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Trimming the fat

Updated: May 27, 2021

With bariatric surgery becoming more and more common, what treatments are out there for this growing problem and should the health service be providing these?

Currently, the NHS will consider patients for bariatric surgery if their BMI is greater than 40, all appropriate non-surgical measures have failed to produce clinically beneficial weight loss. There are many other considerations that are taken into account such as if the patient is fit for surgery and anaesthetic as well as psychological assessment of the patient in order to determine if they are mentally prepared for the undertaking that is involved with having a surgical option. Although it might be viewed as an easy option, the preparation involved and the after-effects, as well as the follow up involved, cannot be underestimated. The reason such procedures are offered on the NHS is that obesity-related conditions cost the NHS billions every year. Obesity increases patients risks of cardiovascular disease, osteoarthritis, metabolic syndrome (combination of diabetes, hypertension and hyperlipidaemia) as well as increasing the risk of many cancers.

There are a few different surgical options for bariatric surgery, aiming either to cause restriction of the gastrointestinal tract or malabsorption. Most procedures require a liver reducing diet prior to the procedure. This is due to the fat deposits that have accumulated within the liver itself. During the operations, the liver needs to be lifted in order to gain access to the stomach. This can be difficult with a fatty liver; therefore a special diet is needed prior to surgery in order to reduce the size of the liver and therefore make surgery easier.

A well-known procedure of a gastric band is where a silicone band is placed around the cardia and fundus of the stomach, restricting the amount of food that can enter the stomach. The silicone band has a port that is brought to the surface of the abdomen. This allows the band to be adjusted by either emptying saline from inside this band to loosen it or injecting saline into the band in order to restrict the entrance of food more. This requires a lot of follow up appointments and massive restriction in diet postoperatively. This has shown to cause rapid reduction of weight however has not been as successful as other procedures in terms of maintaining weight loss. This also can lead to complications such as the band slipping or causing erosion of the oesophagus.

A laparoscopic sleeve biopsy is where the main body and fundus of the stomach is stapled and removed, leaving a tube instead of the classic shape of the stomach. This reduces the area of the stomach so less food content can be ingested and also reduces the amount of acid and enzymes that can be released from the stomach, therefore, decreasing digestion. This is another restrictive technique that has better long-term weight than banding however there is concerns over whether the stomach would expand due to patients increasing their diet.

The current gold standard of surgery is the Roux-en-Y gastric bypass. This is both a restrictive and a malabsorption technique. The jejunum is plumbed into the top of the stomach at the entrance of the oesophagus (cardia). The rest of the stomach is stapled off leaving a small pouch for food to collect before directly entering the jejunum. Therefore, the food contents bypass the stomach and the duodenum, leading to no pancreatic juices or bile acid entering the digestive tract therefore greatly decreasing the number of digestive enzymes leading to malabsorption of food. By blocking off the fundus also stops the production of ghrelin, the hunger hormone, which is produced in the fundus of the stomach, therefore decreasing the patient appetite.

Other hormones are also involved in digestion and are currently being investigated for possible hormonal treatments of obesity. Peptide YY and glucose like peptide-1 are both secreted in the ileum and caecum and are released when undigested food enters this area. There are involved in secreted proportionally to the calorie intake of a meal and increase insulin secretion and cell’s sensitivity to insulin, increasing glucose absorption from the blood. No current treatment has been found but this is an area of ongoing research.

With the NHS at breaking point, why are such procedures being funded when one could argue they are “self-inflicted”? This is a controversial topic for many as although obesity is becoming a greater problem within the UK, it can be argued why the taxpayer shouldn’t be funding procedures that, to put it bluntly, could be avoided. However, if you do take the stance of obesity being self-inflicted, then should smokers not be treated for lung cancer as this was “self-inflicted” or a rugby player presenting at A&E with a fractured tibia during a match, should this not be treated as it was “self-inflicted”?


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