- Restrictive procedures that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.
The Center for Obesity Surgery at the Hospital of Saint Raphael offers the following types of surgery:
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.
- 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 Adjustable Gastric Banding
A Laparoscopic Adjustable 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.
- 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
- gastric perforation 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
Laparoscopic Vertical Banded Gastroplasty
The Laparoscopic Vertical Banded Gastroplasty is a restrictive procedure. This
procedure will limit the amount of food that a person can ingest at any given
time that will result in decreased calorie intake therefore leading to
subsequent weight loss. The upper part of the stomach is stapled vertically and
divided completely from the normal stomach to create a small one-ounce pouch. A
polypropylene band is placed at the lower end of the pouch. This acts to fix
the size of the outlet of the pouch and prevent it from stretching. This slows
the emptying of food and creates a feeling of fullness. Digestion occurs
naturally. There is no surgery performed on the small intestine.
- Laparoscopic approach leads to decreased risk of hernia
- Less extensive surgical procedure with less pain than gastric bypass and faster recovery time
- Digestion occurs naturally; with less risk of micronutrient or protein deficiencies
- Band adjustments are not required as in adjustable gastric band surgery
- Band erosion
- Stenosis
- Blood clot to the lungs or legs
- Wound infection
- Ulceration of the pouch
- Peritonitis
Laparoscopic Sleeve Gastrectomy
The stomach is restricted by dividing it vertically and removing more than
85 percent of it. This part of the procedure is not reversible. The stomach
that remains is shaped like a thin banana and measures from 2-5 ounces (60 -
150cc). The nerves to the stomach and the outlet valve (pylorus) remain intact
with the idea of preserving the functions of the stomach while reducing the
volume. Note that there is no intestinal bypass or malabsorption with this
procedure, only stomach reduction.
- 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 pylorus is preserved.
- 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).
- Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m2).
- Appealing option for people with existing anemia, Crohn’s disease and numerous other conditions that make them too high risk for intestinal bypass procedures.
- Can be done laparoscopically in patients weighing more than 500 pounds
- 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 the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.
- Complications can include: Blood clot in the leg or to lung, postoperative bleeding, small bowel obstruction
- Considered investigational by some surgeons and insurance companies.
Laparoscopic or Minimally Invasive Surgery
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 recommends that laparoscopic weight loss
surgery should only be performed by surgeons who are experienced in both
laparoscopic and open bariatric procedures.