Weight Loss Surgery

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Weight Loss SurgeryGastric Bypass Roux-en-Y (RYGBP)

Combined Restrictive & Malabsorptive Procedure

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States.

In this procedure, the stomach is divided into two separate parts with the use of a stapling device. The stomach pouch (the upper part which receives the food is small (15 to 20cc). The lower portion of the stomach is not removed and continues to make its digestive juices. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the “Y” shape that gives the technique its name. The length of either segment of the intestine can be adjusted at the time of surgery to produce lower or higher levels of malabsorption.

 StomaphyX

This revolutionary procedure is now available for individuals who have had previous gastric bypass surgery and who are regaining weight;  who want an alternative to invasive weight loss surgery. This procedure involves no incisions and in most cases, no recovery.  It involves placing an endoscope through the mouth into the stomach pouch and suturing the connection between the stomach pouch and small intestines resulting in slower emptying of the stomach and earlier satiety and more weight loss. The procedure also shrinks the stomach pouch and makes it small like soon after the original gastric bypass procedure.

Benefits of the StomaphyX procedure include:
No need for abdominal or internal surgical incisions.
Enables the surgeon to reduce the size of the stomach.
Preserves future treatment options.
In most cases, is performed on an outpatient basis.
Essentially painless.
Faster recovery than with open or laparoscopic procedures.
 
The StomaphyX device is an endoluminal fastener and delivery system that consists of an ergonomic, flexible fastener delivery device and sterile polypropylene fastener implants.

Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E)

Combined Resrtictive & More Malabsorptive Procedure

RYGBP-E is a means of achieving far greater malabsorption than a standard RYGBP. The common coduit (the bottom of the Y) is made very short thus causing this to be a more malabsorptive procedure. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it different operative risks than the other malabsorptive procedures by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects. For risks and benfits specific to the greater degree of malabsorption with RYGBP-E please read the advantages and risks associated with the different variations of bilio-pancreatic diversion (BPD) further below.

Advantages

- The average initial excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
- One year after surgery, weight loss can average 70% of excess body weight.
- Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
- A study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.

Risks

- Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
- Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
- A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
A condition known as “dumping syndrome ” can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much refined sugar, fat, or excessive amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, vomitting, abdominal pain, cramps, diarrhea, head-aches, palpitations, weakness, sweating, and faintness. Some patients are unable to eat any form of sweets, and/or fatty and fried foods after surgery.
- 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.
- The bypassed 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.

The LAP-BAND® System Overview

The LAP-BAND® System is an adjustable gastric band designed to help you lose excess body weight, improve weight-related health conditions and enhance quality of life. It reduces the stomach capacity and restricts the amount of food that can be consumed at one time. The LAP-BAND® System procedure does not require stomach cutting and stapling or gastrointestinal re-routing to bypass normal digestion. The LAP-BAND® System is the only adjustable and relatinely easily reversible weight-loss surgery available in the United States and the only weight-loss surgery approved for use by the Food and Drug Administration (FDA).

The name “LAP-BAND” comes from the surgical technique used, laparoscopic, and the name of the implanted medical device, gastric band. The LAP-BAND® System is a silicone ring designed to be placed around the upper part of the stomach and filled with saline on its inner surface. This creates a new, smaller stomach pouch that can hold only a small amount of food, so the food storage area in the stomach is reduced. The band also controls the stoma (stomach outlet) between the new upper pouch and the lower part of the stomach. When the stomach is smaller, you feel full faster, while the food moves more slowly between your upper and lower stomach as it is digested. As a result, you eat less and lose weight.

The Minimally Invasive Procedure

During this procedure, surgeons usually use laparoscopic techniques to wrap the LAP-BAND® System around the patient’s stomach. A narrow camera is passed through a port so the surgeon can view the operative site on a nearby video monitor. Like a wristwatch, the band is fastened around the upper stomach to create the new stomach pouch that limits and controls the amount of food you eat. The band is then locked securely in a ring around the stomach.

