Overview of Surgical Weight Loss Options

Classification of Surgical Procedures for Weight Loss

You can read more detail of the history of weight loss surgery and the procedures that have been and are being performed at the American Society for Bariatric Surgery website at their The Story of Surgery for Obesity section. Read more about all the procedures mentioned below by clicking on the name of the procedure. There are three basic surgical approaches used to achieve weight loss:

1. Malabsorptive procedures. These operations modify digestion by causing food to be incompletely absorbed, so that a part of the ingested calories are eliminated in the stool. There are no purely malabsorptive procedures presently performed, but such a procedure was previously performed: the Jejuno-Ileal Bypass.
   
2. Restrictive procedures. (gastric = stomach restrictive): decrease food intake by significantly reducing the size and capacity of the stomach. Fewer calories are ingested. There have been many version of these procedures, but the essentially the procedures performed world wide include at the present time:
   • Roux-en-Y Gastric Bypass (short limb). This is a procedure we perform laparoscopically and open.
   • Lap-band Adjustable Silicone Gastric Banding. This is a procedure we perform laparoscopically.
   • Gastroplasty. The most well known is Vertical Banded gastroplasty.
     
3. Combination gastric restrictive and malabsorptive procedures. There have been a number of versions of these procedures, but essentially the procedures performed world wide at the present time include:
   1. Roux-en-Y Gastric Bypass (long limb)
      or Distal Gastric Bypass (long limb Roux-en-Y Gastric bypass).
   2. Bilio-Pancreatic Bypass
   3. Duodenal Switch

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A purely malabsorptive procedure – no longer performed. Jejuno-Ileal Bypass (JI Bypass) is not performed in the United States since about the mid 1980s. Please refer to an excellent discussion of this procedure at the American Society for Bariatric Surgery website at their The Trouble with the Jejuno-ileal Bypass section. This operation was developed during the late 1960s and early 1970s and was one of the first surgical procedures performed for weight loss. Generally this procedure radically shortens the overall length of the small intestine to less than 10% of its normal length. The JI Bypass caused severe, non-selective malabsorption of foods, and resulted in severe nutritional and dangerous metabolic side effects. It was associated with profound liver problems and was responsible for a number of deaths. Generally, patients that have had this surgery are advised to have the procedure reversed or modified.

Unfortunately, the JI Bypass to a certain degree gave weight loss surgery a bad name. The effects of this negative experience in society and in the medical profession on weight loss surgery still lingers. Please do not confuse the Jejuno-Ileal Bypass with the operation that the Rocky Mountain Weight Loss Surgery Associates perform, the Roux-en-Y Gastric Bypass. The JI bypass absolutely should not be performed and the Roux-en-Y Gastric Bypass is often the procedure of choice for weight loss surgery.

* Photo courtesy of American Society for Bariatric Surgery

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Vertical Banded Gastroplasty (VBG)

A purely gastric restriction procedure, Gastroplasty, or Stomach Stapling is a procedure that was developed in part due to the concerning experience with the JI bypass. It was developed in the late 1960s and perfected to the Vertical Banded Gastroplasty (VBG) over decades. See more on this operation in the American Society for Bariatric Surgery website. It is still performed sometimes; mostly as an open procedure, by certain surgeons who often do not offer advanced laparoscopic weight loss procedures.

How the VBG is performed The upper stomach near the esophagus is stapled vertically for about 2-1/2 inches (6 cm) to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and helps to create the feeling of fullness.

Advantages of VBG

• The primary advantage of this and other purely restrictive procedures is that food passes through the digestive tract in the natural sequence order. This allows the nutrients and vitamins (as well as the calories) to be naturally absorbed.
• There is good weight loss, but not excellent weight loss.

Risks and Concerns of VBG

• Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection.
• Staple-line disruption may lead to weight gain, so that the stomach achieves its former shape. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption. There is also a risk of the pouch stretching that may also cause weight regain.
• A band is applied to the outlet of the upper stomach pouch, because it was shown that this outlet may dilate over time, and in addition, if the band breaks or migrates, the outlet will enlarge and allow weight gain. The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.
• Statistically, the weight loss is not as good as other procedures in the short term and in the long term. Around 40% to sixty of patients undergoing these procedures have lost less than half their excess body weight over time.. Five or more years after surgery, as few as 30% of patients have maintained a successful weight loss.
• In contrast with the Roux-en-Y Gastric Bypass that we perform, the feeling of fullness after eating with VBG may not seem to be associated with as much of a feeling of satisfaction after eating (satiety) - the feeling one has had enough to eat. There seems to be a sense of satisfaction that comes from the intestinal or small bowel portion of the Roux-en-Y configuration. This may limit the weight loss profile in the Lap Band procedure.

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A combination procedure of gastric restriction with a significant malabsorptive component. 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. A note about the malabsorptive procedures.

