Bariatric
Surgery:
Surgery Types & General Information
Roux-en-Y Gastric
Bypass
Adjustable Gastric Band Surgery
The most
common weight loss surgery in the United States is the Roux-en-Y
Gastric Bypass (RNYGB). Recently the Laparoscopic Adjustable
Gastric Band (AGB), which is a purely restrictive procedure, has
been used with modest short-term success. We perform both of these
bariatric surgeries at the NMMC Bariatric Center. Each surgery
offers improved health and weight loss, and also assists the patient
in reaching his/her weight loss goal as long as the proper diet and
exercise regimen is followed.
We
require the patient to be over the age of 21, generally in good
health, and meet the National Institute of Health (NIH)
recommendations for bariatric surgery. The NIH recommends bariatric
surgery for those individuals with a BMI greater than 40 or a BMI
greater than 35 with obesity related co-morbidities and who are not
successful in losing weight by other means.
Types of Weight
Loss Surgery
Roux-en-Y Gastric
Bypass
Roux-en-Y
Gastric Bypass is the most common form of weight loss surgery in the
United States. It results in reliable weight loss with acceptable
risks and minimal side effects if the patient follows post surgery
requirements such as diet, vitamin supplementation and exercise.
The
surgery creates a very small upper stomach pouch (less than one
ounce) by transecting the stomach. Part of the small intestine is
cut about 24 inches below the stomach and is re-connected to the
small stomach pouch to provide an outlet to the rest of the
intestines. The lower, larger part of the stomach is bypassed by
food but reconnects to the remainder of the small bowel six feet
downstream from the new pouch. Ingested food passes out of the upper
pouch through a small opening into the small intestine. Most of the
stomach and the first part of the small intestine are bypassed by
the food. Thus, the operation is termed a “Gastric Bypass with
Roux-en-Y gastrojejunostomy.” The major objective is to exclude
most of the stomach. The point where the bile and pancreatic
secretions are returned to mix with the ingested food is placed
several feet down from the stomach.
The
surgery is usually done with laparoscopic instruments through
several small incisions. This involves inserting a video telescope
into the abdomen through a 12mm incision. Five additional incisions
(one 12mm and four 5mm) are placed in the upper abdomen. The surgery
is then carried out using specialized instruments. This approach has
the potential advantage of smaller incisions, less pain, quicker
recovery, fewer wound complications, earlier discharge from the
hospital and less scarring while potentially providing the same
weight reduction as the traditional open approach. This requires an
incision from the breastbone to just above the umbilicus in order to
gain access to the internal organs. If for whatever reason, the
surgery cannot be safely completed using the small incisions, the
abdomen will be opened, and the surgery will be completed as an open
procedure.
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 30 to 90 percent
of excess body weight is achievable for many patients. Long-term
maintenance of weight loss is very successful – but does require
adherence to a behavioral regimen. It is important that patients who
have had a gastric bypass procedure make a lifelong commitment to
make the necessary changes in their diet. This includes maintaining
an adequate intake of protein, taking vitamin and mineral
supplements including a multivitamin, B-12, iron and calcium, and
avoiding sweets and fatty foods for the rest of their lives.
Long-term weight control is dependent upon using the pouch/tool
correctly, along with adopting a healthy lifestyle that includes
good nutrition and exercise.
Initial
weight loss (one to six months) occurs because it does not take much
food or liquid to fill the new, small pouch. This works by reducing
the feeling of hunger and thereby reducing the amount of food
intake. The result is a very early sense of fullness after eating,
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. Patients continue to enjoy eating – but they
enjoy eating a lot less. In addition, food that is eaten is not
absorbed as well as it once was, thus causing weight loss. Moderate
to rapid weight loss occurs during this time. However, it is very
important that the patient follow the recommended diet in order to
stay healthy by taking in sufficient amounts of protein, vitamins
and minerals. It is also important during these months that the
patient start getting into the habit of living a healthy lifestyle.
Over
time, the feeling of hunger will return (six to 12 months). The
patient will continue to maintain control over hunger by filling the
pouch/tool with just enough nutritious food at each meal. By doing
so, the pouch/tool actually stretches very slightly, which signals
“stretched nerves” to tell the brain to cut off the feeling of
hunger and replace with the feeling of fullness. It is very
important not to overeat and stretch the pouch too much. If this
occurs, over time the stomach will stretch back out and the
stomach/tool will no longer work effectively. Learning how to use
the pouch correctly and having long-term follow-up with the medical
and nutrition support team is necessary for successful weight loss
and management.
Adjustable Gastric
Band Surgery
This is a restrictive gastric procedure that will restrict the size
(capacity) of the stomach. The Adjustable Gastric Band surgery is
where a specialized silicone gastric band is placed around the upper
part of the stomach and filled with saline on its inner surface.
