Surgical Options For Obesity

Roux-en-Y Gastric Bypass Weight Loss Surgery

According to the American Society for Metabolic & Bariatric Surgery (ASMBS) and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is the most frequently performed operation for weight loss in the United States, accounting for more than 90% of all weight loss surgeries.

In the Roux-en-Y gastric bypass procedures, a surgeon makes a direct connection from the stomach to a lower segment of the small intestine, bypassing the duodenum, and some of the jejunum. A 15 - 60 cc proximal gastric pouch is created using several staple lines. The proximal gastric pouch is drained into a segment of the jejunum and "bypasses" the distal stomach and duodenum. The proximal part of the divided intestine is then connected to the side of the intestine that was previously attached to the pouch. The roux limb is that part of the intestine between the stomach pouch and the connection to the proximal small intestine.

The difference between short limb (or proximal) and long limb (or distal) gastric bypass is the length of the roux limb. Long limb gastric bypass results in more malabsorption than short limb gastric bypass. The result is sustained weight loss of >50% excess body weight in over 80% of patients. The surgery can be done laparoscopically or open. This procedure may be an option for people with a BMI between 35 and 40 who suffer from life-threatening problems for example, severe sleep apnea or obesity-related heart disease or diabetes.

Roux-en-Y Gastric Bypass Weight Loss Surgery Benefits

• One year after surgery, weight loss can average 65-80% of excess weight
• After 10 years, 50-60% of excess body weight loss has been maintained by some patients.
• Associated medical problems, such as diabetes, hypertension, sleep apnea, joint pain, and heartburn are improved or resolved in more than 90% of patients

• Because the duodenum is bypassed, Poor absorption of iron, calcium, and vitamin B12 can result in deficiencies. Metabolic bone disease can also occur but all these problems can usually be prevented by vitamin and mineral supplementation but is especially important for patients who experience chronic blood loss or are prone to osteoporosis.
• Dumping syndrome can occur as the result of rapid emptying of stomach contents into the small intestine which usually happens if too much sugar is consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating.
• The bypass portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using x-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.
• In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
• Risks of surgery include infection, bleeding, blood clots, leaks, strictures, and bowel obstructions. In general, the benefits of gastric bypass outweigh the risks for people with a BMI > 40, or for people with a BMI of 35-40 and the presence of medical problems associated with obesity.

Adjustable Gastric Band (AGB) or Laparoscopic Band (LAP-BAND® System)

A Gastric Band (lap band) surgical procedure is a purely restrictive approach to reducing the capacity of the stomach by which a band is placed around the upper most part of the stomach giving it the shape of an hour glass. This band divides the stomach into two portions, one small and one larger portion. No stomach stapling is required. The LAP-BAND® System induces an early feeling of stomach fullness, thereby decreasing food intake. You naturally feel the need to eat less. Any food you eat will be absorbed by your body at least as well as before the operation, as your digestive system is not altered in any way.

Weight reduction will instead be achieved by the fact that you will simply feel the need to eat less. This is because it only takes a small amount of food for the LAP-BAND® System to give you a true feeling of appetite satisfaction. The LAP-BAND® System is designed so that it can be inflated or deflated at any time after the operation to meet your weight loss requirements, without any further surgery. This is achieved by injecting a fluid solution into a port placed under the skin. This procedure may be an option for people with a BMI between 35 and 40 who suffer from life-threatening problems for example, severe sleep apnea or obesity-related heart disease or diabetes.

Adjustable Gastric Band (AGB) or LAP-BAND® System Benefits

• The tightness of the lap band can be adjusted by injecting fluid into, or withdrawing fluid from, the balloon on the inner aspect of the lap band. This is achieved by passing a needle into the small reservoir that is implanted under the skin at the time of the operation. If the lap band is too tight weight loss will be too rapid and there may be vomiting. This is corrected by withdrawing some of the fluid from the lap band. Conversely, if there is inadequate weight loss more fluid can be introduced thus tightening the lap band.
• The lap band allows food to pass through the digestive tract in the usual order allowing it to be fully absorbed into the body.
• The lap band is normally placed by laparoscopic (lap) or "keyhole or minimally invasive" surgery. This means that there is no major abdominal incision. The lap band weight loss surgery is performed by passing a telescope into the abdomen through a small skin incision, and usually four other small incisions are made through which to pass instruments and to place the lap band. These are quite small punctures. The absence of a major incision means there is very little pain post-operatively and an early return to full activities. On rare occasions it is not possible to place the lap band by the laparoscopic method and an incision or open surgery is required. The operation is still exactly the same; however recovery is usually a little longer.
• Although there is no intention of reversing the operation, if there were to be any unexpected development, the lap band can be removed, usually laparoscopically.
• After removal the stomach will return to its normal shape.
• The lap band procedure has the lowest mortality rate among the various bariatric surgeries.
• No stomach stapling or cutting, or intestinal re-routing involved with the lap band.
• Low malnutrition risk

