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Weight Loss Surgery Options Introduction

Millions of Americans first turn to diet, fitness, and medication to treat their obesity. Unfortunately, studies indicate that people will not achieve long-term weight loss through dietary and behavior modification regimens alone. Weight loss surgery is the only proven method that results in long term weight loss.

Morbidly obese people have an even greater challenge when it comes to sustaining weight loss and resolving their health conditions. Surgery may remain the best hope for these individuals to lose weight and keep it off. The three most common weight loss surgical procedures are Gastric Banding also know as The LAP-BAND® System or the REALIZE™ Band, Gastric Bypass or Roux en-Y, and the Sleeve Gastrectomy. The information provided here is meant only to give you a basic understanding of the most common weight loss surgeries available. Your weight loss surgeon and primary physician are your best resources for information about the various weight loss surgery procedures available to you.

Weight Loss Surgery Options Overview

Before we look at the three most common procedures, it is important to understand how weight loss surgery promotes weight loss and the modern tools used to perform weight loss surgery. In addition, consideration should be given to how your life as well as your body will change as a result of weight loss surgery.

There are only two basic methods of promoting weight loss via surgery: the first is through the "restriction" of food intake to reduce calories consumed, and the second through "malabsorption" which is achieved by altering the digestion process to reduce absorption of calories through the intestine. The following paragraphs will cover some facts for you to consider about the various weight loss surgery options as well as the advantages and possible drawbacks of each method.

Restrictive Procedures: Gastric banding and the sleeve gastrectomy are considered restrictive methods (decreasing food intake). The term restrictive sound negative but there is very little interference with normal absorption of food - weight loss surgery works by reducing food intake, and by reducing the feeling of hunger. The result is a very early sense of fullness, followed by a very profound sense of satisfaction. Even though the portion size may be small, there is no hunger, and no feeling of having been deprived: when truly satisfied, you feel indifferent to even the choicest of foods.  Patients continue to enjoy eating - but they enjoy eating a lot less.
  • The benefit of restrictive bariatric surgery include: a healthy and steady rate of weight loss, low risk of nutritional deficiencies, less hunger, and portion control.
  • The possible drawbacks of restrictive bariatric surgery include:
    • lack of satisfaction with eating
    • the necessity of individual to make healthy eating choices
    • and unsatisfactory weight loss.
Restrictive and Malabsorptive Procedure:

The gastric bypass surgery combines the creation of a small stomach pouch to restrict food intake and construction of bypasses of the duodenum and other segments of the small intestine to cause malabsorption (decreased ability to absorb calories and nutrients from food). This results in a faster weight loss than the purely restrictive methods but requires monitoring what you eat to ensure your body is properly nourished.

All of these weight loss surgery options should be discussed with your surgeon. Every patient is different so learn about all three and be prepared to discuss them with your surgeon. Keep in mind that weight loss surgery is recognized by the American College of Surgeons and the American Heart Association, and it is endorsed by the National Institutes of Health and many other prominent medical institutions.

General incisions for laparoscopic bariatric surgery.
Laparoscopic surgery or minimally invasive surgery first became available around 1990, when small, light-weight, high-resolution video cameras were developed, allowing surgeons to "see" into the abdomen using a pencil-thin optical telescope, and to project the picture from the video camera on a TV monitor at the head of the operating table. The benefits of the laparoscopic approach come from the very small incisions which are necessary, which cause much less pain, and very little scarring. Patients are able to get up and walk within hours after surgery, can breath easier, and move without discomfort. Bowel activity usually is not affected, as it is with an open incision.

The risks of surgery performed laparoscopically are comparable to those the standard operation – when done by an experienced and skilled laparoscopic surgeon. Some bariatric surgeons have been unable to master the techniques of advanced laparoscopic surgery, and therefore do not offer this method – or may even try to claim that it is less effective – which is certainly not true.

The results have been equal to, or better than, those obtained with the open operation, but with major reduction of discomfort, hospital time, and disability, and excellent cosmetic results as an additional benefit.

Life After Weight Loss Surgery
Bariatric surgery is an ongoing process toward weight loss through lifestyle changes. The surgery makes it physically easier to adjust your eating and lifestyle habits but the changes require permanent changes in your eating habits that must be followed for successful long term weight loss.

