In the late 1960’s and 70’s, Dr. Edward Mason began use of a procedure called Roux-en-Y gastric bypass (RYGB), also a malabsorptive procedure. This has since become the surgery of choice. Over 75 percent of surgeons prefer using this procedure because risks are minimal and can be treated.

During surgery:

A surgical device places parallel lines of staples diagonally across the upper end of the stomach and cuts between the lines, partitioning the stomach into two uneven parts. (Some surgeons only staple and do not cut, leaving the stomach in one piece, but divided by the staple line.) The upper pouch is the only part of the stomach that food will enter after the surgery. This pouch is about the size of a golf ball and can hold 20-30 ml. The amount of food a patient can consume in one meal after this surgery is severely restricted.
The surgeon then chooses a point along the small intestine and cuts it. The end of intestine that is no longer joined to the stomach is brought up and sewn on to a hole in the new pouch, creating an outlet for food and bypassing the first section of the small intestine. The end of intestine that drains from the lower (now unused) portion of the stomach is connected to the part of intestine that now exits the pouch. This allows digestive juices formed in the lower portion of the stomach to mix with the food after it leaves the pouch. The intestinal bypass causes some of the food consumed to be absorbed incompletely.

What’s the difference?

Laparoscopic Roux-en-Y gastric bypass is identical to the traditional gastric bypass except that instead of being performed through an incision extending from the lowest aspect of the breastbone (xiphoid process) to the umbilicus (navel), it is performed through several smaller incisions each measuring about an inch or less in length. A laparoscope connected to a video camera is inserted into the abdominal cavity and the surgical field is visualized on video monitors in the operating room. Long thin surgical instruments are inserted through additional small incisions and the surgeon performs the surgery by watching the video monitor. The operation is performed in a virtually identical manner whether it is done laparoscopically or open.

History of the Lap-Band System:

The Lap-Band was first brought about in the 1980’s by a doctor by the name of Lubomyr Kuzmak. The Bioenterics Company took over the original design and attempted to perfect it. Inamed Company purchased Bioenterics and continued work on the Lap-Band. Finally in 1993 a Dr. Mitiku Belachew placed the first Lap-Band in Belgium. Although may people still travel out of the states to have this procedure done, the FDA approved the Lap-Band system in 2001. Surgeons have now preformed over 120,000 procedures, while gastric bypass is still the most common weight loss surgery, the Lap-Band system is by far the most popular.

How the Lap-Band works and who it is for:

The Lap-Band is a procedure preformed through several small incisions with the aid of a fiber optic camera and other specialized instruments. During the surgery an adjustable band is placed around the top part of the stomach to create a small gastric pouch to avoid cutting the intestines. A portion of the tube connects the band to the adjusting port that is placed under the skin in the abdominal wall allowing easy access for adjustments. The inner lining of the band is a balloon that is filled with saline to narrow the opening of the stomach, limiting the amount of food that is able to pass. Saline is either added or withdrawn through a needle and syringe placed in the port. Both the surgery and adjustments are minimally painful. The best part of the Lap-Band is that it is totally adjustable and reversible. So if for example a patient becomes pregnant the physician would simply drain the band for the duration of the pregnancy and then slowly refill it after the baby is born. Although it is not necessary to remove the band after one reaches the goal weight but it is possible to do so.
Provided patients follow the instruction by choosing the right foods and exercise after the procedure most patients will lose between 50 and 75% of the excess weight. The Lap-Band is said to be much safer than other weight loss surgeries mainly because it is minimally invasive and the weight comes off at a much slower rate than with surgeries such as the gastric bypass.
The Lap-Band is designed for those who have dealt with morbid obesity for a long period of time. One is generally 100 pounds or more over weight, with a minimum age of 16 and a maximum of 65. A require BMI of 30-60 and proven 3 weight loss technique failures. It is not necessary to have a physician referral to have the surgery performed. Once these requirements have been met there is a list of things that must be done before the physician will perform the surgery.

Requirements:
1. You must attend a lecture on the procedure
2. You must have a personal consultation with a counselor
3. You must pay the fees
4. You need a mental health evaluation, a dietician evaluation and a physical evaluation
5. You must attend some pre-operative groups

After the surgery a patient can expect to spend one day in the hospital, then 2-3 days of limited activity. There is first a liquid diet, which then moves in to pureed food, such as yogurts etc. After you can handle those you move to mechanical soft foods and finally back to solid foods. There are some foods you may not be able to have anymore but that depends on the patient. The lap band gives you a feeling of being full and limits food intake. It trains patients to eat slower and in moderation. Patients are also encouraged to engage in physical daily activity and are also encouraged to take vitamins as they may not get all of the nutrition they need with the diet changes. http://http://www.alighterme.com/surgery.html

Weight loss (bariatric) surgery is a unique, in that with one operation, a person can be potentially cured of numerous medical diseases including diabetes, hypertension, high cholesterol, sleep apnea, chronic headaches, venous stasis disease, urinary incontinence, liver disease, and arthritis. Bariatric surgery is the only proven method that results in durable weight loss. This proven surgical approach, combined with the dismal failure of dieting, the marked improvement in quality of life and the quick recovery with minimally invasive techniques, has fueled the surge in the number of bariatric procedures performed annually over the last 10 years.


