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Bariatric Surgery, Gastric Bypass, Obesity
Surgery, Laproscopic Surgery, Obesity, Fat Surgery, Morbid Obesity, Body Mass Index |
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Types of Surgical Procedures
Restriction Operations
Food intake is restricted by creating a small pouch at the
top of the stomach where food enters from the esophagus. Initially this holds about an
ounce of food. This expands to hold 2-3 ounces with time. The outlet usually has a
diameter of 1/4 inch. This delays the emptying of food from the pouch to cause a feeling
of fullness.With this procedure a patient eats only a half to one cup of food before
experiencing discomfort or nausea. All food must be well chewed. The ability to eat large
amounts of food is lost to most patients but some do return to eating modest amounts of
food without feeling hungry.
Restriction operations for obesity include gastric banding and vertical banded
gastroplasty. These both only serve to restrict food intake. This does not interfere with
normal digestive process.
 Gastric Banding: This
procedure is performed by a band of special material being surgically placed around the
stomach at the upper end. This created a small pouch and a narrow passage into the
remainder of the stomach.
Vertical Banded Gasoplasty (VBG): This procedure is frequently
used as a restrictive operation for weight control. In figure 1 you can see that both a
band and staples are used to create a small stomach pouch.
Weight loss is found in almost all patients with
restrictive operations. In all weight loss operations, success depends on patient
motivation and behavior. Regaining weight is a risk. Approximately 30% of patients
undergoing vertical banded gastroplasty achieve normal weight. Risks of this procedure
include:
vomiting caused by
stretching of the pouch by food not chewed thoroughly enough
erosion of the band
breakdown of the staple
line
leakage of stomach juices
into the abdomen. The leakage would require an emergency operation.
Gastric Bypass Operations
This type of procedure creates a small stomach pouch and
bypasses part of the small intestine.
Extensive Gastric Bypass: (biliopancreatic
diversion) With this more complicated gastric bypass operation (figure 3) portions of the
stomach are removed. The small pouch that remains is connected directly to the final
segment of the small intestine. This completely bypasses the duodenum and jejunum.
Although this procedure successfully promotes weight loss it is seldom used due to the
high risk of nutritional deficiencies.
Gastric bypass operations cause malabsorption and restrict food intake that produce more
weight loss than restriction operations that only decrease food intake. Generally
patients who have the bypass operations lose two-thirds of their excess weight within 2
years.
Risks for pouch stretching, band erosion, breakdown of staple lines, and leakage of
stomach contents into the abdomen are about the same for gastric bypass as for vertical
banded gastroplasty. Due to the gastric bypass causing food to skip the duodenum, where
most iron and calcium are absorbed, risks for nutritional deficiencies are higher in these
procedures. Anemia may result and decreased absorption of calcium may bring on
osteoporosis and metabolic bone disease. Patients are required to take nutritional
supplements that usually prevent these deficiencies.
Dumping syndrome may occur. This is where stomach contents move too rapidly through the
small intestine. Symptoms include nausea, sweating, weakness, faintness and diarrhea
after eating, as well as the inability to eat sweets without becoming weak and sweaty and
possibly having to lie down till symptoms pass. Generally, the more extensive the bypass
operation, the greater the risk for Complications' and nutritional deficiencies Patients
with extensive bypasses of the normal digestive process require not only close monitoring,
but also life-long use of medications and supplements.
Jejuno-Ileal Bypass: This procedure is no longer
performed in the United States. It was one of the earliest procedures for morbid
obesity and achieved its results by shortening the overall length of the bowel to less
than 10% of its normal length. This caused serious nutritional and metabolic side effects
and contributed to mortality in a significant number of patients. Patients who have
already had this procedure need to be under close medical supervision and should consider
a conversion to another weight control operation.
Roux-en Y Gastric Bypass: This operation is the
benchmark to which other operations are compared, for evaluation of their quality and
effectiveness. A small pouch is created along the inner curve of the stomach, and the
small intestine is attached to the pouch. This procedure provides an excellent tool for
long term control of weight without the feeling of being deprived and hungry. Patients eat
much smaller portions due to the pouch size, but they have the sense of fullness and
satisfaction that make you indifferent to even your favorite foods. You continue to enjoy
eating, just much smaller portions. Nutrition is maintained by faithfuly continuing to
take vitamin and mineral supplements.(figure 2)
Laproscopic Gastric Bypass Roux-en Y: This operation is
similar to the conventional roux-en Y gastric bypass, but is performed with multiple mini
incisions. It has the advantage of avoiding a large incision which can break down, and a
faster recovery than a conventional bypass. Sometimes it is impossible to complete the
bypass with mini incisions and a mid size incision, or conventional incision will be done
during surgery to safely complete the operation. This decision
is made by the surgeon while the patient is under anesthesia, therefore all patients must
consent to both conventional and laparoscopic approaches before surgery.
Our center considers the Gastric bypass Roux-en-Y to be
best of all the weight reduction procedures. By reducing the food intake and still
utilizing the jejunum patients have a satisfied full feeling with much less intake of
food. Studies have shown this procedure to be excellent for long term weight loss success
but requires life time patient behavioral changes. This procedure may be done
"open" or with "mini incisions" and the use of laparoscopy. The
decision of which procedure is best for you will be discussed with you at the
time of your visit.
While everyone would be overjoyed if every patient reached their ideal body weight and
stayed there, we expect on average our patients will remain somewhat overweight, but will
no longer be morbidly obese. On an average patients loose 2/3 of their excess weight in
two years, but typically they gain back a bit after that time. After following patients
for five years, the average patient stabilizes with a loss of a little more than half
their excess weight.
Nationally, less than 25% of patients fail to lose significantly or to regain to previous
levels. Reasons for failure are usually a breakdown of staple line or gradual enlargement
of the pouch. Both are usually a result of taking in too much food at once, or over eating
despite the surgery, by excessive intake of high calorie liquids or constant
"nibbling".
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