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 -  Adjustable Gastric Banding
	Laparoscopic Gastric Sleeve or Vertical Sleeve Gastrectomy
	Combined Restrictive & Malabsorptive Procedure - Gastric Bypass Roux-en-Y
	Laparoscopic or Minimally Invasive Surgery

Gastric Restrictive Procedure - Adjustable Gastric Banding (LapBand®, Realize Band®)

Gastric Banding is a purely restrictive procedure. In this procedure the upper stomach near the esophagus is narrowed by a band or belt to make a smaller stomach pouch. The outlet from the pouch is restricted by a band that slows the emptying of the food and thus creates the feeling of fullness. This surgery called the Adjustable Gastric Banding or is sometimes referred to by it's commercial product names of LapBand® or the Swedish Band®.

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 8 years, studies show that patients can maintain about 50% of targeted excess weight loss and helps heal Diabetes.
• The adjustable gastric bands may be adjusted to change the size of the outlet from the stomach pouch. 

Risks

• Postoperatively, Adjustable Banding may lead to small risk of band slippage and/or erosion. 
• Banding has no stapling involvement and no cutting of bowel. 
• The band or belt applied may lead to complications of obstruction or perforation, requiring surgical intervention.
• Characteristically, these procedures create a sense of fullness.  Small amount of bulk type food may alleviate sense of hunger.  It may be less effective for high calorie drinks and sugar-fat laden dessert. 
• 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.  Adjustable banding has lowered the risk. 
• 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. 

Laparoscopic Gastric Sleeve or Vertical Sleeve Gastrectomy

Gastric Sleeve is surgical removal of most of the stomach for creation of a long tubular or “banana” shaped stomach. This surgery involves surgical stapling, cutting, and removal of stomach parts but unlike gastric bypass, does not alter intestines. Unlike gastric banding surgery, gastric sleeve surgery does not require adjustments after surgery or leave behind an artificial device inside the body. Weight loss resulting from gastric sleeve is thought to be related to gastric restriction or to hormonal changes observed following the procedure. Up to 3 years of follow up studies are available and they reveal Sleeve Gastrectomy to be at least as effective and durable as gastric banding following surgery. Some weight loss results may approach that of gastric bypass. Long term (>5 year) studies are not yet available. Co-morbidity (diabetes, hypertension, hyperlipidemia, or sleep apnea) resolution, 12 to 24 months after sleeve gastrectomy, demonstrates comparable results to other restrictive procedures.

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. 
• There is 30-89% improved survival after 5-10 year follow up from gastric bypass studies. 

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.
• 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 

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 years.  Both the Gastric Bypass and the Adjustable Gastric Banding procedures are typically done by Laparoscopy at National Bariatric Center™. 

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 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. Studies show 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 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. At National Bariatric Center™, we uphold the highest safety standards to achieve the best Laparoscopic surgery outcomes for our patients.  Dr. Frank Chae has years of experience in Laparoscopic weight loss surgery and also trains other surgeons in this field.