could lead to severe stretching and dilatation of the esophageus. It could become another stomach and could accommodate as much or more than the sleeved stomach.

Eating in a hurry and trying to push down with water or other liquid could cause a lot of damage to the esophageus. It is very important to look after the health of the esophageus otherwise long term suffering might be encountered and you might need a bypass to decrease the pressure on the esophageus.

Sport and physical activities.

The importance of physical activities cannot be overstated. Exercise won’t help with weight loss but helps to maintain it and significantly improves your health. Loosing weight alone doesn’t make you healthy. Our body is dynamic and our tissues like muscle and bone will changes with the levels of activities. If we don’t exercise, our muscles gets weaker and our bone becomes brittle which leads to all sorts of problems, ranging from back pain, disc prolapse, osteoporosis and associated fractures, muscle and tendon issues. Our heart and lungs becomes less efficient and our immunity drops— all to the harm of our body.

Our unhealthy modern living is harmful, and the more advanced we are the less activities we engage in. We don’t play games using our body but only our fingers facing computers. Most of us have no idea about building simple things, planting or cooking from scratch— we all want something readily made and don’t want to wait.

We need to keep moving and expose our body to higher and higher levels of physical challenges. Of course starting slowly, otherwise you could harm yourself if you jump from a fully sendary life to doing extreme activities. Consulting personal trainer and or exercise physiologist might optimise your quest for very healthy body.

Changing the management of your pre-existing medical morbidties.

Very important to evaluate the need of your pre-existing medication regularly, especially early on. The effect of weight loss have a variable effect on pre-existing medical conditions, mostly positive. You will need to see our bariatric physician to take you through the changes

Skin laxity

If you loose enough weight regardless of the methods used , skin folds and sagging could become a significant issue that might need surgical intervention. Through our clinic we offer abdomino-plasty (tummy tuck) at an affordable price for our patients.

Pregnancy

Usually advised our ladies to avoid pregnancies in the first 12 month,

Weight maintenance / weight regain

This is one of the most important issue that most of us think about it. We must remember the way our body works and how the surgery works to convenience the body to stay satisfied with a lower weight which is against its inherited survival instinct built into our brain. This surgery is a strong tool given to you, that you need to understand well and maintain. This tool doesn’t and can’t block or stop all our bodies tricks to regain weight. We are giving you the upper hand but you could tip the balance against yourself. You have to put some effort yourself.f You can’t depend 100% on the operation, the percentage of effort unfortunately might need to increase as years passes by.

Having said all that we don’t pretend to understand all the reason beyond some of the weight regain. We are constantly reviewing the effect of the surgery, patient response and adjusting to tackle issues as we discover them.

Gastric bypass surgery (GBS)

 

GBS is one of the earliest surgery performed to treat morbid obesity. There are different levels of bypasses done throughout the years, some of the extreme gastric or small bowel bypasses has been abandoned due to extreme weight loss which made the patient too sick.

Currently few versions of GBS performed

We perform the classic Roux en Y Gastric bypass, mostly to avoid bile refluxing into the stomach pouch and possible long term consequences.

The Classic Roux en Y Gastric Bypass

Principal of the surgery:

The main principal is to divert the passage of the food way from the upper portion of gut where all the acid, and the digestive enzymes from liver and pancreas in abundance. Naturally the stomach will let out the food out the stomach slowly 4 hours following ingestion to allow time to mix it with stomach acid. The gradual passage is aided by the valve at the lower end of the stomach called pyloris, which is muscle arranged in circular manner. It relaxes and goes into spasm as needed. So small amount of partially digested food with come out of the stomach to mix up with other digestive enzymes. This process and timing of the steps will be disturbed with gastric bypass surgery. Leading to partially digested food reaching to the end of small bowel. This will lead to release of enteric enzyme decreasing your appetite and improving insulin sensitivity. Off course this will lead also to some degree of malabsorption and decreases the energy absorbed into your body but will also decreases your ability to absorb vitamin and minerals and that is why you will need replacement.

