Scaled Down

The ins and outs of bariatric surgery, by Mariel Chow

Dr. Somasundaram Sathappan - April 5, 03:45 PM

Bariatric surgery is a procedure limited to only the morbidly obese or those who suffer obesity-related co-morbidities. The surgery induces rapid weight loss through reductions of the stomach’s size, which controls the amount of food one can ingest. By limiting food intake, malabsorption and gastric restriction will not only cause decreases of diabetes, hypertension and high blood pressure but also affect in speedy kilo shedding of up to 100 percent of one’s excess weight in just two years. 
Although patients may enjoy reduced gastric syndrome and a longer life, those who’ve lost so much weight in short periods of time may experience loose, hanging skin not only in the tummy but also the back, chest and thighs. Think of your skin like a pair of stretchy pants. If you’ve been distending and pulling its stretchable fabric for years and expect it to snap back to its original state, it won’t. The fact is, no amount of exercise will help saggy skin. Plastic surgery is the only viable route to a normal-looking body without skin folds that can cause fungal infections, impeded mobility and poor outward appearances. In this article, we round up a panel of doctors who discuss bariatric surgery’s role in saving lives, and ask them why body contouring surgery after great weight loss plays an important role in improving a patient’s self-confidence and quality of life. 

Bariatric Surgery with Consultant Bariatric and Gastrointestinal Surgeon, Dato’ Dr. Tikfu Gee
 