Weight loss operations are divided into two categories, restrictive procedures and malabsorptive procedures. Malabsorptive procedures reduce the absorption of calories, proteins and other nutrients. In contrast, restrictive operations decrease food intake and promote a feeling of fullness (satiety) after meals. Some operations are a combination of both. The gastric bypass, the laparoscopic adjustable band and the biliopancreatic diversion (with or without the duodenal switch) and the sleeve gastrectomy are the primary procedures used currently.


While the majority of patients who undergo these procedures are very successful, no procedure is perfect. Only through an honest discussion with a bariatric surgeon can patients decide which procedure may be best suited for them. With the development of new techniques and innovative procedures, patients and surgeons can learn from pioneering surgeons.

The following information was taken directly from ASBS (American Society for Bariatric Surgery)

***

RATIONALE FOR THE SURGICAL TREATMENT OF MORBID OBESITY
updated November 23, 2005


INTRODUCTION
There is considerable misinformation concerning the validity of bariatric surgery in the management of morbid obesity. The following “Rationale for Surgery” covers the field in general. References are provided to allow the interested reader to obtain more detailed information along with the opportunity to examine the original data on which these statements are based.
Bariatric surgery is a recognized sub-interest in the field of General Surgery. It has been endorsed by the National Institutes of Health Consensus Conference, 1992.[1] The American Society for Bariatric Surgery (ASBS) has a representative on the American College of Surgeons Board of Governors and is a specialty surgical society in the Specialty & Service Society section of the American Medical Association. Regular members of the ASBS are all Board Certified Surgeons who have a special interest in surgical treatment of hugely obese patients. It must be emphasized that these procedures are in no way to be considered as cosmetic surgery, and, as you read on, this should become abundantly clear.


Among recent articles of interest included in the references are the paper from Pories et al. from the University of East Carolina, a group with the finances and personnel to enable follow-up of their entire obesity surgery population, some 600 patients, achieving a patient follow-up of 96% at 14 years after surgery. This paper, while particularly emphasizing the beneficial effects of surgically induced weight loss in Type II diabetics, also includes follow-up data on other aspects of their series.[2] Other papers detailing the results of bariatric surgery in the younger and older age groups and noting improvement in co-morbidities not generally appreciated include results in adolescents,[3-5], those over 55 years of age,[6, 7] and the remarkable improvements in asthmatics which follows surgically induced weight loss.[8, 9] The introduction of the laparoscopic approach to bariatric surgery has achieved dramatic improvement in patient discomfort and length of hospital stay.[10, 11]


RATIONALE FOR THE SURGICAL TREATMENT OF MORBID OBESITY
Morbid obesity (this term is synonymous with “clinically severe obesity”) is a disease of excess energy stores in the form of fat. Morbid obesity correlates with a Body Mass Index (BMI) of 40 kg/m2 or with being 100 pounds overweight. Being overweight is associated with real physical problems which are now well recognized. The most obvious is an increased mortality rate directly related to weight increase.[12]


In a 12 year follow-up of 336,442 men and 419,060 women, it was found that the mortality rates for men 50% above average weight were increased approximately two fold. In the same weight group the mortality was increased five fold for diabetics and four fold for those with digestive tract disease. In women, the mortality was also increased two fold, while in female diabetics the mortality risk increased eight fold and three fold in those with digestive tract disease. It is clear that overweight people of both sexes, especially young overweight people, tend to die sooner than their lean contemporaries. [13-15]
While obesity, of itself, is a risk factor,[16] most mortality and morbidity is associated with the co-morbid conditions. This applies to non-operated as well as peri-operative mortality and morbidity. These conditions have been outlined in the 1985 National Institutes of Health Consensus Conference and include hypertension, hypertrophic cardiomyopathy, hyperlipidemia, diabetes, cholelithiasis, obstructive sleep apnea, hypoventilation, degenerative arthritis and psychosocial impairments.[16, 17]


A Veterans Administration study of 200 morbidly obese men aged 23 to 70 years, with an average weight of 316 lbs (143.5 kg) showed a twelve fold increase in mortality in the 25-34 year age group and a six fold increase in the 35-44 year age group. During the average follow-up period of 7 ½ years, 50 of the original group had died.[18] An interesting ongoing study in this regard is the Swedish Obesity Study (SOS) in which 2000 patients have been randomized to diet therapy and gastric restrictive surgery.[19] The study is still incomplete but indicates reduction in diabetes, hypertension and lipid disturbances in the surgically treated group.[20]


