Surgery of obesity: gastric band, sleeve or by-pass, how to choose?

468,609 people benefited from obesity surgery in 2013 around the world. What are the specificities of the different procedures? Dr. Antonio Valenti, bariatric surgeon, takes stock.

In some cases, bariatric surgery can be a solution to fight obesity. The goal: to limit the absorption of food and thus lose weight.

Gastric ring, sleeve, by-pass ... How to sort through the various techniques proposed? The Haute Autorité de Santé (HAS) imposes criteria common to these three procedures.

The body mass index (BMI) of the patient must be greater than or equal to 40, or greater than or equal to 35, but associated with at least one of the following comorbidities: high blood pressure, sleep apnea syndrome (SAS), syndrome pulmonary restrictive, type 2 diabetes, dyslipidemia, osteoarthritis or nonalcoholic steatohepatitis (NASH).

The sleeve, the procedure that gives the best results

The sleeve, which is a sleeve gastrectomy, consists of cutting two-thirds or four-fifths of the stomach. This procedure is performed by celioscopy: the belly is inflated with air, which allows to look inside with a camera.

This procedure leads to early satiety due to mechanical function and hormonal function. We talk about mechanical function because it is a purely restrictive technique that consists of reducing the gastric sac: it goes from 500 ml to 150 ml. And we talk about hormonal function because this operation leads to a decrease in grelin, which stimulates the appetite at the cerebral level.

This procedure lasts between 60 and 90 minutes, requires a brief hospital stay of about two days, and a work stoppage of three to four weeks.

The sleeve causes a loss of excess weight of 50% to 60%, or 40 to 50 pounds on average in 6 to 9 months.

The sleeve: for whom?

This procedure is usually chosen when the BMI of patients is greater than 40 and they have diabetes, because just like the bypass, the sleeve has the advantage of eliminating diabetes.

It is the most practiced technique, the easiest to perform, and gives the best results.

The gastric band, a reversible technique

The gastric band is a reversible restrictive technique, which involves placing a kind of ring around the stomach by celio. This is connected by a tubular to a subcutaneous device for modulating the clamping and loosening of the ring. As a result, foods, especially solid ones, are blocked.

This simple procedure, which lasts approximately 60 minutes, is performed on an outpatient basis and requires a two-week work stoppage. However, it has one particularity: patients have radiological follow-up every three months in the first year and twice a year starting in the second year.

The gastric band causes a loss of excess weight of 40%, or 25 kilos on average in one year. But the difficulty lies in maintaining this weight loss: this procedure, which is the least practiced in France, shows a failure rate of 30%.

However, it has several advantages: it is reversible, does not require sutures and does not involve significant complications.

The gastric ring: for whom?

The gastric band is usually chosen when the patients are young (between 18 and 30 years old), and when their BMI is between 35 and 38. They must not be nibblers because this constitutes a factor of failure of this procedure .

Patients for whom this intervention is considered may have comorbidity if it is anything other than diabetes. And for good reason: if this disease disappears after the sleeve and the bypass, this is not the case with the gastric band.

By-pass, the last resort

Gastric bypass is a mixed technique because it is both restrictive and malabsorptive.

It is said to be restrictive because it requires the use of a gastric pouch that varies between 60 and 100 ml and is connected to the small intestine instead of the stomach. It is a gastric short circuit whose purpose is to modify the path of food.

This procedure is also malabsorptive because it allows fats to be eliminated directly in the stool, without absorption. But it requires a vitamin intake for at least one year and a follow-up for life.

This procedure lasts about 120 minutes, requires 3 to 4 days of hospitalization and a work stoppage of 3 to 4 weeks. It leads to a loss of excess weight of 70%, or 60 kg in one year.

By-pass: for whom?

By-pass is a technique of last resort, especially when the gastric band and sleeve have failed.

This operation is generally performed on patients over 40 years old and is not recommended if there is a desire for a child, because of the risk of hypovitaminosis.

By-pass is a technique of choice for BMIs greater than 40 and for patients with diabetes. This procedure is also recommended in case of gastro-oesophageal reflux with significant signs of inflammation of the esophagus, because unlike the sleeve, the bypass does not require the suppression of the anti-reflux system.

Thank you to Dr. Antonio Valenti, visceral, digestive and bariatric surgeon, in the obesity department of the Marne-la-Vallée Private Hospital (HPMV) and attached practitioner of the Avicenne Hospital (APHP).

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Video: Gastric Bypass Complications - Mayo Clinic (November 2019).

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