• Gastric perforation or tearing in the stomach wall may require an additional operation.
• Access port leakage or twisting may require an additional operation.
• May not provide the necessary feeling of satisfaction that one has had enough to eat.
• The band portion of the lap band slips and the small gastric pouch above the band becomes larger. This can cause a partial obstruction and vomiting and may require removal of the band. This problem is prone to occur early after the lap band has been placed and is more likely to occur if there is repeated vomiting.
• Generally a liquid diet is recommended for the first month after the lap band operation.
• Slower initial weight loss than Gastric Bypass or BPD.
• Regular follow-up critical for optimal results.
• Requires an implanted medical device (the lap band).
• In some cases, the lap band's access port may leak and require minor revisional surgery.

Gastroplasty (vertical banded) (also known as stomach stapling)

It is a purely restrictive procedure with no malabsorptive effect. The goal of this procedure is to severely restrict the patient's capacity to eat certain foods. The vertical banded gastroplasty creates a small stomach within the regular stomach. In this stomach stapling procedure, a vertically oriented staple line is placed high on the right side of the stomach. The outlet is measured and its size controlled. A mesh band or a silastic ring (flexible, but inelastic) is placed around the outlet of the pouch to keep the pouch outlet from stretching.

Aside from the creation of the small pouch there is no significant change in the gastrointestinal tract. This procedure may be an option for people with a BMI between 35 and 40 who suffer from life-threatening problems for example, severe sleep apnea or obesity-related heart disease or diabetes.

Benefits

• Normal digestive tract order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.
• After 10 years, studies show that patients can maintain 50% of targeted excess weight loss.
• Fully reversible.
• Inherently safer operation than the Gastric Bypass because there is no cutting and sewing of the intestine like in the Gastric Bypass operation.

• Usually results in less weight loss than RNY. It does not restrict intake of high calorie liquids (sweets) and the pouch can stretch with overeating.
• Stomach Stapling disruption may in the long-term, lead to weight gain or leakage and/or serious infection. For these reasons, some surgeons divide the stomach stapling wall of the pouch from the rest of the stomach to reduce the risk of long-term stomach stapling line disruption.
• May lead to complications of obstruction or perforation, requiring surgical intervention.
• Pouch stretching or the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.

Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve gastrectomy (LSG) is the restrictive part of the more extensive mixed restrictive and malabsorptive operation, gastric bypass and duodenal switch (GB/DS). It generates weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption. With this procedure, the surgeon removes approximately 85 percent of the stomach laparoscopically so that the stomach takes the shape of a tube or "sleeve." This part of the procedure is not reversible. Unlike many other forms of bariatric surgery, the outlet valve and the nerves to the stomach remain intact.

Because the modified stomach continues to function normally there are fewer restrictions on the types of foods which patients can consume after surgery. The quantity of food the patient can consume is greatly reduced. This is seen by many patients as being one of the benefits of the laparoscopic sleeve gastrectomy, as is the fact that the removal of the majority of the stomach also results in the virtual elimination of hormones (ghrenlin) produced within the stomach which stimulates hunger.

This procedure is usually performed on superobese or high risk patients with the intention of performing a gastric bypass or duodenal switch at a later time. The stomach that remains is shaped like a thin sleeve and measures 35-60 cc or less, depending on the preference of the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. Note that there is no intestinal bypass or malabsorption with this procedure, only stomach reduction.

Benefits

• No foreign body is used as in the adjustable gastric banding and thus no adjustment is required.
• If weight loss is inadequate, the patient has the option to have the second stage of the operation (gastric bypass or the duodenal switch).
• It does not involve any bypass of the intestinal tract and thus patients avoid the complications of intestinal bypass such as intestinal obstruction, anemia, osteoporosis, vitamin deficiency and protein deficiency.
• For lower BMI patients (35-42) who have complications (inadequate weight loss, band erosion, poor quality of life etc.) associated with gastric banding, LSG maybe a good alternative.
• It also makes it a suitable form of surgery for patients who are already suffering from anemia, Crohn's disease and a variety of other conditions that would place them at high risk for surgery involving intestinal bypass.
• It is one of the few forms of surgery which can be performed laparoscopically in patients who are super obese.
• Better quality of life with less late complications as compared to gastric banding.

• Inadequate weight loss or weight regain is possible with operations that do not include an intestinal bypass. This is true of any form of purely restrictive surgery, but is perhaps especially true in the case of the sleeve gastrectomy.
• The procedure requires stapling of the stomach and therefore leakage and of other complications directly related to stapling may occur.
• Patients who are super obese usually require second stage operations in order to lose the rest of the excess weight if their BMI remains larger than 45, although two stages may ultimately be safer and more effective than one operation for super obese patients.
• LSG is not reversible, but it can be converted to a gastric bypass.
• Long-term weight loss results are unknown.