Weight-Loss Surgery Options
The American Society for Metabolic and Bariatric Surgery describes three basic approaches that weight loss surgery takes to achieve change:
- Restrictive procedures that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing the food to be incompletely absorbed.
- Combination procedures that utilize both a restrictive and a malabsorptive component.
UH Parma Medical Center offers restrictive procedures and the "gold standard" of the combination procedure, gastric bypass.
* Denotes procedures performed at Parma Hospital.
Biliopancreatic Diversion with "Duodenal Switch"
Combined Restrictive & Malabsorptive Procedure*
Gastric Bypass Roux-en-Y*
With this operation, a silastic band is introduced into the abdominal cavity through a laparoscopic approach and placed around the upper portion of the stomach. This creates a small pouch with the capacity of a large egg. This provides a sense of fullness (satiety) with a smaller amount of food. The digestive process is unaffected as the food continues to pass through the remainder of the stomach into the intestinal tract in a normal fashion.
On the underside of the band is a balloon. If weight loss slows down, the band can be tightened periodically to create a smaller pouch. This is accomplished by adding saline to the balloon through a port placed below your skin on your abdominal wall, which is connected to the band by a long, thin tube.
Patients must stay on multivitamins and calcium for the rest of their lives, as a patient would not be consuming enough food to meet daily nutritional requirements. Expected weight loss is 50 percent of a patient's excess body weight in one year.
With this relatively new procedure, approximately 85 percent of the stomach is removed through a laparoscopic approach. This leaves a sleeve, with your stomach the size and shape of a banana, extending from the esophagus to the small intestine. This restricts or limits the amount of food that can be consumed at any one time. The digestive process is unaltered. Satiety, or satisfaction, of having consumed enough food is achieved with less.
Patients must stay on multivitamins and calcium for the rest of their lives, as a patient would not be consuming enough food to meet daily nutritional requirements. Expected weight loss is about 70 percent of a patient's excess body weight in one year.
While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and alter 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 reduced, but to a much greater degree than with the gastric bypass. This procedure differs from the gastric bypass in how and when the digestive juices (i.e., bile) come into contact with the food.
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.
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.
- 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% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
- Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.
- 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, but may 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. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% 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.
Gastric Bypass Roux-en-Y
This is the "gold standard" of weight loss surgeries. According to the American Society for Metabolic and Bariatric Surgery and the National Institutes of Health, it is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (20 to 30cc) 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, thus bypassing calorie absorption. 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 average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
- One year after surgery, weight loss can average 77% of excess body weight.
- Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
- A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.
- 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 fried or greasy foods 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.
- 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.