Dato' Dr Tikfu Gee
What is weight loss and bariatric surgery?
Bariatric surgery is a generic term for a range of procedures, which entail gastrointestinal surgeries for the purpose of weight loss, or for metabolic reasons. This is why bariatric surgery is sometimes known as metabolic surgery. Metabolic or bariatric surgery is a type of gastrointestinal surgery meant for the treatment of morbid obesity as well as metabolic syndromes. The difference between obesity and metabolic syndrome is in its indications. If patients are obese, this does not mean they have metabolic syndrome. For instance, you may be morbidly obese but may not have related medical co-morbidities such as diabetes or heart disease notwithstanding other physical problems including joint pain, back pain and sleep apnea. In short, such patients can be deemed “fairly healthy”. However and in general, obesity does come hand in hand with metabolic syndromes – although not always the case. In instances where a patient suffers from metabolic syndrome, he or she may suffer impaired glucose tolerance, diabetes, hypercholesterolemia, sleep apnea and fatty liver. Female patients may experience additional problems including infertility, irregular menstruation and so forth. Should slim patients ask if they are susceptible to metabolic syndrome, the answer would be: Yes, you can be. Many patients who suffer from Type-2 Diabetes are actually thin but when doctors conduct an ultrasound, we will normally find fatty liver. Nonetheless, although patients are divided into two categories, surgery will be the same albeit serving different purposes.
How can patients find out if they’re applicable for bariatric surgery?
We generally take the BMI as an initial marker and if one falls within a certain range, he or she may qualify. Patients with no medical co-morbidities are accepted as long as BMIs are more than 37.5. If you suffer from metabolic syndrome or some form of co-morbidity including knee and joint pain, patients with a BMI of 32.5 will qualify. Although BMI calculations are an initial marker, there are patients who have a BMI of more than 30 who may be appropriate. This is because apart from BMI, we also check the patient’s fat percentage and if you fall within a certain level, considerations can be taken. For females, we will accept a fat percentage of 25 while males will qualify if they have quantities of 20 percent and above. 
Patients above the age of 18 and below 70 are generally qualified for surgery. Less benefits are seen with much older individuals. Furthermore, patients are only given one life where everyone desires to live healthily during their 30s and 40s because you don’t want excess weight holding you down. If patients are old and not in their prime, it’s not likely they’ll be practicing rigorous daily routines and of course, the older you are, the more unfit for surgery you become. 
Although bariatric procedures are appropriate to both males and females, the number of women desiring surgery trumps males by an average of three to one. This is because women are more conscious about health and beauty. Apart from the negative effects of metabolic syndrome, women – more than men – believe being obese is a deterrent to their outward appearance. 
Men on the other hand, tend to ignore their declining health until it’s too late. Despite males frequently choosing to overlook the importance of weight loss, they’re the ones who actually benefit from bariatric surgery the most. Overweight males normally sport apple shapes and therefore have more truncal fat. Truncal fat or central obesity normally entails internal or visceral fat, which almost always affects in metabolic syndrome. Even if they don’t see it now, ageing and time will catch up and that’s when they suffer fatty liver, fatty pancreas and fat that surrounds arteries and blood vessels that cause heart attacks. Truly, even though males are the ones who need metabolic surgery, lack of motivation and awareness coupled with the fear of surgery has led to many male patients suffering grave consequences. 
How does bariatric surgery help patients lose weight and reduce metabolic problems?
The principal concept of bariatric surgery is to reduce the size of the stomach. In addition and depending on surgical type, we may or may not connect the small intestine to the stomach too. Most people believe there’s only one mechanism, which is the restriction of food. Yes, there is a physical restriction of food, but what most aren’t familiar with is that there’s a second mechanism called the hormonal or metabolic mechanism. Our gastrointestinal tract – stomach and intestine – is responsible for over two hundred types of hormones, making it the largest hormonal organ in the body. If patients undergo bariatric surgery and remove part of the stomach, or cause food to bypass the small intestine, we are causing a change in the production of gastrointestinal hormones which in turn affect our appetite, metabolism and weight loss. 
Bariatric surgery is divided into many techniques but the most popular and effective procedures are sleeve gastrectomies and gastric bypass surgery. In sleeve gastrectomies, surgeons will remove a part of the stomach, which also aids in the reduction of a hormone called ghrelin. This in turn, reduces our appetite and improves metabolism. If we perform gastric bypass surgery, it will produce higher levels of hormones called GLP-1 (Glucagon-like peptide-1), which also positively affects our metabolism. This is the very reason why patients with diabetes may potentially get cured. 
