Gastric
Bypass, Roux en-Y:
The
Gastric Bypass, Roux en-Y is considered the "gold standard"
of modern obesity surgery -- the benchmark to which other
operations are compared, for evaluation of their quality and
effectiveness.
This
operation achieves its effects by creating a very small stomach
pouch (thumb-sized, actually), from which the rest of the
stomach is permanently divided and separated. The small intestine
is cut about 18 inches below the stomach, and is re-arranged
so as to provide an outlet to the small stomach, while maintaining
the flow of digestive juices at the same time. The lower part
of the stomach is bypassed, and food enters the second part
of the small bowel within about 10 minutes of beginning the
meal. Click
here to view an animation of the procedure.
There
is very little interference with normal absorption of food
- the operation works by reducing food intake, and 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
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.
Laparoscopic
Gastric Bypass, Roux en-Y
The
techniques for performing the Gastric Bypass by laparoscopy,
or limited access, was first performed in 1993. This operation
duplicates the anatomy and physiology of the standard, open
procedure.
Laparoscopic
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 surgeon
must develop skills in operating by this new method, without
being able to feel tissue directly, and by learning to determine
where instruments are by seeing them on TV.
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. Most persons find they can
return to normal activities within 10 – 12 days, or even
sooner.
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.
With the Gastric Bypass procedures, using the laparoscopic
technique, results have been equal to, or better than, those
obtained with the open operation, but with major reduction
of discomfort and disability, and excellent cosmetic results
as an additional benefit.
Of
500 patients who have undergone laparoscopic surgery, weight
loss averages over 80% of excess body weight, one year after
surgery, and has been 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. Click
here to learn more about Laparoscopic surgery.
Laparoscopic
Adjustable Gastric Banding
Gastric
Banding is a variation on the gastroplasty, in which the stomach
is neither opened nor stapled -- a band is placed around the
outside of the upper stomach, to create an hourglass-shaped
stomach, and to produce 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, without
the usual large incision.
- 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
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.
The
most significant problem associated with the LapBand has been
alteration in the size of the stomach pouch which is isolated
above the band. This pouch may enlarge in some cases,
either due to slippage of the band, or stretching of the wall
of the pouch. This occurrence may cause poor weight
loss, reflux of gastric acid causing heartburn, and can lead
to obstruction of the stomach outlet. Stretching of
the stomach wall can cause irreversible damage to the upper
stomach, and the result in many cases is a need to remove
the band, and convert to a better operation - which might
have been done in the first place.
Laparoscopic Sleeve gastrectomy (LSG)
Laparoscopic Sleeve gastrectomy (LSG) is the restrictive part of the more extensive mixed restrictive and malabsorptive operation, gastric bypass and duodenal switch (GB/DS).
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 many other forms of bariatric surgery, the outlet valve and the nerves to the stomach remain intact.
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 superobese or high risk patients with the intention of performing a gastric bypass or duodenal switch at a later time. The stomach that remains is shaped like a thin sleeve and measures 35-60 cc 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.
Benefits
- 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 or the duodenal switch).
- 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.
Risks
-
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.
