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Weight Loss Surgery Options

Lady lost more than 100 lbs and is insulin free since Gastric Bypass surgery!

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.
  • Laparoscopic Roux-en-Y Gastric Bypass
  • Laparoscopic Sleeve Gastrectomy
  • Loop Duodenal Switch

 


Laparoscopic Roux-en-Y Gastric Bypass
Click here to see how robotic Gastric Bypass is performed.

Click here to see how robotic Gastric Bypass is performed.

 

 

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 small intestine, 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% 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.

Loop Duodenal Switch

The Loop Duodenal Switch or SIPS procedure (Stomach Intestinal Pylorus Sparing) is a new variation of the standard Duodenal Switch operation. The stomach is restricted and absorption is decreased while providing good long-term weight loss with less complications and malnutrition risks.

In this procedure the upper part of the stomach is removed, creating a banana-shaped sleeve. Although the stomach capacity is reduced, the basic function of the stomach is preserved.

The sleeve is then connected to the small bowel between the pyloric valve and common bile and pancreatic ducts. Approximately half of the upper part of the upper small intestine is bypassed. Three meters of the lower small bowel are looped and connected to the small bowel. Unlike in the standard Duodenal Switch, there is only one opening between the stomach and small intestine, as opposed to two.

Advantages:
  • Highly effective for weight loss
  • Patients keep weight off longer
  • Good diabetes remission rate
  • Lower complications than the bypass
  • Moderate malnutrition risk
  • Reduced diarrhea
  • Can be used for revisions of the sleeve
Disadvantages
  • Newer procedure
  • Need to eat more protein than the bypass
  • Serious vitamin deficiencies possible if protocols not followed