Some doctors may say, “Oh, it’s because they’ve lost weight that their diabetes improved.” The thing is, after undergoing metabolic surgery, patients may potentially stop all forms of diabetic medications the following day or before weight loss has even happened. As such, there’s clearly a hormonal pathway as opposed to simply losing weight. 
Do you recommend patients try to lose some weight before bariatric surgery?
I don’t, as it’s almost an impossible task. The reason why some surgeons recommend patients lose weight before bariatric surgery is because they want to filter out unmotivated patients. In my practice, I tend not to waste time expecting patients to lose significant weight before surgery because apart from them not being able to, fat reduction doesn’t necessarily affect the procedure or the outcome either. 
Many surgeons believe prior weight loss may shrink the liver, but to me, fatty liver is caused by metabolic syndrome, not obesity. Thus, even if patients lose weight the fatty liver may still be present just the same as slim patients with diabetes suffer fatty liver as well. For me, as long as patients fulfill the medical criteria and are found suitable after undertaking blood tests, abdominal ultrasounds and stomach endoscopies, they can undergo surgery as soon as possible. 
I recommend an endoscopy of the stomach because we want to ensure patients aren’t suffering from cancer, polyps, acid reflux or H pylori infection. There are some surgeons who choose to carry out bariatric procedures without endoscopies but this to me is dangerous because what if they cut into a cancer? What if they cut into polyps? I don’t encourage this. I also recommend ultrasounds because we can assess how severe fatty livers are and find out if the patient may have gallstones – which are common among overweight patients. If patients present with gallstones, a removal of the gallbladder would be recommended in conjunction with the bariatric procedure. Finally, patients must undertake blood tests to guarantee they’re fit for surgery, screen for metabolic diseases and to discover potential medical causes for the patient’s obesity. For example, patients with hypothyroidism may experience obesity and if we can fix the underlying problem, surgery may not be necessary. If patients are found to have co-morbidities, it will not affect the chances for surgery but may affect in what type of surgery is recommended. Lastly, should it be discovered patients have had prolonged metabolic syndrome where the heart and lungs are already compromised, it may be a little too late. 
What is a sleeve gastrectomy and gastric bypass and how do they work?
Sleeve gastrectomy is when surgeons cut and remove about 85 percent of the stomach. The area, which is removed, contains the hormone, ghrelin. This procedure is the most popular among patients because it sounds simple and doesn’t alter much of the existing anatomy. While food intake is greatly reduced, absorption and nutrition are normal. Sleeve gastrectomy accounts for more than 60% of bariatric surgeries.
Gastric bypass is a procedure where we create a newer and smaller stomach pouch, which is connected directly to the small intestine, bypassing the rest of the stomach that’s left alive. In the unlikely event patients want to reverse the procedure, it can be safely done. The gastric bypass is the oldest and most established bariatric procedure and is the most effective metabolic surgery for diabetic patients. It holds the number two spot in popularity, coming in at 30% of bariatric surgeries.
So what are the other ten percent of patients undergoing? Well, they’ll probably choose gastric bands or other experimental surgeries like a mini gastric bypass. In my practice, I mainly stick to conventionally accepted bariatric surgeries such as the sleeve gastrectomies and gastric bypasses. 
The choice between these procedures will be based on patient’s preference and pre-existing medical conditions. For example, if they have diabetes, I’ll recommend a surgery that exerts more hormonal or metabolic effects such as the gastric bypass. Even though sleeve gastrectomies have metabolic effects, they are less appropriate for those who have severe metabolic syndrome and more applicable to patients with obesity. Nonetheless, patients have the last say, and after all the advice and recommendations have been provided, it’s up to them to choose what they want. 
How much weight do patients lose?
We aim for an excess weight loss of about 60 to 70 percent in one year. After two years, we expect patients to either maintain their weight or lose up to 80 percent of the excess weight. If patients can achieve this outcome, I would consider the procedure a success. To be frank, there have been some patients who were successful enough to have lost 100 percent of their excess weight! To illustrate, if a patient was 100 kilos with her ideal weight being 52 kilos, he or she would need to lose 48 kilos in order to achieve 100 percent excess weight loss. 
Gastric bypasses normally result in faster losses while the sleeve is slower. Despite this, both procedures reach the same point of weight loss after two years. The gastric band procedure conversely only achieves 48 percent excess weight loss and this is why, the surgery is no longer popular among patients and surgeons alike. 
What can patients expect after bariatric surgery?
Patients undergoing bariatric surgeries will normally heal well. If they have diabetes, there may be chances for poorer wound healing but this is very rare. Bariatric patients will experience a complete change in the quantity in their intake so I try to make this transition as easy as possible. I will first recommend a liquid diet followed by a semi-solid diet and finally, progressing to only solids.
 