The surgery done through key hole (laparoscopy), most of the times unless the patient had multiple open abdominal surgeries.

The first step of the surgery is fashion small pouch out of the proximal stomach as below and the small bowel transacted about 70 cm distal to the stomach

The next step of the surgery is to connect the R (Roux limb) to P   (the pouch), forming the P/R join, as in the diagram below.

The next step is to join the small bowel and restore continuity, usually we measure the R limb of about 1.2 meter and join it to the BP limb, as shown in the diagram above.  Distal to the BP/R join is the common limb which about the distal two third of the small bowel

Changing and diverting the path will lead to potential internal hernia sites, to avoid this we stitch and close these sites, but we couldn’t completely avoid this problem, which is about 2% at well-established centres.

Leakage

from joins are another potential complication, although is less dangerous than sleeve leakage but still has the potential for making you very sick and further procedures might be needed depending on the situation. The most critical one is P/R join leakage, we usually do double layers of stitching and test the join during the surgery.

Bleeding

from the joins, or from any other abdominal structures.

  • Bleeding from abdominal organs or operative site, is similar to other abdominal surgeries, in fact any operation anywhere in the body could lead to bleeding.
  • Bleeding from the join sites
  • Early bleeding, within the first 24 – 48 hours. basically the bleeding inside the bowel lumen, thankfully using finer stapler and oversewing it. Most of the time this type of bleeding settles down spontaneously, but there will be always the possibility of needing surgical intervention.
  • Late bleeding from marginal ulceration at P/R this could be quite troublesome, and quite difficult to control, thankfully it is avoidable by avoiding smoking, we usually decline surgery on patient who is not welling to stop smoking to avoid this complication.

Factors might increase your chance of bleeding are:

  • Congenital deficiency of clotting factors
  • Systemic illness like kidney impairment
  • Medication which thins the blood, sometime we have to send you home with the, if you have high risk of clotting, or have cardiac stent – etc.
  • Herbal medication could increase the risks of bleeding significantly, like ginger, garlic and other herbal medicine.
  • And off course smoking which is major risk factor with gastric bypass surgery, basically you are suffocating areas of the join with poor blood supply cutting oxygen off and leading to ulcer.

Infection

any surgery could lead to infection, either at the site of the surgery or other sites as consequence of surgery, like lung, urine, cannula sites —etc.

Dehydration

usually at early days following the discharge from the hospital. Depending on severity some might need to come back for intra-venous hydration.

Clotting and Deep venous clotting

  • clotting in veins at the vicinity of the operation, like the main bowel vein (portal vein), quite rare with 0.5% possibility. Most of the time we could manage without surgical intervention, rarely could lead to the need to resect part of the bowel
  • clotting in the deep veins, like calf and lungs or combination of both.

What predispose to clotting are?

  • Obesity
  • Contraception
  • Smoking
  • Previous history of clotting
  • Genetic defect of clotting factors.
  • Poor mobilization postoperatively

You will be on clexane usually 40 mg just before you go to sleep and while at the hospital. We do send some of you home with 12 days of clexane, if you have enough risk factors.

Dumping syndrome

it is one of the most specific complication of this surgery, which could be avoidable if proper diet regimen adopted. Basically the food drops into the small bowel very quickly, because we diverted the food away from the valve (pyloris) at the lower end of the stomach. Situation is similar to a factory with conveyer belt, when suddenly large number of product reaches to the next sept but there aren’t enough workers to deal with the sudden gush, so the supervisor rises the alarm and workers from everywhere run to help, leaving their original jobs.

  • Early dumping. That is when significant amount of food especially of carbs drops into the lumen of the small bowel, then we will need to divert significant amount of circulating bloods to the bowel, leading to drop in blood pressure and less blood going to the brain, feeling awful, scared, heart is racing and about to faint.
  • Late dumping, following the initial event as above, there will be sudden surge of blood sugar as a consequences of progressing large amount of carbs suddenly. With will stimulate the pancreas to produce large amount of insulin as knee jerk reaction, leading to severe drop of blood surgery (hypoglycaemia), you will be feeling faint, sweeting, your skin will be clammy

These reactions could be so severe and come patient could come forward to have the surgery reversed. Thankfully with better education and sticking to appropriate diet could counter act all these reactions.

