Coastal Center for Obesity :: Surgery Options

Description of Surgeries

Bariatric surgery is growing in popularity because it has been proven to be safe and to result in significant and permanent weight loss. Bariatric surgery is the treatment of choice for the severely obese. It is recognized by the American College of Surgeons and the American Heart Association, and it is endorsed by the National Institutes of Health.

Contemporary Bariatric Operations

There are many different operations for weight loss, but all depend on the mechanisms of restriction or malabsorption or a combination of the two.

Restriction
Operations that work primarily by restriction, such as the Roux-en-Y gastric bypass and the LAP-BAND® procedure, limit food intake to very small portions. The operations accomplish this by constructing a very small stomach pouch. Because of this, fewer calories can be consumed, and weight is lost. An important aspect of restrictive operations is the feeling of fullness that accompanies the consumption of small amounts of food.

Malabsorption
Operations that work primarily by malabsorption, such as the duodenal switch procedure and the biliopancreatic diversion, limit the quantity of food that the body can digest and absorb. This is accomplished by making food bypass a large portion of the small intestine, where digestion occurs. More normal portions of food can be consumed, but it can't be completely digested and absorbed.

Both Restriction and Malabsorption
The long limb Roux-en-Y gastric bypass (or distal gastric bypass) is an operation that works by both restriction (due to a small stomach pouch) and malabsorption (due to bypassing a large amount of the small intestine).

Contemporary Bariatric Operations:

Restriction	Malabsorption	Combination

Gastric Bypass*	Duodenal Switch	Distal Gastric Bypass

LAP-BAND®*	Bilopancreatic Diversion

* operations performed at Coastal Center for Obesity

The National Institutes of Health published a consensus statement on bariatric surgery in 1991 (ref. 1). They endorsed two procedures for the surgical treatment of obesity: the gastric bypass and the gastroplasty. Gastroplasty, otherwise known as stomach stapling, has subsequently been shown to result in unacceptable weight loss. The gastric bypass operation has therefore become the operation of choice or weight loss in the United States. Currently more than 90% of all weight loss surgeries in the United States are Roux-en-Y gastric bypasses (ref. 2).

Outside the United States, adjustable gastric banding is the operation of choice for severe obesity. The FDA approved the LAP-BAND® (a type of adjustable gastric band) in June 2001 for use in the United States. This appears to be a promising option because of its less invasive nature, its reversibility, and its adjustability. Long term studies in the United States have not been done.

Operations performed at Coastal Center for Obesity
Coastal Center for Obesity offers laparoscopic and open Roux-en-Y gastric bypass and the LAP-BAND® procedure. We do not perform the duodenal switch procedure or the biliopancreatic diversion. We feel these operations are associated with more short and long term complications and therefore are not currently performing them.

Comparison between the LAP-BAND® and Gastric Bypass procedures

Lap-Band		Gastric Bypass

Less invasive Outpatient surgery Reversible Adjustable No rearrangement of anatomy Slower weight loss Not endorsed by NIH Less well studied in US More follow-up required More dietary compliance required		More invasive Inpatient surgery Not easily reversible Not adjustable Anatomy rearranged Faster weight loss Endorsed by NIH Well studied in US Less follow-up required Less dietary compliance required

Roux-en-Y Gastric Bypass

Operation

In the gastric bypass procedure, a 15-20cc stomach pouch is constructed (usual stomach approximately 1500cc or greater). The remainder of the stomach is separated from the new stomach pouch and stapled closed. This part of the stomach is not removed. The new stomach pouch is then connected to the small intestine. This is done by dividing the intestine approximately 40cm from the stomach and attaching the distal part to the stomach pouch. The proximal part of the divided intestine is then connected to the side of the intestine that was previously attached to the pouch. The roux limb is that part of the intestine between the stomach pouch and the connection to the proximal small intestine.

