Obesity Management & Surgery

Life-style changes

Lifestyle changes are essential for managing obesity as a chronic disease. A balanced diet rich in fruits, vegetables, whole grains, and lean proteins, coupled with regular physical activity, can help achieve and maintain a healthy weight. Behavioral modifications, such as mindful eating and stress management techniques, support long-term weight loss and overall well-being. Additionally, adequate sleep and reducing sedentary activities are crucial components of a comprehensive approach to obesity management. Lifestyle modifications are a cornerstone in the management of obesity, though their success rates can vary significantly based on several factors, including individual commitment and the presence of supportive measures. Studies have shown that comprehensive lifestyle interventions combining diet, physical activity, and behavioral therapy can lead to a 5-10% reduction in body weight within six months to one year. 

Long-term success, defined as maintaining a weight loss of at least 5% of initial body weight, is achieved by approximately 20% of individuals who engage in structured lifestyle programs . However, adherence to lifestyle changes is challenging, and many individuals regain some weight over time. Ongoing support, such as regular follow-up and group sessions, significantly improves the chances of sustained weight loss. 

Anti-obesity medication

Anti-obesity medications can be an effective component of a comprehensive weight management program, particularly for individuals who have not achieved significant weight loss through lifestyle modifications alone. These medications work by various mechanisms, including appetite suppression, increased satiety, reduced fat absorption, and enhanced metabolic rate. Clinical trials have demonstrated that patients using FDA-approved anti-obesity drugs, such as orlistat, liraglutide, and phentermine-topiramate, can achieve an additional 5-10% weight loss compared to placebo when combined with lifestyle interventions. 

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Newer class of drugs: GLP1-receptor agonists

One of the newer classes of anti-obesity medications includes GLP-1 (glucagon-like peptide-1) receptor agonists. These drugs, such as liraglutide (Saxenda) and semaglutide (Wegovy) or Tirzepatide (Mounjaro), mimic the GLP-1 hormone that helps regulate appetite and food intake. GLP-1 receptor agonists have shown promising results in weight management:

• Effectiveness: Clinical studies have shown that patients can achieve a 10-15% reduction in body weight with GLP-1 receptor agonists, making them some of the most effective pharmacological treatments for obesity.

• Mechanism of Action: These medications work by slowing gastric emptying, enhancing feelings of fullness, and reducing appetite. This helps patients consume fewer calories and lose weight more effectively.

• Additional Benefits: Beyond weight loss, GLP-1 receptor agonists have been associated with improvements in cardiovascular risk factors, glycemic control, and overall metabolic health.

​However, the success of these medications often depends on long-term adherence and is typically more effective when integrated with dietary changes, physical activity, and behavioral therapy. Regular monitoring by healthcare providers is crucial to manage potential side effects and to adjust treatment plans as necessary.

Endoscopic bariatric procedures

Endoscopic bariatric procedures are minimally invasive weight loss treatments performed using endoscopic techniques, which involve inserting instruments through the mouth and into the stomach without the need for external incisions. These procedures are increasingly popular due to their lower risk profiles and shorter recovery times compared to traditional bariatric surgeries.

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Types of Endoscopic Bariatric Procedures

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1. Intragastric Balloon (IGB):

• Procedure: A saline-filled balloon is placed in the stomach to reduce its capacity and promote satiety.

• Benefits: Can result in a 10-15% reduction in total body weight within six months.

• Risks: Nausea, vomiting, balloon deflation, and migration as well as perforation.

• Outcomes: Short-term weight loss is significant; however, long-term maintenance requires adherence to dietary and lifestyle changes. Main drawback - balloons are not permanent and need to be removed. 

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2. Endoscopic Sleeve Gastroplasty (ESG):

• Procedure: The stomach is sutured endoscopically to reduce its size, similar to a surgical sleeve gastrectomy but without incisions.

• Benefits: Leads to about 15-20% total body weight loss within one year.

• Risks: Bleeding, infection, and stomach perforation.

• Outcomes: Effective short- and mid-term weight loss; long-term outcomes are still being studied but are promising. Main draw back in Australia - not covered by medicare/health funds and results in significant out of pocket costs of patients. Often a ESG is not as durable as a conventional laparoscopic bariatric procedure and weight regain has been commonly reported. 

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3. AspireAssist:

• Procedure: A tube is inserted into the stomach to allow a portion of the stomach contents to be drained after meals.

• Benefits: Can result in up to 30% excess weight loss.

• Risks: Infection, tube-related issues, and potential for misuse.

• Outcomes: Significant weight loss if used consistently; effectiveness is reliant on patient compliance.

• This procedure is not commonly available in Australia and has significant limitations in its application. 

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​Expected Outcomes

• Short-Term: Significant weight loss within the first 6-12 months, improvement in obesity-related comorbidities like type 2 diabetes, hypertension, and sleep apnea.

• Long-Term: Weight maintenance and continued improvement in comorbidities depend on adherence to dietary and lifestyle modifications. Regular follow-up is crucial for sustained success.

