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About the Procedure
Surgery may promote weight loss by several mechanisms, including the following:
- Restriction: decreasing food intake
- Malabsorption: causing food to be poorly digested and absorbed
- Hormonal changes: decreasing chemical signals that control hunger, or improving chemical signals that contribute to type 2 diabetes mellitus.
The options for the type of surgery that may be performed or may have been performed in the past include the following:
The surgical options that patients may have may be limited by their health insurance company. Most health insurance companies will approve and authorize the laparoscopic Roux-en-Y gastric bypass, the laparoscopic adjustable band, and revisional surgery.
Following is some information about each type of surgery.
Laparoscopic Roux-en-Y Gastric Bypass
We presently consider the laparoscopic Roux-en-Y (pronounced “roo on why”) gastric bypass to be the best operation for the treatment of morbid obesity:
- Roux-en-Y gastric bypass is the most commonly performed weight loss operation in the United States.
- It is considered to be the "gold standard" of obesity surgery — the benchmark to which other bariatric operations are compared.
- The Roux-en-Y gastric bypass combines restriction, mild malabsorption, and hormonal changes to optimize both weight loss and improve health problems.
- Open gastric bypass was developed in 1967 and therefore has a long, proven success record (>35 years). The laparoscopic surgical approach provides the benefits of less pain and discomfort and quicker recovery.
The operation is performed laparoscopically using 5 small (½” & ¼”) incisions, as pictured below. Occasionally additional incisions may be required.
About laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery:
- Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery usually takes 1.5 to 2 hours and is performed under general anesthesia, meaning you are fully asleep.
- A needle is inserted into your abdomen and gas is pumped into your abdomen.
- A telescope camera is then inserted through a small incision (½ inch) near your belly button. This allows the surgery to be observed on a large TV monitor.
- Four other small incisions (¼ and ½ inch) are made, through which a number of instruments can access your internal organs.
- In this procedure, stapling creates a small (15- to 20-cc, one-half ounce, “thumb-sized”) stomach pouch.
- The remainder of the stomach is not removed, but is completely stapled closed and cut away from the stomach pouch.
- The small intestine is then cut approximately 18 inches below the stomach and one end is brought up and attached to the small pouch.
- The other end of the small intestine is connected to the side of the Roux limb of the intestine creating the “Y” shape that gives the technique its name.
Normal Anatomy
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After LRYGB Surgery
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- About 1-2 months after surgery, patients should only eat small portions of food (2-4 ounces) at each meal.
- Food passes into the small stomach pouch, then into the first 3-5 feet of intestine where very little is absorbed.
- The food then passes through the “Y” area where the other portion of stomach and small intestine join. It is here where more digestion begins.
- The bypassed portion of stomach, or “gastric remnant”, is still active and produces acid and digestive juices, although no food passes through it.
- Digestive juices from the stomach, pancreas, and liver mix in at the junction of the two portions of intestine (Y anastomosis) and help digestion. From this point on, the digestive tract is normal.
The LRYGB operation helps achieve weight loss by:
- Limiting size of a patient’s meal: A thumb-sized (less than 1 ounce) stomach pouch is created and restricts how much a patient is able to eat. Patients feel full after eating only a few bites of food.
- Limiting the amount of calories and nutrients that are absorbed: The stomach and first portion of small bowel are bypassed, which limits absorption.
- Hormonal changes: Production of ghrelin, a hormone that increases appetite, is reduced after gastric bypass surgery and most patients are not as hungry as they were before surgery. Patients with type 2 diabetes mellitus also improve their blood sugars soon after surgery, before any weight loss has occurred. This is also due to hormonal changes.
Advantages of LRYGB surgery:
- The surgery is an excellent tool for gaining long-term control of weight. Patients, on average, have an excess body weight loss of 60% to 85% at one year, and an average of 50% to 60% at 10 to 14 years.
- Improvement of most obesity-related health problems is achievable for most patients. Long-term weight loss requires dietary compliance, exercise, and behavioral changes. The surgery is only a tool.
Disadvantages of LRYGB surgery (see also Risks and Complications section):
- Due to bypassing of a portion of bowel (duodenum), some vitamin and mineral deficiencies can occur. Iron and calcium are normally absorbed in the duodenum; after surgery, patients need to take iron and calcium supplements, as well as multivitamins and vitamin B-12. If these supplements are not taken regularly, patients may become anemic (low red blood cell count), develop bone disease, or nervous system problems.
- 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 cancer should occur. Rarely, surgery may be needed to assess this part of the gastrointestinal (GI) tract.
- This surgery is meant to be permanent, although reversal would be possible in very rare instances if medically necessary. Reversal would be a very lengthy, risky procedure, and patients would probably gain all of their weight back, along with the associated co-morbidities.
Laparoscopic Adjustable Gastric Banding
Laparoscopic adjustable gastric banding is considered the safest, least invasive, and only adjustable surgical treatment for morbid obesity. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed. It is not meant to be reversible.
This procedure involves placing an inflatable silicone band into the patient's abdomen. Like a wristwatch, the band is fastened around the upper stomach to create a new, tiny stomach pouch that limits and controls the amount of food eaten. It also creates a small outlet that slows the emptying process into the stomach and the intestines. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. In turn, this results in weight loss.
Since there is no cutting, stapling or stomach re-routing involved in the adjustable band procedure, it is considered the safest and least traumatic compared to other weight-loss surgeries.
If for any reason the adjustable band needs to be removed, the stomach generally returns to its original form, but patients will most likely regain their weight.