This creates a
new, smaller stomach pouch that
can hold only a small amount of food, reducing storage area in the
stomach.
Like
a wristwatch, the adjustable gastric band is fastened around the
upper stomach and then locked securely in a ring around the stomach.
The band
controls the stoma (stomach outlet) by dividing the stomach into two
portions: one small and one larger portion. Since the stomach is
divided into smaller parts, most patients feel full faster. The
concept here is to create anatomy that provides a sensation of
satiety after a very small meal. Food
digestion happens through normal digestion. When the stomach is
smaller, one feels full faster. The food moves more slowly between
the upper and lower stomach as it is digested. As a result, patients
eat less and lose weight. The favorable consequences are absence of
anemia, dumping and malabsorption, while the disadvantages include
the need for strict patient compliance.
The
Adjustable Gastric Band is a promising new technology/surgery that
is new to the United States (approved by the FDA in June 2001). This
procedure recalls the principle of doing the smallest (least
invasive) procedure possible to achieve the desired result.
The
gastric band is designed to be permanent and is not meant to be
removed.
Weight
loss for restrictive procedures such as the Adjustable Gastric
Banding is much less than that of the malabsorptive procedures such
as the Roux-en-Y Gastric Bypass. The Adjustable Gastric Band
procedure does not require stomach cutting and stapling or
gastrointestinal re-routing to bypass normal digestion.
As the
name indicates, this band is adjustable. If the rate of weight loss
is not acceptable, the band can be adjusted through an epidermal
port (a small reservoir which is placed under the skin of the
abdomen). The band can be inflated or deflated at any time after the
surgery to assist progression of weight loss. This is done by
inserting a fine needle through the skin into the access port in
order to add or remove saline (salt water). An addition of small
amounts of saline will tighten the band and removal of small amounts
of saline will loosen the band. The process usually takes only a few
minutes and most patients say it is virtually painless.
The access
port is positioned beneath the fat of your abdomen. As you lose
weight, you will be able to feel the port with your own fingertips
but it is positioned well below the surface of the skin, requires no
special care and is not visible to others. The surgeon will adjust
the band to your individual needs and requirements. In most cases
the first adjustment (often referred to as a fill) occurs
approximately six weeks after surgery. This will allow the stomach
to fully heal around the band before the first adjustment. The
number of adjustments depends on your individual weight loss and
will be determined in consultation with your surgeon.
The
diameter of the band can be modified to meet individual needs, which
can change as one loses weight. For example, pregnant patients can
expand their band to accommodate a growing fetus, while patients who
are not experiencing significant weight loss can have their bands
tightened. The Adjustable Gastric Band is also the only adjustable
weight-loss surgery available in the United States to help maintain
restriction and keep the weight off long-term.
Multiple
adjustments of the gastric band may be done every four to eight
weeks in the office as needed. Although many patients lose weight,
some or all of the lost weight can be regained by eating soft foods
that are high in carbohydrates and fat (junk food, soda, ice cream,
etc.).
What
Surgery Will Achieve?
We
consider weight loss of more than approximately 30-50 percent of
pre-surgery weight a good result. For instance, a person weighing
300 pounds who loses 90 pounds would be considered to have a good
weight loss result. We hope and expect approximately 85-90 percent
of patients to achieve good to excellent results.
The
average patient probably will lose approximately 30-35 percent of
the pre-surgery weight, but there is a great deal of variation with
some losing more and some losing less. A distinct minority of
patients will reach a truly normal weight. In fact, such marked
weight loss may not be desirable because of baggy skin and other
related problems. Successful weight loss reduces or resolves high
blood sugar levels in diabetic patients and decreases or eliminates
elevated blood pressure in approximately 90 percent of hypertensive
patients. However, these results will depend on individuals and is
not guaranteed.
Am I a
Candidate for Bariatric Surgery?
Only
morbidly obese persons (usually greater than twice the ideal body
weight) are considered for surgical treatment. Otherwise, the
expected risks may outweigh anticipated benefits. The
ideal person should:
· Clearly
and realistically understand the surgical risks and benefits and how his/her life may change after surgery.
· Be
able to participate in treatment and commit to long-term follow up.
· Be
100 pounds over ideal body weight or have a BMI of 40 or above, or
have a BMI of 35 to 40 with associated severe medical conditions
(co-morbidities).
· Provide
evidence of unsuccessful weight loss in non-surgical established
weight control programs within the past two years.
· Have
no contraindications for surgery.
Potential
Risks and Complications
Surgery
for morbid obesity is considered major surgery. As with all
surgeries, bariatric surgery carries the risk of general anesthesia
and potential complications that are more common as weight
increases.
