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Weight-Loss Surgery Options
The American Society for Bariatric Surgery describes two basic approaches that weight-loss surgery takes to achieve change:
- Restrictive procedures that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.
- Adjustable Gastric Band
- Gastric Restrictive Procedure - Vertical Banded Gastroplasty - rarely done.
- Malabsorptive Procedures - Biliopancreatic Diversion
- Combined Restrictive & Malabsorptive Procedure -
Gastric Bypass Roux-en-Y - Laparoscopic or Minimally Invasive Surgery
LAP-BAND® System Overview
Approved by the FDA in June 2001, the BioEnterics® LAP-BAND Adjustable Gastric Banding System is the newest and the only adjustable surgical treatment for morbid obesity in the United States. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed. Since its clinical introduction in 1993, more than 100,000 LAP-BAND procedures have been performed around the world.
Minimally Invasive Approach
During the procedure, surgeons usually use laparoscopic techniques (using small incisions and long-shafted instruments), to implant an inflatable silicone band into the patient's abdomen. Like a wristwatch, the band is fastened around the upper stomach to create a new, tiny stomach pouch that limits and controls the amount of food you eat. It also creates a small outlet that slows the emptying process into the stomach and the intestines. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. In turn, this results in weight loss.
Least Traumatic Procedure
Since there is no cutting, stapling or stomach re-routing involved in the LAP-BAND System procedure, it is considered the least traumatic of all weight loss surgeries. The laparoscopic approach to the surgery also offers the advantages of reduced post-operative pain, shortened hospital stay and quicker recovery. If for any reason the LAP-BAND System needs to be removed, the stomach generally returns to its original form.
Adjustable Treatment
The LAP-BAND System is also the only adjustable weight loss surgery. The diameter of the band is adjustable for a customized weight-loss rate. Your individual needs can change as you lose weight. For example, pregnant patients can expand their band to accommodate a growing fetus, while patients who aren't experiencing significant weight loss can have their bands tightened.
To modify the size of the band, its inner surface can be inflated or deflated with a saline solution. The band is connected by tubing to an access port, which is placed well below the skin during surgery. After the operation, the surgeon can control the amount of saline in the band by entering the port with a fine needle through the skin.
The LAP-BAND® System Advantage
Minimal Trauma
- Least invasive surgical option
- No intestinal re-routing
- No cutting or stapling of the stomach wall or bowel
- Reduced patient pain, hospital length-of-stay and recovery period
- Significantly lower mortality risk than other obesity surgery procedures
- Low risk of nutritional deficiencies associated with gastric bypass
- Reduced risk of hair loss
- No "dumping syndrome" related to dietary intake restrictions
- Allows individualized degree of restriction for ideal, long-term weight loss
- Adjustments performed without additional surgery
- Supports pregnancy by allowing stomach outlet size to be opened for increased nutritional needs
- Removable at any time
- Stomach and other anatomy are generally restored to their original forms and functions
- More than 100,000 cases performed worldwide
- Standard of care for hundreds of practices around the world
- Academic publications with up to 7 years of follow-up
Gastric Restrictive Procedure - Vertical Banded Gastroplasty
Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. 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.
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Malabsorptive Procedures - Biliopancreatic Diversion
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) Infrequently Performed.
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.
Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E) Infrequently Performed.
RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it fewer operative risks 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.
Biliopancreatic Diversion with "Duodenal Switch" Infrequently Performed.
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.
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Combined Restrictive & Malabsorptive Procedure -
Gastric Bypass Roux-en-Y
In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.
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, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. 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 just 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 increased to produce lower or higher levels of malabsorption.
Advantages
- The average 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 77% 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 2000 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.
- 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 sugar or large 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, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets 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.
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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, we 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. This gives better 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. A recent study shows that patients having had laparoscopic weight loss surgery experience less 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 hernia, and patients returning more quickly to pre-surgical levels of activity.
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 not all bariatric surgeons are 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.
Bypass surgery requires a two day hospital stay versus same day surgery for the LAP-BAND® System procedure.
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