A Centres of Excellence for Metabolic Medicine and Surgery of SA (CEMMS) should be able to offer a patient access to all the acceptable operative procedures. If not they should at least be able to refer the patient to a center who can perform a procedure, which is most appropriate for that patient.
There are essentially two main components to the surgery offered to these patients; a restrictive procedure and a malabsorptive procedure or combination of both. The purely restrictive procedures include adjustable gastric banding (AGB), gastric sleeve (GS) and vertical banded gastroplasty (VGB), the last of which is becoming obsolete due to its poor longterm success and unacceptable complication rates.
A gastric Roux-en-Y bypass procedure (GBP) is predominantly restrictive procedure with a longer Roux limb (> 150cm) adding to the procedure a malabsorptive component. The better long term success achieved by the GBP over the purely restrictive operations is largely due to the hormonal changes that occur in the bypassed stomach and duodenum that in turn regulate the appetite and satiety centers of the brain.
Malabsorptive procedures lead to the best longterm outcome results. There are two acceptable procedures; these being the biliopancreatic bypass procedure as described by Scopinaro (BPD) and the biliopancreatic bypass with duodenal switch operation (BPD-DS).
The jejunoileal bypass procedure (JIB), also a malabsorptive procedure but was recently banned in South Africa. This procedure has unacceptably high longterm complication rate resulting in poor quality of health and decreased longevity in a significant number of patients who underwent this procedure.
With all malabsorptive procedures, these operations are surgically challenging; particularly when performed laparoscopically.
If one rates a laparoscopic cholecystectomy as being a level 1 difficulty, an AGB would be a level 2, a GBP level 5 and a BPD-DS level 10 difficulty. It is therefore easy to see why even in the CEMMS’s, the rate at which these complex malabsorptive procedures are performed is only in 2-3% of cases. (Complexity Figure)