Gastric reduction referral: Information for referring physicians

Your patient has been struggling with severe obesity for years, and as a primary care physician or specialist, you notice that attempts to achieve permanent weight loss fail time and again. The (risk of) physical complaints, such as diabetes, sleep apnea and elevated cholesterol, are increasing and you wonder if gastric bypass surgery is the right step. But what exactly are the benefits? And do they outweigh the risks of surgery? Dr. Kevin Göttgens, gastrointestinal surgeon at WeightWorks, has successfully performed more than a thousand gastric reduction surgeries since 2015. With this experience, he understands the questions and concerns referrers face when it comes to bariatric surgery. In dit artikel leggen we uit wat bariatrische chirurgie inhoudt, de soorten maagverkleiningsoperaties die WeightWorks aanbiedt, voor wie deze ingrepen geschikt zijn, en welke voordelen én risico’s eraan verbonden zijn. Dit helpt u om goed geïnformeerd te beslissen over een verwijzing en uw patiënt de best mogelijke ondersteuning te bieden.

What is bariatric surgery?

Bariatric surgery, or weight loss surgery, includes various surgeries intended to bring about weight loss by modifying the digestive system. The goal of these surgical procedures is not only weight loss, but also to improve or even reverse obesity-related conditions, such as type 2 diabetes, high blood pressure, sleep apnea, etc.

What types of bariatric surgery exist?

There are several types of bariatric surgery, each with its own approaches and benefits. These are the most commonly performed procedures worldwide:

• Gastric Sleeve (sleeve gastrectomy): This involves removing about 75% of the stomach, making the stomach a narrow tube or “sleeve. There is less food in the stomach that is created which also reduces the feeling of hunger.
• Gastric Bypass (Roux-en-Y Gastric bypass): In this procedure, a small part of the stomach is separated (gastric pouch) from the rest and connected directly to the small intestine (jejunum). This not only reduces food intake but also limits calorie intake. In this type of bypass, 2 connections are made: A Gastroenterostomy (Stomach to intestine) and an Entero-enterostomy (small intestine to small intestine) so that there is a “Y” split in the trajectory of the intestine.
• Mini Gastric Bypass (One-anastomosis gastric bypass; previously also called the Omega loop bypass)): This bariatric procedure is similar to the gastric bypass, a variant that requires a little less technically and can be performed a little faster (35 min vs. 45-50 min). The difference from a “regular” gastric bypass is the way the small stomach is connected to the small intestine. In mini bypass, only one connection is made between the stomach and small intestine (gastroenterostomy).

Patients are informed at WeightWorks during an information session by the surgeons about the types of surgeries. They are then consulted on which type of surgery is most appropriate. Long-term results show that the majority of people with gastric bypass remain at a healthy weight after 20 years. Results of the gastric sleeve show that people sometimes show an increase in weight after 5 years. Long-term results of mini- gastric bypass are still being studied; current results are promising.

For whom is bariatric surgery appropriate?

In any case, patients must meet specific criteria, namely

• BMI >40
• BMI >35 with one of the following 6 comorbidities: Hypertension, Hypercholesterolemia, Diabetes Mellitus, OSAS, Reflux, radiologically demonstrated osteoarthritis in lower back or below.
• BMI >30 and poorly adjustable Diabetes Mellitus eligible for reimbursement by insurer (at least 2 medications used with unacceptable glucose/HbA1c values).
• BMI > 30 where there is no ill-adjusted DM: gastric bypass may be appropriate for the patient, but the insurer will not reimburse for the course.

These criteria are also called gastric bypass criteria. It is important that patients make informed decisions about bariatric surgery, being aware of the lifelong lifestyle changes involved.

What are the benefits of bariatric surgery?

The benefits of bariatric surgery go beyond just weight loss. Many patients experience significant improvements or even complete cure of comorbid conditions, a better quality of life, and even a longer life expectancy. To best inform your patients about the positive effects of gastric bypass surgery, we 8 have listed the most important benefits below:

8 Benefits of Stomach Reduction Surgery:

The 8 main reasons to choose bariatric surgery are:

• Significant weight loss: On average, patients lose 30-35% of total weight or 60-80% of excess weight. This makes daily activities and exercise much easier.
• Overall health improves: Comorbidities improve rapidly and may even heal completely. Note: Sometimes medication for hypertension or Diabetes Mellitus, for example, may need to be adjusted after only 1-2 weeks because it can react very quickly to the procedure, such as before there is much weight loss.
• Reduced hunger: The craving for sweets or fatty foods decreases, making healthier eating easier.
• More freedom of movement: Movement and sports are much easier; Activities that were no longer possible due to physical complaints become part of daily life again.
• Minimal scars: The surgeries are always done laparoscopically, so the scars are small.
• Quick recovery after surgery; On average, most people are back to work after 2-3 weeks. Heavy physical work/heavy lifting is discouraged for 3 weeks.
• Improvement of body image and reduction of shame about appearance
• Less avoidance of activities due to e.g. embarrassment about appearance (e.g. swimming, trying on clothes while shopping, going to an amusement park, etc.)

The above benefits demonstrate the great impact that gastric bypass surgery can have on virtually every aspect of a patient’s daily life.

What are the risks and considerations in bariatric surgery?

