Procedure Detailed
Restrictive Operations
Purely restrictive operations only limit food intake and do not interfere with the normal digestive process. To perform the operation, doctors create a small pouch at the top of the stomach where food enters from the esophagus. At first, the pouch holds about 1 ounce of food and later may stretch to 2-3 ounces. This small outlet delays the emptying of food from the pouch into the larger part of the stomach and causes a feeling of fullness.
After the operation, patients can no longer eat large amounts of food at one time. Most patients can eat a few oundes of food without discomfort or nausea, but the food has to be soft, moist, and well chewed. Patients who undergo restrictive procedures generally are not able to eat as much as those who have combined operations.
1. Lap Band - In this procedure, a hollow band made of silicone rubber is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the rest of the stomach. The band is then inflated with a saline solution through a tube that connects the band to a plastic access port placed under the skin in the upper abdomen. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of saline solution.
Advantages:
- Simple and relatively safe
- Short recovery period
- Major complication rate is low
- No removal of any part of the stomach or intestines
- No altering of the natural anatomy
- Very short recovery periods
Disadvantages:
- About 15% failure rate because of
- Balloon leakage
- Band erosion/migration into stomach, which can cause infection
- Deep infection
- Identifying patients who will not eat through the operation is difficult
- Must return to surgeon periodically for adjustments to band via the access port to regulate stomach restriction
- Port is sometimes visible through the skin
- Not a permanent procedure and weight gain generally occurs once band is removed
2.Vertical Gastrectomy - (also called Vertical Sleeve Gastrectomy, Greater Curvature Gastrectomy, Parietal Gastrectomy, Gastric Reduction and even Vertical Gastroplasty) is performed by approximately 15 surgeons worldwide. It generates weight loss by restricting the amount of food that can be eaten (removal of stomach or vertical gastrectomy) without any bypass of the intestines or malabsorption. The stomach pouch is usually made smaller than the pouch used in the Duodenal Switch, but it is essentially the first part of the Duodenal Switch (DS)
Advantages:
- Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.
- Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
- No “dumping syndrome” because the pyloric valve which regulates the food exiting the stomach into the intestines, is preserved and the stomach functions normally
- Minimizes the chance of an ulcer occurring.
- By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are almost eliminated.
- Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2).
- Promising as a procedure for low BMI patients who cannot qualify for traditional bariatric surgery (BMI 35-45 kg/m2).
- Appealing option for those considering the Lap Band since there is no “maintenance” involved as there is with the Lap Band with saline fills, etc
- Appealing option for people with existing anemia, Crohn's disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
- It can be converted to almost any other weight loss procedure if satisfactory results are not achieved.
- Desirable alternative to a failed lap band procedure (because of erosion, infection, etc) where the patient did well on just the restrictive procedure but the band eroded or for some other reason, had to be removed.
- Can be done laparoscopically even in patients weighing more than 500 pounds
Disadvantages:
- Potential for inadequate weight loss or weight regain. While true for all procedures, it is theoretically more possible with procedures without intestinal bypass.
- Higher BMI patients will may need to have a second stage procedure later to help lose all of their excess weight. Two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.
- Soft calories from ice cream, milk shakes, etc., can be absorbed and may slow weight loss.
- This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
- Because a large portion of the stomach is removed, technically it is not reversible. However, it can be converted to almost any other weight loss procedure.
- Considered investigational by some surgeons and insurance companies.
Advantages/Disadvantages Overview
Advantages: Restrictive operations are easier to perform and are generally safer than malabsorptive operations. Both procedures can be done via laparoscopy, which uses smaller incisions, creates less tissue damage, and involves shorter operating time and hospital stays than open procedures. Restrictive operations result in few nutritional deficiencies.
Disadvantages: Patients who undergo restrictive-only operations generally lose less weight than patients who have malabsorptive operations, and are less likely to maintain weight loss over the long term. Patients generally lose about half of their excess body weight in the first year after restrictive procedures. However, in the first 3 to 5 years after VBG patients may regain some of the weight they lost. By 10 years, as few as 20 percent of patients have kept the weight off. (Although there is less information about long-term results with the Lap Band, there is some evidence that weight loss results are better than with VBG.) Some patients regain weight by eating high-calorie soft foods that easily pass through the opening to the stomach. Others are unable to change their eating habits and do not lose much weight to begin with. Successful results depend on the patient's willingness to adopt a long-term plan of healthy eating and regular physical activity.
Risks: One of the most common risks of restrictive operations is vomiting, which occurs when the patient eats too much or the narrow passage into the larger part of the stomach is blocked. Another is slippage or wearing away of the band. A common risk of the Lap Band is breaks in the tubing between the band and the access port. This can cause the salt solution to leak, requiring another operation to repair. Some patients experience infections and bleeding, but this is much less common than other risks. Between 15 and 20 percent of VBG patients may have to undergo a second operation for a problem related to the procedure. Although restrictive operations are the safest of the bariatric procedures, they still carry risk in less than 1 percent of all cases, complications can result in death.
Because combined operations result in greater weight loss than restrictive operations, they may also be more effective in improving the health problems associated with severe obesity, such as hypertension (high blood pressure), sleep apnea, type 2 diabetes, and osteoarthritis.
Combined Restrictive/Malabsorptive Operations
Combined operations are the most common bariatric procedures. They restrict both food intake and the amount of calories and nutrients the body absorbs.