The Nurses Health Study has reported obesity related health risks in women at much less impressive degrees of obesity. Weight gain after the age of 18 years was shown to be a strong predictor of cardiovascular risk. This large prospective cohort study involving 115,886 women apparently healthy at baseline, showed a strong association between BMI and cardiovascular disease. As compared with women whose BMI was less than 21 kg/m2, the age and smoking adjusted relative risk of non-fatal myocardial infarction and fatal coronary artery disease for women with BMI of 25-29 was 1.8 (95%CI: 1.2-2.5), and that for women with BMI ≥ 29 was 3.3 (95%CI:2.3-4.5).[21]


The Framington study noted that the first cohort to terminate because of demise of all participants was the morbidly obese. Finally, in this litany of risk, the Guinness Book of Records memorializes the worlds heaviest individuals. Note that none of these lived over 40 years of age. Recent work suggests that the significantly increased mortality risk of morbid obesity reverts to normal following successful weight loss surgery.[22]


Obesity is dangerous to health because of the associated increased prevalence of cardiovascular risk factors such as hypertension, diabetes mellitus, hypertriglyceridemia, hyperinsulinemia and low levels of high density lipoprotein (HDL) cholesterol. Statistically significant improvements have been observed in both diabetes and hypertension, with >10 percent weight loss, and in cardiovascular conditions, with 5 percent weight loss.[23] Data from the Framingham study support the estimate that a ten percent reduction in body weight corresponds to a twenty percent reduction in the risk of developing coronary heart disease.[24] Serious consequences of severe obesity are well documented and include cardiac dysfunction, pulmonary problems, digestive diseases, and endocrine disorders as well as obstetric, orthopedic, and dermatologic complications.


The association between average weight of population groups and the prevalence of non-insulin-dependent diabetes has been repeatedly observed.[25, 26] The risk for diabetes has been reported to be about twofold in the mildly obese, fivefold in moderately obese and tenfold in severely obese persons.[27] The duration of obesity is also an important determinant of the risk for developing diabetes.[28] In cross-sectional studies, obesity has been shown to be associated with an increased prevalence of non-insulin-dependent diabetes in both men and women.[29] The NHANES II data found that the overall relative risk of developing diabetes was 2.9 times higher for obese persons who are 20-75 years old.[30] The risk of developing diabetes also increases with age,[31, 32] if a family history is present [33] and if the obesity is central.[34] A prospective study in Scandinavia showed that moderate obesity was associated with a 10 fold increase in the risk of diabetes. This risk increased sharply as obesity became more severe.[34] In patients who are morbidly obese and candidates for surgical treatment, diabetes and hypertension are highly correlated with body weight and waist-hip ratio.[35]


Cancer mortality rates are increased in severely obese females; e.g. endometrium (5.4 times), gallbladder (3.6 times), uterine cervix (2.4 times), ovary (1.6 times), breast (1.5 times). Cancer mortality rates are increased in severely obese males; e.g. colorectum (1.7 times), and prostate (1.3 times). [36]


The 2000 US Census estimates the adult population &#8805; 20 years and < 70 years at 185,634,000 persons. Prevalence estimates, using NHANES III data obtained a few years previously, are 2.8% for US adults with a body mass index (BMI) &#8805;40 kg/m2 and 8% for those with a BMI &#8805;35 kg/m2,[37] These numbers approximate to six million morbidly obese adults and another 9.6 million (8.0-2.8 =5.2%) with BMI >35 but <40. The relative risk for all cause mortality is increased at BMI levels &#8805;30 kg/m2. [37, 38]


Health care for the six million morbidly obese adults in the United States of America, [37, 39] eighty percent of whom are women of childbearing age,[40] has been hampered by the misconception that body weight is not a physiologically regulated variable, but rather determined by acquired food habits and conscious and unconscious desires. Obesity represents a management challenge for physicians and a psychological and biological challenge for patients.


Lack of respect for the morbidly obese is an issue of concern. A survey of severely obese individuals found that nearly eighty percent reported being treated disrespectfully by the medical profession.[41, 42] There are widespread negative attitudes that the morbidly obese adult is weak-willed, ugly, awkward, self-indulgent and immoral. This intense prejudice cuts across age, sex, religion, race, and socioeconomic status. Numerous studies have documented the stigmatization of obese persons in most areas of social functioning. This can promote psychological distress and increase the risk of developing a psychological disorder. The morbidly obese patient is at risk for affective, anxiety and substance abuse disorders. The obese often consider their condition as a greater handicap than deafness, dyslexia or blindness.[43, 44]


NON-OPERATIVE TREATMENT:
Published scientific reports document that non-operative methods alone have not been effective in achieving a medically significant long term weight loss in severely obese adults. It has been shown that the majority of patients regain all the weight lost over the next five years.[45, 46] The average medical weight reduction trial is a 10-12 week study with average weight loss of 2.5 kg [47] The use of anorectic medications has recently been advocated as a long term therapeutic modality in management of what is clearly a chronic disease. In a nearly four year study, utilizing a two drug regimen of Phentermine and Fenfluramine, behavior modification, diet and exercise, the initial optimistic results have not been sustained, with a one third drop out rate and a final average weight loss of only three pounds in those who were followed for the four years of the study.[48] This drug combination appears to have an unacceptably high association with cardiac valvular disease and has been withdrawn from therapeutic use because of these potentially life threatening sequelae. Dietary weight loss attempts often cause depression, anxiety, irritability, weakness and preoccupation with food [49]. The treatment goal for morbid obesity should be an improvement in health achieved by a durable weight loss that reduces life threatening risk factors and improves performance of activities of daily living. Temporary fluctuations of body weight from calorie restricted diets should be avoided.