Adjustable treatment:
The diameter of the band is adjustable for a customized weight-loss rate. Your individual needs can change as you lose weight. For example, pregnant patients can expand their band to accommodate a growing fetus, while patients who aren't experiencing significant weight loss can have their bands tightened.
To modify the size of the band, its inner surface can be inflated or deflated with a saline solution. The band is connected by tubing to an access port, which is placed in the abdomen below the skin during surgery. After the operation, the surgeon can control the amount of saline in the band by entering the port with a fine needle through the skin.
Weight-loss results vary from patient to patient, and the amount of weight you lose depends on several things. The band needs to be in the right position, and you need to be committed to your new lifestyle and eating habits.
Obesity surgery is not a miracle cure:
Surgery is not a miracle cure for obesity - the pounds won’t come off by themselves.
- It is very important to set achievable weight-loss goals from the beginning. A weight loss of 2 to 3 pounds a week in the first year after the operation is possible, but one pound a week is more likely.
- Twelve to 18 months after the operation, weekly weight loss is usually less. Gastric bypass patients lose weight faster in the first year.
- The average excess weight loss achieved after adjustable banding is in the range of 35% to 40% at one year after surgery and increases to 50% to 60% at 3 years. At 5 years, some adjustable banding patients may achieve weight loss comparable to that of gastric bypass patients.
In order to have a successful outcome with adjustable banding, it is extremely important that you attend regular follow-up appointments with your bariatric surgeon. Lap-band is not meant to be removed after desired weight loss. The lifestyle changes are permanent.
Advantages of Lap-band surgery:
- Lowest mortality and complication rate
- Least invasive surgical approach
- No stapling, cutting, or intestinal re-routing
- Adjustable
Disadvantages of Lap-band surgery (see also Risks and Complications):
- Initially, weight loss is slower compared to the gastric bypass procedure.
- Weight loss with adjustable banding is quite variable. While some patients have excellent weight loss with the device, others have very little.
- It is not an effective treatment for sweet-eaters.
- Regular follow-up appointments are critical for optimal results.
- Everyone requires multiple band adjustments (at least 3 or 4). Some people require substantially more adjustments. For some people, it may be difficult to find the "green zone" where the band is tight enough for good weight loss but not so tight that it causes vomiting.
- The surgery requires implanting a foreign body. Late complications such as erosion of the band into the stomach, infection, slippage, and esophageal dilation (widening of the esophagus) (if the band is too tight) may occur.
Laparoscopic Sleeve Gastrectomy
 The laparoscopic sleeve gastrectomy procedure is a restrictive procedure that involves stapling, cutting, and removing 70% to 80% of the stomach.
The result is a stomach “tube”.
This procedure was originally developed as the first part of a “two-stage” procedure (biliopancreatic diversion or gastric bypass) to be performed in high-risk patients prior to the bypass part of the operation.
This procedure is relatively new. One study from San Francisco that enrolled 40 patients showed that the average excess weight loss at 3 years was 71%.
The risks of this surgery include staple-line leak, bleeding, and too-narrow gastric tube.
This surgery may be a good alternative in patients who are undergoing a gastric bypass operation but who have many adhesions (areas of scar tissue) from previous operations.
Patients may need to have the second portion of the procedure (converting to gastric bypass) to achieve further weight loss.
Because it is so new, currently there is limited health insurance coverage for this procedure.
Vertical Banded Gastroplasty (VBG)
 Vertical banded gastroplasty (VBG) is a “stomach stapling and banding” procedure that was performed in the past. However, this procedure has essentially been abandoned in favor of other operations.
Although early weight loss results after VBG were reported to be about 60%, long-term failure rates are 50% to 80% - meaning that over the long term, more than half of patients regain their weight or develop complications. Because of these poor long-term results, and also a high rate of blockage of the banded pouch and tendency of patients to adopt a high-calorie liquid diet, leading to regain of weight, we do not recommend or perform this surgery.
However, when revisional surgery is needed for patients who have undergone VBG, Roux-en-Y gastric bypass has with good results (see Revisional Surgery section).
Biliopancreatic Diversion (BPD) and Biliopancreatic Diversion with “Duodenal Switch”
 The biliopancreatic diversion (BPD) and bililiopancreatic diversion with "duodenoal switch" operations produce weight loss primarily by causing malabsorption, although they do have a mild restrictive component.
Weight loss with these more complicated surgeries is excellent (70% to 80% excess weight loss long-term), but patients must be very careful to strictly comply with taking vitamins and eating enough protein to avoid severe malnutrition. Replacement of fat-soluble vitamins is mandatory for patients who have undergone one of these procedures.
The risk of death with these operations is the highest among weight-loss surgeries (0.5% to 2%). A relatively large percentage of patients complain of diarrhea, unpleasant odor of stools, and flatus. Abdominal bloating is experienced by one third of patients more than once weekly. Approximately 5% to 7% of patients require nutrition through an intravenous catheter because of low protein absorption. In some cases revisional surgery is necessary to treat severe malnutrition.
We presently do not perform this procedure. Insurance coverage for this procedure is limited.
Jejunal-Ileal Bypass
Jejunal-ileal bypass surgery was the first weight-loss surgery performed, in the 1970s and early 1980s, but it is no longer performed. Although this surgery resulted in good weight loss, many problems and complications (liver disease, kidney disease, electrolyte abnormalities, severe diarrhea, bacteria overgrowth in the bowel) developed.
Patients who have had this surgery are usually advised to have it revised ‘back’ to normal gastrointestinal tract anatomy or to a gastric bypass procedure.
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