Postsurgery dietary guidelines will vary by bariatric surgeon and the type of weight loss surgery you undergo. What is most important is that you follow your surgeon's guidelines. The reason for the guidelines is that your digestive system has been altered and will not function in the same manner as before the surgery. The types of food, quantity, quality, and consistency of the food will all need to be monitored. In the case of gastric bypass, you will not be absorbing nutrients as you did before so it is essential that you follow a diet that allows you to get all the nutrients your body needs with the intake of very little food.

The following are some of the generally accepted dietary tips to follow after bariatric surgery:
  • Don't drink fluids while eating. They will make you feel full before you have eaten enough food. Fluids consumed with meals can cause vomiting and dumping syndrome, and can lead to feeling hungry sooner after a meal. Separate food and fluid by at least a half an hour, whenever you can.
  • Avoid carbonated drinks, high-calorie nutritional supplements, milk shakes, foods high in fat, and foods that have no nutritional value.
  • When you start eating solid food, it is important to chew your food thoroughly and eat very slowly. It is important to wait two to three minutes after swallowing before putting the next bite of food in your mouth. You will not be able to digest steaks or other chunks of meat if they are not ground or chewed thoroughly. Large chunks of food can have trouble passing through the digestive tract after surgery, and if it gets stuck along the way, it can cause pain.
  • Don't eat desserts and other items with sugar if they have more than 3 to 5 grams per serving size.
  • Avoid alcohol as you will be consuming empty callories with no nutritional value and it decreases the absorption of many vitamins and minerals, possibly contributing to vitamin/mineral deficiencies. It can also contribute to stomach ulcers, which you are already at risk for because of your surgery. Weight loss surgery also makes you more sensitive to alcohol than you were before, new research has emerged that has provided another good reason to avoid alcohol after gastric bypass surgery. Gastric bypass surgery alters the absorption and/or metabolism of alcohol in such a fashion as to increase alcohol sensitivity.

    Studies show blood alcohol levels of gastric bypass patients were 50% higher than their non-surgical counterparts. So, with one glass of wine at dinner, your blood alcohol level may be well over the legal limit allowed to drive. This can have serious ramifications for driving or doing other tasks which could jeopardize the safety of you and those around you.
  • Limit snacking between meals. Eating after bariatric surgery will be much different than before!
  • Don’t take over-the-counter drugs without your surgeon’s approval. Over-the-counter drugs can pose risks after surgery that were not a concern prior to surgery. Pain relievers like ibuprofen and acetaminophen increase the likelihood that you will develop an ulcer. Remedies for constipation shouldn’t be taken without physician approval, as constipation can be a sign of complications or a need for a change in diet.
  • Mind over matter. Don’t eat if you aren’t hungry. Just because the clock says it is time for a meal, doesn’t mean you should eat one. Learn to listen to your smaller stomach and only eat when your body wants you to.

Gastric Banding also known as The LAP-BAND® System or the REALIZE™ Band

Gastric Band
In Gastric Banding a band is placed around the outside of the upper stomach, to create a a small pouch with a narrow outlet. The special device used to accomplish this is made of implantable silicone rubber, and contains an adjustable balloon, which allows us to adjust the function of the band, without re-operation. This device enjoys considerable advantage over the standard gastroplasty:
  • It can be inserted laparoscopically.
  • It does not require any opening in the gastrointestinal tract, so infection risk is reduced.
  • There is no staple line to come apart.
  • It is adjustable.

This device has been approved by the Food and Drug Administration (FDA) for use in the United States. Since 1993, many hundreds of thousands of these devices have been used world wide, primarily overseas. Studies have proven that the adjustable gastric band is safe and effective, at least over a 12 year period when inserted by a skilled laparoscopic surgeon, and that they produce an average weight loss of more than half the excess body weight, for most patients.   If there is a problem with the band, if you can't lose enough weight or can't adjust to the new eating habits, your surgeon may suggest removal of the band. This decision will come after your surgeon consults with you. Generally after gastric band system removal, your stomach will be restored to its original form, and the digestive tract should function normally. Please keep in mind that when the band is removed your weight will likely increase.

