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Bariatric operations

Laparoscopic Gastric Bypass

Gastric bypass cost:               5950 EUR (all-inclusive) Look what is included >>

Required BMI:                         Starting from 30kg/m2, depending on co-morbidities

Expected weight loss:             70-80% of excess body weight

Anaesthesia:                           General anaesthesia

Surgery time:                          1 – 1.5 hours

Hospital stay:                          2-3 nights

Sick leave:                                2 weeks

Operation reversible:                Yes

Need for supplements:             ++

Insufficient weight loss/regain: Trimming the pouch or bypassing more small bowel

Laparoscopic gastric bypass surgery is the most popular type of weight loss surgery in the world and the so called gold standard of weight loss surgeries. The reason for this is good and sustained loss of weight, very good control of accompanying diseases and low risk of surgical complications. The long term results of the surgery – weight loss, effect on accompanying diseases, low mortality rate – are well documented and reliable.

Laparoscpic gastric bypassThere are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 millilitres in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

How does gastric bypass surgery work?

First, the newly created small stomach pouch necessitates significantly smaller meals.  As a result, patients feel full after eating a small quantity of food,  and thus consume less calories.

Secondly, because there is less digestion of food by the smaller stomach pouch and bypassed part of the small bowel,  some extent less absorption of calories and nutrients will occur.

Additionally, rerouting of the food stream leads to changes in gut hormones that promote satiety and suppress hunger.

The main difference of gastric bypass surgery compared with sleeve gastrectomy is the shortening of the food’s path in the digestive system.

What are the long term effects of the surgery?

Long term effects of any gastric surgery are reliant on a patient making the necessary changes to lifestyle, particularly in relation to diet and exercise ?

Many studies have been carried out and published on the long term (over 5 years) effects of gastric bypass surgery. The loss of weight is expressed as an excess body weight loss percentage.

2 years after the surgery, the weight loss is 75-85% of excess body weight. 5 years after the surgery, the excess body weight loss is 52-72%, based on different studies.

Important! In  2015  research at  North Estonian Medical Centre was carried out studying patients who had undergone bypass surgery at least 5 years ago.  After the bypass surgery they had lost on average 68% of their excess body weight. This is comparable with the published international research.

The percent of excess body weight loss is higher in  patients of younger age and lower BMI.

Many diseases connected to being overweight like sleep apnea, type 2 diabetes, joint diseases, high blood pressure or polycystic ovary syndrome (PCOS) improve or disappear as a result of a bypass surgery.

Pros

  • 70%  excess body weight loss, lasting results;
  • Rise of life expectancy;
  • 95% of patients experience improvement in their life quality;
  • Type 2 diabetes goes into remission in 75-85% cases;
  • Sleep apnoea and snoring disappear in 90% cases;
  • Heartburn disappears in 100% cases;
  • Disappearance or major relief from back and joint pain;
  • Mortality rate of the surgery is low: less than 0.1%;
  • The risk of serious surgical complications (ones that need reoperation, blood transfusion or a hospitalisation of more than 1 week) is low: 2%;
  • Reversal of the procedure and restoration of the original anatomy is possible;
  • There is a large amount of data published about the long term outcomes of the treatment compared to other types of weight loss surgery.

Cons

  • Long term usage of food supplements and vitamins is necessary for all patients;
  • Risk of anaemia (low haemoglobin), caused by low iron levels.  Women of child-bearing age most at risk;
  • Intolerance of certain food ingredients (lactose, fats, simple sugars);
  • Stomach ache episodes experienced by approx. 10% of patients;
  • Dumping syndrome experienced by approx. 20% of patients;
  • Small bowel obstruction experienced by approx. 2-3% of patients;
  • The risk of forming an ulcer in the stomach pouch (for smokers and chronic pain killer users);
  • The limit of consumption of alcohol, especially for men;
  • The need to take annual blood tests.

Possible complications

Early: peritonitis; post-surgery bleeding; thrombus of deep veins and lung artery; myocardial infarction; pneumonia; abdominal abscess; wound infections.

