Weight Loss Surgery Options


The American Society for Metabolic and 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, causing the food to be poorly digested and incompletely absorbed so that it is eliminated
in the stool.

• Realize™ Adjustable Gastric Band
• The LAP-BAND® System
• Laparoscopic Roux-en-Y Gastric Bypass
• Laparoscopic Sleeve Gastrectomy
• Laparoscopic or Minimally Invasive Surgery


Realize™ Adjustable Gastric Band

The Realize™ Adjustable Gastric Band is comprised of two medical devices that are implanted at the same time during surgery. The Realize Band wraps completely around the upper part of the stomach, and the Realize Injection Port is attached to the abdominal wall underneath the skin. The injection port is used to add or remove saline after surgery. The two implants are connected by a soft, thin, hollow tube.

The Realize Band is made of strong, flexible silicone and has a soft balloon that fits around the stomach. The balloon holds up to 1.8 teaspoons of sterile saline. The amount of saline controls the tightness around the stomach, which in turn determines how much food patients are able to eat and how long it takes for the food to travel to the digestive system. The system allows patients to feel full more quickly and for longer periods of time.

Advantages

• Realize mySuccess™

Realize mySuccess™ is an innovative and interactive tool designed to promote long-term success after surgery. This highly interactive Web application offers timely, valuable information and provides a vital link to your health care team between visits, enabling your bariatric program to track your progress and gather information needed to determine the correct band fill level for you. Benefits include:

  • Personalized goal setting and tracking
 

•

 Increased communication with your surgeon regarding progress
  • Better planning and tracking through interactive tools such as a food diary, exercise tracker, body image diary and daily reminders
  • Access to additional information and resources including healthy, “band-friendly” recipes

• Effective Solution for Comorbid Conditions

  • Proven to resolve or improve Type 2 diabetes, gastroesophageal reflux, hypertension, asthma and sleep apnea
 

•

Conditions often improve within weeks following surgery

• Less Trauma

  •

One of the least invasive surgical options
 

•

 No intestinal re-routing
  • No cutting or stapling of the stomach wall or bowel
  • Reduced patient pain, hospital length of stay (can be less than 24 hours) and recovery period. Most patients resume normal routines within one to two weeks.

• Adjustable

  •

Allows individualized stoma size for ideal, long-term weight loss
 

•

 Adjustments performed without additional surgery and only take about 10 minutes
  • Customized stoma size reduces incidence of dilatations and obstructions
  • Supports pregnancy by allowing stoma opening to facilitate increased nutritional needs

• Reversible

  •

Removable at any time
 

•

 Stomach and other anatomy are generally restored to their original form and function

• Fewer Side Effects

  •

Has a lower leak rate than all other adjustable gastric bands
 

•

 Food digestion happens through normal digestion, and healthy weight loss occurs at a target rate of one to two pounds per week.
  • Restrictive procedure ensures low risk of nutritional deficiencies and no risk of malabsorptive complications
  • No increased risk of hair loss
  • No “dumping syndrome” related to dietary intake restrictions

• Lower Risk of Complications

  •

Minimal peri- and post-operative complications
 

•

 No risk of staple line disruption and associated complications
  • Reduced anesthesia time
  • Reduced tissue handling and trauma
  • Lower mortality risk as compared to other invasive obesity surgery procedures


The LAP-BAND® System

The LAP-BAND® System is a restrictive device that wraps around the stomach to limit food consumption. Patients feel full more quickly, enabling them to eat less and lose weight. There is no cutting, stapling or intestinal re-routing. The LAP-BAND® System is the least invasive bariatric procedure and is performed laparoscopically. The LAP-BAND® System is the only reversible and adjustable option. Patients receive adjustments in an office setting for a customized rate of weight loss.

The LAP-BAND® System is a fully adjustable silicone band that is placed around the upper stomach to form a small gastric pouch and stoma. The band is connected by kink-resistant tubing to a subcutaneous access port. To adjust the LAP-BAND® System, a special non-coring needle is inserted into the port, and saline is added or removed to inflate or deflate the LAP-BAND® System.