This operation may be particularly suited to persons between 200 and 270 lb weight, who need to find a rapid and more convenient solution, and to return to full activity very quickly:  businesspersons, salespersons, and the self-employed.  Although its effects may not be as profound as the gastric bypass, the risk of the procedure appears to be less, and the recovery time is the shortest.

Gastric Band Advantages

Minimal Trauma
  • Least invasive surgical option
  • No intestinal re-routing
  • No cutting or stapling or the stomach wall or bowel
  • Small incisions and minimal scarring
  • Reduced patient pain, length of hospital stay and recovery period
Fewer Risks and Side Effects
  • Significantly lower mortality risk compared to other obesity surgeries
  • Low risk of nutritional deficiencies associated with BPD and Gastric Bypass
  • Reduced risk of hair loss
  • No "dumping syndrome" with certain dietary elements
Adjustable
    Allows individualized degree of restriction for ideal, long-term weight-loss rate
  • Adjustments performed without additional surgery
  • Supports pregnancy by allowing stomach outlet size to be opened to accommodate increased nutritional needs
Reversible
  • Removable at any time
  • Stomach and other anatomy are generally restored to their original forms and functions
Effective Long-Term Weight Loss
  • More than 100,000 gastric bandS placed worldwide
  • Standard of care for hundreds of surgeons around the world
  • Academic publication with up to 7 years of follow-up

Gastric Band Candidates

You may be eligible for gastric band system surgery if:
1. You are at least 18 years old.
2. Your BMI is > 40 or you weigh at least 100 pounds more than your ideal weight.
3. You have been overweight for more than 5 years.
4. Your serious weight-loss attempts have only had short-term success.
5. You are not suffering from any other disease that my have caused your obesity.
6. You are prepared to make substantial changes in your eating habits and lifestyle.
7. You are willing to continue being monitored by the specialist treating you.
8. You do not drink alcohol in excess.

If you do not meet the BMI or weight criteria, you still may be considered for surgery if your BMI is over 35 and you are suffering from serious health problems causes by your weight. Your surgeon may have additional criteria to those listed above.

Gastric Band Contraindications

The gastric band system is not right for you if:
1. You have an inflammatory disease or condition of the gastrointestinal tract, such as ulcers, severe esophagitis.
2. You have severe heart or lung disease that makes you a poor candidate for surgery.
3. You have some other disease that makes you a poor candidate for surgery.
4. You have a problem that could cause bleeding in the esophagus or stomach. This might include esophageal or gastric varices (a dilated vein). It might also be something such as congenital or acquired intestinal telangiectasias (dilation of a small blood vessel).
5. You have portal hypertension.
6. Your esophagus, stomach, or intestine is not normal (congenital or acquired). For instance you might have a narrowed opening.
7. You have or have experienced an intra-operative gastric perforation at or near the location of the intended band placement.
8. You have cirrhosis.
9. You have chronic pancreatitis.
10. You are pregnant. (If you become pregnant after the gastric band system has been placed, the band may need to be deflated. The same is true if you need more nutrition for any other reason, such as becoming seriously ill. In rare cases, removal may be needed).
11. You are addicted to alcohol or drugs.
12. You are under 18 years of age.
13. You have an infection anywhere in your body or one that could contaminate the surgical area.
14. You are on chronic, long-term steroid treatment.
15. You cannot or do not want to follow the dietary rules that come with this procedure.
16. You might be allergic to materials in the device.
17. You cannot tolerate pain from an implanted device.
18. You or someone in your family has an autoimmune connective tissue disease. That might be a disease such as systemic lupus erythematosus or scleroderma. The same is true if you have symptoms of one of these diseases.


Your surgeon will not do the operation unless he or she knows you understand the problems your excess weight is causing. Also, your surgeon will make sure you know that you have responsibilities, such as adopting new eating patterns and a new lifestyle. If you are ready to take an active part in reducing your weight, your surgeon will consider the treatment. You should be well-informed about the advantages, disadvantages, and risks involved. Be sure to investigate whether this treatment is right for you.

