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Bariatric Surgery

Surgical Procedures

Surgery may promote weight loss by several mechanisms, including the following:

  • Restriction: decreasing food intake
  • Malabsorption: causing food to be poorly digested and absorbed
  • Hormonal changes: decreasing chemical signals that control hunger, or improving chemical signals that contribute to type 2 diabetes mellitus and metabolism.

Several types of surgery for weight loss may be performed or may have been performed in the past.

An individual patient's surgical options may be limited by the health insurance company.  Following is some information about each type of surgery.  Please check with your insurance company about your options:


Laparoscopic Roux-en-Y Gastric Bypass

We presently consider the laparoscopic Roux-en-Y (pronounced “roo on why”) gastric bypass to be the best operation for the treatment of morbid obesity:

  • Roux-en-Y gastric bypass is the most commonly performed weight loss operation in the United States.
  • It is considered to be the "gold standard" of obesity surgery — the benchmark to which other bariatric operations are compared.
  • The Roux-en-Y gastric bypass combines restriction, mild malabsorption, and hormonal changes to optimize both weight loss and improve health problems.
  • Open gastric bypass was developed in 1967 and therefore has a long, proven success record (>43 years). The laparoscopic surgical approach provides the benefits of less pain and discomfort and quicker recovery.

The operation is performed laparoscopically using 5 small (½” & ¼”) incisions, as pictured below. Occasionally additional incisions may be required.

 Laprascopic Surgery


About laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery:

  • Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery usually takes 1 to 2 hours and is performed under general anesthesia, meaning you are fully asleep.
  • A needle is inserted into your abdomen and gas is pumped into your abdomen.
  • A telescope camera is then inserted through a small incision (½ inch) near your belly button. This allows the surgery to be observed on a large TV monitor.
  • Four other small incisions (¼ and ½ inch) are made, through which a number of instruments can access your internal organs.
  • In this procedure, stapling creates a small (15- to 20-cc, one-half ounce, “thumb-sized”) stomach pouch.
  • The remainder of the stomach is not removed, but is completely stapled closed and cut away from the stomach pouch.
  • The small intestine is then cut approximately 18 inches below the stomach and one end is brought up and attached to the small pouch.
  • The other end of the small intestine is connected to the side of the Roux limb of the intestine creating the “Y” shape that gives the technique its name.
Normal Anatomy After LRYGB Surgery

Normal Anatomy

After LRYGB Surgery
  • About 1-2 months after surgery, patients should only eat small portions of food (2-4 ounces) at each meal.
  • Food passes into the small stomach pouch, then into the first 3-5 feet of intestine where very little is absorbed.
  • The food then passes through the “Y” area where the other portion of stomach and small intestine join. It is here where more digestion begins.
  • The bypassed portion of stomach, or “gastric remnant,” is still active and produces acid and digestive juices, although no food passes through it.
  • Digestive juices from the stomach, pancreas and liver mix in at the junction of the two portions of intestine (Y anastomosis) and help digestion. From this point on, the digestive tract is normal.

The LRYGB operation helps achieve weight loss by:

  • Limiting size of a patient’s meal: A thumb-sized (less than 1 ounce) stomach pouch is created and restricts how much a patient is able to eat. Patients feel full after eating only a few bites of food.
  • Limiting the amount of calories and nutrients that are absorbed: The stomach and first portion of small bowel are bypassed, which limits absorption.
  • Hormonal changes: Production of ghrelin, a hormone that increases appetite, is reduced after gastric bypass surgery and most patients are not as hungry as they were before surgery. Patients with type 2 diabetes mellitus also improve their blood sugars soon after surgery, before any weight loss has occurred. This is also due to hormonal changes.

Advantages of LRYGB surgery:

  • The surgery is an excellent tool for gaining long-term control of weight. Patients, on average, have an excess body weight loss of 60% to 85% at one year, and an average of 50% to 60% at 10 to 14 years.
  • Improvement of most obesity-related health problems is achievable for most patients. Long-term weight loss requires dietary compliance, exercise and behavioral changes. The surgery is only a tool.

Disadvantages of LRYGB surgery (see also Risks and Complications section):

  • Due to bypassing of a portion of bowel (duodenum), some vitamin and mineral deficiencies can occur. Iron and calcium are normally absorbed in the duodenum; after surgery, patients need to take iron and calcium supplements, as well as multivitamins and vitamin B-12. If these supplements are not taken regularly, patients may become anemic (low red blood cell count), develop bone disease, or nervous system problems.
  • 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 cancer should occur. Rarely, surgery may be needed to assess this part of the gastrointestinal (GI) tract.
  • This surgery is meant to be permanent, although reversal would be possible in very rare instances if medically necessary. Reversal would be a very lengthy, risky procedure, and patients would probably gain all of their weight back, along with the associated co-morbidities.