Before and After
While there are significant changes in the beginning, food choices will return to normal once patients has stabilised their food intake. In fact, they can eat whatever they want albeit in smaller proportions. All my patients are adults and even though I encourage healthy diets, they must be motivated and practice self-control. If patients want to live a long life, they must eat healthily and in moderation. 
When patients regain weight after bariatric surgery, we call this weight recidivism. This problem is caused by two factors with the commonest issue being excessive sugar intake – especially in liquid form as there are less restrictions to fluids following bariatric surgery. To illustrate, if patients drink a can of Coke, the caloric intake that’s equivalent to two bowls of rice will be absorbed immediately. If I were to give patients two portions of rice after bariatric surgery, they couldn’t even finish it even if they had the whole day to try. 
Although the bowel’s hormones won’t accept the sugar well and will trigger an alarm similar to pain, the body will eventually get accustomed to sugar if patients ingest sweet drinks every day. The second reason patients regain weight is due to an expansion of the stomach. Unlike wood, the stomach is made of living tissue, which can stretch and increase in size. There are ways to encourage reduced chances for re-expansion but again, patients must follow the rules, be compliant and return for regular check-ups.

The 8 Golden Rules After Bariatric Surgery:  
·       Eat four or more small meals a day
·      Do not eat and drink at the same time
·       Chew your food well before swallowing 
·       Stop eating and drinking when feeling full
·       Avoid sugar-loaded and calorie-dense beverages 
·       Sip water throughout the day to keep hydrated
·       Eat protein foods first
·       Take multivitamins and health supplements 

What are the complications and side effects of bariatric surgery?
Patients who’ve undergone stapled procedures can be susceptible to a leak rate of about one percent – even at the best of hands. This complication is not usually life threatening but it may incur additional costs because a second procedure is required. Long-term side effects like nutritional issues are possible especially if patients have undergone bypass surgeries. Patients must recognise that poor compliance rather than the surgery’s effects causes nutritional problems. Ask yourself this: Who controls the hand which puts food in the mouth? Because patients can only eat a certain amount but yet choose to partake in carbs only, they’ll lack the vitamins, minerals and protein found in meat, vegetables and eggs. Furthermore, bariatric patients can’t follow a normal person’s dietary recommendations and should primarily focus on proteins. When patients fail to follow the advocated nutritional plan, the first signs of poor nutrition would be waning dermal quality, hair loss, strange sensations and even paralysis. 
What can patients expect during follow-up consultations?
In my practice I advise that patients return on a weekly basis for the first two to three weeks. I then see them once a month for the first six months and then on a bi-monthly or quarterly basis. Once they’re very stable, I recommend that patients return every six months. During follow-ups, I won’t look for progressive weight loss but remain focused on whether they’re well hydrated and tolerant of food. For me, ensuring patients are complying to nutritional aspects are far more important so I advise they start a daily food log and from the collected information, the dietician and myself will calculate if patients are partaking in enough natural proteins, vitamins and minerals. 
 
Body Contouring Surgery with Consultant Plastic and Reconstructive Surgeon, Dr. Somasundaram Sathappan and Dr. Jagjeet Singh.

Why does the body have skin folds after bariatric surgery? Does redundant skin cause physical problems?
Dr. Jagjeet: Bariatric patients lose about 1.5 kilos or 1.5 percent of the body’s weight per week. As you can imagine, it’s impossible for skin to accommodate the loss, and when this is coupled with pre-existing skin, the result would be large quantities of loose, hanging folds all over the body, beginning from the face, neck, chest and arms down to the back, tummy, pubic region, buttocks and thighs. 
Dr. Soma: There are no physical problems and disabilities per se. The issue most patients living in hot climates complain of is that when one has folds along the abdomen, thighs and groin, sweat may collect along these regions and affect in macerated, itchy skin, which is susceptible to fungal infections. To reduce occurrences of infection, patients have to consciously keep skin clean. If patients live in hot climates, they’ll have to maintain dermal dryness by padding the skin in order to maintain appropriate sweat absorption. Otherwise, sweat can accumulate and leak and this is where horrid side effects arise. At the end of the day, although patients may not suffer many physiological hindrances, they may be vulnerable to discomfort and chronic infections and this is why body contouring surgery is advised. 
What is body contouring surgery after bariatric surgery and how does it differ to conventional contouring procedures?
Dr. Soma: Body contouring after bariatric surgery means liposuction won’t solve the patient’s problems. There will be excess skin hanging in folds and this is what needs to be excised. The issue with loose skin is that it hangs in specific areas – below the breasts, above the belly button and lower hip, arms, lateral chest and inner thighs. If patients choose to undergo body contouring, it will have to be in a staged manner as surgeons won’t be able to carry out all the surgeries in one sitting. The reason for this is not only because there are too many regions to treat but also because procedures are invasive, extensive and time consuming. Moreover, patients who’ve undergone bariatric surgeries – even if they’ve lost massive quantities of weight – have the same levels of surgical risks as before they’ve undergone bariatric surgery, meaning co-morbidities are present. Bariatric patients cannot assume that just because they’ve lost weight that they’re fit and healthy. While I may agree that problems such as hypertension are decreased, studies have proven complication rates continue. 
Dr. Jagjeet: Individuals who’ve undergone bariatric surgery enjoy dramatic weight loss but yet are stigmatised by large volumes of loose, hanging skin. As such, body contouring surgery among these individuals are geared towards removal of excess skin in a safe manner. 
The difference between body contouring after bariatric surgery and conventional body contouring is significant. To make it easier to understand, let’s break things down to before, during and after surgery. Before bariatric surgery, most patients suffer from other medical conditions like high blood pressure and diabetes. Although bariatric surgery helps improve these conditions – or even treats them, patients who desire body contouring will still need to be screened for diseases. This is not usually the case with patients who are not in the massive weight loss category. 
During surgery, the difference is in procedural magnitude. Large quantities of excess skin are removed and the risk of blood loss and hypothermia becomes higher compared to conventional body contouring. After surgery, patients are at greater risk of complications like blood clots and infections and thus require aggressive rehabilitation after procedures. 
 
