Mr Shamsi El-Hasani is a Consultant General Surgeon at BMI Chelsfield Park Hospital and BMI The Sloane Hospital. Here we ask him about what is involved in laparoscopic gastric bypass surgery, including the benefits, risks and recovery.
Who qualifies for a laparoscopic bypass and what are the requirements?
Gastric bypass is one of the most common bariatric surgical procedures. People that qualify typically have excessive body fat, defined by its clinical terms 'Obesity', which is a systemic disease that can affects all organs in the body.
To qualify for weight loss procedures all individuals/patients need to exhaust all non-surgical methods by specific dietary program sustained for a good period of time, associated with daily regular exercise. International measurement of obesity is by body mass index which is the relation of weight in kilograms to the height in metres. Categories of BMI's are as follows:
- A BMI of less than 25 is normal
- A BMI of 25-29 is overweight
- A BMI of 30-39 is obese
- A BMI of 40-49 is morbidly obese
- A BMI above 50 is super obese
In order to qualify for a gastric bypass an individual needs to have a BMI of 35-39 with related comorbidities or a BMI above 40.
What are the three most important things a patient should consider before undergoing this surgery?
- Patients need to exhaust the non-surgical methods which are mainly controlling portion sizes, healthy eating and regular daily exercise. These measures need to be sustained for a few months regularly in order to assess the outcome.
- Before proceeding with weight loss surgery, a patient should understand the impact of their daily life after the operation and the changes required in their eating habit and lifestyle. This can be aided by reading available literature, speaking to specialist health professionals and/or attending a group information session.
- Giving up smoking is important for wound healing and the safety of the operation.
What happens during a laparoscopic gastric bypass?
During gastric bypass the following elements are strategically achieved:
- The capacity of the stomach will dramatically decrease bacause a gastric pouch is inserted in the stomach. As such patients will need to eat less amounts of food to feel full, and this provides the mechanism for portion control.
- The rest of the stomach, duodenum and major part of the jejunum are bypassed which means that the food will not enter this part of the gastrointestinal tract and therefore there is less opportunity for absorption.
- Completing the bypass in the above two steps, the gastric pouch and the exclusion of part of the proximal gastrointestinal tract will initiate some hormonal changes that will help to decrease hunger pain, craving for food and will improve satiety.
- These hormonal changes will also help to decrease the natural resistance to insulin and hence this operation is considered one of the therapeutic pathways that can be offered to patients with diabetes and hyperlipidaemia.
The operation is done by keyhole surgery with 6 to 8 small cuts and to achieve the operation a stapling device is required.
What is typically involved in the recovery?
The recovery after this operation is swift as you will beencouraged out of bed two hours after the procedure and encouraged to walk around and do breathing exercises for as long as you are in hospital.
The length of stay in hospital is usually two to three nights and when patients go home they are usually pain free on minimal doses of ordinary pain killers. They can usually walk independently and will be advised to do increased daily exercise, and after two weeks patients can do any form of exercise they want.
They will be encouraged to take liquids only for the first four weeks, soft food for the second four weeks and eight weeks after the operation they can starting eating small amounts of normal healthy food.
We advise that patients take daily anti-thrombotic injections to prevent deep vein thrombosis daily for the first four weeks after the operation. This is self-administered and patients are taught to do it while in hospital.
Two weeks after the operation patients will start taking vitamin and mineral supplements that will need to be continued for the rest of their lives.
How long does it take until a patient experiences significant weight loss?
Weight loss will start from the two-week pre-operative diet and continue immediately after the operation. However, the rate of weight loss will vary from one person to another and it is known that the weight loss will be significant in the first six months after the operation and then will slow down.
Usually, the weight stabilises about 16-18 months after the operation. I usually advise patients to work hard by exercising and concentrating on regular weight loss rather than the amount of weight loss as the amount of weight loss will vary from one individual to another and from one week to another depending on a variety of factors.
It is expected that gastric bypass will provide 65-75% of excess body weight loss two years after the operation.
Is excess skin following laparoscopic gastric bypass common? What are some other potential side effects?
There is no significant weight loss without loose skin and this will be decreased by taking large amounts of protein and regular daily exercise. The majority of my patients will have loose skin following a significant amount of weight loss, but only a minority will be functionally bothered by the loose skin and need a form of surgical intervention.
The early side effects of the operation which occur in the first two weeks following the operation may include infection, organ injury, bleeding, anastamotic leak, narrowing of the anastomosis, lung and cardiovascular problems.
Late possible problems following gastric bypass will be stomal ulceration, developing gallstones, internal herniation and very important vitamin and mineral deficiency especially if patients are not compliant and committed to lifelong supplements. Anaemia is very common if patients do not take iron.
What inspired you to specialise in weight loss surgery?
I am now in the 36th year of my surgical career. I started my journey as a general surgeon and then specialised in laparoscopic abdominal/gastrointestinal surgery before I developed my skills and knowledge into specialist bariatric surgery. I found this surgery very satisfying as successful surgery will help to change patients' lives.
It is a challenging surgery, technically and mentally with a lot of possible problems that need solutions. Needless to say, bariatric/obesity surgery is an evolving science with rapidly developing new invention theories and techniques.
I find bariatric surgery is the ultimate combination of knowledge and craft that makes surgery a special art.