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Surgical Operations for Morbid Obesity
Gastric Bypass, Roux en-Y
We consider Gastric Bypass to be the premium operation, offering the best combination of maximum weight control, and minimum nutritional risk.
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. Our group has experience with over 6000 of these procedures, and we have striven to refine our techniques and methods to produce the maximum sustained weight loss achievable.
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.
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
We developed the techniques for performing the Gastric Bypass by laparoscopy, or limited access, and performed the first such procedure in 1993 -- we have now performed over 1200 such operations. 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.
We have now performed over 1200 Gastric Bypass procedures, using the laparoscopic technique the largest series of this procedure in the world. Our 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.
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 device has now been approved by the Food and Drug Administration (FDA) for use in the United States. Several thousand have been implanted in Europe, and the early track record of safety appeared well established. We are one of eight centers in the United States which participated in the early trial of the device.
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.
Bilio Pancreatic Diversion
The most powerful operation currently available, but accompanied by significant nutritional problems in some patients. We're concerned about this, and no longer recommend the operation for most patients.
This very powerful operation involves removal of approximately 2/3 of the stomach, and re-arrangement of the intestinal tract so that the digestive enzymes are diverted away from the foodstream, until very late in its passage through the intestine. The effect is to selectively reduce absorption of fats and starches, while allowing near-normal absorption of protein, and of sugars. Calorie intake is much reduced, even while normal-sized food portions are eaten.
Although this operation is very powerful, patients are subject to increased risk of nutritional deficiencies of protein, vitamins and minerals. Vitamin supplementation recommendations must be carefully followed, and dietary intake of protein must be maintained, while intake of fat must be limited. Patients are annoyed by frequent large bowel movements, which have a strong odor. Excess fat intake leads to irritable bowel symptoms, and may lead to rectal problems.
We have performed over 400 of these operations, and have analyzed our results and outcomes over a long term. Although most patients obtain excellent weight loss, and maintain good health and nutrition, we have been concerned that some do not maintain contact with us, or follow a healthful diet and vitamin regimen, and that this may lead to serious nutritional disturbances, or the need to revise the operation. When compared to the Gastric Bypass, in our hands, this operation achieves similar weight loss, but at a higher risk of nutritional side-effects. Therefore, we recommend it only in certain specific situations, and advise against its routine performance.
Distal Gastric Bypass
This procedure is offered by some, as a means of avoiding late weight gain which may follow the restrictive operations. We prefer to perform the restrictive operation to a higher standard, and to emphasize the importance of appropriate eating afterward.
The Gastric Bypass operation can be modified, to alter absorption of food, be moving the Y-connection downstream ("distally"), effectively shortening the bowel available for absorption of food. The weight loss effect is then a combination of the very small stomach, which limits intake of food, with malabsorption of the nutrients which are eaten, reducing caloric intake even further. Patients have increased frequency of bowel movements and increased fat in their stools (bowel movements). The odor of bowel gas is very strong, which can cause social problems or embarassment. Calcium absorption may be impaired, as well as absorption of vitamins, particularly those which are soluble in fat (Vitamins A, D, and E). Vitamin supplements must be used daily, and failure to follow the prescribed diet and supplement regimen can lead to serious nutritional problems in a small percentage of patients. We. and others, have noted an increased incidence of ulcers post-operatively, in patients having this procedure.
We have performed approximately 50 of these operations, as the primary procedure, and have generally been disappointed in the results. Our experience is that patients do not experience the feeling of satisfaction with food, which is a prominent effect of the standard Gastric Bypass, and that the risks of malnutritional complications is significantly increased. Since our results with the standard Gastric Bypass have been very gratifying, and the lifestyle of our patients is very comfortable, we do not advise this procedure, except in special circumstances - such as when a standard Gastric Bypass requires revision. In a sense, this procedure combines the least-desirable features of the Gastric Bypass with the most troublesome aspects of the Biliopancreatic Diversion. We do not offer this procedure as primary treatment.
