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Clinical Services at Rush Choosing Surgery

Weight-loss surgery is major surgery. Although most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image and self-esteem) after the successful results of weight-loss surgery, these results should not be the overriding motivation for having the procedure. The goal is to live better, healthier and longer.

That is why you should make the decision to have weight-loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight-loss surgery, require that you consult with a dietitian/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the postoperative changes in behavior that are essential for long-term success.

It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight-loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight-loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dietitians and other forms of continuing education.

Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.

Weight Loss Surgery Options

The American Society for Bariatric Surgery describes two basic approaches that weight-loss surgery takes to achieve change. The first approach includes restrictive procedures that decrease food intake. The second approach involves malabsorptive procedures that alter digestion, causing food to be poorly digested and incompletely absorbed so that it is eliminated in the stool. The following describes a range of weight-loss procedures.

Gastric Restrictive Procedure - Vertical Sleeve Gastrectomy

As its name indicates, part of the stomach is removed, leaving a small sleeve-shaped stomach tube that limits food intake. Also, because of the now-smaller stomach produces less of a certain "hunger hormone," appetite may be reduced.

In patients with a very high BMI or those with a history of high surgical risk, the gastric sleeve procedure is sometimes done as the first stage of a 2-surgery treatment plan, with a malabsorptive procedure (biliopancreatic diversion with duodenal switch) performed a year or more later.

Advantages**:

  • It restricts the amount of food that can be consumed at a meal.
  • Digestion and absorption are normal food consumed passes through the digestive tract in the usual order, allowing it to be fully absorbed in the body.
  • As with all bariatric procedures, lifelong follow-up with your health care professional is required. There are no post-operative adjustments needed with this procedure.
  • Had resolution rates f type 2 diabetes, hypertensions, hyperlipidemia, and sleep apnea comparable to other restrictive procedures.
  • In studies patients lost from 33 percent to 83 percent of their excess weight.
  • Resolved other serious, obesity-related conditions.

**These results were seen in 345 patients in the 12 to 24 months following the procedure.

Risks: (The following are in addition to the general risks of surgery.)

  • Complications due to stomach stapling, including separation of tissue that was stapled or stitched together and leaks from staple lines
  • non-reversible procedure since part of the stomach is removed
  • Gastric leakage
  • Fistula
  • Other risks associated with bariatric surgery
  • Ulcers
  • Dyspepsia
  • Esophageal dysmotility

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Laparoscopic Adjustable Gastric Banding
 

Laparoscopic adjustable gastric banding (LAGB) provides a safe, effective, adjustable, and if needed, reversible surgical option for weight loss. 

The laparoscopic adjustable gastric band is a silicone band that is placed around the upper portion of the stomach to create a small "virtual pouch." After ingesting small portions of food, the pouch becomes full, thus inducing a feeling of satiety. The band can be gradually tightened when the patient reports a cessation of weight loss or loss of satiety after meals. LAGB is one of the most common bariatric procedures performed worldwide and is gaining popularity in the United States after receiving approval for use by the Food and Drug Administration in 2001.

Advantages
  • LAGB has consistently been shown to be one of the safest bariatric procedures available. The procedure is performed laparoscopically, without the need for bowel division or anastomosis.
  • The procedure takes about 1 hour, and most patients go home later the same day or the day after surgery.
  • LAGB provides an effective means of gradual weight loss over months to years. The pattern of weight loss exhibited by LAGB tends to be a steady rise with expectations of an average of 40 percent excess weight loss (EWL) after one year, and up to 50 to 60 percent EWL after two to three years.
  • Health and quality of life continue to improve after the weight loss achieved from LAGB. Marked improvement in diabetes, hypertension, dyslipidemia, reflux esophagitis, asthma, depression, and obstructive sleep apnea has been observed in postoperative patients.
  • The LAGB is completely adjustable. When patients note that they are able to ingest larger meals, or fail to achieve adequate weight loss, they schedule an adjustment. This is performed under X-ray guidance and takes approximately 10 minutes. In general, patients require an average of five to six adjustments in the first year, and two to four adjustments per year in subsequent years.
  • The procedure is reversible. When the band is placed, it is intended to be permanent, however, under certain circumstances it may need to be removed. If this occurs, the patient may be a candidate for another bariatric surgical option.

Risks

  • Weight loss with LAGB is slower and more gradual than with many of the malabsorptive and combined procedures.
  • Perioperative complications associated with placement of the LAGB have been reported. These include the chance of gastric or esophageal injury, wound infection, and injury to the spleen or liver.
  • Long-term complications including pouch formation, band slippage, port flip, catheter breakage, and erosion of the band into the stomach may necessitate further surgery to revise or remove the band. 

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Combined Restrictive and Malabsorptive Procedure - Gastric Bypass Roux-en-Y
In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.

Advantages

  • The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
  • One year after surgery, weight loss can average 77 percent of excess body weight.
  • Studies show that after 10 to 14 years, 50-60 percent of excess body weight loss has been maintained by some patients.

Risks

  • Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
  • Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
  • A chronic anemia due to vitamin B12 deficiency may occur. The problem can usually be managed with vitamin B12 pills or injections.
  • A condition known as "dumping syndrome" can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
  • In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30 cc.
  • The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.

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Laparoscopic or Minimally Invasive Surgery

New techniques in recent years now avoid larger incisions. This is a big step forward for patients, because they are in the hospital shorter times, there is a significant reduction in pain, and they are able to return to normal activities sooner.

When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.

The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia. Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.





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