SURGICAL TREATMENT GOALS:
Surgical treatment is medically necessary because it is the only proven method of achieving long term weight control for the morbidly obese. Surgical treatment is not a cosmetic procedure. Surgical treatment of severe obesity does not involve the removal of adipose tissue (fat) by suction or excision. Bariatric surgery involves reducing the size of the gastric reservoir, with or without a degree of associated malabsorption. Eating behavior improves dramatically.[50] This reduces caloric intake and ensures that the patient practices behavior modification by eating small amounts slowly, and chews each mouthful well. Success of surgical treatment must begin with realistic goals and progress through the best possible use of well designed and tested operations. These have been worked out over the last thirty years, and are now standardized, clearly defined procedures, with well recognized and documented outcome results.


Prevention of secondary complications of morbid obesity is an important goal of management. Therefore, the option of surgical treatment is a rational one supported by the time honored principle that diseases which harm call for therapeutic intervention that, while vigorous, is less harmful than the disease being treated. The biological basis for morbid obesity is unknown, though recent work has demonstrated a genetic component of between 25 and 50%.[51] Several studies confirm the influence of genetically determined proteins produced by the fat cell[52, 53] to be among the many mechanisms which have a place in the control of satiety.[54] These studies confirm that morbid obesity is a disease, not a disorder of willpower, as sometimes implied. The physiologic, biochemical and genetic evidence is overwhelming that morbid obesity is a complex disorder. Contributing causes include inheritance and environmental, cultural, socioeconomic and psychological factors.


PATIENT SELECTION:
The option of surgical treatment should be offered to patients who are morbidly obese, well informed, motivated, and acceptable operative risks. The patient should be able to participate in treatment and long term follow-up. Some patients with manifest psychopathology that jeopardizes an informed consent and cooperation with long term follow up may need to be excluded. A decision to elect surgical treatment requires an assessment of the risk and benefit in each case. Increased abdominal fat or “central obesity” (apple shaped as opposed to pear shaped) is an important risk factor associated with the major complications of obesity. Functional impairments associated with obesity are also important deciding factors for surgical treatment. An important conclusion of the 1991 National Institutes Consensus Development Conference Statement on the surgical treatment of obesity was that “patients judged by experienced clinicians to have a low probability of success with non-surgical measures, as demonstrated, for example, by failure in established weight control programs or reluctance by the patient to enter such a program, may be considered for surgical treatment”.[1]


Patients whose BMI exceeds 40 are potential candidates for surgery if they strongly desire substantial weight loss, because obesity severely impairs the quality of their lives. They must clearly and realistically understand how their lives may change after operation.


In certain circumstances, less severely obese patients (with BMI’s between 35 and 40) also may be considered for surgery. Included in this category are patients with high risk co-morbid conditions such as life threatening cardiopulmonary problems (e.g. severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy, or severe diabetes mellitus). Other possible indications for patients with BMI’s between 35 and 40 include obesity-induced physical problems that are interfering with lifestyle (e.g. musculoskeletal or neurologic or body size problems precluding or severely interfering with employment, family function and ambulation).


End stage obesity syndrome: Some candidates for surgical treatment of severe obesity have such impaired health that they must be hospitalized pre-operatively and undergo treatment to improve their operative risk.


Bariatric procedures:



GASTRIC BANDING
Nonadjustable Gastric Banding

An example of a purely restrictive bariatric procedure is nonadjustable gastric banding. It was first introduced in 1978 by Wilkinson, who applied a 2 cm Marlex mesh round the upper part of the stomach and separated the stomach into a small upper pouch and the rest of the stomach. Eventual pouch dilatation resulted in unsatisfactory weight loss.


In 1980, Molina described the gastric segmentation procedure, in which a Dacron vascular graft was placed around the upper stomach. The gastric pouch was smaller than Wilkinson’s procedure. Because the Dacron graft produced adherence of the liver to the band, it was replaced ultimately by PTFE (Gortex®).


In 1983, Kuzmak began using a 1 cm Silicone® band to encircle the stomach, creating a 13 mm stoma and a 30-50 mL proximal gastric pouch. This band was later modified to provide adjustability of the band diameter using an inflatable balloon (see below: “Laparoscopic adjustable gastric banding”).


