TOWARDS THE LIGHT

Mr Shaw Somers, consultant gastrointestinal surgeon at The London Clinic, on the medical and surgical interventions used in the fight against obesity

Interview: Viel Richardson

Q: What is your role at The London Clinic?

I am a consultant in general surgery, but I specialise in upper gastrointestinal and weight loss surgery. My team has partnered with The London Clinic to run specialist weight management services. Obesity is now recognised as a major public health issue, with up to 30 per cent of the population significantly overweight. People’s ability to control their weight in the current food environment is becoming increasingly difficult. We now accept that many people who have struggled with their weight for years need medical or surgical intervention rather than diet and lifestyle advice.

Q: What happens when a patient requests a consultation?

The patient will see a surgical consultant, a dietician and, if necessary, a food psychologist. After some in-depth discussion with the patient about their present situation and what they wish to achieve, we explain the different options available and between us create a plan. This might be a medical regime at first with an option of a surgical procedure later, or we may go straight to the surgical option.

Q: What are the medical and surgical approaches?

There are three standard medical interventions. One involves a three-month treatment programme based around hormone injections used to speed up the metabolism, alongside a weight loss plan. Gastric balloons are the second intervention. Then there is the endoscopic sleeve gastroplasty (ESG) – with this we reduce the size of the stomach by closing off a section using an endoscopic suturing device. Even though the ESG involves an anaesthetic and some internal stitching, none of these procedures are classed as surgical, as they don’t involve accessing the stomach through an external surgical incision.

“This is one of those areas where people actively want your help. These patients have struggled with their weight for so long that your intervention is seen as a huge positive. It is a very happy clinic to do, and incredibly satisfying when you see your patients going off to enjoy a much higher quality of life.” keyhole surgery as opposed to feeding an endoscope down the patient’s throat.

Q: Why would you choose one over the other?

After counselling and discussion with a consultant the patient will decide on the best option. People who are not that much overweight may want a gastric band. People with other medical issues, such as diabetes, high cholesterol, high blood pressure, may want to go for a gastric sleeve or a gastric bypass, which can help control these medical problems more effectively.

Q: What is involved in the gastric band procedure?

Q: What is a gastric balloon?

There are two types: a short-term balloon, which is in place for up to six months, and longer-term implants, which can be in place for around a year. A deflated balloon is inserted into the stomach, either by swallowing a capsule or using an endoscope. Once in place, the balloon is inflated remotely. It helps to reduce the patient’s appetite and improves their ability to reduce their food intake. These balloons are doing something much more complex than just taking up space. They change the way people experience hunger and reduce their desire to eat.

Q: What are the surgical options?

The main ones are the gastric band, gastric sleeve and the gastric bypass. We define them as surgical because they involve a full anaesthetic and

This is an inflatable rubber band that sits around the top of the stomach and is designed to last the rest of the patient’s life. It is adjusted by a small button that we implant in the abdomen which allows us to inflate or deflate the band as required. Some people need it quite tight to stop them eating, while others need just enough of a restriction to remind them to slow down. We tend to adjust it quite often in the first year so we can get it just right for that individual. After that, we need to change things far less often.

Q: If the capacity of the stomach stays the same, what is the mechanism by which it works?

The mechanism at work here is that by slowing down the rate at which a person eats, we allow time for the stomach to send messages to the brain saying it is full. The body takes between 20 minutes and half an hour to register the nutritional value of your food and send the message to your brain to tell you to stop eating when you have taken on enough calories. Part of the problem is that many modern foods are so packed with calories that we have taken on far too many in that 30-minute timeframe. It means we eat more than we need before the message to stop comes through.

Q: Do the gastric sleeve and gastric bypass have the same effect? These do reduce the capacity of the stomach as well as changing the way the stomach talks to the brain. The great thing about all these procedures is that the patient still enjoys the food they eat, they just do not feel the need to eat as much. I have a number of chefs and cookery writers under my care who tell me that undergoing their procedure has been a huge blessing.

Q: How invasive is the gastric sleeve surgery?

Using a very thin stapling instrument, we reshape the stomach. We will typically remove about three-quarters of the stomach, including the part that sends messages to the brain that say you’re hungry. Patients have told me that while food still smells appetising, and they do still get hungry, they are not as desperate to eat it as they were before. However, they still receive the signal saying they are satiated and no longer need to eat, and crucially this happens much more quickly than before, taking place in more like 10-15 minutes.

Q: What about the gastric bypass? This is a slightly more involved procedure. Not only do we reduce the size of the stomach, giving the patients those benefits, but we also create a minor short-circuit in a part of the small intestine called the duodenum. Doing this changes the messages sent to the pancreas gland that controls the way that your body metabolises sugars.

Q: How does this affect people who have diabetes?

It has a profound effect on those suffering from type 2 diabetes. They often find that they go into complete remission once they have had a gastric bypass. We do not completely understand the mechanism, but it seems to make their own insulin system work much better than before. Most can safely come off their diabetic medication completely after the procedure.

Q: Is it possible for people to undergo this procedure primarily to cure the diabetes then, rather than obesity?

Yes it is. We modify the bypass so that the weight loss effect is minimised, but the anti-diabetic effect is maximised. However, in my experience it is very rare to find someone who is type 2 diabetic and not overweight. A patient may be only modestly overweight but still have the procedure to cure their diabetes. I have had doctors who were not significantly overweight approach me for the surgery because they know what a dangerous disease diabetes is.

Q: All interventions involve some risk. What are the risks here? These are among the safest operations you can do. The chances of a complication are between 1-2 per cent. It is incredibly rare that something happens that we cannot easily remedy. We occasionally find that people just can’t tolerate the balloon, so we have to remove it. There is often some initial discomfort, but with our guidance the vast majority get through that in a couple of weeks. With endoscopic procedures, there can be a small risk of some post-procedure bleeding, but we can deal with that very effectively. For many people, any complication from the procedure still poses far less of a risk to their health than not having the procedure at all. This is especially true over the long term when considering the risks posed by cardiovascular disease or diabetes.

Q: What happens after the procedures?

Each patient receives post-operative coaching to help them develop a healthier and more enjoyable diet. The whole multi-disciplinary team remains available to them, so if they need extra psychological as well as technical support, we will arrange that for them.

Q: Are there clinical issues that would render people unsuited to these procedures?

Possibly some people who cannot tolerate anaesthetic. However, in over 3,000 cases I can’t recall the last time I had to tell a patient that there was a clinical reason why I could not help them. Psychologically it is different. Patients such as those with an uncontrolled psychiatric illness or those dependant on drugs or alcohol do not respond well. This is because it is very difficult for them to comply with the post-procedure programme. These procedures involve a three-way partnership. We will perform the right operation, the dietician and psychologist offer the right aftercare and coaching but the patient has a role to play as well. The good news is I have seen many people use this as a springboard to overcoming these issues and go on to have very successful procedures.

Q: What is the gender balance of the patients you treat?

We treat twice as many women as we do men. The frustration is that we know weight-related disease kills more men than women. Men carry their extra weight internally, around organs like the heart, where it is doing real damage, whereas women tend to carry it under their skin. The problem is men are less likely to act, so putting themselves at greater risk.

Q: Has Covid had much of an impact on your field?

I have seen a significant increase in Covid-related enquiries for obesity treatment. Obesity is linked to what we call metabolic syndrome, where many of the body’s metabolic functions such as diabetes control begin to fail. These conditions can ‘creep up’ on obese individuals and only manifest when an acute illness like Covid arises. This compounds the effects of Covid and can complicate the recovery.