(Keyhole Surgery for Morbid Obesity)

Surgery has become a very popular and successful option for patients with morbid obesity. Patients who have morbid obesity, and would like to consider surgery should have first undergone a detailed medical assessment by a multi-disciplinary team that includes a physician, surgeon, clinical nurse specialist, psychologist and dietician. If the individual is thought suitable for surgery, and fulfilled a number of pre-defined criteria, they will be offered this.

Although numerous types of operation for morbid obesity have been described historically. The principles that such operations are based on are either restrictive (limiting the intake of food and calories) or malabsorptive (reducing the absorption of food and calories from the gut). Two main surgical procedures that are usually offered are either Laparoscopic Gastric Banding, or Laparoscopic Gastric Bypass, both of which have proven to be effective at causing long-term weight loss.

Banding involves the insertion of an inflatable band device around the upper portion of the stomach. This forms a small pouch of a stomach, resulting in rapid satiety and therefore the intake of much smaller meals and calorie consumption. This procedure can be performed using keyhole surgery, and patients normally only need to be in hospital for one or two days after the operation. Following the procedure, the band inflation needs to be adjusted in order to establish the optimal level of restriction. This is done via the injection of saline into the system via a small reservoir positioned in the subcutaneous tissues. Although this procedure is relatively straightforward, it is not always effective at causing significant weight loss in individuals with a very high BMI. Some patients can still maintain a high calorie intake in spite of the band being present. The other risks of the band include slippage or erosion into the stomach, which may then require surgery to adjust or remove it completely.

Bypass is a major operation, but can also be done by keyhole surgery. In this complex procedure, the stomach itself is stapled off to form a small pouch. Small bowel, much lower down the digestive tract is then brought up to join the pouch. In this way, there is both a restrictive component with a small stomach, and now a malabsorptive component with food entering the stomach and bypassing a long segment of intestine, therefore not being absorbed. The combination of these two components results in a significant and successful loss of weight in the majority of patients, even with a very high starting BMI. Gastric bypass has very good long-term results in relation to sustained weight loss, and can virtually cure medical problems such as diabetes and high blood pressure. Despite the complexity of the procedure, the attractive long-term results making this operation increasingly popular. There are significant risks however, with the possibility of internal twists of the bowel or leakages after the stapling.

The National Institute for Clinical Excellence (NICE) in 2002 published a review on the use of surgery for weight reduction in people with obesity. It recommended that obesity services be set up in a multi-disciplinary team approach, and if patient have fulfilled the specific criteria, then be offered obesity surgery, either banding or bypass as most appropriate. The high cost of this procedure, combined with the large number of potential individuals who might eventually be suitable for surgery has lead to reluctance on the part of primary healthcare providers to offer this service. We are at present negotiating the set-up of a combined medical and surgical obesity service in Exeter, offering treatment for patients throughout the southwest peninsula. We aim hopefully to have this established by early 2006.

---