Laparoscopic Adjustable Gastric Banding

Laparoscopic adjustable gastric banding is considered the safest, least invasive, and only adjustable surgical treatment for morbid obesity. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed. It is not meant to be reversible.

 gastric banding

This procedure involves placing an inflatable silicone band into the patient's abdomen. Like a wristwatch, the band is fastened around the upper stomach to create a new, tiny stomach pouch that limits and controls the amount of food eaten. It also creates a small outlet that slows the emptying process into the stomach and the intestines. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. In turn, this hopefully will result in weight loss.

Since there is no cutting, stapling or stomach re-routing involved in the adjustable band procedure, it is considered the safest and least traumatic compared to other weight-loss surgeries.

If for any reason the adjustable band needs to be removed, the stomach generally returns to its original form, but patients will most likely regain their weight.

Adjustable treatment:
The diameter of the band is adjustable for a customized weight-loss rate. Your individual needs can change as you lose weight. For example, pregnant patients can expand their band to accommodate a growing fetus, while patients who aren't experiencing significant weight loss can have their bands tightened.

To modify the size of the band, its inner surface can be inflated or deflated with a saline solution. The band is connected by tubing to an access port, which is placed in the abdomen below the skin during surgery. After the operation, the surgeon can control the amount of saline in the band by entering the port with a fine needle through the skin.

Weight-loss results vary widely from patient to patient, and the amount of weight you lose depends on several things. The band needs to be in the right position, and you need to be committed to your new lifestyle and eating habits.

Obesity surgery is not a miracle cure:
Surgery is not a miracle cure for obesity - the pounds won’t come off by themselves.

  • It is very important to set achievable weight-loss goals from the beginning. A weight loss of 2 to 3 pounds a week in the first year after the operation is possible, but one pound a week is more likely.
  • Twelve to 18 months after the operation, weekly weight loss is usually less. Gastric bypass patients lose weight faster in the first year.
  • The average excess weight loss achieved after adjustable banding is in the range of 35% to 40% at one year after surgery and increases to 40-50% at 3 years. Some adjustable banding patients may achieve weight loss comparable to that of gastric bypass patients.
  • Patients that achieve the best results typically are younger (less than 45 years old) and have a BMI 45 or less.
  • Some patients may not lose much weight - the adjustable band just restricts how much one eats. Some patients may need a gastric bypass to affect the hormones that control their metabolism - restricting their diet isn't always enough to cause weight loss.

In order to have a successful outcome with adjustable banding, it is extremely important that you attend regular follow-up appointments with your bariatric surgeon. Adjustable gastric banding is not meant to be removed after desired weight loss. The lifestyle changes are permanent.

Advantages of adjustable gastric band surgery:

  • Lowest mortality and complication rate
  • Least invasive surgical approach
  • No stapling, cutting, or intestinal re-routing
  • Adjustable

Disadvantages of adjustable gastric band surgery (see also Risks and Complications):

  • Initially, weight loss is slower compared to the gastric bypass procedure.
  • Weight loss with adjustable banding is quite variable. While some patients have excellent weight loss with the device, others have very little.
  • It is not an effective treatment for sweet-eaters.
  • Regular follow-up appointments are critical for optimal results.
  • Everyone requires multiple band adjustments (at least 3 or 4). Some people require substantially more adjustments. For some people, it may be difficult to find the "green zone" where the band is tight enough for good weight loss but not so tight that it causes vomiting.
  • The surgery requires implanting a foreign body. Late complications such as erosion of the band into the stomach, infection, slippage, and esophageal dilation (widening of the esophagus) (if the band is too tight) may occur.

Laparoscopic Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy procedure is a restrictive procedure that involves stapling, cutting and removing 70% to 80% of the stomach.
The result is a stomach “tube."

This procedure was originally developed as the first part of a “two-stage” procedure (biliopancreatic diversion or gastric bypass) to be performed in high-risk patients prior to the bypass part of the operation.

This procedure is relatively new. One study from San Francisco that enrolled 40 patients showed that the average excess weight loss at 3 years was 71%.

The risks of this surgery include staple-line leak, bleeding, and too-narrow gastric tube.

This surgery may be a good alternative in patients who are undergoing a gastric bypass operation but who have many adhesions (areas of scar tissue) from previous operations.