Delayed: ulcers on the connection of the stomach and small intestine; constriction of the connection of the stomach and small intestine and difficulties in  swallowing; low iron levels and haemoglobin; low levels of vitamin B-12; low levels of calcium and vitamin D; dumping syndrome; gallstones; bowel obstruction; excess skin; constipation; diarrhoea; loss of hair; alcohol addiction; weight regain or suboptimal weight loss.

To summarise, this is a surgery suitable for almost all patients; it results in remarkable and sustainable weight loss and good control of accompanying diseases, improved quality of life and increased life expectancy.

 

Laparoscopic Sleeve Gastrectomy (Gastric Sleeve)

Gastric Sleeve  cost:              5950 EUR (all-inclusive) Look what is included >>

Required BMI:                         Starting from 30kg/m2, depending on co-morbidities

Expected weight loss:             60-65% of excess body weight

Anaesthesia:                           General anaesthesia

Surgery time:                          1 – 1.5 hours

Hospital stay:                          2-3 nights

Sick leave:                               2 weeks

Operation reversible:               No

Need for supplements:            +

Laparoscopic gastric sleeve resectionIn this operation, 85% of the stomach is removed and a banana-shaped gastric tube with a diameter of approximately 2-2.5 cm and volume of 100-150ml/3.4-5 fl. oz  is formed.  This reduces the gastric volume and the quantities of food ingested.  In comparison, an average sized  normal stomach of  medium fullness is 1-1.5 litres / 34-50 fl. oz. The surgery is always performed laparoscopically.

 

How does Sleeve Gastrectomy (Gastric Sleeve) work?

Gastric Sleeve surgery reduces appetite (hunger) and the amount of food eaten. Appetite is reduced because the part of stomach that produces the hunger hormone  ghrelin is removed. A stomach reduced  in size to  100-150 ml / 3.4-5 fl. oz. as opposed to the normal size of 1500 ml / 50 fl. oz. fills up remarkably more quickly and the feeling of satiety is achieved by swallowing just a couple of mouthfuls. Also the  faster flow of food from the stomach’s tube to the small intestine plays a role in the reduction of appetite, as the small intestine’s contact with freshly swallowed food amplifies the feeling of a full stomach.

The main difference of sleeve gastrectomy compared with bypass surgery is that, in the case of gastric sleeve, food still flows through every part of the digestive system and therefore the absorption of nutrients (including vitamins and minerals) and medications is not affected. After the surgery, the stomach and duodenum can still be examined laparoscopically , which is important for patients with certain types of stomach and biliary diseases.

What are the long term effects of the gastric sleeve surgery?

Important! The precondition of long term effects of any gastric surgery is the change of a patient’s lifestyle, primarily diet and exercise.

There have been many studies conducted on the long term (more than 5 years) effects of gastric sleeve surgery. The loss of weight is expressed as an excess body weight loss percentage. A survey review article analysing 16 original studies concluded that 5 years  post-surgery the average excess body weight loss was 62.3% (ranging from 52% to 69% in the different  studies examined). 7 years after surgeries the patients had lost on average 67% of their excess body weight. The percentage of weight loss was  greater in those with a pre-surgery BMI  below 45 kg/m2

Important!  In cases where body weight loss is insufficient or body weight starts to rise, it is possible to convert a gastric sleeve into a gastric bypass

Many diseases connected to being overweight like sleep apnoea, type 2 diabetes, joint diseases, high blood pressure or polycystic ovary syndrome (PCOS)  improve or disappear as a result of  gastric sleeve surgery.

Sleeve gastrectomy may be advisable  for patients with:

  • a BMI below 45 kg/m2
  • aged over 70;
  • small bowel adhesions resulting from previous surgeries, making the patient unsuitable for laparoscopic bypass surgery;
  • a preference not to have to use as many vitamins and food supplements as are needed in the case of bypass surgery;
  • a propensity to develop anaemia as a result of iron deficiency even prior to the surgery;
  • the prospect of getting pregnant and giving birth;
  • the need to use a daily dose of pain killers like diclofenac or ibuprofen;
  • imminent or freshly performed organ transplant surgery;
  • a diagnosed inflammatory bowel disease (ulcerous colitis, Crohn’s disease);
  • a potential necessity for future endoscopic access to the stomach and duodenum.