Advantages of gastric banding
Absence of anemia
Absence of dumping
Lack of malabsorption
Short hospital stay
Very low mortality rate
Complications of gastric banding
Gastric perforation
Incisional hernia
Stomal stenosis
Band slippage
Band erosion into stomach
Need for reversal or revision


LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING
The adjustable band was developed by Kuzmak who devised a Silicone® band lined with an inflatable balloon in 1986. This balloon was connected to a small reservoir that is placed under the skin of the abdomen through which the diameter of the band can be adjusted. Inflation of the balloon functionally tightens the band and thereby increases weight loss, while deflation of the balloon loosens the band and reduces weight loss. These bands can be inserted laparoscopically, thereby reducing the complications and discomfort of an open procedure.


Currently several brands of adjustable bands are available – the LAP-BAND ® System, the Swedish Adjustable Band and the Mid-Band. None have yet been shown clearly to be superior to the other. The LAP-BAND ® system (Inamed, Santa Barbara, CA) received US FDA approval in 2001.


Since these procedures do not involve an intestinal bypass, laparoscopic adjustable gastric banding (LAGB) is a procedure which induces weight loss solely through the restriction of food intake. For optimal results, strict patient compliance and frequent follow-up for band adjustments are required. The LAP-BAND ® is a reversible procedure that does not carry the risks of nutritional and mineral deficiencies of other bariatric procedures. The mortality risk with the LAGB is about 0.1% , which is less than that with the RYGBP.


The LAGB is safe and has a low rate of life-threatening complications. Excess weight loss with the laparoscopic adjustable gastric band is lower than that with the gastric bypass or malabsorptive procedures, varying between 28% and 65% at 2 years and 54% at 5 years. An improvement in weight-related comorbidities has been observed, including Type II diabetes mellitus, dyslipidemia, sleep apnea, gastroesophageal reflux, hypertension, and asthma. However, compared to the gastric bypass, the impact on co-morbidities appears to be somewhat less favorable. Remission of diabetes with LAGB is seen in 64-66% at one year and 80% at 2 yrs versus 93% at 9 years with RYGBP. Long-term results comparing LAGB with gastric bypass or BPD are not yet available.
While some studies have documented weight loss equal to RYGBP with fewer complications, other groups have had disappointing outcomes. Some studies document a substantial number of patients who have required re-operation for long-term complications of the adjustable band (such as for port problems, erosions and slippage, or inadequate weight loss). Conversion of a failed LAGB to another bariatric procedure may be technically more difficult and associated with more complications than with a first time RYGBP or DS operation.


Advantages of LAGB
Same as gastric banding
Adjustability of the band
Reversibility (by band removal)
Laparoscopic placement


Complications after LAGB
Intraoperative : Postoperative :
Hemorrhage Band slippage (stomach prolapse)
Injury to the spleen, stomach, or esophagus Leakage of the balloon or tubing
Conversion to open procedure Port Infection, Band Infection Obstruction Nausea and vomiting


Late Complications
Band erossion into the Stomach
Esophageal Cialation Failure to lose weight


REFERENCES
Gastric Banding
Oria, HE. Gastric banding for morbid obesity. Eur J Gastroenterol Hepatol 1999;11:105-114.
Kuzmak, LI, Yap, IS, McGuire L, et al. Surgery for morbid obesity. Using an inflatable gastric band. AORN J 1990;51:1307-24.
Laparoscopic adjustable gastric banding Belachew M, Belva PH, Desaive C. Long-term results of laparoscopic adjustable gastric banding for the treatment of morbid obesity. Obes Surg 2002;12:564-568.
O'Brien PE, Dixon JB, Brown W, et al. The laparoscopic adjustable gastric band (Lap-Band): a prospective study of medium-term effects on weight, health and quality of life. Obes Surg 2002;12:652-60.
Dixon JB, O'Brien PE. Health outcomes of severely obese type 2 diabetic subjects 1 year after laparoscopic adjustable gastric banding. Diabetes Care 2002;25:358-63.
Ponce J, Haynes B, Paynter S, et al. Effect of Lap-Band-induced weight loss on type 2 diabetes mellitus and hypertension. Obes Surg 2004;14:1335-42.


GASTRIC BYPASS
Open Procedure

Drs. Mason and Ito initially developed this procedure in the 1960s. The gastric bypass was based on the weight loss observed among patients undergoing partial stomach removal for ulcers. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of intestine (RYGBP). The RYGBP is the most commonly performed operation for weight loss in the United States. In the U.S, approximately 140,000 gastric bypass procedures will be performed in 2005, far outnumbering the LAP-BAND®, duodenal switch, and vertical banded gastroplasty procedures.


Initially the operation was performed as a loop bypass with a much larger stomach. Because of bile reflux that occurred with the loop configuration, the operation is now performed as a “Roux-en-Y” with a limb of intestine connected to a very small stomach pouch which prevents the bile from entering the upper part of the stomach and esophagus.


The remaining stomach and first segment of small intestine are bypassed. In the standard RYGBP, the amount of intestine bypassed is not enough to create malabsorption of protein or other macronutrients. However, because the bypassed portion of intestine is where the majority of calcium and iron absorption takes place, anemia and osteoporosis are the most common long-term complications of the RYGBP. Therefore, lifelong mineral supplementation is mandatory. Other clinically important deficiencies that may occur include deficiencies of Vitamin B 1 (thiamine) and Vitamin B 12. Lifelong follow-up with a bariatric program and daily multi-vitamins are strongly recommended prevent nutritional complications.