Gastric Bypass Roux en-Y

Gastric Bypass Roux-en-Y

The most common surgical procedure for weight loss is Gastric Bypass surgery. The Gastric Bypass, Roux en-Y is considered the "gold standard" of modern weight loss surgery, the benchmark to which other operations are compared, for evaluation of their quality and effectiveness.

The objective of Gastric Bypass, Roux en-Y surgery is to make a very small pouch (thumb-sized) out of the upper stomach, to restrict the amount of food which can be eaten.  That pouch is separated from the rest of the stomach, which is bypassed, by creating a new pathway into the intestines.  This pathway is called a “Roux en-Y” (named after the French surgeon, Dr. Roux, who first described this reconstruction in the 1800's).  The bowel is cut, and reconstructed in a Y configuration, so that two parts of the GI tract can feed into one.

Although the reconstructed "Y" configuration creates some malabsorptive traits, there is very little interference with normal absorption of food. The Gastric Bypass provides an excellent tool for gaining long-term control of weight, without the hunger or craving usually associated with small portions, or with dieting. Weight loss of 80 - 100% of excess body weight is achievable for most patients, and long-term maintenance of weight loss is very successful, but does require adherence to a simple and straightforward behavioral regimen.

Of patients who have undergone laparoscopic gastric bypass surgery; weight loss averages over 80% of excess body weight, one year after surgery, and is usually maintained over 80% for over 5 years. Over 95% of all health problems (co-morbidities) associated with their obesity have been resolved following surgery.

Patients enjoy a normal-style diet, and are satisfied to eat smaller portions.

Advantages to Gastric Bypass Surgery

  • Limits the amount of food you can consume at one time (restrictive)
  • Intestinal rerouting limits amount of calories absorbed by the body (malabsorption)
  • results in more rapid weight loss following surgery than with purely restrictive methods
  • Resolves and/or improves certain obesity-related health conditions as weight loss occurs (see list below)
  • Enables you to feel satisfied after smaller portions (provided you do not stretch our your new stomach)
  • Provides deterrent to eating sweets by giving most patients ”the dumping syndrome” (which causes cramping, diarrhea and other unpleasant symptoms) after consumption of concentrated sweets. This helps alleviate the craving for desserts and sweetened beverages in most patients. Sugar substitutes are used instead.
  • no band or foreign mechanism is introduced into the body
  • Provides you with a ”tool” to help achieve the permanent weight loss you desire
  • Gastric Bypass is designed to be permanent (resulting in long term weight loss), but it is possible to reverse the treatment. Reversal would only be considered in extreme situations and once reversed, the patient would likely regain any weight and return to morbidly obese state of health

 

Usually, the majority of all health problems (co-morbidities) associated with your obesity are resolved following surgery. Gastric Bypass often helps eliminate many medical problems like:
  • High Blood Pressure (Hypertension is high blood pressure. Blood pressure is the force of blood pushing against the walls of arteries as it flows through them. Arteries are the blood vessels that carry oxygenated blood from the heart to the body's tissues)
  • Diabetes (Type II diabetics sometimes called age-onset or adult-onset diabetes, this form of diabetes occurs most often in people who are overweight and who do not exercise)
  • Sleep Apnea (condition in which breathing stops for more than 10 seconds during sleep. Sleep apnea is a major, though often unrecognized, cause of daytime sleepiness)
  • Reflux (Heartburn - A burning pain behind the sternum that often seems to be rising from the stomach into the throat. It is usually caused by regurgitation of the acidic contents of the stomach into the oesophagus)
  • Joint Pain
  • Heel Pain
  • High Cholesterol
  • Urine Control Problems
  • Shortness of Breath
  • Leg Swelling
  • Leg Ulcers
  • Pseudotumor Cerebri (intracranial pressure that can result in headache, visual impairment, pain, and hearing problems)
  • Menstrual Irregularities
  • Obesity Hypoventilation Syndrome (excess amounts of fatty tissue surrounding the chest muscles. This excess fat places a strain on the heart, lungs, and diaphragm of the patient, making it difficult to breathe)
  • Chronic Headaches

Laparoscopic Sleeve Gastrectomy (LSG)

Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy (LSG) is the restrictive part of the more extensive mixed restrictive and malabsorptive operation called gastric bypass.