Pros

  • Excess body weight loss of 60-65%;
  • Improved quality of life for 95% of patients;
  • The food flow in the digestive system doesn’t change;
  • Remission of type 2 diabetes: 55-60%;
  • Remission of sleep apnoea and snoring: 90%;
  • Disappearance or major relief from back and joint pain;
  • Reduced risk of developing dumping syndrome compared to bypass surgery;
  • Mortality rate of the surgery is low: less than 0.1%;
  • The risk of serious surgical complications (ones that need reoperation, blood transfusion or a hospitalisation of more than 1 week) is low: 2%;
  • Complications as a result of reduced absorption of vitamins and minerals are much more rare compared with bypass surgery;
  • The stomach and duodenum remain endoscopically examinable.

Cons

  • Weight loss is a little lower compared with bypass surgery;
  • Increased risk of weight regain in the years following surgery;
  • Not suitable for patients with a sweet tooth;
  • Increase in heartburn frequency  in 20% of  patients;
  • Reversal of the procedure and restoration of the original anatomy is not possible;
  • Increased recovery time compared with bypass surgery.

Possible complications

Early: peritonitis; post-surgery bleeding; thrombus of deep veins and lung artery; myocardial infarction; pneumonia; abdominal abscess; wound infections; narrowing of the stomach tube; difficulties  in swallowing.

Delayed: stretching of the stomach tube and weight regain after initial weight loss; heartburn; gallstones; constipation; diarrhoea; excess skin; loss of hair; dumping syndrome.

To summarise, sleeve gastrectomy  results in somewhat lower excess body weight loss than a gastric bypass but is technically easier to perform and helps to avoid certain specific adverse effects of bypass surgery like vitamin and mineral malabsorption. This operation is indicated  in particular for those whose  BMI is under 45kg/m2 or for those for whom a laparoscopic bypass operation would be difficult to perform due to small intestinal adhesions  as a result of previous surgeries.

 

Laparoscopic adjustable gastric banding

Laparoscopic adjustable gastric bandingIn the course of  a gastric band surgery, a silicone band is placed around the upper part of the stomach, constricting it and forming the stomach into an hour-glass shape which restricts the fast flow of food . The diameter of the band can be adjusted by injecting fluid into it through a port placed under the skin.  The placement of the band reduces the size of the stomach  and the amount of food  that can be eaten. The post-surgery weight loss is  less compared to sleeve or bypass surgeries: 40-50% of excessweight.

Gastric band surgery is fully reversible, the band can be removed and the original anatomy restored.

Compared to gastric bypass surgery, gastric band surgery does not reduce absorption of nutrients and therefore subsequent vitamin deficiency  is unlikely. The main post-surgery problems  are difficulty  in swallowing, nausea, inadequate weight loss and the need for frequent band adjustments. The gastric band is a foreign body, which will need to be removed or replaced  at some point.

Important! The number of gastric band surgeries has dropped recently  worldwide. The main reason for this is inadequate weight loss with subsequent weight gain and frequent need for reoperation.

Pros

  • Excess body weight loss of 40-50%;
  • Remission of type 2 diabetes: 40-60%;
  • Mortality rate of the surgery is low: less than 0.1%;
  • Reversal of the procedure and restoration of the original anatomy is possible; ?
  • Post-surgery use of food supplements and vitamins is required during the first year, after that it is recommended.

Cons

  • Possibility of foreign body complications ;
  • Frequent need for reoperation;
  • Frequently inadequate weight loss and subsequent weight gain.

 

Laparoscopic gastric plication

Laparoscopic gastric plicationThis is a relatively new type of surgery. Similar to a sleeve gastrectomy, gastric volume is reduced, forming a stomach tube with a reduced diameter, but no part of the stomach is removed. Instead the wall of the stomach is inverted with several rows of sutures. There is little data about long term results of the surgery. In the studies that compared plication and sleeve operations published so far, plication has been shown to be less effective. The weight loss is smaller, risk of subsequent weight regain is higher, complications of surgery are more frequent and the need for reoperation is much higher (due to unsatisfactory weight loss or complications). Reoperation after plication is difficult and there is a high risk of complications.