Advantages

-Since there is no stomach cutting, stapling, or gastrointestinal re-routing involved in the LAP-BAND® System procedure, it is considered the safest, least invasive, and least traumatic of all weight-loss surgeries. The laparoscopic approach to the surgery also has the advantages of reduced post-operative pain, shortened hospital stay, and quicker recovery. Often placement of a LAP-BAND is an out-patient procedure. If for any reason the LAP-BAND® System needs to be removed, the stomach generally returns to its original form.

Adjustable Weight Loss

The diameter of the band can be modified to meet your individual needs, which can change as you lose weight. For example, pregnant patients can have their band loosened to accommodate a growing fetus, while patients who aren’t experiencing significant weight loss can have their bands tightened.

Risks

- Like any complex gastric operation, there are risks associated with lap band surgery. Be sure you review the risks associated with lap band surgery with your surgeon. Risks specific to this surgery include: infection, spleen bleeding or injury, gastric perforation (a tear in the stomach wall), and access port leakage. Additional uncommon risks include band “slippage” and erosion.Beyond surgical risks, patients may experience one or more side effect during recovery. These side effects include nausea and vomiting, heartburn, and abdominal pain.

Gastric Restrictive Procedure – Vertical Banded Gastroplasty

Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. VBG’s have gone the way of the dinosaurs. Today this procedure is very rarely performed. If you or a friend has had this procedure and continue to be successful with the weight loss, nothing further need be done. In this procedure the upper stomach near the esophagus is stapled vertically for about 2-1/2 inches (6 cm) to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and thus creates the feeling of fullness.

Advantages

- The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual 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.

Risks

- Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection. This may require prolonged hospitalization with antibiotic treatment and/or additional operations.
- Staple-line disruption may also, in the long-term, lead to weight gain. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption.
- The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.
- Characteristically, these procedures, while creating a sense of fullness, do not provide the necessary feeling of satisfaction that one has had “enough” to eat.
- Because restrictive procedures rely solely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or of the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.
- Around 40% of patients undergoing these procedures have lost less than half their excess body weight.
- As is the case with all weight loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.

Malabsorptive Procedures – Biliopancreatic Diversion

While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to modestly restrict the amount of food consumed and dramatically alter the normal digestive process. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the end of the small intestine. With the three approaches discussed below, absorption of nutrients and calories is also reduced, but to a much greater degree than with previously discussed procedures. Each of the three differs in how and when the digestive juices (i.e., bile) come into contact with the food.

Since food bypasses the duodenum, all the risk considerations discussed in the gastric bypass section regarding the malabsorption of some minerals and vitamins also apply to these techniques, only to a greater degree.

Biliopancreatic Diversion (BPD)

BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an “alimentary limb.” All the food moves through this segment, however, not much is absorbed. The bile and pancreatic juices move through the “biliopancreatic limb,” which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the “common limb.” The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.

Biliopancreatic Diversion with “Duodenal Switch”

This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the “alimentary limb” is then attached to the beginning of the duodenum, while the “common limb” is created in the same way as described above.

Advantages

- These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
- These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
- In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved. –
- Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.

Risks

- For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
- Abdominal bloating and malodorous stool or gas may occur.
- Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
- Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.

Laparoscopic or Minimally Invasive Surgery

For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still “experimental.” In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.

When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them excellent visualization and access to key anatomical structures.

The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen.

Advantages

A recent study shows that patients having had laparoscopic weight loss surgery experience less initial pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or abdominal wall hernia, and patients returning more quickly to pre-surgical levels of activity.

Risks

Compared to the open procedures the laparoscopic approach (except the LAP-BAND) carry a greater risk of bleeding, intestinal leakage, and internal hernias. Longer operative times may lead to higher incidence of anesthetic complications.

Laparoscopic procedures for weight loss surgery employ the same principles as their “open” counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.

THE SLEEVE

            The gastric sleeve is a recent addition to the surgical armamentarium for the treatment of obesity. In this operation a large portion of the stomach is removed leaving only a tube or “sleeve” of stomach connecting the esophagus to the duodenum. Due to the small diameter of the “sleeve” this operation does have a restrictive component. However, it appears that a major factor contributing to the success of this operation is not what is left, but what is removed. Removing a large portion of the stomach markedly decreases the amount of grehlin, a hunger producing hormone. Consequently, most patients report a remarkable decrease in their appetites.