The RYGBP has been proven in numerous studies to result in durable weight loss and an improvement in weight-related medical illnesses. Half of the weight loss often occurs during the first six months after surgery; weight loss usually peaks at 18-24 months. The obesity-related comorbidities that may be improved or cured with the RYGBP include diabetes mellitus of the adult onset type (so-called insulin resistant), hypertension, high cholesterol, arthritis, venous stasis disease, bladder incontinence, liver disease, certain types of headaches, heartburn, sleep apnea and many other disorders. Furthermore, the RYGBP has resulted in marked improvements in quality of life.


Although the most commonly performed RYGBP (sometimes called the proximal gastric bypass) involves little malabsorption, some surgeons modify the RYGBP to incorporate an element of malabsorption for the purpose of augmenting weight loss in special circumstances. This modification is sometimes called a distal gastric bypass, which may result in more severe nutritional complications than the proximal RYGBP . Whether long-term weight loss is superior to the proximal RYGBP or whether the malabsorptive complications are worth the possible improvements in weight loss has not been well established . Many surgeons reserve the distal RYGBP for very select circumstances.


The mechanism in which the RYGBP works is complex. After surgery, patients often experience marked changes in their behavior. Most patients have a reduction in hunger and feel full sooner after eating. Patients often state that they enjoy healthy foods and lose many of their improper food cravings. Rarely do people feel deprived of food. These complex behavioral changes are partially due to alterations in several hormones (ghrelin, GIP, GLP, PYY) and neural signals produced in the GI tract that communicate with the hunger centers in the brain. Another mechanism for weight loss after the RYGBP is referred to as the dumping syndrome. Dumping may result in lightheadedness, flushing, heart palpitations, diarrhea and other symptoms early (within 10 to 30 minutes) after eating sweets or foods with a high concentration of sugar. Some people remain extremely sensitive to sweets for the rest of their lives; most patients lose some or all of their sweets sensitivity over time.


The risk of dying in the first month after a RYGBP from complications of the operation is about 0.2 to 0.5% in expert centers. Studies have demonstrated that the mortality rate from hospitals with a low experience with the procedure is far higher than that reported by expert centers. The American Society of Bariatric Surgeons fully supports the initiative of the Surgical Review Committee to establish rigid criteria to certify that hospitals with quality programs will be designated as a “Center of Excellence.”


Advantages of RYGBP:
Better weight loss than after purely restrictive procedures
Low incidence of protein-calorie malnutrition and diarrhea
Rapid improvement or resolution of weight-related comorbidities
Appetite reduction


Complications of RYGBP:
Early: Late:
Anastomotic Leak Incisional hernia
Pulmonary embolism Bowel obstruction
Wound infection Internal hernia
Gastrointestinal hemorrhage Stomal stenosis
Respiratory insufficiency Micronutrient deficiencies
Mortality Marginal ulcer


LAPAROSCOPIC GASTRIC BYPASS

Although the open RYGBP can be performed with a relatively low morbidity and mortality, the wound-related complications such as infection and incisional hernia can be troublesome. Wound infection occurs in as many as 8% of patients after open RYGBP and late incisional hernia occurs in as many as 20% of patients. However, some surgeons have reported a much lower rate. The laparoscopic approach to RYGBP was initiated in an effort to improve the early outcomes including a reduction in postoperative complications arising from a large incision in a severely obese patient.


In 1994, Drs. Wittgrove and Clark reported the first case series of laparoscopic RYGBP. The primary differences between laparoscopic and open RYGBP are the method of access and method of exposure. Laparoscopic RYGBP is normally performed through 5-6 small abdominal incisions (0.5-2.0 cm), the peritoneal cavity (abdomen) is insufflated with carbon dioxide gas which creates a space within which to work, allowing exposure of the operative field (Figure 1a). In contrast, open RYGBP is performed through a larger incision and abdominal wall retractors are used for exposure (Figure 1b). By reducing the size of the surgical incision and the trauma associated with the operative exposure, the surgical insult has been shown to be less after laparoscopic compared to open RYGBP. However, not all patients are candidates for a laparoscopic approach based on body habitus, previous intra-abdominal surgery, etc.


Clinical studies have demonstrated that laparoscopic RYGBP is a safe and effective alternative to open RYGBP for the treatment of morbid obesity. Higa and colleagues reported the largest laparoscopic RYGBP experience with 1,500 operations. There have been three prospective, randomized trials comparing the outcomes of laparoscopic vs open RYGBP. The largest trial was reported by Nguyen and colleagues in 2001. In 2004, a group from Murcia, Spain published their results. Long-term weight loss after laparoscopic and open RYGBP should not differ, as the primary differences between the two techniques is largely in the method of access and not the gastrointestinal reconstruction.