Blind loop syndrome

As you could see from the above diagram, the BP limb has no follow of food through, this area usually sterile and have no bacteria, but with stagnation colonisation of the limb with bacteria could lead to troublesome diarrhoea, as bacteria could lead to interference with bile structure and augmenting the malabsorption effect of gastric bypass surgery.  Oral antibiotics might be needed if significant diarrhoea experienced.

Blind loop syndrome

As you could see from the above diagram, the BP limb has no follow of food through, this area usually sterile and have no bacteria, but with stagnation colonisation of the limb with bacteria could lead to troublesome diarrhoea, as bacteria could lead to interference with bile structure and augmenting the malabsorption effect of gastric bypass surgery.  Oral antibiotics might be needed if significant diarrhoea experienced.

Vitamin and mineral deficiencies

Bypass is not as forgiving as sleeve or lap band, in term of supplements, you will need to adherent to the recommendation by our bariatric physician and dietician’s advise.  Regular blood test and supplement is important. Vitamins and mineral plays very important role in keeping our body functioning normally. Over supplement could be harmful too.

  1. Iron, usually absorbed slowly and will need acid to help its absorption, which is disturbed with bypass surgery. Iron is very important for blood production and overall strength of the body.
  2. Vitamin B12, this vitamin needs special protein produced in the stomach to help absorption. B12 is very important for our nerve cell function and deficiencies could lead to numbness and it also help blood production and special type of anaemia develops if we are deficient in B12.
  3. Vitamin D and Calcium. Calcium needs vitamin D and acid to absorb from our bowel. Less calcium, weaker our bones are, and could eventually affect the small glands behind our thyroid glands function, worsening the situation. Vitamin D has other functions as well, it has significant influence on our immunity, skin and hair.
  4. Other vitamins, minerals, and trace element also disturbed unless proper replacement ensured.

Protein deficiency, hair loss, nail weakness and decreased energy

  • Proper diet and vitamin supplement is very important to avoid these issues
  • Hair loss could follow any stress, surgery or significant drop in calories consumed. If appropriate amount of protein consumed and vitamin level optimised hair loss should be a temporary experience. Off course other factors might worse the hair loss, but permanent hair loss is not common.
  • Inpatient, usually we will keep you for about 2 days in the hospital
  • If you are well and no issues at the first day post-surgery, we will allow you sips of water and progress to clear fluid as appropriate. Overall diet is discussed at the next paragraph
  • Pain is not severe as the surgery done by keyhole, unless we needed open surgery. Pain threshold is quite different between different patient and in between different cultures.
  • If you are diabetic then we will set a plan for the interim management until full adjustment done, we will need to decrease your medication significantly.
  • Heart and blood medication should be recommenced as soon as possible unless otherwise other changes encountered.
  • Arthritis medication, should be stopped and finding alternative medication or routes of administrations might be needed.
  • Blood thinning medication will be discussed and arranged according to individual patient’s situation.
  • Cholesterol medications, are not essential and could be stopped for a while
  • Vitamin and minerals, could start with liquid form until able to consume normal food.
  • Daily activities, the wound covered with water proof dressing and you could have shower, should be able to walk around from the first day, drive by about 5 – 7 days. Gentle walking in the first 2 weeks, and do brisker walking between 2 – 4 weeks, jogging after 4 weeks and full activities 6 weeks’ post-surgery.

1. Could attend light duties at work by 1 – 2 weeks

2. Intimacy by 3 – 4 weeks, gently off course to start with

3. Long distance travelling not before 4 weeks

4. Smoking, — never

5. Swimming about 4 weeks

  • Discharged home day 2, if all well and there is enough support at home
  • Follow up at the rooms, 1 -2 weeks’ post-surgery
  • Could call my rooms during working hours and the private hospital after hours or the weekend. You could also attend the public hospital, but I will need to know, and if I am away, there will be another surgeon which I will nominate to look after your and will be someone how has similar practice as myself and I trust.