The sleeve gastrectomy is not a new procedure, but is growing in use. It is the first part of a two-stage operation. Originally, the gastric sleeve surgery was designed to be followed up by a second procedure, either gastric bypass or duodenal switch surgery. It generates weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption. With this procedure, the surgeon removes approximately 85 percent of the stomach laparoscopically so that the stomach takes the shape of a tube or "sleeve." This part of the procedure is not reversible. Unlike the gastric bypass, the outlet valve and the nerves to the stomach remain intact. Sleeve gastrectomy is primarily used to make weight loss surgery safer for high-risk patients, particularly individuals with a high body mass index (BMI greater than 50 to 60) and/or with health conditions that make them unacceptable candidates for a single, combined restrictive and malabsorptive surgery.

Because the modified stomach continues to function normally there are fewer restrictions on the types of foods which patients can consume after surgery. The quantity of food the patient can consume is greatly reduced. This is seen by many patients as being one of the benefits of the laparoscopic sleeve gastrectomy, as is the fact that the removal of the majority of the stomach also results in the virtual elimination of hormones (ghrenlin) produced within the stomach which stimulates hunger.

This procedure is usually performed on super obese or high risk patients with the intention of performing a full gastric bypass Roux en-Y at a later time. The stomach that remains is shaped like a thin sleeve and measures 35-60cc or less, depending on the preference of the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. Note that there is no intestinal bypass or malabsorption with this procedure, only stomach reduction.

Advantages of Sleeve Gastrectomy:

  • No foreign body is used (as in the adjustable gastric banding) and thus no adjustment is required.
  • If weight loss is inadequate, the patient has the option to have the second stage of the operation (gastric bypass).
  • It does not involve any bypass of the intestinal tract and thus patients avoid the complications of intestinal bypass such as intestinal obstruction, anemia, osteoporosis, vitamin deficiency and protein deficiency.
  • For lower BMI patients (35-42) who have complications (inadequate weight loss, band erosion, poor quality of life etc.) associated with gastric banding, LSG maybe a good alternative.
  • It also makes it a suitable form of surgery for patients who are already suffering from anemia, Crohn's disease and a variety of other conditions that would place them at high risk for surgery involving intestinal bypass.
  • It is one of the few forms of surgery which can be performed laparoscopically in patients who are super obese.
  • Better quality of life with less late complications as compared to gastric banding.

 

Disadvantages of Sleeve Gastrectomy:

  • Inadequate weight loss or weight regain is possible with operations that do not include an intestinal bypass. This is true of any form of purely restrictive surgery, but is perhaps especially true in the case of the sleeve Gastrectomy
  • The procedure requires stapling of the stomach and therefore leakage and of other complications directly related to stapling may occur.
  • Patients who are super obese usually require second stage operations in order to lose the rest of the excess weight if their BMI remains larger than 45, although two stages may ultimately be safer and more effective than one operation for super obese patients.
  • LSG is not reversible, but it can be converted to a gastric bypass.
  • Long-term weight loss results are unknown.

Results show that gastric sleeve patients can expect to achieve a 60 to 75% excess weight loss at 2 years. Long term results are not yet available. If weight loss is insufficient following gastric sleeve surgery, a malabsorptive weight loss procedure such as the duodenal switch may be performed in order to promote further weight loss.

If you have struggled with obesity and are looking into your bariatric options, discuss the various alternatives with your bariatric surgeon before making a decision. While you may want to get input from friends, family members and other patients as well, the final decision is ultimately yours.

The best weight loss surgery for you is not the procedure that works best for someone else, but the one that you and your doctor determine is most appropriate for your personal situation.

Weight Loss Surgery Options Conclusion

The bariatric surgery options reviewed above are just 3 of the more popular weight loss surgery treatments used today and may not be appropriate for your condition. You should discuss the various alternatives with your bariatric surgeon before deciding which one is best for you. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period, and the reality of the follow-up care that will be required. As part of routine evaluation for weight-loss surgery, they may require you to consult with a dietitian/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.

It is important to remember that there are no guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight-loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples.

Ultimately, the decision to have the procedure is up to you. After having heard all the information, you must decide if the benefits outweigh the risks. Remember, this surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

Schedule an appointment to meet with our surgeon today.