Despite the advantages of the laparoscopic approach, open bariatric surgery still plays a prominent role in management of morbidly obese patients. Relative contraindications for laparoscopic bariatric surgery include patients with extremely high body mass index, patients with multiple previous upper abdominal surgeries, and patients with prior bariatric surgery. Another limitation of the laparoscopic approach is the steep learning curve of this technically challenging procedure for the surgeon, so it is not an operation for the surgeon who has not been trained specifically in this technique. The advantages and disadvantages of laparoscopic RYGBP are listed below.


Advantages of laparoscopic compared to open RYGBP
Lesser intraoperative blood loss
Shorter hospitalization
Reduced postoperative pain
Less pulmonary complications (atelectasis)
Faster recovery
Better cosmesis
Fewer wound complications (incisional hernias and infections)


Disadvantages of laparoscopic compared to open RYGBP
Complex laparoscopic operation associated with a steep learning curve
Possible increase in the rate of internal hernia


REFERENCES
Gastric bypass
Mason, EE and Ito C. Gastric bypass in obesity. Surg Clin North Am 1967;47:1345-51.
MacDonald KG Jr, Long SD, Swanson MS,et al. The gastric bypass operation reduces the progression and mortality of non-insulin-dependent diabetes mellitus. J Gastrointest Surg 1997;1:213-220.
Sugerman HJ, Starkey JV, Birkenhauer R. A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Ann Surg 1987;205:613-24.
Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 4:353-357, 1994.
Higa KD, Ho T, Boone KB. Laparoscopic Roux-en-Y gastric bypass: technique and 3-year follow-up. J Laparoendosc Adv Surg Tech 2001;11:377-382.
Nguyen NT, Goldman C, Rosenquist CJ, et al: Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279-289.
Lugan JA, Frutos D, Hernandez Q, et al. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. 2004;239:433-437.
Podnos YD, Jimenez JC, Wilson SE, Stevens M, Nguyen NT. Complications after laparoscopic gastric bypass. Arch Surg 2003;138:957-961.
Banded gastric bypass
Fobi MAL, Lee H, Holness R, Cabinda D. Gastric bypass operation for obesity. World J Surg 1998;22:925-935.


BILIOPANCREATIC DIVERSION
Scopinaro first performed the biliopancreatic diversion (BPD) which was designed to be a safer malabsorptive alternative to the JIB. This operation induces controlled malabsorption without many of the potential side effects caused by bacterial overgrowth associated with the JIB. The malabsorptive operations differ from the RYGBP and the gastric banding, which work mainly through restriction.


Malabsorption is defined by the incomplete uptake of calories and nutrients and occurs via two mechanisms. First, the bile and pancreatic fluids released into the duodenum to digest food and break down fats, carbohydrates and proteins are diverted away from ingested food – hence the name, biliopancreatic diversion. The digestive enzymes eventually join the ingested food – but at a point in the distal small intestine (ileum) where there is much less chance for complete breakdown and absorption. When food is in the diverted small intestine it is not absorbed as well because of the lack of enzymes to break down the larger fat, protein and carbohydrate molecules into their smaller building blocks, the actual particles absorbed. Because of the particular digestive aids necessary to absorb fats (bile and lipase are crucial), fat calorie malabsorption predominates. Unfortunately, undigested fats cause gas and loose, foul-smelling bowel movements, called steatorrhea. The second mechanism through which malabsorption occurs is by decreasing the amount of small intestine through which the ingested food passes. With less surface area of intestine with which food is in contact, less nutrients can be absorbed.


Unlike the RYGBP where no stomach is removed (only bypassed), the BPD involves the removal of 70% of the stomach. This procedure is done to decrease the amount of acid produced by the remaining stomach. Gastrin, a hormone produced by G-cells in the antrum, is responsible for stimulating the upper stomach to produce acid. Of note, the portion of the remaining upper stomach is far larger than the small “pouch” created for the RYGBP. This allows patients to eat larger volumes than after a restrictive operation before feeling full (satiety). After entering the upper stomach, food passes through a newly created connection (anastomosis) into the small intestine (alimentary limb). This anatomy is very similar in principle to the standard RYGBP, except that the length of the intestine from the stomach to the colon is much shorter – promoting malabsorption. The bile and pancreatic secretions pass through the bypassed biliopancreatic channel and connect with the alimentary channel (where the food travels) 50-100 cm from the colon. Some of these secretions are reabsorbed in this channel prior to meeting the alimentary tract. The part of the intestines where bile and pancreatic fluids (from the biliopancreatic channel) and food (from the alimentary channel) mix is called the common channel. Surgeons use various formulas to determine the appropriate length of the alimentary channel and the common channel.


The amount of excess weight loss after the BPD has been reported to be around 70 percent – with weight loss in some patients persisting up to 18 years. However, like all weight loss data, this percentage of excess weight lost varies depending on the length of follow-up, the quality of follow-up, the country where the procedure was performed, the surgeon, and the initial weight of the patient. Being a malabsorption operation, however, the BPD requires life-long medical follow-up.


