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Types of Surgery
The American Society for Metabolic and Bariatric Surgery describes two basic approaches that weight loss surgery uses to achieve results:
- Restrictive procedures that decrease food consumption and create a feeling of being satisfied and full with just a small amount of food.
- Malabosprtive procedures that alter digestion, which causes incomplete absorption of food and calories in the small intestine and eventually is eliminated in the stool.
At Sequoia Hospital, we specialize in having bariatric surgery performed with minimally-invasive techniques. Laparoscopic weight loss surgery is performed with much smaller incisions and specialized strategies to minimize pain and scars in order to optimize recovery.
1. Roux-en-Y Gastric Bypass (RGB, or RNY, gastric bypass, stomach bypass)
The Roux-en-Y Gastric Bypass combines restriction and some degree of malabsorption. A much smaller stomach pouch of 1-2 ounces in size is created. This pouch is physically cut and separated from the much larger, rest of the stomach so that the patient feels full with just a few bites of food. The stomach pouch is then connected to the small intestine. The majority of the stomach and a portion of the small intestine are bypassed which results in some lesser absorption of ingested food. Most patients experience "dumping" when attempting to eat small amounts of high calorie foods or sweets which can further limits calorie intake.
Advantages
Disadvantages
Adjustable Gastric Band Procedures (LAP-BAND System(R) or REALIZE(TM) Adjustable Gastric Band
Currently, there are only 2 FDA-approved, adjustable gastric banding device systems. The first one approved in the U.S. in June 1991 is the Allergan Lap-BAND(R) System and is in its 4th generation of improvements. The REALIZE(TM) Band system was recently approved for use in the United States in September 2007. Both systems involve laparoscopically placing a band, or "belt" around the upper stomach creating a smaller, upper stomach pouch about 2 ounces in size with a narrower path, or "waist" leading to the rest of the stomach. Picture an hourglass-shaped stomach with a small top and much larger bottom. This belt has a balloon system to allow tightening of this passage, or stoma, so that the patient feels full with smaller amounts of food. A small access port is placed under the skin so that the balloon can be filled with saline, tightening the Band. Making the Band tighter can slow how much food enters the lower stomach, thus keeping the patient feeling fuller for a longer period of time with the right diet. Gastric band procedures are purely restrictive with no malabsorptive component.
Advantages
Disadvantages
Restrictive Vertical Gastroplasty with Gastrectomy (VG, or VSG, Vertical Gastrectomy, Sleeve Gastrectomy, or Vertical Sleeve Gastrectomy)
The Restrictive Vertical Gastroplasty with Gastrectomy, or simply, Vertical Gastrectomy or Sleeve Gastrectomy is a purely restrictive procedure. There is no re-routing or reconnecting of the intestines. The stomach is just made much smaller, into a narrow tube of 3-4 ounces in size. The larger, more elastic portion (greater curvature) of the stomach is actually removed from the patient. The tube-like, or "sleeve" of, stomach pouch that remains can limit the amount of food that a patient can ingest, again aiding in the limiting of calorie intake which can ultimately result in weight loss if the patient follows the proper dietary, supplement and exercise recommendations. The stomach still acts like a stomach with the valve at the beginning of the stomach as well as the valve at the end of the stomach still in place and functioning.
One of the exciting aspects of this procedure is that it can be still be performed laparoscopically for patients who are extremely obese with BMI over 60 kg/m2, or super, super-obese patients while minimizing the risks of complications in these high-risk patients. If revision of the surgery is necessary, conversion to Gastric Bypass or Duodenal Switch configurations are probably less likely to result in complications. Revision surgery usually has higher complication rates. Many patients who undergo the Restrictive Vertical Gastroplasty/Gastrectomy do not seem to need additional procedures, and reach their goals adequately.
Advantages
Disadvantages
Duodenal Switch (DS, or BPD-DS, "Switch," biliopancreatic diversion with duodenal switch, vertical gastrectomy with duodenal switch)
The Duodenal Switch more a malabsorptive procedure than restrictive. A vertical gastrectomy is performed but with a larger capacity stomach, about 6-8 ounces. The intestine just past the pylorus of the smaller stomach pouch is then connected to the small intestine. Much more small intestine bypassed, compared to the Gastric Byass, which results in even lesser absorption of ingested food. This malabsorption purposefully limits absorption of calories from fats, resulting in oily diarrhea at times and malodorous flatus and stool, which can be frequent. In addition, protein and certain vitamins and minerals are also malabsorbed, and more supplements with protein and vitamins and minerals are required.
Advantages
Disadvantages
Overview
Overall, when researchers put together the data of bariatric surgery performed over the years (Journal of the American Medical Association 2004, Volume 292, pages 1724-1737), they found that more than 60% of excess body weight is lost in most patients on average when you combined the results of all types of procedures. Adjustable gastric banding resulted in about 50% excess weight loss, with gastric bypass over 60%, and gastroplasty surgery and malabsorption surgery about 68-70% excess body weight loss. It appears that more recent data from doing these procedures laparoscopically (the old data were a combination of open and laparoscopic surgery), average excess body weight loss from gastric banding can be 60-70%, transected Roux-en-Y gastric bypass at 70-80%, vertical gastroplasty/gastrectomy at 70-80%, with duodenal switch surgery 70-90%. And, fortunately, risk of dying after surgery was found to be very low with a 1/1000 risk in gastric band or gastroplasty patients, 5/1000 in gastric bypass, and 1.1/100 in malabsorption procedures like the Duodenal Switch. Each surgery provides a different strategy at losing weight with different risks and benefits, with some more aggressive than others and some riskier than others. Insurance companies also may not cover certain procedures, especially revision surgery. Your surgeon and you will be able to discuss these issues in detail during your consultation.
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