• Roux-en-Y Gastric Bypass
• Laparoscopic Adjustable Gastric Banding
• Biliopancreatic Diversion with Duodenal Switch
• Laparoscopic Sleeve Gastrectomy

Gastric Bypass Roux-en-Y

Roux-En-Y Gastric Bpyass The Roux-en-Y gastric bypass operation has been used to achieve significant weight-loss in people affected by morbid obesity. The operation leads to weight-loss by combining a restrictive and malabsorptive component.

The Operation
A gastric bypass can be done through a single long incision (open) or through a series of small incisions (laparoscopic). Regardless of how the operation performed, the “inside part” is the same.

The surgery involves three basic steps:

• Creation of a small pouch (Proximal Pouch of Stomach)
• Bypassing part of the small intestine (creating the “Short” Intestinal Roux Limb)
• Attaching the bypassed intestine (Roux Limb) to the pouch

How does it reduce weight?
The small gastric pouch created during the gastric bypass limits the amount of food a person can eat during a meal. The pouch will initially hold a very small amount of food; however, by one year after surgery, a gastric bypass patient should be able to eat a meal equal in size to what a child can eat. Although the meals after gastric bypass surgery are much smaller than they were before surgery, they still give the individual the same “full” or “satisfied” feeling they used to get with a much larger meal.

After a gastric bypass, food does not have contact with the duodenum (or the first several feet of the small intestine) and results in fewer calories being absorbed overall (malabsorption). As a result of this malabsorption vitamins and minerals aren’t as well absorbed so patients must be on vitamin and mineral supplements for the remainder of their lives.

Weight-loss: After a gastric bypass, patients can expect to lose around 50-70 percent of the extra weight they are carrying. This means if someone were 100 pounds overweight, they would be expected to lose 50-70 pounds after gastric bypass.

Complications: The major complications that can occur early on after gastric bypass include bleeding, leakage, infections, bowel blockages, blood clots in the lungs (pulmonary emboli) and death. The chance of dying in the first 30 days after a gastric bypass is around .02-.5 percent.

Long-term complications that can occur after a gastric bypass include strictures, ulcers, hernias, weight regain, vitamin and mineral deficiencies and malnutrition. Most of the long-term problems linked to the gastric bypass operation can be prevented with good follow-up.

Laparoscopic Adjustable Gastric Banding

Laparoscopic Adjustable Gastric Banding is a restrictive procedure and involves placing a silastic band around the upper part of the stomach. The band essentially separates the stomach into two parts: a tiny upper pouch and a larger lower pouch. The band is connected by tubing to a port or reservoir that sits below the skin of the abdominal wall usually around the belly button (the port site varies widely by surgeon). The port cannot be seen (and often cannot be felt) from the outside. Inside of the band is a balloon that can be filled by placing fluid through the port. As the balloon is filled, it narrows the passage from upper to lower stomach which slows the passage of food. As the band is progressively filled, patients will feel “full” with smaller amounts of food.

The Operation
The procedure is performed though a number of small incisions. The operations consist of two main components:

• Securing the band in place around the top of the stomach
• Installing and attaching the fill port

How does it reduce weight?
By creating a smaller proximal stomach patients become “full” with much smaller meals. This control of hunger allows individuals to be more successful on a lifestyle change program.

Weight-loss: Weight-loss with an adjustable gastric band is typically slower than with bypass operations but steady. Band patients generally lose one to two pounds per week during the first year after band placement. Weight-loss can continue for two to three years after surgery and most patients will eventually lose 35 to 55 percent of their excess weight.

Complications: Patients contemplating adjustable gastric banding must be comfortable with the thought of having a medical device in their body for life. Although the band has an excellent safety profile, there are complications that can occur with any weight-loss operation, and the band is no different. It is important for patients to have routine follow up visits with their doctors for adjustments and monitoring, especially in the first year after surgery when the band is being adjusted.

Adjustments are made by filling the band through the port with fluid via a needle.

Biliopancreatic Diversion with Duodenal Switch

What is a Biliopancreatic Diversion with Duodenal Switch? The Biliopancreatic Diversion with Duodenal Switch (BPD/DS) is often an open operative procedure, however it may be performed laparoscopically. The Operation BPD/DS is based on a smaller stomach and combines a lower restriction and a higher level of malabsorption than the previously mentioned Roux-En-Y bypass. The outer margin of the stomach is removed (approximately two thirds) and the intestines are then rearranged so that the area where the food mixes with the digestive juices is short.

A portion of the stomach is then left with the pylorus still attached and the duodenum beginning at its end. The duodenum is then divided, allowing for the pancreatic and bile drainage to be bypassed. It is a pyloric saving procedure, which eliminates the “dumping syndrome” that is inherent to gastric bypass.

Weight-loss: The procedure allows for increased malabsorption, resulting in increased weight-loss. Foods high in fat content are not easily absorbed and will be eliminated along with the usually high calories associated with foods high fat.

In all weight-loss surgery options, carbohydrates and sugars are absorbed, so eating foods high in sugar (and calories) will still cause unwanted weight gain or inability to lose weight.

Complications: The BPD/DS requires a much longer recovery period (usually six to eight weeks), causes the greatest risk for infection (due to the size of the incision, increased operative time and exposure of the digestive organs) and usually carries a 25 percent chance for development of incisional hernia post-operatively (due to the length of the incision). The BPD/DS also carries the highest risk of nutritional deficiencies post-operatively due to malabsorption.

B-12 deficiencies are not created by the Duodenal Switch. Of course, all patients are monitored for iron and B-12 as well as other fat soluble vitamin deficiencies. BPD/DS patients are specifically monitored for fat soluble (A,D,E,K) deficiencies.

Patients who undergo BPD/DS are able to enjoy nutritional foods and eat more normally without the restriction of a small pouch (one to two ounces) as in a gastric bypass.

The BPD/DS is a more invasive operation. According to a recent analysis, BPD/DS carries a mortality rate of 1.1 percent within 30 days after surgery.

Laparoscopic Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy (LSG) originated as the restrictive part of the duodenal switch operation. In the last several years, though, it has been used by some surgeons as a staging procedure prior to a gastric bypass or duodenal switch in very high risk patients. It has also been used as a primary, stand-alone procedure by some surgeons. The Operation The majority of sleeve gastrectomies performed today are completed laparoscopically. During the sleeve gastrectomy, about 75 percent of the stomach is removed leaving a narrow gastric tube or “sleeve.” No intestines are removed or bypassed during the sleeve gastrectomy. This procedure takes one to two hours to complete.

Weight-loss: LSG is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. LSG may also cause a decrease in appetite.

Complications: LSG has been used successfully for many different types of bariatric patients. Since it is a relatively new procedure, there is only a small amount of data regarding weight-loss or weight regain beyond five years. The risk of death from LSG is 0.2 percent within 30 days after surgery.

Complications that can occur after LSG include: a leak from the sleeve can result in an infection or abscess, deep venous thrombosis or pulmonary embolism, narrowing of the sleeve (stricture) requiring endoscopic dilation, and bleeding. Major complications requiring re-operation are uncommon after sleeve gastrectomy and occur in less than 5 percent of patients.