If you’re considering bariatric surgery, you’re likely faced with a confusing vocabulary of different procedures, some of which have similar-sounding names. So let’s untangle it and sort out what the pros and cons are of current bariatric procedures as we near the end of 2020. Quick note – a lot of the experts in this field prefer the term metabolic surgery because the surgery is designed to affect the metabolism. In fact, the research shows that it’s the only real treatment that affects the hormones which control body weight metabolism and the setpoint, as well as blood sugar regulation over the long-haul.
Current Bariatric/Metabolic Procedures
The current most commonly performed procedures include:
So which of these is right for you, and what are the pros and cons as things stand today?
Laparoscopic Sleeve Gastrectomy
Let’s start with laparoscopic sleeve gastrectomy, since it is the most widely performed procedure. It has become the most popular among both surgeons and patients, and with good reason. Over the last 15 years or so, sleeve gastrectomy has proven itself to be the least invasive, simplest, and safest procedure. It has excellent metabolic effects – in trimming off some carefully chosen stomach tissue, the hormones and biochemistry of the body change, resulting in a lower body weight setpoint and lower, better controlled blood sugar. Most studies say the long-term results are similar to – but perhaps just shy of – the body weight and blood sugar results of gastric bypass, but with far fewer side effects and complications. All of this makes the sleeve gastrectomy a very good procedure to consider. In experienced hands, it’s a 45-minute procedure that’s statistically safer than an appendectomy.
A disadvantage of the sleeve is that a fraction of people, perhaps 10%, will experience worsening acid reflux, and for perhaps 2% of those people, the reflux is so severe that they eventually go on to have the surgery revised to treat the reflux.
Roux-en-Y Gastric Bypass
Roux-en-Y gastric bypass surgery continues to have its ardent supporters. This was the most dominant procedure prior to 2010 and it has a long track record of success. Somewhat more invasive than the sleeve procedure, it has excellent long-term results of improved body weight and blood sugar. There are a few side effects and complications which can occur affecting several percent of people including some vitamin malabsorption, very low blood sugar drops, and blockage of the intestine.
The disadvantages would be more side effects and complications in the sleeve, but on the positive side it usually leads to complete resolution of any acid reflux symptoms and the long-term diabetes and weight results are quite good.
Duodenal switch is the procedure with the most outstanding results in terms of long-term weight control and blood sugar control. For decades it has consistently delivered the highest rate of complete diabetes reversal of any procedure. Such high success rates came with costs, namely far more malabsorption complications and vitamin deficiencies. And here is where the research and nomenclature become most confusing: the procedure has evolved and goes by a number of different names (including Biliopancreatic diversion), such that the different centers and surgeons may be performing the same procedure under a different name, or performing very different procedures under the same name.
In today’s world, the best centers are using a simplified, safer, simpler, but very effective version of duodenal switch. Many centers such as ours utilize this procedure as the go-to for any return of obesity or diabetes in patients who have had a prior sleeve procedure. Often referred to as SADI (single anastamoisis duodenoileostomy), the less invasive, modern version of duodenal switch delivers excellent results and very few of the vitamin complications that came from older versions of this procedure.
The lap band has mostly seen its use come and go as better procedures came on the horizon. Not exactly a metabolic procedure since it involves a restrictive mechanism at the stomach, the gastric band involves placement of a device around the upper stomach. The results are fairly good but inconsistent, and over the long term, the side effects of trouble eating and swallowing tend to increase. Still a useful option in a few cases, the band does not deliver the kind of high percentage predictable success of the other metabolic procedure options. A long-term downside is erosion of the band into the stomach tissue, and aspiration pneumonia.
Are there other procedures on the horizon? Undoubtedly, as the science of metabolic hormonal regulation and surgical interventions continue to evolve. For now, your best bet is to do your homework and schedule a consultation with an experienced bariatric surgeon with a great track record. In most cases, the data demonstrate that long term health benefits of metabolic surgery are profound.