Bariatric Weight Loss Surgery Options in Australia

Medical Disclaimer: The content of this blog is for informational purposes only and does not replace professional medical diagnosis, advice, or treatment.

Who is eligible for bariatric surgery?

Weight loss surgery

Also known as bariatric surgery, is sometimes confused for liposuction, in which fat is removed from the body. Liposuction is a cosmetic surgery in which weight returns after a few months. It is ineffective for weight-loss. Bariatric surgery on the other hand offers effective, clinically recognized management options for sustained weight reduction weight loss procedures for patients who will commit to long-term lifestyle changes, including diet and exercise. The Australian Medical Association states there is only a very limited role for pharmacological management (medicines) for obesity. They have found that bariatric surgery is an effective measure for long term reductions in weight and improved health outcomes. The Australian Institute of Health and Well-being is the Australian government's medical statistics agency. They have found that weight loss surgery in Australia is typically sought for:

• Managing obesity (68% of the time)
• Adjusting and managing implanted devices such as a gastric band (13.1%)
• Revisional surgery for a complication of other internal prosthetic devices, implants and grafts (8.3%)
• Managing type 2 diabetes mellitus (6.5%)
• Post procedural disorders of the digestive system (0.6%)
• Other diagnoses (3.2%)

Latest Guidelines (2022) recommended by American Society for Metabolic and Bariatric Surgery (ASMBS) and The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) -

• Metabolic and Bariatric Surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.
• MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.
• BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.
• Long-term results of MBS consistently demonstrate safety and efficacy

Individuals with obesity

• Medical research has established that bariatric weight-loss surgery is safe and usually results in 20–30 kg weight loss for those with obesity. That's 20–30% body weight for those with a BMI greater than 35 kg/m2.
• Many people are aware that some individuals who undergo bariatric weight-loss surgery may regain a portion of their lost weight. In fact, it is common for about 15% of a patient's maximum weight loss to be regained, typically starting around two years' post-surgery. However, on an average, patients maintain their initial weight loss for a decade. Those who struggle to lose weight often do so because they have not adhered to the prescribed post-surgery diet. It's important to understand that it is not the surgery that has failed the patient; rather, Weight maintenance depends on long-term adherence to clinical lifestyle protocols.

Individuals with morbid obesity and other weight-related conditions

Adults

Weight loss surgery is the most effective treatment for morbid obesity. In fact, weight loss surgery is the only treatment offering both significant and sustained weight-loss. That's because dieting and exercise are very limited in their long-term effectiveness once morbid obesity has set in. Weight loss surgery leads to greater weight-loss, remission of type 2 diabetes and metabolic disorder as compared to non-surgical treatments.

Youth

Morbidly obese adolescents can also benefit from substantial weight-loss and the resolution of weight-related conditions from bariatric weight-loss surgery. Children can also benefit from significant and sustained weight-loss due to weight-loss surgery, but they are at a greater risk for serious complications. Parents and guardians should note that children and adolescents may be sensitive to discussions about weight if they have been teased or bullied. Talk to a trusted bariatric surgeon to clear all your doubts and start your journey towards health and well-being.

Bariatric surgery procedures in Australia

Understanding Roux-en-Y gastric bypass surgery

Obesity has become a significant health concern in Australia, with an alarming rise in the number of obese individuals. Recent reports indicate that, on average, an Australian develops diabetes every five minutes. While factors such as sedentary lifestyles, poor dietary choices, and lack of physical activity may contribute to this issue, morbid obesity remains a pressing reality for many, necessitating proactive measures. Weight-loss or bariatric surgery presents a reliable solution for achieving substantial weight loss and improving overall well-being. This approach is particularly recommended for individuals who have been unsuccessful in losing weight through conventional methods. Among the various weight loss surgical procedures, Roux-en-Y Gastric Bypass Surgery stands as the gold standard.

Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass surgery is a highly sought-after bariatric procedure that involves reducing the stomach to a small pouch, approximately the size of an egg, at the upper end. This newly created pouch is then surgically connected to the middle section of the small intestine, effectively bypassing a significant portion of the stomach and the upper part of the small intestine. As a result, the newly formed pouch becomes the sole recipient of food, triggering a series of intricate neuroendocrine changes in response to this rerouting, which ultimately facilitates weight loss. Roux-en-Y gastric bypass surgery can be performed either as an open surgery or laparoscopically. The majority of bariatric surgeons opt for the laparoscopic approach due to its advantages, such as smaller incisions, reduced risk of scarring and infections, and a faster recovery period with a lower likelihood of infections.

Eligibility for Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass surgery is not a quick fix or a permanent solution for weight loss. It is a major surgical procedure that should only be considered after other weight loss methods, such as diet and exercise, have failed. Roux-en-Y gastric bypass surgery is typically recommended for morbidly obese patients with a body mass index (BMI) of 40 or higher. It may also be recommended for patients with a BMI of 35 or higher who have obesity-related health problems, such as type 2 diabetes, high blood pressure, sleep apnoea, or heart disease. In general, Roux-en-Y gastric bypass surgery is a safe and effective procedure that can help morbidly obese patients lose weight and improve their health. However, it is important to understand the risks and benefits of surgery before making a decision.

