What Are the Procedures for Metabolic Surgery?

A consequence of the growing sedentary lifestyle, poor nutritional habits and a lack of exercise which has come to characterize 21st- century man is increasing weight gain, overweight and obesity. This stems from a disproportion in the balance of our energy intake and expenditure with the excess calories being stored as body fat. This leads to derangement in the body’s metabolic balance with increased predisposition to hypertension, high levels of lipid in blood circulation especially triglycerides (dyslipidemia) and high blood sugar. This constellation of symptoms and signs is called metabolic syndrome and it poses a greater risk for cardiovascular disease, stroke and type 2 Diabetes Mellitus.

Different methods have been used to address this disorder especially with the use of drugs, lifestyle modifications and exercise with minimal and at best modest results. Late in the 20th century, trials and experiments began to be conducted with a view to establishing whether surgical procedures could be offered as a treatment option for metabolic disorders. Results obtained were astounding. This birthed metabolic surgery. Since then, there has been mounting evidence of the efficacy of metabolic surgery as a treatment option for metabolic conditions like diabetes mellitus.

Metabolic surgery, known by its other names – Bariatric surgery or diabetes surgery – makes use of Bariatric techniques and principles which include ileal interposition, transit bipartition, gastric bypass, sleeve gastrectomy, gastric banding etc. The procedures are usually carried out using minimal access incisions (laparoscopic incisions). Results so far have been phenomenal to stay the least.

The indications for metabolic surgery or who qualifies for metabolic surgery includes the following criteria

· Having a body mass index of 40 or more or weighing over 100 pounds.

· Having a body mass index of 35 or more with a minimum of one or more co-morbidities related to obesity, which include type 2 diabetes Mellitus, Non-alcoholic fatty liver disease, hypertension, heart disease to mention a few.

· Difficulty or being unable to attain healthy weight in spite of conscious weight loss efforts.


The basic principle by which metabolic surgery works is decreasing the length of the gut, thus decreasing the amount of food absorbed and increasing satiety. Also, there is an alteration in gut hormones which contribute to known effects.

Some of the procedures include

Ileal interposition: this procedure involves placing the ileum between the stomach and proximal part of the small intestine. This works to increase secretion of certain gut hormones e.g GLP-1, GIP, decreasing Ghrelin levels, regulation of glucagon levels.


Increased GLP-1 leads to increased early phase insulin secretion

Long-term regulation of insulin secretion

Decrease in insulin resistance

Decreased glucose output from the liver

Control of Type 2 Diabetes Mellitus


Technically difficult

Gastric bypass surgery: A small portion of the stomach is divided Sam into the small intestine. The distal segment of the small intestine is joined to the small portion of the stomach. The proximal intestinal portion is then connected to the side of the distal intestinal portion to ensure mixing of the gastric secretions and enzymes with the food. This creates a smaller stomach pouch and less digestion and absorption of food nutrients.


Attainment of rapid weight loss

Increased satiety with small food portions

Long-term maintenance of weight loss.


A complex procedure

Can predispose to vitamin and mineral deficiency in the long-term

Leads to longer hospital stay than the other techniques.

Transit Bipartition: this can be combined with sleeve gastrectomy. The small bowel is divided at a given point. The distal portion is attached to the lower portion of the stomach while the proximal portion of the intestine is attached to the small bowel.


Patients can lose up to 70{2dd333ed9c7b2074fdfda098a56357c21ab487243e335d9241a31e34dbd5cf30} of weight

Leads to achievement of good sugar control

Decreased occurrence of leaks as compared to sleeve gastrectomy


A complex procedure

May lead to vitamin and mineral deficiency

Sleeve gastrectomy: here, over 4/5 of the stomach is removed. The portion that is left resembles a banana. This significantly decreases the stomach capacity and alters gut hormone production.


Decreases the capacity of the stomach

Leads to after and more rapid weight loss

Hospital stay is short

Alters gut hormones leading to less feeling of hunger


Can’t be reversed

May lead to vitamin and mineral deficiency

Gastric banding: here, an inflatable band is secured around the upper part of the stomach. A small pouch is created above the band, same as below the band. This leads to increased satiety and fulness with smaller food portions.


Leads to weight loss of over 40{2dd333ed9c7b2074fdfda098a56357c21ab487243e335d9241a31e34dbd5cf30}

There is no cutting involved

Decreases the functional capacity of the stomach.

Very low post-operative complications


Weight loss is achieved more slowly compared to other procedures

The band can slip

Increased rate of repeat procedures.

Pungky Dwiasmoro Hiswardhani

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