Loop Gastric Bypass ("Mini Gastric Bypass")
This form of Gastric Bypass was developed years ago, and has generally been abandoned by nearly all bariatric surgeons as unsafe -- several years ago, a consensus of the American Society for Bariatric Surgery was that the procedure should never be performed.
Although easier to perform than the Roux en-Y, it creates a severe hazard in the event of any leakage after surgery. It seriously increases the risk of ulcer formation, and irritation of the stomach pouch by bile, as well as risking the potential of esophageal cancer. Many persons who underwent this procedure in the past have required major revisional operations to correct severe discomfort and life-threatening pathophysiologic effects. Most bariatric surgeons agree that this operation is obsolete, and should remain defunct.
This operation has been resurrected, in order to make the laparoscopic procedure easier to perform, by possibly less-skilled surgeons. As shown by the single surgeon performing the procedure, the gastric pouch is excessively large, which may lead to loss of weight control over time.
A fundamental principle of laparoscopic surgery is that the underlying operation should not be compromised or degraded, in order to accomplish it, by using limited access techniques. The loop bypass does not meet this standard. There is no reliable long-term data to support use of this anatomic variation.
You can also find info about this operation, and why most surgeons don't do it, at www.Mini-GastricBypass.com.
Gastroplasty (Stomach Stapling, Gastric Stapling)
We mention this operation for completeness, although we do not offer it, because we do not believe in it, as an effective treatment.
Gastroplasty, or Stomach Stapling (Gastric Partitioning) is widely performed in the United States and elsewhere. It is a technically simple operation, accomplished by stapling the upper stomach, to create a small pouch, about the size of your thumb, into which food flows after it is swallowed. The outlet of this pouch is restricted by a band of synthetic mesh, which slows its emptying, so that the person having it feels full after only a few bites (one thumbful) of food. Characteristically, this feeling of fullness is not associated with a feeling of satisfaction - the feeling one has had enough to eat.
Patients who have this procedure, because they seldom experience any satisfaction from eating, tend to seek ways to get around the operation. Trying to eat more causes vomiting, which can tear out the staple line and destroy the operation. Some people discover that eating junk food, or eating all day long by "grazing" helps them to feel more sense of satisfaction and fulfillment -- but weight loss is defeated. In a sense, the operation tends to encourage behavior which defeats its objective.
Overall, about 40% of persons who have this operation never achieve loss of more than half of their excess body weight. In the long run, five or more years after surgery, only about 30% of patients have maintained a successful weight loss. Many patients must undergo another, revisional operation, to obtain the results they seek.
Because of the poor reported results with this surgery, we do not recommend or offer it - we can achieve far better results, with no increased risk, or increased expense. When revision of a Gastroplasty is necessary, we recommend conversion to a Gastric Bypass.
Historical Note, and Caution: Jejuno-Ileal Bypass
JI Bypass, or Intestinal Bypass, is no longer performed in the United States, and has not been for about 18 years. This operation was one of the earliest procedures devised for serious obesity, and achieved its effects by shortening the overall length of the bowel to less than 10% of its normal length. It caused severe, non-selective malabsorption of foods, which brought about weight loss, but also resulted in serious nutritional and metabolic side-effects, some of which were very dangerous.
This operation contributed to mortality in significant numbers of patients, and its risks certainly outweigh any benefits of weight loss by this method. Persons who have already undergone the procedure should take care to have close medical surveillance by their personal physician, and should undergo reversal (preferably with conversion to another weight-control operation) at the first sign of abnormalities of liver or kidney function, or other complication. We believe that conversion of this operation to a gastric bypass offers the best results - but this is a difficult operation, often with a slow recovery.
We only mention this operation, because many persons who are poorly informed confuse it with the Gastric Bypass (it has the same last name). Even some physicians do not understand that these are totally different procedures, with very different anatomy and physiology. When someone tells you that the "bypass" causes diarrhea, or liver trouble, or kidney problems, this is the bypass they are thinking and talking about -- not the Gastric Bypass.
The Gastric Bypass is the best operation, while the intestinal bypass is the worst.
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