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Since surgery is staged, which part of the body do you normally target first, and does this differ based on sex?
Dr. Soma: The answer to this is individualised because different patients find some areas more irritating than others. In my practice, and as far as male patients are concerned, men tend to find chest and stomach folds the most exasperating. This is because even if they’ve put in all the time, money and effort into losing weight, they still aren’t able to remove shirts in public. If male patients were to complain of such folds, I will have to firstly remove the tummy’s excess skin because abdomens require circumferential cuts – from the back all the way to the front. 
The difference between an abdominal lift and a tummy tuck is its procedure. With tummy tucks, surgeons will tighten the rectus muscles; relocate belly buttons and re-drape excess skin. Abdominal lifts won’t require muscle tightening or belly button repositioning but does necessitate a 360-degree skin removal with added chances of hernia correction. 
Women will normally desire mammary lifts before other procedures because breasts hang low. Once the breasts are corrected, women will move on with tummy procedures – either a tummy tuck or abdominal lifts depending on how severe hernias are – and then finish with arm and thigh lifts.
Should patients ask for my professional opinion and recommendation, it’s best they start with the tummy and chest because these procedures require extensive surgical time and are far more invasive than arm or thigh tightening surgeries. Like the tummy – which involves circumferential cuts – chest excisions comprise excisions of large areas including the middle of the chest all the way to the sides in order to remove redundant skin in the back. 
Dr. Jagjeet: Safety comes first and the best way to ensure a patient’s welfare is to stage procedures. These operations are lengthy, technically demanding and time intensive versions of standard body contouring surgeries. If patients are found appropriate for surgery, it’s important to focus on their goals. What I like to do is to list down areas that trouble the individual the most and then these regions should be prioritised first. The next step is to discuss – in detail – each surgical procedure and the changes it would bring, including related recovery. Later, the planning begins. Some centres have the luxury of a ‘two team approach’ where two surgeons can operate on the same patient together. In such instances, staging processes focus more on space around the patient as one team may operate on the abdomen while the other works on the arms. 
The first stage of body contouring surgery is usually a combination of abdominoplasty and mastopexy. They can be handled in a team approach to minimise surgical time and the need for increased follow-ups. Quite commonly, abdominoplasties among bariatric patients require an additional scar that runs in the midline of the patient’s abdomen – from the pubic area up to the middle of the chest. In cases like this, there may be shifts in the breast’s location and hence, have to be taken into consideration before combination surgeries are given the go ahead. 
After patients have corrected the tummy and waist, they can undergo a lower body lift (LBL) coupled with other minor surgeries. The LBL procedure usually starts with patients lying in the prone position or on their tummies. Then, they’ll be turned over during surgery to address the sides and abdomen. This adds surgical complexity, procedural time and recovery so it’s usually recommended that procedures are broken into smaller parts to reduce downtime and ease recovery. LBLs will have an impact on the hips and outer thighs affecting in a lateral shift of the inner thighs, which creates some element of skin tightening along the inner corners. If a patient has previously undergone a tummy tuck, he or she won’t be required to change positions during surgery. 
Another common second stage procedure is the upper body lift (UBL) and brachioplasty (arm lift). The UBL targets the mid-back and lateral axillary rolls. Performing arm lifts with UBLs allow continuities of the scar patterns and can be readily combined with a breast lifting procedure as well.
The procedures described are some examples of how staging is done. In any case, surgical choice depends on the patient’s willingness to have procedures done together or separately, the surgeon’s expertise in conducting such challenging cases and also the comfort of the anaesthesiologist in supporting these individuals during the surgery. 
What are body contouring’s complications?
Dr. Soma: Let’s make this very clear, those who’ve undergone bariatric surgery have higher rates of co-morbidities, no matter how thin they currently are. Along with seromas and infection, patients have increased risks of deep vein thrombosis, lung complications and wound breakdowns. Furthermore, it’s important to note that body contouring after bariatric surgery is long and extensive because there’s a lot of tissue to cut, affecting in more stitched wounds and increased blood loss and trauma. 