The cost of plication surgery is lower because, in contrast to bypass and sleeve surgeries, no endoscopic staplers are used.

Pros:

  • Excess body weight loss of 30-55%;
  • Remission of type 2 diabetes: 40-60%;
  • Mortality rate of the surgery is low: less than 0.1%;
  • Post-surgery use of food supplements and vitamins is required during the first year, after that it is recommended.
  • Low cost

Cons:

  • Weight loss is less than with sleeve or bypass surgeries;
  • Reversal of the procedure and restoration of the original anatomy is not possible; ?
  • There is no data on the long term effectiveness and safety of the operation;
  • High need for reoperation;

Important!  Bariatric Services does not recommend stomach plication to its patients as a method of treatment until sufficient data about its effectiveness and safety are published.

 

 

Revision operations

There is a good reason weight loss surgery patients usually do not have to be disappointed in long term surgical outcomes: good and sustainable weight loss, excellent control of chronic illnesses and improved quality of life. Today, surgery is and remains for a foreseeable future a single effective and accessible method of treatment for morbid obesity. If there would not be surgery those patients would practically have no chance for care.

Nevertheless it can’t be stated that surgery is invariably effective and there is sometimes a gap between surgical outcomes and patients expectations. Weight loss less than expected, weight regain over years, uncomfortable side effects with nutritional issues are problems laying frequently behind dissatisfaction. Treating obesity is like treating any other chronic and multi factorial health condition. Hardly ever is there one universally effective method available for achieving equal results in all patients. Combining and redoing different surgical procedures gives us a chance to overcome those limitations. Disappointing or non-durable results of primary weight loss surgery do not automatically mean permanent failure of treatment.

Revision weight loss surgery refers to different bariatric procedures that are undertaken after any primary weight loss surgery. Depending on the primary surgery there can be several reasons for that but most often its inadequate weight loss or weight regain later on. For instance when results of primary lap-band surgery are unsatisfactory or band is poorly tolerated the band removal with simultaneous gastric bypass or gastric sleeve surgery can be performed. Just detaching the band results invariably in weight gain to pre-surgery level within few months.

Reasons for poor surgical outcomes

Patient related

All patients vary in their biological response to surgery and in certain cases a well performed and technically correct primary procedure does not give expected results regardless of patients adherence to dietary and lifestyle guidelines after surgery. Also, the side effects of otherwise effective procedure may prove to be intolerable like severe hypoglycemic episodes after gastric bypass or heartburn after sleeve gastrectomy. A revision surgery can strongly be considered here with excellent results.

On the other hand, inability and unwillingness to change ones lifestyle after surgery, or substance abuse occasionally may lay behind failure and it is unlikely that secondary surgery would improve the outcome without adopting new habits.

Some medicines may increase appetite by affect eating behavior and metabolism leading to weight regain after good initial weight reduction. Revising medicine lists and searching for alternatives should be considered here.

Surgeon related

Technical errors made in primary surgery may reveal themselves 1-2 years later when initial excellent weight loss is halted and replaced with weight gain. For instance, oversized gastric pouch in gastric bypass or gastric sleeve too large in diameter may enable good initial weight loss followed by loss of restriction and appetite control later, leading to weight regain. If the patient is well motivated and follows the lifestyle guidelines their revision surgery may have excellent results here. A prerequisite for efficient revision is understanding of “normal” weight loss facilitating post-surgical anatomy and recognition of the technical shortcomings in every particular case. 

Procedure related

It is obvious, that not all weight loss procedures can stand the test of time and some of them inherently require further actions. In up to 10 years perspective gastric band can function predictably and satisfactorily but being a foreign body it eventually breaks down or migrates loosing its effect. Longstanding weight loss after sleeve gastrectomy may fade as gastric tube stretches out resulting in loss of restriction and portion control.

