Coastal Center for Obesity : Weight Loss Surgery : Surgery Options

Weight Loss Surgery

Bariatric Surgery

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.

Please note: Dr. Owens offers a Bloodless Medicine and Surgery (BMSP) program through select hospitals which meet the requirements of Jehovahā€™s Witnesses position. Our program, managed with medical staff guidance and oversight, provides an alternative for patients who choose to receive and/or surgical care without the use of blood transfusions. With an increase in concerns over transfusion-related reactions and disease transmission, many patients want an alternative to blood. We respect that patients have a right to refuse blood transfusions, regardless of their reasonsā€”whether they be based on religious principles or health related fears.

Obesity Treatment Options

Non-surgical methods result in little long-term success
▪ Diet and exercise
▪ Weight-loss programs
▪ Appetite suppressants
▪ Hypnosis, jaw-wiring, counseling
Doing nothing is really not an option

Using Surgery to Treat Obesity

Surgery is an option when other weight-loss therapies have failed
Types of weight-loss surgeris
▪ Malabsoptive procedures shorten the digestive tract
▪ Restrictive procedures reduce how much the stomach can hold
▪ Combined procedures shorten the digestive tract and reduce how much the stomach can hold

Malabsorptive	Restrictive	Combined	Restrictive and Adjustable

Bilio-Pancreatic Diversion (BPD)	Vertical Banded Gastroplasty (VBG)	Gastric Bypass (GBP)	LAP-BANDĀ® System

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.

Restriction

Restriction Operations that work primarily by restriction, such as the Roux-en-Y gastric bypass and the LAP-BANDĀ® 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.

Both Malabsorption and Restriction

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).

The National Institute 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-BANDĀ® (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, LAP-BANDĀ® and sleeve gastroplasty procedure.

Gastric Bypass:

Gastric Bypass is the most common surgical procedure for weight loss. The Gastric Bypass creates a small upper stomach pouch from which the rest of the stomach is permanently divided. A segment of the small intestine is then attached to the pouch allowing food to bypass most of the stomach and the first part of the small intestine. No stomach or intestine is removed during surgery. The new connection between stomach pouch and intestine restricts intake and changes the way food is digested. The new small stomach pouch allows the patient to feel full with much smaller meals.

Sleeve Gastroplasty:

This procedure works by restricting food intake without any bypass of the intestines or malabsorption. The stomach is restricted by dividing it vertically, creating a small vertical stomach pouch shaped like a banana. The new stomach pouch measures 2-5 ounces. The remaining part of the stomach is removed. The portion of the stomach that is removed is thought to be responsible for secreting Ghrelin, the hormone that is responsible for appetite and hunger. By removing this portion of the stomach, the appetite hormone is reduced to almost nothing, usually causing a loss of appetite.

LAP-BANDĀ®:

The LAP-BANDĀ® is a device that is surgically placed around the stomach to cause weight loss. It consists of a small adjustable ring and an attached access port. The ring is placed around the top part of the stomach, partitioning the stomach into a small pouch , proximal to the ring and the remainder of the stomach distal tot the ring. The access port is implanted under the skin of the abdomen. By adding or removing saline from the access port, the tightness of the ring can be adjusted. As food is consumed, it quickly fills the small pouch, which causes a feeling of fullness.

Comparing Weight-Loss Results of Gastric Bypass to Adjustable Band

Comparing Gastric Bypass, Adjustable Band and Sleeve Gastroplasty

	Gastric Bypass	Sleeve Gastroplasty	Adjustable Band
Weight Loss:	70% one year; 60% 5-15 yr.	70% one year; later results uncertain	40-50% one year; 60% five year.
Mortality	1/500-1/600; complications 1/10 patients moderate severity.	Mortality and complications appear to be intermediate in both magnitude and number.	Mortality 1/2000; complications 1/10 patients lesser severity.
Long term complications:	Intermediate. Ulcers, bowel obstruction, reflux, anemia.	Smallest. Anticipated to be very small, reflux reported, ideal operation if high risk of stomach cancer.	Intermediate. Slip, band failure, erosion.
Magnitude of surgery:	Greatest with anatomic rearrangement.	Intermediate, involves partial gastrectomy but there are no reconnections	Smallest operation but with placement of foreign bodyā€”the band.
Surgical track record:	Largest and longest in the US. The gold standard operation.	Several small series reported with promising results but follow-up is only one year or less.	Track record is largest and longest in Europe and Australia and is 4-5 years in the US.
Ease of secondary operation:	Band may be placed over bypass with moderate difficulty and uncertain results	Easily converted to a gastric bypass with reported good results.	Moderately challenging conversion to bypass or sleeve.
Hospitalization:	Approximately 2 Ā½ days.	2 Ā½ days	0-1 days
Effect on ghrellin:	Profound	Profound	None, late elevation.
Hunger control:	Almost complete first year; usually lesser thereafter.	Like gastric bypass first year, unknown thereafter.	Minimal to moderate but consistent.
Follow-up:	Necessary at longer intervals.	Same as gastric bypass.	More frequent follow-up necessary as are fills. Follow-up costs highest.
Need for vitamins:	B12, iron, calcium.	None	None
Dumping:		None	None

References

National Institutes of Health Conference. Gastrointestinal Surgery for Severe Obesity: Consensus Development Conference Panel. Ann Intern Med 1991;115:956-961.
Mason EE, Tang S, Renquist K, Cullen J, Doherty C, Maher J. A Decade of Change in Obesity Surgery [Abstract] Obes Surg 1996;6:114.
Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, Wolfe BM. Laparoscopic vs. Open Roux-en-Y Gastric Bypass: A Randomized Study of Outcomes, Quality of Life, and Costs. Ann Surg 2001;234:279-291.
Oliak D, Ballantyne GH, Weber P, Wasielewski A, Davies RJ, Schmidt HJ. Laparoscopic Roux-en-Y Gastric Bypass: Defining the Learning Curve. Surg Endosc. In press 2002.
Oliak D, Ballantyne GH, Davies RJ, Wasielewski A, Schmidt HJ. Short-term Results of Laparoscopic Gastric Bypass in Patients with BMI Ā³ 60. Obes Surg. In press 2002.
Brolin RE. Gastric Bypass. In: Sugarman HJ, editor. The Surgical Clinics of North America: Obesity Surgery, 2001 Oct. p.1077-96.
Pories WJ, Swanson MS, MacDonald KG et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg 1995;222:339-52.
Wittgrove AC, Clark GW. Laparoscopic Roux-en-Y gastric bypass in 500 patients: technique and results, with 3-60 month follow-up. Obes Surg 2000;10:233-9.
Cadiere G.B., Himpens J., Vertruyen M., Germay O., Favretti F., Segato G. Laparoscopic Gastroplasty (Adjustable Silicone Gastric Banding). Sem Lap Surg 2000; 7:55-65.
Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obesity Surgery 1999; 9:446-452.
O'Brien P.E., Brown W.A., Smith A., McMurrick P.J., Stephens M. Prospective Study of a Laparoscopically Placed, Adjustable Gastric Band in the Treatment of Morbid Obesity. Br J of Surg; 86:113-118.