Likewise, patients cannot request for minimal removals of a certain region at a time because if I were to start with a circumferential abdominal lift, I can’t just excise the frontal aspect of the tummy and leave the back for another day. Once surgeons begin with a targeted area, the entire region must be corrected in one sitting due to the procedure’s extensiveness and monetary cost. 
The thigh lift is another procedure that comes with its own unique problems due to its proximity to the groin, which is a hotbed for germs. This area is also prone to sweatiness and can be further irritated due to natural mobility and constant sitting or lying down. These unavoidable movements can stress stitches and even if surgeons recommended tight bandages along the thighs, other complications such as venous stasis and deep vein thrombosis can occur. In my practice, I try to avoid thigh lifts or minimally correct the area because the more one moves, the less wounds will heal but if patients don’t move, they may suffer blood clots in the legs. 
I only allow weight loss surgery once patients have been well managed pre-operatively to guarantee low rates of co-morbidities. To do this, I’ll admit patients into hospital a week prior to surgery and with the help of other physicians, try to reduce gastric syndrome down to normal levels. Due to advanced chances of complications, plastic surgeons will also have to work quickly in order to reduce surgical time and additionally be conscious of blood loss and hypothermia. 
After the procedure, patients have to be mobilized, as lying down for long periods can affect in blood clots, lung stasis, coughs and other problems. Lastly, body contouring surgery after bariatric surgery is not recommended for smokers because chances for poor wound healing can be caused by not only diabetes but nicotine inhalation too. Should smokers have the desire for the procedure, it’s advised they stop smoking for at least a month. 
How will patients look and feel after surgery, and how expensive are these procedures?
Dr. Jagjeet: Most of the physiological benefits patients experience come from the bariatric surgery itself. This is proven with an overall improvement of high blood pressure and diabetes. To add to this, patients who’ve undergone body contouring will enjoy easier mobility due to reduced excess skin. The excess skin’s weight can be significant and once it’s removed, patients will find that mobility will be much easier as they are carrying less weight overall. They’re also better able to maintain their hygiene and have fewer occurrences of fungal infections and rashes that can be very troublesome. 
How patients look after surgery depends on whether they agree to exchange loose skin with scars. Nevertheless, scars are easily hidden under clothes and swimwear. The psychological benefits after body contouring are astounding. After bariatric surgery, patients are excited and motivated because of how much they’re losing. This goes on for the first and second year. What’s left unfortunately is the residual loose, hanging skin that leads to poor self-esteem, further affecting prospective relationships. Body contouring has proven to have great positive outcomes, as patients can better accept outward appearances, which in turn, gives them confidence boosts leading to an overall improvement in social interactions and quality of life. 
Although body contouring boasts overwhelming emotional and functional advantages, it’s not covered by insurance because companies deem such procedures as purely cosmetic – even when they’re clearly not. Body contouring costs are normally based on the surgeon’s fees and his or her medical facility, so I strongly recommend a consultation to discuss surgical pathways and costs. 
Patients who’ve undergone body contouring post bariatric surgery will enjoy easier mobility due to reduced excess skin.
How should patients prepare for body contouring surgery?
Dr. Soma: Once patients begin losing weight, it’s advised they consult with a plastic surgeon as soon as possible. Once they speak to doctors early in their weight loss programme, we’re able to better advise them on what to do, what is going to be done and the procedures’ related complications. This way, timely consultations will give patients time to wrap their head around the idea and plan the funding and downtime needed. As explained, body contouring after bariatric surgery is extensive and thus, more expensive, with downtime of two weeks per procedure.
Dr. Jagjeet: Following bariatric surgery, my advice is to maintain a close relationship with your bariatric surgeon to ensure that general health is monitored by a specialist who understands the changes you’re experiencing. Moving forward, there’s nothing specific that needs to be done in preparation for surgery but research is important. Patients should have an idea of what basic procedures entail and with this foundation in place, a more productive discussion can be had.

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