Most common situations requiring revision surgery in our practice


Weight loss after revision surgery is usually slower and smaller than that would be after primary surgery. Usually, a loss of 50% of excess weight patient is having at the moment of secondary surgery can be expected and considered satisfactory.

We are here to help You

We perform 25-30 revision surgeries per year (250 primary procedures). Most of them can be performed safely laparoscopically even after open primary surgery. Revision procedures are always complex implying excellent surgical skills and understanding anatomic and surgical principles that are prerequisite for sustainable weight reduction. Detailed history of weight loss, appetite control, eating patterns and adverse outcomes after primary procedure is mandatory before considering redo surgery to understand what has gone wrong. Additional instrumental investigations like upper gastrointestinal endoscopy and radiography are always used before elaborating definite treatment plan. Please, contact us for further information and guidance.

Laparoscopic Mini-Gastric Bypass

Mini-Gastric Bypass cost:      5950 EUR (all-inclusive) Look what is included >>

Required BMI:                         Starting from 35kg/m2, depending on co-morbidities

Expected weight loss:             70-80% of excess body weight

Anaesthesia:                           General anaesthesia

Surgery time:                          1 – 1.5 hours

Hospital stay:                          2-3 nights

Sick leave:                                2 weeks

Operation reversible:                Yes

Need for supplements:             ++

Insufficient weight loss/regain: Trimming the pouch or bypassing more small bowel

The mini-gastric bypass, or single anastomosis gastric bypass, is an effective and well-established procedure which combines some of the properties of a gastric sleeve and a standard gastric bypass. The upper part of the stomach is divided into a tube, similar to the top three quarters of a sleeve, and then joined to a loop of intestine.

The mini-gastric bypass can be used as a primary weight loss procedure. It can also be used in patients who have had previous gastric banding or sleeve surgery but have been unsuccessful with weight loss, or who have had band-related complications and have decided on revision surgery.

It is not ideally suited to patients with symptoms of reflux disease (severe heartburn that needs medication).

How does the mini-gastric bypass help you to lose weight?

The mini-gastric bypass procedure helps you to lose weight in different ways:

  • By reducing the feeling of hunger through altered gut to brain signalling
  • By enabling an earlier feeling of satiety and fullness when eating a meal resulting in a healthy portion size
  • By decreasing the amount of calories you absorb from your food as a result of bypassing 150 to 200cm of the upper part of the small intestine
  • Rerouting of the food stream produces changes in gut hormones that reverse one of the primary mechanisms by which obesity-induced type 2 diabetes occurs

It is an operation that provides good weight loss with great quality of life. The long-term results of the surgery – weight loss, effect on accompanying diseases, low mortality rate – are well documented and reliable.

Mini-Gastric Bypass

Mini-Gastric Bypass

The mini-gastric bypass procedure is performed laparoscopically (keyhole surgery) under general anaesthesia. Five small incisions (between 5 and 12mm in length) are made for the insertion of the keyhole surgery instruments. Using these instruments, the top of the stomach is stapled to form a thin tube (30ml to 50ml in size). The thin tube becomes the new, smaller stomach and is completely separate to the rest of the stomach. This stomach is then sewn to a loop of the small intestine, bypassing the first part of the intestine called the duodenum and approximately 150–200cm of the bowel. The rest of the stomach and upper part of the small intestine remains in the body but is no longer used for food digestion. In skilled hands, the surgery takes approximately 60 minutes to perform.

What are the long-term effects of the mini-gastric bypass?

Long-term effects of any weight loss surgery are reliant on a patient making the necessary changes to lifestyle, particularly in relation to diet and exercise.

Several studies have been carried out and published on the long term (over 5 years) effects of mini-gastric bypass surgery. Two years after the surgery, weight loss is 75-85% of excess body weight; five years after the surgery, the excess body weight loss is 70-75%.

Weight loss with mini-gastric bypass is as good, if not better, than that achieved with standard gastric bypass surgery in people with a higher BMI.

Many diseases connected to being overweight like sleep apnoea, type 2 diabetes, joint diseases, high blood pressure or polycystic ovary syndrome (PCOS) improve or disappear as a result of the surgery.

