Bariatric Surgery – Bypass surgery vs bypassing standards of care and patient safety

What is Bariatric Surgery?

Weight loss surgery, also referred to as Bariatric surgery, is used to treat overweight patients whose weight poses potentially life threatening future health problems. Surgery is often the last resort where other weight loss attempts have been unsuccessful, and there is a serious health risk.

Types of Bariatric Surgery

There are several types of bariatric surgery, which suit different circumstances and patient needs. They also vary depending on the need for the changes to be reversible or irreversible.

Gastric Band

This procedure involves the placing of a ring around the top of the stomach, near the oesohpagus, to constrict the passageway. This reduces the amount of food the stomach can hold. The band is adjustable so it can be altered for that person once it is in place. The band is adjusted via a port just below the skin. This is done by injecting or removing fluid via the port.

There are pros and cons to a gastric band procedure:-

Pros:

• Good for larger portion eaters
• Very safe and reversible

Cons:

• Band management in the future
• High incidence of revision surgery

Gastric Bypass

This procedure, using staples, diverts the digestive system past most of the stomach so less food is digested. The top third of the stomach is effectively dissected and sealed from the rest of the stomach. The small intestine is then connected to this top section of the stomach, bypassing the usual route to the intestine via the duodenum.

It is also known as a Roux-en-Y bypass. It is more often used in cases where there is severe obesity, given the immediate impact it can have on portion intake.

Pros:

• Good for patients with severe morbid obesity
• Great weight loss profile and diabetic resolution

Cons:

• Higher operative risk
• Need for vitamin supplementation

Gastric Sleeve

A gastric sleeve procedure is the most severe of the available treatment options, and a permanent bariatric procedure. It is only for the most serious cases of obesity and where there is a real concern about the ability to maintain wait at in the long term, or possible psychological issues.

Most of the stomach is removed during this procedure and a sleeve shaped cylinder of stomach is left to reduce the capacity for food. This is a permanent procedure. Effectively the majority of the stomach is removed, but the digestive tract and process are undisturbed, unlike a bypass procedure.

Pros:

• Good weight loss profile and effective diabetic resolution

Cons:

• Higher operative risk than other procedures
• Irreversible
• Any complications, whilst rare, are quite serious with long recovery periods

Gastric Balloon

This procedure is endoscopic rather than surgical, and involves placing a silicone balloon into the stomach. The balloon is then inflated whilst in the stomach, to make the patient feel fuller for longer after eating only a small meal. It’s for short term issues, where it is felt that weight management can be maintained in the long term by the patient. Complications can however involve stomach erosions and ulcers.

NHS v Private Treatment

Weight loss surgery is available on the NHS to those with life potentially threatening obesity. Potentially life threatening obesity is defined as having a BMI level of 45 or above or having a BMI of 35 or above and also having other serious health conditions such as high blood pressure or diabetes.

It is only ever considered as a last resort and patients should have attempted conservative weight loss management for at least 6 months before being referred for surgery. The patient should be managed within a multi-discipline environment with input from physicians, psychologists, dieticians, anaesthetists and specialist surgeons.

Most surgeons, whether working for the NHS or privately, would only usually consider weight loss surgery for someone where there is an obvious clinical need rather, than for cosmetic reasons only because of the high risks. However there may be different criteria that would apply if the weight loss surgery is undertaken privately. It is becoming a more common procedure in the private sector where people are looking for a quick fix to lose weight.

Not everyone is suitable for weight loss surgery and those patients need to be correctly identified and advised.  A weight loss surgeon discusses this further in the below video.

Benefits of Bariatric Surgery

It is argued that the benefits of weight loss surgery far outweigh the risks. The most obvious benefit is weight loss which will improve someone’s health, day to day life and future life expectancy. Losing weight can also have a major beneficial impact on other medical conditions such as heart disease, diabetes and hypertension. Weight loss is also clinically known to reduce the risks of heart attacks and strokes.

Weight loss surgery is seen as a safe and cost effective way of treating obesity in the UK, where there has been a dramatic rise in procedures. This clip discusses the 18,203 weight loss procedures which took place from 2010-2013 on the NHS.

Risks of Bariatric Surgery

Despite the benefits as discussed above, weight loss surgery is still very much specialised surgery which carries its own high number of risks and potential complications.