1st week

clear fluid diet:

Options, Skim milk, Water, Sugar free jelly and Low fat broth

The idea is to have 30 mls every hour and to have very small sips.

2nd and 3rd week

pureed food and protein shakes.

You should have several small meals throughout the day; daily intake should be roughly 60-70 grams of protein (protein shakes, egg white, pureed fish/meat/ chicken, low fat soft cheese and low fat cottage cheese).

These food substances should be pureed with water, fat-free milk, or fat-free broth. Clear liquids (water) should not be consumed at the same time as the pureed foods. As a general guideline, it is usually suggested that the patient not drink any clear liquid 30 minutes before a meal and 60 minutes after a meal.

It is essential to have one or two multivitamins (containing iron) every day in order to prevent nutrient deficiencies. The multivitamins should be in chewable or liquid form.

It is also vital to supplement diet with calcium citrate, which is easier to absorb compared to calcium carbonate; the optional amount will be two doses with each dose ranging from 400 mg to 600 mg. Calcium citrate supplementation should be separated from the multivitamin dosages by at least two hours. This is because iron and calcium can interfere with each other’s absorption.

4th and 5th week

soft diet stage

The nutrient goals will be similar to the 2nd and 3rd week. 60-70 grams of protein and 64 ounces of fluid are advised daily. The serving size of protein in stage three should be about 30-60 ml and you likely to have 3 to 6 small meals.

Stage three, like 2nd and 3rd week, focuses on high-quality lean protein sources.

Options are:
Meat, Dairy, and Eggs

  • lean chicken
  • lean turkey
  • fish
  • egg whites
  • non-fat cottage cheese
  • non-fat cheese
  • tofu

Vegetables

  • potatoes
  • carrots
  • green beans
  • tomatoes
  • squash
  • cucumbers
  • bananas
  • avocados

During the 4th & 5th week multivitamin supplements should be taken daily as well with vitamin D 3 & calcium tables as recommended earlier.

Week 6

A diet consisting of protein, vegetables, a limited amount of grains, and very little, if any, refined sugars should be followed for the rest of your life.

Tips for starting solid foods:

  • Introduce one new food at a time; ideally not more than one new food a day so you can gauge your body’s reaction.
  • Eat slowly. Chew your food well, 15 seconds each bite.
  • Separate your food and water by at least 30 minutes.
  • Continue to drink at least 1.8 liters of water a day.
  • Eat your protein first, vegetables second and carbohydrates third (ideally healthy grains and/or fruits, not processed foods).
  • Eat real nutrient dense foods. Stay away from pre-packaged and processed foods with a lot of ingredients.
  • Read labels. Focus on foods low in carbohydrates and a calorie to protein ratio of 10 to 1 or less (add a zero to the grams of protein and if the total calories are more than that then you may want to avoid that food – particularly if you are struggling to reach your protein goals).

To reduce the risk of dumping:

  • Avoid high sugar/refined carbohydrate foods.
  • Eat very slowly.
  • Chew your food well.

Some foods are very difficult to digest and should be taken carefully:

  • beef
  • pork
  • shellfish
  • grapes
  • nuts
  • whole grains
  • corn
  • beans

Omega Loop Gastric Bypass

Before talking about gastric bypass, just quick overview of the surgical approach to the management of obesity.The main aim of any treatment option (surgical or non-surgical) is to decrease the amount of calories we generate by our stomach and the intestine (gastro-intestinal system). Please note it is very important to explore all the options and try non-surgical options before embarking on surgical treatment.

Surgery will make changes to your gastro-intestinal structure and or functions, depending on type of surgery performed. We could reverse some of the surgical changes made, but don’t expect to go back to the original shape completely. Some surgery more drastic than others, and some we can’t reverse at all.  Your full understanding of the type of surgery you having is very important. It is your right and responsibility to know and ask as many questions as possible.