Patients may need to have the second portion of the procedure (converting to gastric bypass) to achieve further weight loss.

Because it is so new, currently there is limited health insurance coverage for this procedure. As of May 2010, the only insurances that approve this procedure are Aetna Inc, United Healthcare, and CIGNA.


Vertical Banded Gastroplasty (VBG)

vertical bandingVertical banded gastroplasty (VBG) is a “stomach stapling and banding” procedure that was performed in the past. However, this procedure has essentially been abandoned in favor of other operations.

Although early weight loss results after VBG were reported to be about 60%, long-term failure rates are 50% to 80% - meaning that over the long term, more than half of patients regain their weight or develop complications. Because of these poor long-term results, and also a high rate of blockage of the banded pouch and tendency of patients to adopt a high-calorie liquid diet, leading to regain of weight, we do not recommend or perform this surgery.

However, when revisional surgery is needed for patients who have undergone VBG, Roux-en-Y gastric bypass has with good results (see Revisional Surgery section).


Biliopancreatic Diversion (BPD) and Biliopancreatic Diversion with “Duodenal Switch”

The biliopancreatic diversion (BPD) and bililiopancreatic diversion with "duodenoal switch" operations produce weight loss primarily by causing malabsorption, although they do have a mild restrictive component.

Weight loss with these more complicated surgeries is excellent (70% to 80% excess weight loss long-term), but patients must be very careful to strictly comply with taking vitamins and eating enough protein to avoid severe malnutrition. Replacement of fat-soluble vitamins is mandatory for patients who have undergone one of these procedures.

The risk of death with these operations is the highest among weight-loss surgeries (0.5% to 2%). A relatively large percentage of patients complain of diarrhea, unpleasant odor of stools, and flatus. Abdominal bloating is experienced by one third of patients more than once weekly. Approximately 5% to 7% of patients require nutrition through an intravenous catheter because of low protein absorption. In some cases revisional is necessary to treat severe malnutrition.

We presently do not perform this procedure. Insurance coverage for this procedure is limited.


Jejunal-Ileal Bypass

Jejunal-ileal bypass surgery was the first weight-loss surgery performed, in the 1970s and early 1980s, but it is no longer performed. Although this surgery resulted in good weight loss, many problems and complications (liver disease, kidney disease, electrolyte abnormalities, severe diarrhea, bacteria overgrowth in the bowel) developed.

Patients who have had this surgery are usually advised to have it revised ‘back’ to normal gastrointestinal tract anatomy or to a gastric bypass procedure.


Revisional Bariatric Surgery

Some patients who have undergone a previous surgical procedure for obesity may desire to have their surgery revised or ‘fixed.' Reasons may include the following:

  • weight regain
  • inadequate weight loss
  • poor tolerance of solid food
  • persistent vomiting
  • gastroesophageal reflux, ulcers, or other problems

Revisional bariatric surgery is complicated and should only be undertaken after evaluating the risks and benefits. Not every patient with poor weight loss after bariatric surgery is a candidate for revisional surgery.

All patients being evaluated for a revision of bariatric surgery will need to have the following information/evaluations:

  • original operative reports (if possible)
  • upper GI X-ray series – we will set this up
  • upper endoscopy – we will set this up
  • evaluation by our bariatric team
  • food diary compliance

Types of revision surgery are described below.

 

Revision of vertical-banded gastroplasty (VBG) to Roux-en Y gastric bypass (RYGB)

Vertical banded gastroplasty (VBG) is referred to by many patients as ‘stomach stapling.” Although VBG was often performed in the 1980s and 1990s for the treatment of severe obesity, this procedure has largely been abandoned in the United States in favor of other operations. It has been reported that after VBG, up to 80% of patients have poor long-term (10 year) results, including the following:

  • poor weight loss
  • high rate of blockage of the banded pouch
  • tendency to adopt a high-calorie, sweet-liquid diet that leads to poor nutrition and regaining of weight


Revision of VBG to RYGB should be considered if a patient has any of the following conditions or complications:

  • Poor weight loss or weight regain
  • Symptoms due to the banded portion of stomach
  • Solid food intolerance (protein, vegetables)
  • Frequent vomiting
  • Protein malnutrition
  • Gastroesophageal reflux symptoms and complications
  • Band erosion

Laparoscopic (minimally invasive) revision of VBG to Roux-en-Y gastric bypass is possible.