Loop Gastric Bypass ("Mini Gastric Bypass")

A gastric restrictive procedure without a significant malabsorptive component touted to be an equivalent of RYGB (s). This Gastric bypass was developed in order to make the laparoscopic Gastric Bypass easier to perform. It is criticized for a number of reasons and is considered by most weight loss surgeons as having worrisome features. This operation seems to increase the risk of peptic ulcer formation, and irritation of the stomach pouch by bile (bile reflux), and may expose the patient to the potential for a certain kind of esophageal cancer. Most weight loss surgeons agree that this operation is not ideal.

Several years ago, a consensus from the American Society for Bariatric Surgery was that the “Mini Gastric Bypass" should not be performed. Proponents of this procedure seem to make controversial and difficult to believe claims. Since it is technically easier than the Roux-en-Y gastric bypass the Rocky Mountain Weight Loss Surgery Associates could certainly offer this operation, but we believe that we offer better alternatives.

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These operations reduce the size of the stomach, but the stomach pouch created is much larger than with other procedures. The intention is to only partially restrict the amount of food consumed. The rest of the operation creates malabsorption. The configuration of the small intestine diverts the bile and pancreatic juices so they mix with the ingested food closer to the end of the small intestine. This "common limb" as it is called means that there is less overall small intestine to absorb nutrients and calories. See more on these operations at the American Society for Bariatric Surgery website.

1. Biliopancreatic Diversion (BPD)
   Combination Gastric Restriction and Malabsorptive procedure. Dr. Scopinaro, of the University of Genoa, Italy, developed this procedure in 1996. It was an attempt to achieve the profound weight loss of the JI bypass, yet minimize the profound complications of that procedure.
2.   Biliopancreatic Diversion with "Duodenal Switch" (BPD-DS)
   Combination Gastric Restriction and Malabsorptive procedure. This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above. Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause bile and pancreatic juice reflux and ulcers. The “duodenal switch” operation was invented to try to and has partially lessened some of these concerns.

Advantages (BPD and BPD-DS)

1. These operations are appealing to patients because they potentially are able to eat larger meals than with purely restrictive or standard Roux-en-Y gastric bypass procedures. However, this is only partially true (see Risks and Concerns below).
2. These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption. For instance, one study has documented excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years.
3. Long-term maintenance of excess body weight loss can be successful and safe if the patient adheres to a dietary, supplement, exercise and behavioral regimen. This is true of all weight loss procedures, but these procedures have a higher concern and rate of metabolic complications. (see Risks and Concerns below).

Risks and Concerns

1. With malabsorption procedures, there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
2. Abdominal bloating and malodorous stool or gas occur, especially if the patent does not eat properly, such as high fat content foods.
3. Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. Lifelong vitamin supplementation is required. It has been shown that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
4. Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause bile and pancreatic juice reflux and ulcers. The “duodenal switch” operation was invented to try to and has partially lessened some of these concerns.

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Choosing Minimally Invasive Laparoscopic Surgery with Rocky Mountain Weight Loss Surgery Associates

If a shorter hospital stay, reduced discomfort and disability, and superior cosmetic results are important to your decision, the choice of Laparoscopic Gastric Bypass or LapBand are choices you should consider.

Laparoscopic (Minimally Invasive) Surgery

Laparoscopic surgery is a type of intra-abdominal surgery that uses tiny incisions and TV cameras to accomplish complex abdominal surgeries. It is called “minimally invasive” because of the small incisions. One of the obvious benefits of laparoscopic surgery compared to “open” or conventional surgery is that with smaller incisions, the recovery is faster and overall less painful.

For the last ten years or so, laparoscopic procedures have been used in a variety of abdominal surgeries. Laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for over a decade. Although many weight loss surgeons perform laparoscopic weight loss surgeries, not all surgeons offer the procedures laparoscopically. The Rocky Mountain Weight Loss Surgery Associates, Dr. Parnell and Dr. Fermelia, are pleased to offer most weight loss surgery patients a laparoscopic procedure. The American Society for Bariatric Surgery recommends that only surgeons who are experienced in both laparoscopic and open weight loss procedures should perform laparoscopic weight loss surgery. The Rocky Mountain Weight Loss Surgery Associates, Dr. Parnell and Dr. Fermelia, are experienced at the open procedure. During your initial consultation, your surgeon can tell you if you are a candidate for the laparoscopic procedures.

During a laparoscopic operation, the abdomen is gently inflated with carbon dioxide, which gives the surgeon a working space in the abdomen. A small video camera and the surgical instruments are inserted through small incisions made in the abdominal wall. The surgeon views the procedure on a video monitor. We believe that this technique actually provides better view than open surgery because of the magnification and the additional angles of view that are achieved by the camera. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen.

The Benefits of Laparoscopic Surgery include:

• Small incisions
• Substantially fewer hernias in the incision(s)
• Less pain and discomfort
• Less pain medication is needed
• Better mobility after the surgery
• Better ability to breathe after the surgery
• Reduced physiological stress on the body
• Shorter Hospital Recovery Time
• Quicker return to work and pre-surgical levels of activity

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