It is also worth to remember that without your contribution, committing and adopting healthy life style any surgical or non-surgical weight loss method would fail. What surgery does basicallyis to give you the upper hand to lose weight, but without your contribution you wont reach your target.

Basics of surgical procedures

If we look at our gastro-intestinal system as factory that produces Calories, so we have to do something to decrease the production of calories. Two options

  • Restriction, not allowing enough raw material enter our factory (gastro-intestinal system), obviously the raw material used is food: e.g. gastric band, sleeve surgery
  • Decrease efficiency of the factory (gastro-intestinal system). E.g. bypass surgery.
  • Combination of two (restriction and decrease of efficiency) , bypass surgery

Important point: Asyou could see above that bypass works by combination of restriction and decrease efficiency of the gastro-intestinal system compare to sleeve gastrectomy, which works mainly by restriction. So if you stretch your stomach pouch or your esophagus by not adopting healthy eating habit, you will lose most or all the help provided by the sleeve and roughly half the help provided by bypass. So theoretically bypass is more resilient and resistant to sabotage, but you could regain all your weight even with bypass too. Again there are no ways around getting your goal without your serious contribution.

Bypass is one of the oldest and first approaches used to tackle obesity, since 1950. But bypass have that many different types depending on how and how much interference made to our factory setting (gastro-intestinal system). Many of original type caused significant mal-absorption and ill health. Thankfully most of the drastic types of gastric bypass surgeries are not done nowadays.

One of the most famous and ever lasting one is Roux-en-Y gastric bypass, and the newest and emerging type is Omega loop gastric bypass (type of what we call single anastomosis bypass, or single join bypass).

 

 

 

Over the years, surgeons try new ways to tackle obesity. This happens with other surgical procedures as well, but it is more noticeable with obesity, merely because we don’t have perfect surgical method to treat obesity. The basis for trying new technique is to tackle few issues. In perfect world you want a surgery that is simple, safe, easily reproducible, gives you long lasting weight loss, allow you best life style and doesn’t cause complications. Unfortunately we are nowhere near there.

Omega loop, based at producing simpler surgery than Roux-en-Y gastric bypass, less complications, like leakage (one join instead of two) and internal hernia. Better weight loss, as claimed. But more possible chances of causing bile reflux.

Possible contra-indication for surgery, are inflammatory bowel disease, e.g. Crohn’s disease, severe reflux and Barrett’s esophagus, extreme ages with significant anesthetic risks.

Supplement is essential to keep healthy. You will need multivitamins and occasionally protein supplement as well depending on you food intake. You will be regularly assessed by our team, especially by the Bariatric physician. Patient whom failed to follow up they tend to fail or regain weight more than other.

 

Surgery performed laparoscopically(keyhole surgery). Needing to convert to open surgery always possible especially in patients whom had previous or multiple open abdominal surgeries.

Our unit will conduct full pre-surgery assessment and preparations. To check your fitness for surgery and make sure that there are no contra-indication for surgery.

Please note that you will need to quit smoking completely, and avoid alcohol. Smoking might cause significant ulceration at the joining site with possible severe bleeding that might need major surgery to control. In addition to the high calories in alcohol, you will be at extra-risks of developing alcoholism.

­­­The first step of the this operation, is to partition small pouch out of the stomach as below

https://sydneymetabolicsurgery.com.au/wp-content/uploads/2018/09/img1.jpg

https://sydneymetabolicsurgery.com.au/wp-content/uploads/2018/09/im2.jpg

The second step is to bring the small bowel about 2 meters distal to the stomach and attach it to the small pouch we made above. Bring the bowel up in shape similar to the shape of Omega  d . Just to decrease the possibility of reflux by developing siphoning effect of the bowel distal to the join site. As below.

So as you could see we miniaturized the gastro-intestinal system. By this configuration, we have decommissioned over 90% of the stomach and 30% of the small bowel. Our newly made stomach is about 80 ml instead of about 2 liters, and 4 meters of small bowel instead of 6 meters.