Advantages

  • Mini-gastric bypass is particularly effective for patients with a higher BMI as the procedure has more predictable and durable weight loss outcomes compared with standard gastric bypass.
  • Most patients have an almost immediate reduction in their need for diabetic medication and some are able to completely stop diabetic medication altogether.
  • It does not require any on-going adjustments which are required with other procedures, such as the gastric band. Regular follow-up is, however, necessary to ensure weight loss is appropriate and food intake is nutritionally adequate.
  • It is effective for those people who tend towards high sugar or high fat foods. Dumping syndrome is directly linked to a high sugar, high fat intake. Symptoms of dumping are unpleasant and therefore discourage the intake of high calorie and sweet foods.

Disadvantages

  • Lifelong usage of food supplements and vitamins is necessary for all patients.
  • Risk of severe malnutrition requiring reoperation in 0.5-1% of patients.
  • Risk of anaemia (low haemoglobin), caused by low iron levels.  Women of child-bearing age are most at risk.
  • Contrary to common concern, no studies have shown that mini-gastric bypass increases the likelihood of severe reflux or gastroesophageal cancer.

Complications

As with any surgical procedure, the mini-gastric bypass operation has a risk profile which is important to understand before proceeding. The following is a comprehensive list of issues which can occur. Most of these complications are very rare and 90–95% of patients have no issues. This list is extensive and is not intended to worry you, but simply inform you about the range of possible complications, regardless of how rare the issue may be.

Short term complications include (but are not limited to):

  • Bleeding – This occurs in less than 1 in 100 patients after the procedure. This may require blood transfusion or, very rarely, reoperation.
  • Infection – If an infection develops it may require treatment with antibiotics and can occasionally require reoperation.
  • Leaks at the staple line – This can at times require a repeat surgery, occasionally in the first few days after surgery. If these leaks persist they can turn into either communications with the skin or wound (fistula) or persistent infections within the abdominal cavity (abscesses). If this complication occurs, the length of stay in hospital can extend to weeks or potentially months after surgery. This can be a life-threatening problem. This occurs in less than 0.5% of cases.
  • Damage to organs – Any keyhole procedure can be complicated by unintentional injury to the organs near the area of operation. This may require a repeat operation to repair the damaged organs.
  • Blood clots – Deep vein thrombosis (clots in the veins) and pulmonary embolism (clots in the lungs).
  • Pneumonia/ chest infection – This occurs in less than 0.5% of cases.

Your surgical team will take all possible measures to reduce these risks, but if these complications occur, treatment may be necessary.

Possible long-term complications

  • Internal hernia – Risk of internal hernia is considerably lower after mini-gastric bypass (1:500) than after standard gastric bypass (2:100). Occasionally the loops of bowel in the abdomen can become entangled and get stuck. If this occurs, a reoperation is required to fix the problem.
  • Adhesions – Any procedure in the abdomen can cause adhesions (scar tissue). This can occur any time after the operation and can sometimes cause problems with the bowel getting stuck or twisted. This may require hospitalisation and may even require re-operation.
  • Gastro-esophageal reflux – If reflux occurs post-operatively some patients may require acid-suppressing medication. This operation should be avoided for those people with severe symptoms of reflux prior to surgery.
  • Dumping syndrome – Dumping syndrome is a group of signs and symptoms that usually occurs due to poor food choices. It is the result of high sugar foods passing too quickly into the small intestine. Symptoms can include cramping, nausea, dizziness, weakness and fatigue. Dietary advice to avoid dumping is provided by the clinic’s dietician.
  • Malabsorption of vitamins and minerals – Low levels of iron, B12 vitamin and other micronutrients can occur even if recommendations for supplementation are followed. For this reason, regular follow-up visits and blood tests once a year are strongly recommended.
  • Risk of malnutrition – 0.5-1% of patients require re-operation due to malnutrition.

In summary, mini-gastric bypass is suitable for almost all patients; it results in remarkable and sustainable weight loss and good control of accompanying diseases, improved quality of life and increased life expectancy.




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