Revising VBG to gastric bypass is a longer operative procedure due to the previous scar tissue. The hospital stay is usually 2 days. A temporary drain (plastic tube) is placed at the time of surgery and patients are discharged to home with this in place. The drain is usually removed 7-10 days later. A temporary feeding tube may be placed into the bypassed portion of stomach at the time of surgery in case there is a leak. This G-tube allows liquids and nutrition for the patient until the leak heals.

The improvement that can be expected in obesity-related health problems after this type of revision surgery is similar to the improvement that can be expected after initial gastric bypass:

  • Most patients have an improvement or remission of their diabetes, high blood pressure, and sleep apnea.
  • Patients are able to tolerate protein and solid food better than with the vertical banded gastroplasty.
  • Weight loss is averages about 50% of excess weight, but can range from 0 to 100% excess weight loss.

There is a higher risk of complications (leak, stenosis, abscess) when RYGB is performed as a revision (second) versus the first weight-loss surgery, because of scar tissue from the previous operation. These complications are usually managed by keeping the drain in place (for leaks), and stretching the stricture with upper endoscopy balloon dilatation.

Patients need to be compliant with diet and follow-up appointments with us to have long-term success.

 

Revision of laparoscopic adjustable band surgery

The laparoscopic adjustable band is a restrictive surgical weight loss procedure. The weight loss achieved with the band is, on average, not as much as seen with a gastric bypass procedure. This can be frustrating to patients who were expecting to lose more weight.

Complications of laparoscopic gastric banding that may require revision include the following:

  • poor weight loss
  • band slippage
  • early pouch dilation
  • perforation
  • infection of the port or band
  • erosion of the band
  • problems with the band

Some of these complications can be addressed while leaving the band in place. Some adjustable bands may need to be removed and a gastric bypass procedure performed.

Weight loss results after converting adjustable band to gastric bypass is typically very good, with patients achieving about a weight loss of 50 to 80% of their excess weight.


Follow-Up Care with or without revision surgery after previous gastric bypass

Patients who have undergone gastric bypass surgery elsewhere are welcome to receive follow-up care in our program. Some patients can be helped by just having guidance and involvement in our organized bariatric program. Some patients may need surgical help to fix a problem or to help with their weight.

Weight loss after a primary gastric bypass operation usually ranges from 60% to 85% of excess body weight at 12 to 18 months postoperatively. Follow-up care is important because of the following:

  • Approximately 10% to 15% of patients who undergo a gastric bypass procedure will fail to achieve ‘adequate’ weight loss of 50% of their excess weight, although obesity-related health problems (diabetes, blood pressure, sleep apnea) usually improve.
  • Patients may gain weight after the first year and at 5-10 years after surgery, average excess weight loss ranges from 50% to 60%.
  • Most often this weight gain is due to poor patient compliance with diet, behavioral changes, or lack of exercise.
  • It is recommended that patients begin by keeping a food diary, limit their portion sizes, and make better food choices (avoiding carbohydrates, avoiding “grazing”).
  • An exercise program and behavioral awareness of eating habits are also important.

For some patients with weight gain after gastric bypass, revisional surgery may be able to fix a ‘technical’ problem. There may be a connection from the small gastric pouch to the ‘old’ bypassed portion of stomach. This is called a gastro-gastric fistula. This can be evaluated and detected by upper GI X-rays and endoscopy. This problem can also lead to ulcer disease and should be repaired by surgery. The weight loss result of these technical problems tends to be good.

Patients with an enlarged pouch or a wide gastric pouch-small bowel connection (gastro-jejunal anastomosis or connection) may be able to eat more than they should at meal time. Unfortunately, there are few options presently available to help fix this. Patients sometimes want surgery “to make my gastric pouch smaller.” Surgery may be of help, but health insurance companies may not approve revision surgery and thus will not cover its costs. Patients need to be extremely compliant with their preoperative evaluation to even hope for approval through their insurance company. The surgical results of weight loss after these revisions can be good, but only occurs if the patient is extremely compliant with the diet and behavioral changes required after surgery.

Some patients expect the gastric bypass surgery “to do all the work” of weight loss, without changing their behavior or eating habits.

Patients have requested “bypassing more bowel” to increase the malabsorption part of the procedure. The weight loss results of this revision surgery are usually not good, and there is an increased risk of severe nutritional problems. Patients will have to adjust their diet habits and lifestyle in order to achieve more weight loss. Further surgery of this type does not usually help with additional weight loss.

Often, with proper guidance from our bariatric team and patient compliance with our recommendations, patients can achieve further weight loss without additional surgery – but hard work and discipline are required.

 

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