The difference between short limb (or proximal) and long limb (or distal) gastric bypass is the length of the roux limb. Long limb gastric bypass results in more malabsorption than short limb gastric bypass.

(click here to watch a short animation of the Roux-en-Y Bypass procedure)*
*Requires

Laparoscopic vs Open

The most significant recent advance in bariatric surgery is the technique of laparoscopy. Using laparoscopy, Roux-en-Y gastric bypass can be done with five small incisions rather that one large incision. Otherwise the laparoscopic procedure is the same as the open procedure. The laparoscopic approach results in less pain, quicker recovery, shorter hospital stay, less scarring, and quicker return to normal activity (Ref. 3). Complications related to the incision, such as infections and hernias, are nearly eliminated with the laparoscopic approach (Ref. 3).

Despite these benefits of laparoscopic surgery, only a small percentage of gastric bypasses are currently being done laparoscopically. This is because the laparoscopic approach is new and is difficult to learn. Research completed by Dr. Oliak demonstrated the difficulty of learning laparoscopic gastric bypass (Ref. 4). Dr. Oliak found that complication rates and operative times are much higher during a surgeon's first 75 laparoscopic gastric bypasses (Ref. 4). Complication rates and operative times stabilize at low rates beyond 75 procedures. The importance of this is that an experienced laparoscopic gastric bypass surgeon is essential for good outcomes. Dr. Owens, Dr. Hajduczek and Dr. Oliak have combined experience of well over 600 laparoscopic bariatric procedures, operations, and bypasses (including laparoscopic revisions). Not all patients are

appropriate for laparoscopy. Open gastric bypass is probably better for patients with BMI's of 60 or higher (more than 200 pounds overweight) (Ref. 5). Other research completed by Dr. Oliak demonstrates that serious complications occur more often in patients with BMI's of 60 or higher after the laparoscopic approach (Ref. 5). Open surgery is likely safer in this group of patients.

Results of Gastric Bypass

One-two years after surgery, weight loss averages 65-80% of excess weight (Ref. 6).
10 years after surgery, weight loss averages 55% of excess weight (Ref. 7).
Associated medical problems, such as diabetes, hypertension, sleep apnea, joint pain, and heartburn are improved or resolved in more than 90% of patients (Ref. 7,8).

Risks of Gastric Bypass

Vitamin and mineral deficiency (usually can be prevented by taking supplements).
The bypass 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.
Risks of surgery include infection, bleeding, blood clots, leaks, strictures, and bowel obstructions. In general, the benefits of gastric bypass outweigh the risks for people with BMI > 40, and for people with BMI 35-40 In the presence of medical problems associated with obesity.

Adjustable Gastric Banding (LAP-BAND®)

Adjustable gastric banding operations have been performed for the treatment of obesity in Europe and Australia for many years with proven effectiveness and safety (ref. 9-11). The LAP-BAND®, a type of adjustable gastric band, was recently approved (June 2002) for use in the United States. It is an attractive procedure because it is less invasive than a gastric bypass, adjustable, and reversible.

Operation

The LAP-BAND® consists of a silicone inflatable band and an attached access port (see picture). The band is placed around the top part of the stomach (like a belt) to form a narrow constriction. This functionally divides the stomach into a small (15cc) proximal gastric pouch and the large remainder of the stomach. Eating small amounts fills the pouch and causes a feeling of fullness.

The access port is implanted under the skin of the abdomen and connected to the band via a small tube. After surgery the tightness of the band can be adjusted for optimal weight loss by injecting or removing saline from the access port.

The operation is performed laparoscopically using five small incisions. The operation takes about an hour and patients can usually go home the day of surgery or the morning after.

Results

Long-term weight loss 40-60% of excess weight (ref. 9-11)
Weight loss 1-2 pounds per week after surgery

Risks of surgery

Vitamin and mineral deficiencies (usually can be prevented by taking supplements)
Infection, bleeding, blood clots, band slippage, and band erosion