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Bariatric Surgery

Bariatric surgery encompasses various procedures designed to help individuals with severe obesity achieve significant and sustained weight loss. These surgeries are typically considered for patients with a Body Mass Index (BMI) of 35 or higher, or a BMI of 30 or higher with obesity-related comorbidities such as type 2 diabetes, hypertension, or sleep apnea. The primary types of bariatric surgery include gastric bypass (Roux-en-Y or one-anastomosis ["mini"] gastric bypass), sleeve gastrectomy, and biliopancreatic diversion procedures such as SADI-S. Laparoscopic adjustable gastric banding procedures are virtually never performed these days, however management of patients with bands is still very much required given the high numbers of bands that were placed in Australia. 

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Gastric Bypass (Roux-en-Y and OAGB): This procedure involves creating a small pouch at the top of the stomach and connecting it directly to the small intestine, bypassing a large portion of the stomach and the first segment of the small intestine. It is highly effective for weight loss and improving obesity-related conditions.

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Sleeve Gastrectomy: This surgery involves removing approximately 80% of the stomach, leaving a tube-like structure about the size & shape of a banana. It reduces the amount of food the stomach can hold and decreases the production of the hunger hormone ghrelin.

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Biliopancreatic Diversion with Duodenal Switch (BPD/DS) or similar procedures (SADI-S): This complex procedure involves a sleeve gastrectomy followed by rerouting the intestines to allow food to bypass most of the small intestine, reducing nutrient absorption.

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Adjustable Gastric Banding: A band is placed around the upper part of the stomach to create a small pouch, which limits food intake. The band can be adjusted to control the rate of weight loss. This procedure is largely outdated in Australia and is only performed in highly specific circumstances. However, ongoing band management is required for patients with already implanted bands. 

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Revisional Bariatric Surgery: In certain instances, revisional procedures may be required after previous bariatric surgery. This can be for example due to weight regain, or issues such as gastro-oesophageal reflux, swallowing difficulties, intractable hypoglycaemia or similar. Revisional surgery always comes with its own challenges, due to the altered anatomy from previous surgery. Often extensive work up prior to surgery is required and thus revisional procedures should only be performed by those with extensive experience in managing bariatric patients as well as those who are versed in a variety of complex foregut surgical procedures to best help manage patients and their expectations. 

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Risks and Benefits: Bariatric surgery carries risks such as infection, malnutrition, and complications from surgery. However, the benefits often outweigh these risks, as patients typically experience significant weight loss, improved quality of life, and resolution of comorbidities. Long-term success depends on adherence to dietary, exercise, and lifestyle changes.

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Outcomes of Bariatric Surgery: Short- and Long-Term

Short-Term Outcomes:

Bariatric surgery typically results in substantial weight loss within the first year post-operation. Patients often lose 50-70% of their excess body weight, with the most rapid weight loss occurring in the first six months. Improvements in obesity-related comorbidities are also seen shortly after surgery. These include:

• Type 2 Diabetes: Many patients experience significant improvements or remission of diabetes within weeks to months post-surgery due to changes in gut hormones and insulin sensitivity.

• Hypertension: Blood pressure often improves, reducing the need for medications.

• Sleep Apnea: Symptoms often decrease, and the need for continuous positive airway pressure (CPAP) therapy may be reduced.

• Mobility and Joint Pain: Weight loss alleviates stress on joints, improving mobility and reducing pain.

• Cancer: Bariatric surgery has been associated with a significant reduction in cancer risk of cancers such as breast cancer, endometrial cancer, colon cancer and similar. 

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Long-term Outcomes:

Long-term success of bariatric surgery depends on sustained lifestyle changes. Patients typically maintain a weight loss of 50-60% of their excess weight five years post-surgery. The long-term benefits include:

• Sustained Weight Loss: Many patients maintain significant weight loss over the long term, although some weight regain is common.

• Long-Term Remission of Comorbidities: Sustained improvements in diabetes, hypertension, and dyslipidaemia, with many patients experiencing prolonged remission.

• Quality of Life: Improved physical and mental health, increased activity levels, and overall better quality of life.

• Reduction in Mortality: Studies indicate a significant reduction in overall mortality and obesity-related mortality in patients who have undergone bariatric surgery compared to those who have not.

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Risks and Considerations:

• Nutritional Deficiencies: Long-term monitoring for deficiencies in vitamins and minerals is crucial, particularly in procedures that involve malabsorption.

• Surgical Complications: Risks include infection, hernias, and the need for additional surgeries.

• Psychological Impact: Some patients may experience changes in mood or eating behaviours, necessitating psychological support.

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Despite certain risks and considerations, the fact remains that in the modern era bariatric surgery remains the most effective and durable treatment for patients suffering from obesity. Nevertheless, surgery is generally regarded as non-reversible and thus thorough work-up and consideration is required prior to embarking on this life-changing journey.