Expected weight loss

Following the procedure, the majority of patients experience a significant reduction in their excess weight, typically ranging from 90% to 95%. Notably, the most pronounced results are observed within the initial 18 months post-surgery. While there exists a potential for weight regain, Roux-en-Y gastric bypass surgery stands as the preeminent "Gold Standard" among bariatric procedures, surpassing traditional sleeve gastrectomy in terms of effectiveness. To ensure sustained weight management, strict adherence to a prescribed diet plan and regular follow-up consultations with your bariatric surgeon are essential.

Potential complications

RNY gastric bypass surgery carries certain risks that can be managed with the assistance of an experienced bariatric surgeon. Notable risks and complications include:

• Dumping syndrome
• Nausea or vomiting
• Dehydration
• Indigestion
• Small bowel obstruction
• Staple line leaks
• Stomach pouch issues requiring revision surgery
• Nutritional deficiency

If you experience severe, worsening, or life-threatening symptoms following surgery, such as acute abdominal pain, fever, or persistent vomiting, call 000 immediately or attend your nearest Emergency Department (ED).

Post-operative care for RNY gastric bypass patients

1. A two-night hospital stay is required for RNY gastric bypass patients before discharge. Due to initial stomach sensitivity, patients must consume only liquids or pureed foods for 4-6 weeks before gradually introducing solid foods.
2. Mild discomfort and pain may occur in the initial days post-surgery, requiring pain medication. This discomfort subsides as the wound heals.
3. Dumping syndrome is a potential complication, as food moves directly from the stomach pouch to the small intestine. To prevent this, patients should chew food thoroughly and avoid carbonated beverages and fatty foods.
4. Weight loss will be gradual but noticeable within the first 18 months. To prevent nutritional deficiencies during recovery, patients should adhere to a medication regimen, including multivitamins, Calcium Citrate, Vitamin D3, Vitamin B12, and Iron.

A comprehensive guide to SADI-S/SIPS surgical procedure

SADI-S (Single Anastomosis Duodenal–Ileal Bypass with Sleeve Gastrectomy) or SIPS (Stomach Intestinal Pylorus Sparing) surgery is a relatively new option in the realm of weight loss surgical procedures. Nonetheless, it presents an intriguing alternative for individuals struggling with morbid obesity, demonstrating encouraging initial outcomes. This procedure facilitates long-term weight loss by curtailing food intake and inducing neuroendocrine modifications.

SADI-S procedure

The SADI-S procedure closely resembles the duodenal switch operation, with the primary distinction being the execution of a single loop Anastomosis of the small intestine rather than two. The surgical intervention entails the creation of a sleeve, akin to sleeve gastrectomy, albeit with a slightly larger dimension. Furthermore, the surgeon bypasses the proximal half of the small intestine, approximately 300 cm from the ileocecal valve, and meticulously sutures the initial segment of the duodenum beyond the pylorus to the designated bypass point. Post-operatively, the stomach's capacity is effectively restricted to roughly 120 ml, resulting in a sense of satiety after consuming a mere 3 to 4 ounces of sustenance.

How SADI-S procedure works?

The SADI-S weight loss surgical procedure preserves crucial functional components of the stomach, including the antrum and pylorus. This technique allows patients to consume smaller portions of their preferred foods and feel satiated without experiencing "dumping" syndrome, unlike other restrictive procedures that impose strict dietary limitations. Additionally, surgeons modify the intestinal pathway to trigger neuroendocrine reflexes, resulting in facilitates metabolic changes that may assist in weight loss. Post-surgery, the upper section of the small intestine solely transports digestive fluids, such as bile and pancreatic juices. This shortened digestive tract contributes to weight loss by reducing calorie absorption.

Benefits of SADI-S

SADI-S weight loss surgery effectively addresses various complications commonly experienced by patients who have undergone gastric bypass surgery, such as:

• Marginal ulcers at the upper joint
• Dumping syndrome
• Unpredictable fluctuations in blood glucose levels
• Severe intolerance to certain food items

Post-surgery experience

On average, patients who undergo SADI-S can expect a weight loss comparable to that achieved through duodenal switch surgery, surpassing the results of gastric bypass or gastric sleeve procedures. However, SADI-S induces weight loss at a slower, more gradual pace. Notably, SADI-S exhibits a more favourable complication profile and superior initial outcomes compared to other weight loss surgeries. Consequently, this surgical intervention is particularly well-suited for patients who have regained weight after sleeve gastrectomy, as well as individuals with morbid obesity accompanied by severe metabolic syndrome.

Wrapping up

SADI-S weight loss surgery enables patients to achieve substantial weight reduction within a shorter timeframe following the procedure. Notably, patients are spared from experiencing dumping syndrome, ulcers, and other common adverse effects associated with bypass surgery.

