Weight Loss Surgery Options

Gastric Banding

This is a purely restrictive procedure in which a band is placed around the uppermost 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 and absorption process.

Advantages

• It 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 a U.S. study, the average weight loss at three years after surgery was 36.2 percent of excess weight.
• The band can be adjusted to increase or decrease restriction.

Disadvantages

• Gastric perforation or erosion of the band into the stomach wall may require an additional operation to fix.
• Access port leakage or twisting may require an additional operation to fix.
• This may not provide the necessary feeling of satisfaction that one has had “enough” to eat.
• Nausea and vomiting
• The band can migrate, move or break
• Pouch dilatation
• Outlet obstruction
• Stomach herniation
• Gastroesophageal reflux

Gastric Restriction Procedure­­-Vertical Banded Gastroplasty

This is a purely restrictive procedure where the upper stomach is stapled vertically for approximately 2-1/2 inches, creating a small pouch. The outlet from this pouch is restricted by a band that slows the emptying of food, creating the feeling of having a full stomach.

Advantages

• This procedure allows a reduced amount of well-chewed food to enter and pass through the digestive tract. Nutrients and vitamins are fully absorbed into the body.
• Studies show that after 5 years, patients can maintain 25-50 percent of their targeted excess weight loss.

Disadvantages

• Post-operatively, stapling carries the risk of staple line disruption resulting in potential leakage and/or serious infection. Prolonged hospitalization with antibiotic treatment and additional surgery may be necessary.
• Long-term, staple-line disruption may also lead to weight gain. For these reasons, some surgeons divide the staple line wall of the pouch from the rest of the stomach, reducing disruption.
• The band may lead to complications of obstruction or perforation requiring surgical intervention.
• While the procedure creates a sensation of fullness, it does not provide the feeling of satisfaction that one has had enough to eat.
• There is a risk of the pouch stretching or of the band migrating or breaking, allowing patients to eat too much.
• Approximately 40 percent of patients who have undergone the procedure have lost less than half their excess body weight.

Combined Restrictive and Malabsorptive Procedure – Gastric Bypass Roux-en-Y

Combining restrictive and malabsorptive approaches increases the effectiveness of weight loss surgery for thousands of patients. Malabsorption delays food from mixing with bile and pancreatic juices that aid in the digestion and absorption of nutrients. This results in an early feeling of being both full and satisfied and reduces the desire to continue eating.

According to the American Society for Bariatric Surgery and the National Institute of Health, Roux-en-Y is the current “gold standard” for weight loss surgery and is one of the most frequently performed. In this procedure, stapling creates a small stomach pouch. The remaining stomach is not removed, but is completely divided from the new stomach pouch. The outlet for the new pouch leads directly to the small intestine. This is accomplished by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a new connection to the small stomach pouch. The length of either resulting segment of the small intestine can be increased to produce lower or higher rates of malabsorption.

Advantages

• The average excess weight loss is generally higher in a compliant Roux-en-Y patient than with purely restrictive procedures.
• One year after surgery, average weight loss can average 77 percent of excess body weight.
• Studies show that after 10 to 14 years, some patients have maintained 50 to 60 percent of excess body weight loss.

Disadvantages

• Poor absorption of iron and calcium due to the bypass can result in the lowering of total body iron and a predisposition to iron deficiency anemia. Women at risk for post-menopausal osteoporosis 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 hipbones. All of these ailments, however, can be managed with the use of a proper diet and vitamin supplements.
• A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed by Vitamin B12 pills or injections.
• A condition known as “dumping syndrome” can occur. This is when the stomach rapidly empties its contents into the small intestine when too much sugar or large amounts of food are consumed. While not considered a serious health risk, it can be unpleasant, with symptoms ranging from nausea, weakness, sweating and faintness to diarrhea after eating. After surgery, some patients may be unable to eat any sweets.
• The effectiveness of the surgery may be reduced if the stomach pouch is stretched and/or if it is initially created larger than 15-30cc.
• Should ulcers or bleeding occur, the bypassed portions of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy.

Malabsorptive Procedures – Biliopancreatic Diversion

While malabsorptive procedures reduce the size of the stomach, the resulting stomach pouch is much larger than with other procedures. The desired result of the procedures is to limit the amount of food consumed and alter the normal digestive process, but to a much greater degree. The small intestine’s anatomy is altered to divert bile and pancreatic juices, allowing them to meet ingested food in the middle or end of the small intestine. Absorption of nutrients and calories is reduced to a much greater degree than with other procedures.

Like the gastric bypass procedure, malabsorptive procedures bypass the duodenum, creating the same risk considerations involving the malabsorption of certain minerals and vitamins, only to a greater degree.

There are three approaches to biliopancreatic procedures. Each differs in how and when digestive juices come into contact with consumed food.

Biliopancreatic Diversion (BPD)

This procedure removes approximately ¾ of the stomach, reducing both food intake and acid output. To maintain proper nutrition, a large portion of the upper stomach is left intact. The small intestine is then divided into “limbs.” The alimentary limb attaches the new stomach pouch. The food moves through this segment, but little is absorbed. The second limb, the biliopancreatic limb, is connected to the side of the intestine, close to the end. This supplies digestive juices to the section of the intestine now known as the common limb. The length of the common limb determines the amount of absorption of protein, fat and fat-soluble vitamins.

Extended (Distal) Roux-en-Y Gastric Bypass

This is an alternate means of achieving malabsorption by creating a small, divided or stapled gastric pouch. A long limb of the small intestine is attached to the stomach to divert bile and pancreatic juices, avoiding the associated risks of removing the lower ¾ of the stomach. The new stomach pouch size and the length of the bypassed intestine determine the risks of ulcers, malnutrition and other side effects.

Biliopancreatic Diversion with “Duodenal Switch”

This procedure is a variation of the BPD procedure in which the stomach removal is restricted to the outer margin. A sleeve of the stomach is left along with the pylorus and the beginning of the duodenum. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The alimentary limb of the intestine is then attached to the beginning of the duodenum, while the common limb is created as it is in the BPD procedure.

Advantages

• These three techniques often result in high patient satisfaction because patients are able to eat larger meals than with other procedures.
• They can result in the greatest excess weight loss because they provide the highest rates of malabsorption.
• In a study involving 125 patients, excess weight loss of 74 percent after one year occurred, 78 percent after two years, 81 percent after three years, 84 percent after four years and 91 percent after five years.
• Long-term weight loss can be successfully maintained if the patient adheres to a dietary, supplement, exercise and behavioral regimen.

Disadvantages

• With all malabsorption procedures, there will be a period of adaptation when bowel movements may be more frequent and liquid. Most likely, this condition will lessen over time, but may be a permanent side effect.
• Abdominal bloating and malodorous stool and gas may occur.
• Lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. Lifelong vitamin supplements and proper eating must be observed.
• If not rigorously followed, at least 25 percent of patients will develop conditions requiring treatment.
• Changes in the intestinal structure can result in the increased possibility of gallstone formation and the removal of the gallbladder.
• Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.