Most patients who present to a sub-specialist surgeon for Bariatric Surgery are surprisingly well-researched, but this would have required them to spend countless hours talking to friends of friends, relatives, viewing websites and trawling over internet forums. In some cases this may have been a confusing experience. Even the name Bariatric Surgery is confusing, as the derivation of the word ‘Bariatric’ pertains to pressure changes, not weight. But obesity surgery has unsatisfactory connotations to our American colleagues, so could not be countenanced for international usage. Weight loss surgery gets confused with cosmetic surgery (like liposuction) and ignores the established facts that Bariatric Surgery can lead to better health irrespective of weight loss it induces. So now we are stuck with a misnomer unfortunately.
If you can get past this you are then possibly baffled by claims of scientific validity for a variety of different procedures. Why is it not clear which operation is best? Well there are a number of reasons in my opinion.
One reason is that Bariatric surgery adheres to the well-known medical ‘law’ that if there are several different treatments available for a condition, with vociferous proponents of each, it means that there is no clearly superior treatment, and the scientific literature has been unable to reach a consensus about which is best.
In Australia, the 3 commonly-used operations are the Laparoscopic Adjustable Gastric Band (LapBand), the Roux-en-Y Gastric Bypass (or just ‘gastric bypass’), and the Sleeve Gastrectomy (sometimes shortened to just ‘sleeve’). The term ‘stomach stapling’ is also in common parlance, but is taken to mean the old-fashioned Vertically-Banded Gastroplasty; a procedure which was common until 15 years or so ago, and has been since mostly abandoned because of inferior results to more modern procedures. But remember that the modern operations of gastric bypass and sleeve gastrectomy also use stapling technology during the procedure but have nothing to do with the aforementioned stomach stapling operation which we will no longer consider.
Which of the 3 common operations is the best? This needs to be considered from both a scientific and your own personal point-of-view. The latter first: you may have a friend or relative who has been through one of the 3 procedures with good results. They may have a mature understanding of what is required for success, have extensive knowledge which they can share with you, and perhaps have even offered to be a support person during your journey to better health. If that it the case, these personal factors may be a strong factor in your choice of operation, and you should not ignore this opportunity.
From the scientific point-of-view, the truth is that each operation has advantages and disadvantages. My reading of the current state of play is that the LapBand is far and away the safest upfront operation. It is extremely rare for there to be a serious in-hospital complication1. It is the least painful, and the quickest to recover from. However it is not 100% successful, it is 94% successful: 6% of patients will require a second operation down the track to have the LapBand removed. However the majority who proceed to have the situation surgically corrected end up with the same good long term outcome as those who had no such problem. The LapBand has good long term outcomes in terms of weight loss, remission of the co-morbidities associated with obesity, and improved survival; but not quite as good as the gastric bypass.
The gastric bypass appears to have generally superior weight loss outcomes, better control of diabetes and some other medical co-morbidities of obesity compared with the LapBand. And it too has a 6% major complication rate. But these complications occur in hospital, rather than months or years later like the LapBand. These serious complications can include re-operation for bleeding, incisional hernias, removal of the spleen, bowel blockages, and blood clots in the legs and lungs (DVT/PE). However down the track, the gastric bypass patients rarely require any further surgery. The gastric bypass may not always be able to be done with keyhole surgery, and usually requires a longer stay in hospital and at-home recovery period, but not by much.
The sleeve gastrectomy is a different beast. In some respects it falls midway between LapBanding and gastric bypass. Its weight loss may be better that the LapBand (although long term data is lacking), but not quite as good as the gastric bypass. Like the LapBand it can almost always be done with keyhole surgery, and the recovery period falls somewhere in the middle too. However, the surgery involves permanently removing the majority of the stomach from the body. In this respect it is more ‘radical’ than the other 2 operations, and is obviously completely irreversible in case something goes wrong.
In contrast, both the LapBand and gastric bypass are fully reversible (with another operation). In the case of the Lapband this takes under 30 minutes and can be done as day-surgery. In the case of gastric bypass this is more complicated, but in some cases not unduly difficult.
Not all surgeons do all operations, and there may be very good reasons why this happens. They may extensive experience in one over the other, and have good results in their hands. The local facilities may be more suited to one more than the other, or they may interpret the scientific literature to favour one. There is no right or wrong answer, and this is where you need to listen to your surgeon very clearly so you understand what options are available, and what is recommended to yield the best results in your unique case. Chances are this question has been raised many times before, and so he/she will be able to explain very clearly what is in your best interests. However you should still be part of the decision-making process.
1. Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in community setting: weight loss and surgical outcomes. NQ Nguyen, P Game, J Bessell, T Debreceni , M Neo, C Burgstad , P Taylor , G Wittert. Submitted for publication.