Effects of bariatric surgery on cardiovascular outcomes

Obesity is a major public health problem that is associated with serious comorbidities, including diabetes, dyslipidemia, cancer, and cardiovascular disease (CVD) with premature mortality. Its prevalence has been up trending over the last few decades and is a modern-day pandemic since 2012. Per the American Society for Metabolic and Bariatric Surgery 2023 guidelines, overweight is a body mass index (BMI) of 25 to <30 kg/m2 and obesity as a BMI of 30 kg/m2. Over the last decade, the proportion of Australian adults who were overweight or obese has increased from 62.8% in 2011–12 to 65.8% in 2022. This was due to the increase in the proportion of Australian adults categorised as obese, which increased from 27.5% to 31.7% over the same period. Bariatric surgery is increasingly used as a therapeutic option for obesity.

How does obesity contribute to cardiovascular risk?

Obesity is a major contributor to cardiovascular risk factors including hypertension, hyperlipidemia, coronary artery disease (CAD), heart failure (HF), stroke, sleep apnea, and arrhythmias. Its pathogenesis is linked to proinflammatory factors and vessel wall remodelling, among others. Obesity accelerates atherosclerosis by promoting lipid deposition and atherothrombosis formation. It further activates the cytokines and interleukins causing endothelial dysfunction and vascular remodelling. This translates into cardiovascular disease events including CAD, myocardial infarction, and stroke. Excess visceral adiposity leads to the activation of renin-angiotensin-aldosterone system, cytokine gene expression, and increased systemic circulation of proatherogenic factors. This in turn leads to myocardial fat accumulation, increased stroke volume, cardiac wall remodelling, and fibrosis manifesting as heart failure. Similar mechanisms lead to left atrial enlargement and fibrosis contributing to arrhythmogenesis.

Management of obesity

Lifestyle modifications and increased physical activity are the initial modalities recommended in the management of obesity. The commonly performed bariatric surgeries include Sleeve gastrectomy, Roux-en-Y gastric bypass and modified Duodenal Switches. The benefits of bariatric surgery include greater long-term weight loss, reduction of major adverse cardiovascular events (MACE), and cardiovascular mortality. Obesity poses a high risk for atheroma formation. Bariatric surgery provides a beneficial effect by altering molecular mechanisms involving inflammation. Bariatric surgery decreases the levels of oxidative stress and inflammatory markers. It reduces circulating levels of adhesion molecules and improves endothelium-dependent vasodilatory response. Objectively, several studies have shown that surgery reduces carotid intimal wall thickness in concordance with weight loss. These processes in turn contribute to the risk reduction of atherosclerotic diseases such as CAD, MI, and CVA. Although CAD and MI are atherosclerotic processes, they differ in their pathophysiology and clinical manifestations. CAD is defined as the presence of atherosclerotic plaque within the epicardial coronary arteries. Over time, risk factors potentiate plaque growth. During periods of myocardial oxygen demand, there is endothelial dysfunction causing plaque rupture. This in turn leads to atherothrombosis, vessel occlusion, and myocardial infarction. This information is for educational purposes only. You should consult a medical practitioner before attempting new wellness programs or lifestyle changes to ensure they are safe for your specific condition.

Cardiovascular benefits offered by bariatric surgery

Bariatric surgery improves left ventricular systolic dysfunction including hypertension, hyperlipidemia, and diabetes. It also directly acts on the myocardium causing changes in the left ventricle (LV) wall and ejection fraction (EF) percentage. Bariatric surgery improves left ventricular systolic dysfunction and resulted in a statistically significant improvement in left ventricle ejection fraction (LVEF). Another study showed a 43% reduction in left ventricular mass with subsequent reduction in left atrial and right ventricular wall diameter and epicardial fat. A meta-analysis done by Cuspidi et al. showed significant changes in LV thickness, improvement in LV diastolic function, and a decrease in left atrial diameter. Given the significant cardiovascular benefits offered by bariatric surgery, the referral from doctor or medical practitioner and primary care physicians has been lower. This could be attributed to knowledge gaps, hesitancy, or concerns regarding postoperative care. A recent Canadian survey showed that more than 50% of physician respondents did not feel equipped to counsel the patients on surgical options and only 11.6% of the obese patients were counselled. In a Swedish survey, interestingly, 84% of respondents stated that the patients themselves initiated bariatric surgery referral. Physician's knowledge showed a positive correlation toward referral and management of postoperative issues. This brings into perspective that education and awareness would lead to better patient sampling, thereby cumulatively improving cardiovascular outcomes. In conclusion, bariatric surgery shows a statistically significant risk reduction with CAD, MI, HF, CVA, and cardiovascular disease-specific mortality and a non-significant risk reduction of atrial fibrillation. Note: Hola Health does not provide consultations, assessments, or management plans for Type 2 Diabetes. This service is not provided directly by Hola Health and is included for informational purposes only. We recommend consulting your regular medical practitioner or an endocrinologist for the ongoing in-person management of this condition.