CALIFORNIA BARIATRICS AND ADVANCED LAPAROSCOPY
1381 E Herndon Ave, Suite 104
Fresno, CA 93720
   559-432-3434

   californiabariatrics@yahoo.com

 
 
 
Weight Loss Surgery Options

The American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

  1. Restrictive procedures that decrease food intake.
  2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.

Gastric Restrictive Procedure - Laparoscopic Gastric Band and Sleeve Gastrectomy
Malabsorptive Procedures - Biliopancreatic Diversion
Combined Restrictive & Malabsorptive Procedure -
Gastric Bypass Roux-en-Y
Laparoscopic or Minimally Invasive Surgery

 Gastric Band 
The Gastric Band comes in two varieties; the Lap Band (Allergan) and the Realize Band (Ethicon/Johnson & Johnson). These bands are purely restrictive and work by creating a false pouch at the top of the stomach. This pouch has very little capacity and when it stretches, will give you the sense of fullness required to avoid overeating. It can significantly and successfully help you control the "quantity" of food you eat; but it does not impact the "quality" of what you choose to eat!

Advantages

  • The primary advantage of this restrictive procedure is the ability to reduce the amount you eat via low risk procedure.
  • It does not alter your intestinal anatomy and thus does not affect your absorptive process or alter the ability to absorb your nutrients.
  • It is a simple and quick operation that requires about thirty minutes to peform and is usually an outpatient operation; no hospital stay is required.
  • On average, patients lose but are not limited to a 50% to 60% excess body weight loss.
  • Weight loss is gradual (1-2 lbs per week) and accomplished through appropriate fill adjustments and behavioral modification which may lead to longer lasting results.

Risks

  • The main risk is failure to lose weight! Purely restrictive procedures rely more heavily on dietary modification and excercise output to accomplish and maintain weight loss. Restriction can only take you so far. Soft calories, like ice cream and sodas, are not affected by the band and thus elimination from the diet is up to the patient.
  • Band prolapse/slippage (about 3%) may occur and necessitate operative adjustment or removal. In this condition, part of the main body of the stomach slides above the band and makes the pouch too large and ineffective or obstructive.
  • Band erosion (about 3%) is when the band itself erodes through the stomach and thus becomes contaminated an requires operative closure of the stomach hole and removal of the band.
  • Adjustment port (the subcutaneous device) can get infected or twist and necessitate operative adjustment or replacement.
  • The general risks of abdominal surgery apply; including but not limited to adhesions, bowel obstructions, bleeding, organ injury, conversion to open surgery, blood clots, pulmonary embolus, or need for repeat operations.
  • 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.

Sleeve Gastrectomy 
The sleeve gastrectomy is the latest procedure and works by limiting your stomach capacity and helping with satiety in a metabolic fashion. It is a permanent metabolic procedure that does not utilize a foreign body. You are left with a thin sausage shaped stomach after removing 80-90% of your native stomach.

Advantages

  • The primary advantage of this is the ability to reduce the amount you eat without the use of a foreign body.
  • It does not alter your intestinal anatomy and thus does not affect your absorptive process or alter the ability to absorb your nutrients.
  • It significantly reduces production of Ghrelin (hunger hormone) by the stomach and thus diminishes your appetite.
  • On average, patients lose but are not limited to a 50% to 60% excess body weight loss.
  • No adjustments are needed and weight loss begins immediately after the operation.

Risks

  • The main risk is failure to lose weight! Purely restrictive procedures rely more heavily on dietary modification and excercise output to accomplish and maintain weight loss. Restriction can only take you so far. Soft calories, like ice cream and sodas, are not affected by the band and thus elimination from the diet is up to the patient.
  • The gastrectomy is permanent, you cannot reverse the procedure, the majority of your stomach is physically removed.
  • Because there is transection of the stomach, there will be a staple line that is at risk for leakage from disruption of the staple line. This would require further operations to control the drainage and/or repair the leak.
  • The general risks of abdominal surgery apply; including but not limited to adhesions, bowel obstructions, bleeding, organ injury, conversion to open surgery, blood clots, pulmonary embolus, or need for repeat operations.
  • 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 restrict the amount of food consumed and alter the normal digestive process, but to a much greater degree. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or 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

  1. 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.
  2. These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
  3. 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.
  4. 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

  1. 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.
  2. Abdominal bloating and malodorous stool or gas may occur.
  3. 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.
  4. Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
  5. Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.


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.

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 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.
  • Internal hernias, chronic anastamotic ulcers, and intussusception are the main long term risks of surgery that may necessitate more future operations.
  • 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.


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 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 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.

 
 


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