If you are
interested in bariatric surgery to get control of morbid obesity and
other health problems, you must first consider the benefits
to be gained from surgery versus the risks that you must go
through in order to have the surgery. Usually the risks occur right
away when the surgery is performed. The benefits take a while to pay
you back in the form of improved health, reduced long-term risk of
illness and enhancement of your lifestyle.
Risks and
complications during either surgery may include perforation of the
stomach or intestine, internal bleeding, bowel obstruction. Wound
infection (including opening of the wound), incisional hernia, and
injury to the spleen with potential removal of the spleen.
Pulmonary
embolism (blood clots to your lungs from your legs), pneumonia,
atelectasis (collapse of lung tissue), fluid in the chest or other
breathing problems may occur. Compression hose and walking after
surgery assist in decreasing the incidence of blood clots. With any
major surgery, there is the risk of myocardial infarction (heart
attack), congestive heart failure, irregular heartbeat, stroke,
liver or kidney problems. Although rare (approx. 0.5-1 percent),
surgical complications may cause death. Other complications include
minor wound or skin infections, urinary tract infection, allergic
reaction to medications, excessive vomiting, dehydration,
development of loose skin, narrowing or stretching of the
anastomosis (outlet of the stomach), peptic ulcer disease, and/or
psychological reactions (i.e. depression while adjusting to new
eating and lifestyle habits). Other late problems may include
failure to lose weight or weight regain.
Roux-en-Y
Gastric Bypass surgery achieves weight loss by decreasing intestinal
absorption of food and by restricting food intake. Instead of
following its usual path, food bypasses a portion of the stomach and
small bowel. In addition to surgical complications, some people
experience long-term deficiencies of vitamins. Deficiencies reported
are B vitamins, A, C, E, K, D, folate and iron. Vitamin deficiencies
will be monitored through regular follow-up visits. Ulcers at the
site of the stomach or intestinal anastomoses (stomal ulcer) or acid
peptic ulcers in the nonfunctional large stomach pouch may occur
with Roux-en-Y Gastric Bypass surgery. Stomal ulcers may be caused
by smoking, overeating, aspirin or non-steroidal anti-inflammatory
drugs (ibuprofen, naproxen, etc.). Cortisone use in the post-surgery
period may also lead to a higher incidence of ulcers. Anemia may
occur after Gastric Bypass. Close attention must be given to iron
deficiency, especially in women of childbearing age. Taking a
multivitamin with iron usually prevents this problem. Vitamin B12
supplements may be necessary to prevent anemia.
The
benefit of improved confidence and self-esteem may occur; however,
some patients experience social or emotional upheavals. Emotional
crises such as divorce, acute job dissatisfaction, and other
problems can occur as a result of all the changes that occur after
these surgeries. Whether these problems are related to the surgeries
or weight reduction is unclear, but they have been noted.
Setting
Realistic Expectations
The goal
of surgery is to help you lose more than half of your excess weight.
This can reduce or prevent health problems. It is not cosmetic
surgery. Keep in mind that:
· Other medically managed
weight loss methods must be tried first and documented. Surgery is
only an option if other methods have not been successful.
· Surgery is meant to be
permanent. You will need to make lifestyle changes for the rest of
your life.
· You must commit to
making good food choices and being more active after surgery,
otherwise you will not maximize your weight loss.
· You will not reach a
healthy weight right away. Most of the weight is lost steadily over
12-24 months after surgery.
· The surgery is a tool
that will help you lose weight. However, by being diligent with
exercise and attending support groups and workshops, your chances of
losing more weight will dramatically increase.
Having
surgery is a personal decision as well as a medical one. Your
medical team can teach you about the surgeries and help you measure
the benefits versus the risks based on your individual situation.
The final decision is up to you. To make it intelligently, you need
to know all about the risks and benefits of the
surgery.
In order
for you to make the right decision, you will be scheduled for
several appointments with a variety doctors and/or specialists, a
psychologist, a dietitian, and other departments to have lab work
and tests done. During these visits, you will be able to ask
questions and gain more information about the surgery and recovery
period.
Benefits
of Surgery
Weight
loss is not the only reason that weight loss surgery should be
undertaken. The more important benefits of surgical treatment are
the improvements of general health and quality of life. The
following medical conditions are normally improved or eliminated
after weight loss:
·
Hypertension (high blood
pressure)
· Hyperlipidemia (high
cholesterol)
·
Heart disease
·
Diabetes
·
Asthma
·
Respiratory
insufficiency (shortness of breath)
·
Sleep apnea
·
Gastroesophageal reflux
disease (GERD) and/or heartburn
·
Gallbladder disease
·
Stress urinary
incontinence
·
Low back
pain/Degenerative disk disease
·
Arthritis/Degenerative
joint disease
·
Leg ulcers
·
A reduction in
medications
·
And others not listed
