When other medically supervised methods have failed, surgery offers the best option of long-term weight control for those with clinically severe obesity.
Gastric Bypass Surgery
One of the most popular and successful surgical approaches is the Roux-en-Y gastric bypass. This procedure involves stapling off a small pouch at the top of the stomach, effectively shrinking the volume of the stomach to two ounces from one gallon.
Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the duodenum (the first segment of the small intestine) as well as the first portion of the jejunum (the second segment of the small intestine). The pouch is sealed shut with a line of staples.
As gastric "bypass" implies, food is routed past much of the stomach and the first part of the small intestine. Patients lose weight because not only does this small pouch restrict the amount of food that can be eaten comfortably, but there is significantly less nutrient and calorie absorption due to the intestinal bypass. Gastric bypass patients must take calcium and multivitamin/mineral supplements daily for the rest of their life.
The majority of gastric bypass procedures now are performed using minimally invasive surgical techniques (also known as laparoscopic.) Specially designed instruments are inserted through several small incisions. Surgical video cameras called laparoscopes are also inserted, so the surgeon can see inside the body. Surgeons watch on monitors as they perform the surgery. This surgical approach reduces post-surgical pain, shortens post-surgical time in the hospital, lessens overall your recovery time and sharply reduces the risk of infections.
Some patients, depending on their weight and other health conditions, may not be eligible for the laparoscopic procedure and will require an open incision. Your surgeon will discuss this with you if necessary. Regardless of the surgical technique, Roux-en-Y gastric bypass is the same and patients experience the same results.
Laparoscopic Adjustable Gastric Band (LAP-BAND®)
Another surgical weight loss option is the LAP-BAND®, in which an inflatable band is placed around the upper part of the stomach by laparoscopic instruments inserted into the patient's abdomen through several small incisions. Like gastric bypass surgery, a new small upper stomach pouch is created that limits the stomach capacity to approximately two ounces.
As the LAP-BAND® is tightened it creates a small stomach pouch and smaller outlet to the rest of the intestines. The narrowed outlet from the stomach makes you feel full faster and it empties more slowly so you do not feel hungry between meals. The band is connected to an access port, which is placed under the skin of the abdomen. In a follow-up visit after you are healed from the surgery, the surgeon can add more fluid to the band to make it tighter and reducing the size of the stomach outlet. Fluid can also be removed to loosen the band should your nutritional needs change, such as during pregnancy. The LAP-BAND® is the only adjustable and reversible obesity surgery, though reversals should only be considered in extreme cases.
In contrast to gastric bypass, banding does not bypass the intestines and nutrients and calories are absorbed through the normal digestion process. Because of this, weight loss is typically slower than with gastric bypass and you must be very careful with your diet.
Through laparoscopic incisions, surgeons staple the stomach vertically and remove more than 85 percent of it. The stomach that remains is shaped like a slim banana, or sleeve, and remains connected to the intestines as before. This greatly restricts the amount of food that can be eaten, but does not affect the way that calories and nutrients are absorbed, potentially leading to fewer nutritional issues in the long-term.
Overall, weight loss is slightly slower than with a gastric bypass but much more rapid than after a gastric band. There is the chance for the stomach to stretch out over time allowing more food to be consumed. This procedure can be done as an alternative to the gastric band or gastric bypass, or as a first step toward gastric bypass in patients with a high BMI.
A Comparison of Procedures
||Laparoscopic Adjustable Gastric Band (LAP-BAND®)
- Relatively easy operation
- No protein/calorie malabsorption
- No vitamin or mineral deficiencies due to malabsorption
- LAP-BAND® placed by minimally invasive laparoscope
- Band can be loosened to provide more food intake during pregnancy
- Slower weight loss
- Pouch can stretch out from overeating
- Less effective with sweets eaters
- Significant dietary compliance required
- Risk of damage to the ability to swallow food
- Risk of band erosion, band slippage and allergic reaction to band
|Malabsorbative and Restrictive
||Roux-en-Y Gastric Bypass
- Sustained weight loss with limited dietary compliance
- Can be performed via minimally invasive laparoscope or open incision
- Increased risk of malnutrition and vitamin deficiency
- Limited Vitamin B absorption
- Gradual weight gain over 15 years
- Loosening of the line of staples used to create the Roux-en-Y pouch, pouch stretching or leakage
- Increased risk of gallstones
- Dumping syndrome
- Not reversible
- Reduces stomach capacity but it still functions normally so most food items can be eaten in small amounts.
- Eliminates the portion of the stomach that produces the hormones that stimulates hunger (Ghrelin).
- Dumping syndrome is avoided or minimized because the pylorus is preserved.
- By avoiding the intestinal bypass, almost eliminates the chance of intestinal obstruction (blockage), marginal ulcers, anemia, osteoporosis, protein deficiency and vitamin deficiency.
- Can be a first stage procedure for high BMI patients (BMI > 55) or a single stage procedure for low BMI patients (BMI 30-50).
- Can be done minimally invasively.
- Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss.
- Loosening of the line of staples used to create the sleeve pouch, pouch stretching or leakage.
- Not reversible, though it can be converted to a bypass.
- Considered investigational by some surgeons and insurance companies.
Benefits and Risks
The medical and emotional benefits of these weight loss surgery begin almost immediately after surgery, and the cosmetic benefits follow in their wake, including:
- Significant sustained weight loss
- Blood-sugar levels for patients with Type 2 diabetes that improve almost immediately and become completely normal within a year of surgery, especially with gastric bypass.
- Lower blood pressure
- Lower cholesterol
- Relief from sleep apnea and acid reflux
- Less osteoarthritis pain and improved mobility
- Improved mood and self-esteem
Gastric bypass, sleeve gastrectomy and gastric banding are major surgical procedures, which have risks. These include:
- Loosening of the line of staples used to create the Roux-en-Y pouch and the sleeve pouch.
- Pouch stretching or leakage.
- Vomiting because of the decreased size of the stomach, especially after overeating.
- With gastric bypass, you may experience "dumping syndrome" caused by stomach contents moving too quickly through the small intestine and rapid changes in the blood sugar levels causing bloating, pain, vomiting, sweating, rapid heart rate, lightheadedness and diarrhea.
- Wound infection –- a risk that is greatly reduced when the procedure is done laparoscopically.
- A tissue tear at the site of the incision, also called a hernia. This is a risk that is reduced by laparoscopic surgery.
- Development of gallstones, which could lead to a laparoscopic procedure known as cholecystectomy to remove the gallbladder.
- Blood clots–which most times can be avoided by wearing special stockings, compression boots and injected blood thinners for a few days after surgery.
- Vitamin deficiencies–prevented by taking daily vitamin supplements for life.
- Complications from the body's ability to tolerate the gastric band implanted in the body.
- Band slippage, erosion and deflation.
- Obstruction of the stomach or dilation of the esophagus.