The overall risk of death in hospital after having any kind of weight loss surgery is around 1 in 1,000. Certain risk factors, such as high blood pressure or a BMI of 50 or above, also increase the risk of complications.^[1] Generally, Surgery for high BMI patients is considered high risk.

Surgery must only ever be considered as a last option. If the procedure is not performed with care, it could cause very serious problems for the patient and could be fatal. Patients should always be correctly identified as being suitable for surgery and should not be put at any risk if they do not fit the criteria.

Patients being elected for weight loss surgery are most likely to have other co-morbidities which add further risk to any procedure including diabetes, heart disease and thrombosis.

It is considered very technical and complicated surgery and other potential complications can include:

• Blood clots;
• Infection;
• Leakage of gastric fluid which can cause severe infection called peritonitis, which is severe and can be life threatening;
• Bowel obstruction;
• Hernias;
• Stomal stenosis – one of the most common complications is that the hole that connects the stomach pouch to the small intestine can become blocked with food;
• Malnutrition – patients can see deficiencies in iron and calcium following surgery which needs to be carefully monitored;
• Excess skin- as it is considered cosmetic and not clinical treatment is not available on the NHS and patients will need to seek and pay for private treatment to remove any excess skin as a result of weight loss;
• Psychological effects;
• Food intolerance- around 1 in 35 people with a gastric band develop a food intolerance

Medico-Legal Issues

Weight loss surgery and adapting your life afterwards is a difficult process and it requires the input of many different medical professionals. They need to work together as a team to ensure the patient is getting the right care before and after surgery. A duty of care will be owed by all members of the medical team looking after the patient from the surgical team, to the patient’s own GP, nutritionist and psychologist. Patients should receive regular specialist advice after the surgery has been performed.

There can significant concerns for patients who undertake private surgery if there are surgeons and medical professionals who are not highly specialised in this area. The treatment often involves complex patients with other health concerns which need to be correctly cared for. 

Many weight loss negligence claims involve the delay in recognising and treating any early complications such as leaks and bleeds which can lead to long term complications and further procedures and long term hospital stays and recovery times. Leaks can also lead to infections, which if discovered too late can be fatal. A delay in acting on symptoms and diagnosing leaks and sepsis can be a negligence issue.

The surgeon is under a duty to warn the patient of any potential risks and complications before the surgery takes place. If the risks are not fully disclosed and the complications do then occur, then this could be negligent as the patient may not have chosen to agree to the surgery had they known of the risk.

Common claims involving weight loss surgery can include:

• Incorrect placement of the gastric band causing blockages and requiring further procedures;
• Incorrect stapling of the joins in gastric bypass surgery;
• Failure to perform the surgery to an accepted standard;
• Failure to complete a gastric bypass leading to a leak or the failure to identify the leak promptly which leads to further complications requiring treatment;
• Failure to promptly identify and treat problems such as band slippage or post operative infections and malnutrition;
• Failure to recognise and treat promptly punctures to the stomach causes by the surgery

Wider regulatory concerns

Due to the risks, weight loss surgery should be used for clinical purposes only and not for cosmetic reasons. However there are options out there for people to have surgery in the private sector which can cause problems if the surgery is unwarranted or is not performed by a specialist with the correct support team for the patient following the treatment.

Weight loss surgery is now more than ever frequently carried out within the cosmetic surgery industry. If thorough research is not done into the chosen surgeon, or the surgeon advertises themselves to be an expert in the area without the necessary experience, this could cause complications after the surgery.

A further potential problem for patients having private surgery is the continued care after the surgery has taken place. A patient may find themselves financially struggling to keep up with aftercare and follow up appointments if they have been offered a fixed price for the surgery but they have not taken into account or been advised on the post surgery aftercare.

How we can help?

The medical negligence team at Bolt Burdon Kemp are experienced in dealing with claims where there has been negligent care during or following weight loss surgery.

At Bolt Burdon Kemp, we understand the importance of regaining your quality of life after you have been injured. We are familiar with the problems that you may face as a result of your injuries including difficulties in accessing the right medical treatment, therapies and equipment you need to help with your recovery. We are also able to provide our clients with practical help and support to help minimise the impact of their injuries in the immediate, medium and longer term.

^[1] http://www.nhs.uk/conditions/weight-loss-surgery/Pages/Introduction.aspx