Roux-en-Y Gastric Bypass - (RNY) This operation is the most common combined procedure in the United States. First, the surgeon creates a small stomach pouch to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This reduces the amount of calories and nutrients the body absorbs. Rarely, a cholecystectomy (gall bladder removal) is performed to avoid the gallstones that may result from rapid weight loss. More commonly, patients take medication after the operation to dissolve gallstones.
Advantages:
- greatly controls food intake
- “dumping syndrome” (nausea, light-headedness, sometimes vomiting) upon consumption of sweets and simple carbohydrates that can help train someone NOT to eat them
- partially reversible in an emergency
Disadvantages:
- staple line failure
- ulcers
- narrowing/blockage of the stoma
- should be considered an irreversible procedure
- vomiting if food is not properly chewed or if food is eaten too quickly
- weight re-gain is known to happen if dietary changes are not followed long term
- “dumping syndrome” - an unpleasant reaction that can occur after a meal high in simple carbohydrates, which contain sugars that are rapidly absorbed by the body. Stomach contents move too quickly through the small intestine, causing symptoms such as nausea, bloating, abdominal pain, weakness, sweating, faintness, and sometimes diarrhea after eating.
2. Duodenal Switch - (also called vertical gastrectomy with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS) is performed by approximately 50 surgeons worldwide. It generates weight loss by restricting the amount of food that can be eaten (partial gastrectomy (i.e., vertical gastrectomy, see above) and by limiting the amount of food (specifically fat) that is absorbed into the body (intestinal bypass or duodenal switch). It is more controversial because it has a significant component of malabsorption (bypass of the intestinal tract), which seems to provide greater overall weight loss (than the RNY for example) and help maintain long-term weight loss. Of the procedures currently performed for the treatment of obesity, it has some powerful and effective components. Due to concerns of possible long-term effects of malabsorption and the technical difficulty involved with this procedure, few surgeons perform this surgery. Many insurance companies will not pay for this procedure if the RNY is available.
Advantages:
- More normal stomach allows for better eating quality, drink with meals
- No “dumping syndrome” because the pyloric valve is preserved and the stomach still functions normally
- Minimizes ulcer risk
- Very effective for high BMI patients (BMI>55 kg/m2), but can be done on lower BMI just as effectively
- The intestinal bypass is partially reversible for those having malabsorptive complications
- Laparoscopic approach is offered by some surgeons
Disadvantages:
- Chance of chronic diarrhea, possibly more foul smelling stools and gas. This can be due to dieting intake, but for the most part controlled.
- Malabsorption can lead to anemia, protein deficiency and metabolic bone disease in up to 5 percent of patients
- Carbohydrates can be well absorbed and if eaten in significant quantities lead to inadequate weight loss
- This procedure is the most complex surgical weight loss procedure. As with any of the surgeries listed complications can occur in high risk patients.(heart failure, sleep apnea)
Advantages/Disadvantages Overview
Advantages: Most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. With the Roux-en-Y gastric bypass, many patients maintain a weight loss of 60 to 70 percent of their excess weight for 10 years or more. With BPD/DS, most studies report an average weight loss of 75 to 80 percent or more of excess weight. Because combined operations result in greater weight loss than restrictive operations, they may also be more effective in improving the health problems associated with severe obesity, such as hypertension (high blood pressure), sleep apnea, type 2 diabetes, and osteoarthritis.
Disadvantages: Combined procedures are more difficult to perform than the restrictive procedures. They are also more likely to result in long-term nutritional deficiencies. This is because the operation causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed.
Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and related bone diseases. Patients must take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion procedure must also take fat-soluble (dissolved by fat) vitamins A, D, E, and K supplements.
RNY operations may also cause “dumping syndrome.” However, because the duodenal switch operation keeps the pyloric valve intact, it reduces the likelihood of dumping syndrome.
Risks:In addition to risks associated with restrictive procedures such as infection, combined operations are more likely to lead to complications. Combined operations carry a greater risk than restrictive operations for abdominal hernias if performed as an “open technique procedure” (up to 28 percent), which require a follow-up operation to correct. The risk of hernia, however, is lower (about 3 percent) when laparoscopic techniques are used.
As with any surgery, there can be complications. This list can include:
- Deep vein thrombophlebitis
- Non-fatal pulmonary embolus
- Pneumonia
- Acute respiratory distress syndrome
- Splenectomy
- Gastric leak and fistula
- Duodenal leak
- Distal Roux-en-Y leak
- Postoperative bleeding
- Duodenal stomal obstruction
- Small bowel obstruction
- Death
Laparoscopic Bariatric Surgery
In laparoscopy, the surgeon makes one or more small incisions through which slender surgical instruments are passed. This technique eliminates the need for a large incision and creates less tissue damage. Patients who are super-obese (more than 350 pounds) or have had previous abdominal operations may not be good candidates for laparoscopy, however. Adjustable gastric banding (lap band) and the vertical gastrectomy are routinely performed via laparoscopy.
This technique is often used for Roux-en-Y gastric bypass, and although less common, biliopancreatic diversion can also be performed laparoscopically. The small incisions result in less blood loss, shorter hospitalization, a faster recovery, and fewer complications than open operations. However, combined laparoscopic procedures are more difficult to perform than open procedures and can create serious problems if done incorrectly.