As with any surgical procedure, there are risks associated with bariatric surgery. These can range from complications immediately after surgery to long-term effects that affect dietary intake. Adequate follow-up care and implementation of lifestyle modifications are therefore essentential for a successful long-term outcome.

9 Risks and concerns after gastric bypass surgery:

The 9 main concerns or risks associated with gastric bypass surgery are:

• Dumping: This can be seen as a drop in blood sugar (reactive hypoglycemia) which feels very unpleasant (palpitations, sweat attack, dizziness, diarrhea, becoming very tired or faint, etc). Dumping occurs particularly when ingesting sugary products. Due to the rapid passage to the small intestine and the rapid absorption of the sugars, the glucose level is set too high, causing hypoglycemia. This corrects itself and is best avoided by paying close attention to product choices.
• Medical complications: Short-term risks include bleeding and seam leakage. In the later term, gastric ulceration (marginal ulcer), formation of gallstones and kidney stones, internal herniation or blockages (particularly from poor chewing or excessive bites) may occur.
• Vitamin deficiencies: May occur if supplements are not used and is due to lesser intake and somewhat decreased absorption. This is the reason lifetime bariatric-specific supplements are advised.
• Dietary restrictions.: Some foods can no longer be tolerated (well); However, this may change over time and also improve.
• Gastrointestinal problems: On average, stools are thinner after a bypass, after six months to a year we often see this improve spontaneously as well, but there is a chance it will stay that way. The color and composition of the stool can also vary greatly after bypass depending on the products taken. With medication, frequency and consistency can often be adjusted quite well.
• Development of lactose intolerance: A new sensitivity to lactose after surgery is frequently seen.
• Postponement of pregnancy wish: This can be for people with a desire to have children It is advisable to wait one year before getting pregnant after surgery because of the rapid weight loss in the first year after surgery. After this there is no objection, but it is recommended that the obstetrician always refer to a gynecologist for additional checks (blood values, etc).
• Excess skin: A consequence of rapid and significant weight loss. The likelihood of excess skin after gastric bypass surgery seems somewhat greater in patients of older age. Not everyone suffers from this. A plastic surgeon can often do something about this, but the procedures are rarely covered by an insurance company. Weight must sit at the new low weight for a year before a plastic surgeon will consider surgery. On average, patients will not qualify until 2 years after bariatric surgery.
• Hair loss: We frequently see patients’ hair become a lot thinner in the first few months after surgery. This is a reaction to the weight loss and the major surgery. This is unrelated to vitamin deficiencies since they already get this supplemented as standard and is actually a reaction to the major change. It will start to recover when the balance is back; Patients do not go bald.
• Learning new, adequate coping strategies In patients who are prone to emotional eating, binge eating or have a history of substance abuse (such as alcohol)

After the surgical procedure, patients at WeightWorks are supervised by the multidisciplinary team focusing on both physical and mental health. Patients are encouraged to adopt a healthy lifestyle to minimize the risk of complications. The follow-up process at WeightWorks lasts for 5 years. It is important that patients follow all the appointments, as this increases the chances of a good long-term result many times over. The checks of vitamins, iron, etc. are taken care of by WeightWorks during these 5 years and, if necessary, supplemented extra by our internists.

As a referrer, how do you make the choice of a bariatric center?

When choosing a gastric bypass hospital for your patient, it is important to consider the expertise of the surgical team, the availability of multidisciplinary care and the quality of follow-up care. We recommend a referral to an obesity clinic within the Netherlands, because of the high quality of care and scientifically proven treatment pathways. We advise against gastric reduction pathways abroad. Abroad, choices for the type of gastric reduction are often limited, mainly determined by the surgeon’s expertise, and follow-up care for gastric reduction in the trajectory is often absent, giving patients little or no guidance on how to perpetuate a long-term behavioral change. In addition, bariatric surgery, including the pre- and after-care process in the Netherlands, is reimbursed by insurers if the patient meets the gastric reduction criteria. Finally, to determine an appropriate bariatric center, you can look online at patient reviews for an honest assessment of the treatment center.

You want to refer your patient to a bariatric center

Bariatric surgery offers patients a path not only to significant weight loss, but also to a life with fewer health issues, more energy and a higher quality of life. You have read the necessary information about the different types of gastric reduction surgery, the benefits and risks, and the criteria a patient must meet, and at WeightWorks, we understand that this comprehensive information can help you guide your patient in the best possible decision making process. If you would like to refer your patient for a gastric bypass procedure, you will find information on how to refer, an overview of our pre- and post-operative procedures, and you will find our contact information on our referral page. If you have any questions for us, we would be happy to think with you!

About WeightWorks

Established in 2021, the WeightWorks clinic is specially built and equipped for this type of surgery. Together with the multidisciplinary team consisting of internists, psychologists, dieticians, lifestyle coaches and nurses, they ensure that patients receive the very best treatment and aftercare. In addition, the waiting times to screening and surgery short. At WeightWorks, patients receive an individualized treatment program, which allows us to offer the patient a customized program. The aftercare program lasts 5 years, during which the patient will be guided in employing a healthy lifestyle, preventing relapse into old, unhealthy patterns, improving body image and monitoring physical health. For consultation around bariatrics and physical health of your patient, as a referring physician, please contact the WeightWorks treatment team.