DUODENAL SWITCH
The duodenal switch (DS) is a modification of the BPD designed to prevent ulcers, increase the amount of gastric restriction, minimize the incidence of dumping syndrome, and reduce the severity of protein-calorie malnutrition. However, the dumping syndrome is also believed by many to be a benefit, rather than a detriment, in that it helps patients avoid eating sugary and high fat foods which would adversely affect weight loss. The DS was first reported by Dr. Doug Hess in 1986.


The DS works through an element of gastric restriction as well as malabsorption. The stomach is fashioned into a small tube, preserving the pylorus, transecting the duodenum and connecting the intestine to the duodenum above where digestive juices enter the intestine. Compared to the BPD, the DS leaves a much smaller stomach that creates a feeling of restriction much like that of a RYGBP. Anatomically, the main difference between the DS and the BPD is the shape of the stomach – the malabsorptive component is essentially identical to that of the BPD. Instead of cutting the stomach horizontally and removing the lower half (such as with the BPD), the DS cuts the stomach vertically and leaves a tube of stomach that empties into a very short (2-4 cm) segment of duodenum.


The duodenum is tolerant of stomach acid and therefore is much more resistant to ulceration compared to the small intestine. Removing part of the stomach also decreases the amount of acid present. Whereas the BPD involves an anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the duodenum and the intestine. The duodenum is cut about 2-4 cm from the stomach (measured from the pyloric valve). The intestine is sewn to the end of the duodenum which remains in continuity with the stomach. The other side of the duodenum will carry all the bile and pancreatic secretions. A theoretical (but clinically unproven) benefit of the DS is an improvement in absorption of iron and calcium in comparison to the BPD. The disadvantage of transecting the duodenum is the large number of vital structures immediately adjacent to the duodenum. Several large blood vessels and the major bile duct are located here. Injury to these structures can be life-threatening.


These procedures have some of the highest reported weight loss in long-term studies, but also have the highest rate of nutritional complications compared to the RYGBP and the purely restrictive procedures. These operations are some of the most complex in bariatric surgery. However, as with most studies of weight loss surgery, there is wide variability in long-term results between different centers. Only multi-center comparative studies can establish definitively the true differences between all these operations.


Some patients and surgeons believe that the DS is a superior operation to the RYGBP and BPD because of the lack of a “dumping syndrome”, described above. The DS and BPD have their own particular side effects. After a meal that is high in fat, people can experience foul smelling gas and diarrhea.


Advantages of BPD and DS:
Increased amount of food intake compared to the bypass and band
Less food intolerance
Possibly greater long-term weight loss
More rapid weight loss compared with gastric banding procedures


Complications of BPD and DS:
Diarrhea and foul smelling gas, with an average of 3-4 loose bowel movements a day
Malabsorption of fat soluble vitamins (Vitamins A, D, E, and K)
Vitamin A deficiency, which causes night blindness
Vitamin D deficiency, which causes osteoporosis
Iron deficiency –a similar incidence with the RYGBP
Protein-calorie malnutrition, which might require a second operation to lengthen the common channel
Ulcers (less frequent with DS)
Dumping syndrome (less frequent with DS)


Summary
Both the BPD and the DS can be performed laparoscopically. However, these operations are more demanding technically than the RYGBP and should only be performed in the most experienced hands. Long-term follow up and daily vitamin supplements are crucial to the success of these operations. Life-long monitoring is necessary to prevent nutritional and mineral deficiencies – just as with the RYGBP.


REFERENCES
Biliopancreatic diversion and duodenal switch
Scopinaro, N., Gianetta, E, et al. Biliopancreatic diversion for obesity at eighteen years. Surgery 1996;119:261-8.
Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998;8:267-82.
Marceau P, Hould FS, Simard S, et al. Biliopancreatic diversion with duodenal switch. World J Surg. 1998;22:947-54.


STAGED PROCEDURES
Surgeons are also devising different procedures to decrease the complication rate in high-risk patients - patients who have extreme obesity or severe medical co-morbidities. Some surgeons are using a staged approach to bariatric surgery. This approach involves performing a less invasive procedure that reduces weight to a safer level (which in itself is not effective enough on its own) and improves overall medical condition first; then a more complex, definitive procedure is performed once the operative risks of the patient decrease significantly due to the initial weight loss. These less invasive steps have included the “sleeve gastrectomy,” the gastric balloon and the adjustable band as an interim step before a RYGBP or DS is performed.


SUMMARY
Almost all bariatric procedures have resulted in consistent short-term weight loss. Unfortunately there is no perfect operation. The remarkable drive for the obese patient to regain weight cannot be eliminated in all patients. Furthermore, the history of bariatric surgery is replete with procedures that seemed initially to be very promising and safe in theory, but which were later found to be failures. As such, newer procedures should always be viewed with caution. The RYGBP, LAGB, DS and BPD have withstood appropriate scrutiny through the literature. Only through careful research and discussion with a qualified bariatric surgeon can patients decide which procedure may be the best for them.
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