Hospital staff will call you and let you the approximate time to attend. If your operation in the morning, you will need to be fasting from midnight the night before. And could have liquid in the morning if your operation in the afternoon.

Some of your medication will need to stop, adjust or could take with small amount of water; our bariatric physician will discuss all these issues before surgery. You will need to bring all your medication with you.

Could bring your daily simple hygiene and grooming kits. Please try to remove most of the jewelries especially piercing. Artificial nails will affect oxygen monitory gadget.

Usually two nights in the hospital. Could start driving your car and attend office duties in a week or ten days. Moderate heavy work not before four weeks. Full activities in 6 weeks.

Dressing could come off day five, and could have shower from the first day. Pain and some bruising around the wound is not uncommon, but small number of patient could have significant bruising of all the lower part of their abdomen, which could look horrible but thankfully all goes away without long term consequences.

Will be send home with acid medication that you would need to have in the first two weeks to help healing. Pain medication and occasionally blood thinning medication if you are at higher risks of clotting, previous deep venous thrombosis.

For ladies contraception is important especially in the first year post surgery. Intimacy could be resumed about 3 weeks.

Your routine medication might need adjustment and will discussed individually with you. Generally we don’t allow arthritis medication, we don’t need to restart cholesterol medication immediately, and diabetes medication needs adjustment. Anxiety and depression medication could be commenced once you passed water test day one post surgery.

Post-operative diet sheet will be given, basically all liquid in the first month, starting with water, juice and broth from day one following water sip test, slowly progressing to thick puree and mashed food by the of one month.

Liquid or chewable multivitamins could be commenced about 3 – 5 days post surgery.

 

Possible complications

  • Anesthetic complications, although modern anaesthetic is safer, but complication could happen. Reaction to medication, anaphylaxis, lung complication, aspiration pneumonia. You could further discuss with the anaesthetist before the procedure.
  • Bleeding, any surgical procedure could cause bleeding. Average rate about 1 – 2 % possibilities of significant bleedings.
  • Infection, including wound, Urinary infection.
  • Leakage, from anastomosis or join site.
  • Vomiting, fluid intolerance, bowel blockage
  • Inadvertent injury to other abdominal organs during surgery.
  • Deep venous clotting, lung clots, and clots of abdominal organs including bowel

Long-term issues

  • Bile reflux
  • Weight regain
  • Food intolerance
  • Ulceration
  • Vitamins and nutritional deficiencies.
  • Gall stones.
  • Other possible unforeseen complications

 

 

Long term Management

Very important that you commit yourself for regular follow up with us, especially with our Bariatric physician, we will set the plan for regular blood check and monitoring your health in general.

Exercise

Couldn’t emphasised enough about the importance of regular exercise, you won’t be healthy unless you exercise, most of slim people are unhealthy unless they exercise. It also helps to stabilizes your weight. Osteoporosis or bone thinning is afflicting younger and younger people, and could be quite crippling, and the main reason behind this epidemic is the lack of resistance exercise and the jobs we perform have hardly any significant physical activities. You could contact our recommended personal trainer or a trainer of your choice.

Skin laxity and other aesthetic issues

Before contemplating any surgery, you should wait until your weight plateaus and remains that way for about 6 months. We have plastic surgeon specialised in these operation attached to our unit.

Social, sexual and psychological health

Most of my patient came together and open face book page “sleeved by Dr K”, which is very good for sport and getting to know others and develop bond with them, the future hope will be to arrange group outing and socialising. It is to stand against the ignorance and patient blaming by the some of the general public and doctors. This ignorance led to significant depression among obese patient. Unfortunately, Medicare Australia still not recognising obesity as a chronic disease.

Due to hormonal changes and other factors, sexual ability might be affected, in our unit we have sex therapist whom could help you with these issues.

Most of you will feel much better following surgery, as weight loss boosts your confidence and unchain your body and could enjoy freedom of movement. We will help some of you whom still need psychological support and refer when appropriate.

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