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We work closely with our patients to find out what surgical approach will work best for their health. We perform laparoscopic weight loss surgery that combines restrictive and metabolic components.
.jpg) 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." Laparoscopy, however, 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 who 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 use 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.
In recent years, better clinical understanding of procedures combining restrictive and metabolic approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding the metabolic component, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The chemical or metabolic change that occurs with bypassing the body of the stomach and the first part of the small intestine results in 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, bypassing some nutrient absorption and adding the metabolic aspect of this operation. 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 patients committed to their care than with purely restrictive procedures.
- One year after surgery, weight loss can average 77 percent of excess body weight.
- Studies show that after 10 to 14 years, 50 to 60 percent of excess body weight loss has been maintained by some patients.
- A 2000 study of 500 patients showed that 96 percent 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.
Sleeve Gastrectomy
Sleeve gastrectomy is a restrictive and metabolic bariatric surgery. Indications for sleeve gastrectomy are evolving and the procedure is considered investigational unless used as the first stage of a two-part treatment. It is usually considered for patients with a BMI of 60 or higher. The sleeve gastrectomy will allow patients to lose enough weight to become eligible for other weight loss surgery options.
During this procedure, the surgeon creates a small, sleeve-shaped stomach - about the size of a banana. It is larger than the stomach pouch created during Roux-en-Y bypass. Approximately 85 percent of the stomach is removed leaving the sleeve-shaped stomach.
Advantages
- While the size of the stomach is reduced and a patient must minimize the amount of food they eat, their stomach still functions normally.
- Patients do not face the complications of intestinal bypass like protein and vitamin deficiencies, intestinal obstruction, anemia and osteoporosis.
- The part of the stomach that produces hormones that stimulate hunger is removed.
- There is less risk for "dumping syndrome" and ulcers.
- High-risk patients with anemia, Crohn's disease and other conditions affected by intestinal bypass can now have the surgery.
- It can be performed laparoscopically in extremely overweight patients.
Risks
- Weight gain can occur in the long term.
- Stomach stapling complications like leakage can occur.
- The procedure is not reversible.
- Post-operative bleeding, pneumonia and small bowel obstruction can occur.
- The procedure usually requires a second procedure - patients with a very high BMI will often require follow-up weight loss surgery to achieve their goal.
Lap Band
The Lap Band is a restrictive weight loss procedure. A band is placed around the top part of the stomach, separating the stomach into one small and one large portion.
The band can be adjusted to increase or decrease restriction, surgery can be reversed and digestion and absorption are normal.
This procedure is not offered at the Center for Weight Loss Surgery.
Vertical Banded Gastroplasty
Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. In this procedure, the upper stomach near the esophagus is stapled about 2.5 inches (6 cm) vertically to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and creates the feeling of fullness.
Advantages
- The major advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order. This allows nutrients and vitamins, as well as calories, to be fully absorbed into the body.
- After 10 years, studies show that patients can maintain 50 percent of their targeted excess weight loss.
Risks
- After surgery there is always the risk that stomach stapling can result in staple-line disruption causing leakage and/or serious infection. This can require prolonged hospitalization with antibiotic treatment and/or additional operations.
- Staple-line disruption in the long term can also lead to weight gain. Surgeons will sometimes divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term, staple-line disruption.
- The band or ring applied can lead to complications of obstruction or perforation, requiring surgical intervention.
- While the surgery often creates a sense of fullness, it usually does not provide the necessary feeling of satisfaction that one has had "enough" to eat.
- Because restrictive procedures completely rely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or the restricting band or ring at the pouch outlet breaking or moving, therefore allowing patients to eat too much.
- Approximately 40 percent of patients undergoing these procedures have lost less than half their excess body weight.
- As is the case with all weight loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.
This procedure is not offered at the Center for Weight Loss Surgery.
These operations also reduce the size of the stomach. But the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and change the normal digestive process - but to a much greater degree.
The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine. Absorption of nutrients and calories is also reduced, but to a much greater degree than Vertical Banded Gastroplasty.
Since food bypasses the duodenum (short section of the small intestine connecting the rest of the intestine to the stomach), these procedures have the same risks as gastric bypass - but to a greater degree.
Three different malabsorptive procedures include:
- Biliopancreatic Diversion (BPD)
- Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E)
- Biliopancreatic Diversion with "Duodenal Switch"
 Biliopancreatic Diversion (BPD)
BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb."
All the food moves through this segment - however, not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.
Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E)
RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices.
This procedure has fewer operative risks by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects.
Biliopancreatic Diversion with "Duodenal Switch"
This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end.
The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed.
The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above.
Advantages
- These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
- These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
- In one study of 125 patients, excess weight loss of 74 percent at one year, 78 percent at two years, 81 percent at three years, 84 percent at four years, and 91 percent at five years was achieved.
- Long-term maintenance of excess body weight loss can be successful if the patient follows a straightforward dietary, supplement, exercise and behavioral regimen.
Risks
- For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time or be a permanent lifelong occurrence.
- Abdominal bloating and malodorous stool or gas may occur.
- Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. Lifelong vitamin supplementing is required. If eating and vitamin supplement instructions are not rigorously followed, at least 25 percent of patients will develop problems that require treatment.
- Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
- Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.
These procedures are not offered at the Center for Weight Loss Surgery.
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