Advantages

• Effective Solution for Comorbid Conditions

  • Proven to resolve or improve Type 2 diabetes, gastroesophageal reflux, hypertension, asthma and sleep apnea
  • Conditions often improve within weeks following surgery

• Less Trauma

  • One of the least invasive surgical options
  • No intestinal re-routing
  • No cutting or stapling of the stomach wall or bowel
  • Reduced patient pain, hospital length of stay (can be less than 24 hours) and recovery period. Most patients resume normal routines within one to two weeks

• Adjustable

  • Allows individualized stoma size for ideal, long-term weight loss
  • Adjustments performed without additional surgery
  • Customized stoma size reduces incidence of dilatations and obstructions
  • Supports pregnancy by allowing stoma opening to facilitate increased nutritional needs

• Reversible

  • Removable at any time
  • Stomach and other anatomy are generally restored to their original form and function

• Fewer Side Effects

  • Restrictive procedure ensures low risk of nutritional deficiencies and no risk of malabsorptive complications
  • No increased risk of hair loss
  • No “dumping syndrome” related to dietary intake restrictions

• Lower Risk of Complications

  • Minimal peri- and post-operative complications
  • No risk of staple line disruption and associated complications
  • Reduced anesthesia time
  • Reduced tissue handling and trauma
  • Lowest mortality risk as compared to other invasive obesity surgery procedures

The LAP-BAND® System is one of the safest, simplest weight-loss surgery option available, and is highly effective in long-term success. Since its international introduction in 1993, nearly 150,000 procedures have been performed worldwide. All certified LAP-BAND® System surgeons complete a comprehensive training workshop and must meet the requirements of the mandatory proctoring session with an experienced LAP-BAND® System proctor.

LAP-BAND® is a registered trademark of Allergan, Inc.


Laparoscopic Roux-en-Y Gastric Bypass

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 Metabolic and 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.

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 Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy involves surgically removing 85% or more of the stomach, resulting in a new stomach roughly the size and shape of a banana. It is a purely restrictive operation and generates weight loss by restricting the amount of food (and therefore calories) that can be consumed. The procedure is also believed to have some affect on the gastrointestinal tract hormones responsible for control of hunger and diabetes. Laparoscopic sleeve gastrectomy differs from gastric banding procedures in that it does not require implantation of an artificial device and is not reversible.

Laparoscopic sleeve gastrectomy is currently used as a primary bariatric procedure for patients with a body mass index (BMI) greater than 35 kg/m2, and as the first of a two-step process for patients with a BMI of 50 or greater, with further bariatric surgery taking place once the patient’s weight has fallen to a point where other forms of surgery are viable. It is also used in high risk patients who may have otherwise been considered poor candidates for the laparoscopic gastric bypass.

A typical laparoscopic sleeve gastrectomy patient would expect to spend one night in the hospital and would be placed on a liquid diet for the first week following surgery and gradually progress to soft proteins then solid food. Patients must remember that since this is a relatively new procedure, long term results are not yet available. From what we know so far, the expected weight loss should be between that of the gastric banding and the gastric bypass procedures. As with any bariatric or weight loss procedure, success is highly dependent on the patient’s ability to commit to the bariatric program, which includes compliance with diet, exercise, office visits, vitamins and support group attendance.

Advantages

• Although the stomach is reduced in size and the amount of food that can be consumed is restricted, the stomach otherwise functions normally and most foods can be eaten in small amounts.
• The portion of the stomach that produces ghrelin, the hormone responsible for appetite and hunger, is removed. By removing this portion of the stomach, the level of ghrelin decreases, resulting in a reduction in appetite.
• There is no disconnecting or reconnecting of the intestines, lessening the risk of complications.
• Because there is no intestinal bypass, patients would not be expected to have complications associated with that procedure, which might include intestinal obstruction, “dumping syndrome,” anemia, osteoporosis, vitamin deficiency and protein deficiency.
• The procedure is performed laparoscopically even on patients weighing more than 500 pounds. The stomach restriction can allow these patients to lose more than 100 pounds, thereby improving health and resolving medical problems such as diabetes and sleep apnea and placing these patients in a lower risk group, making other weight loss surgery possible.

Disadvantages

• Because the stomach is removed, the procedure is not reversible.
• There is a greater potential for insufficient weight loss or weight regain because the procedure does not limit the types of food that can be eaten.
• A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
• The procedure involves stomach stapling; and, although the risk is minimal, leaks and other complications related to stapling may occur.
• Insurance coverage of the procedure is very limited and most patients would need to consider self-pay or other financing options.


Laparoscopic or Minimally Invasive Surgery

For the last decade, 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 several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.

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 Metabolic and Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.


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