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Watch
the Gastric Bypass Roux-en-Y Animation
 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 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, GERD, 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.
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 as
a result of patients failing to follow the nutrition
plan by overfilling the pouch.
- 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.
Watch
the LAP-BAND® Video
 A
Gastric Band procedure is a purely restrictive surgical
procedure in which a band is placed around the upper most
part of the stomach. This band divides the stomach into
two portions, one small and one larger portion. Because
food is regulated, most patients feel full faster. Food
digestion occurs through the normal digestive process.
Advantages
- restricts the amount of food that can be consumed
at a meal
- food consumed passes through the digestive tract in
the usual order allowing it to be fully absorbed into
the body
- in multiple studies involving over 3000 patients,
excess weight loss ranged from 28-87%, with a minimum
of 2 year postoperative follow-up
- band can be adjusted to increase or decrease restriction
- surgery can be reversed
Risks
- band erosion into the stomach wall, or tearing in
the stomach wall may require additional operation
- access port leakage or twisting may require additional
operation
- may not provide the necessary feeling of satisfaction
that one has had enough to eat
- nausea and vomiting
- outlet obstruction
- pouch dilatation
- band migration/slippage, also known as gastric prolapse
may require re-operation
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 (ASBS) recommends that laparoscopic
weight loss surgery should only be performed by surgeons
who are experienced in both laparoscopic and open bariatric
procedures. Membership in the society is predicated on
completing additional training in advanced laparoscopic
bariatric surgical techniques and demonstrating a high
level of clinical experience.
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