Weight Loss Surgery Procedures

Laparoscopic gastric bypass

This operation makes you eat less food as well as absorb less calories, especially early after the surgery. The operation divides the stomach into two uneven parts, one small pouch that sees food and the other remainder or remnant of stomach does not. In order for the food to drain out of the pouch, small intestine is "hooked up" to the pouch (aka gastrojejunostomy). This small intestine is called the Roux limb. This Roux limb is measured for a certain length, and I use 150cm. At this point, I re-attach the intestine to complete the circuit (aka enteroenterostomy) (see Fig 1). In general, the operation is performed with small incisions known as laparoscopy. Occasionally, the gastric bypass has to be done with a large incision, known as open gastric bypass.

This operation is still the most common weight loss procedure in the United States. Risks of this procedure can include bleeding, infection, leak and blood clots to name a few of the complications. Occasionally, reoperation or additional procedures are required after the bypass to manage complications. In the long-term, operations may be necessary to evaluate for bowel obstruction.

On average, at five years, this operation helps you to lose about 60% of your excess weight. Excess weight is the weight above the weight you should be (ideal weight). Health problems such as diabetes, high blood pressure, sleep apnea, joint pain all can improve or resolve depending on your individual history. Lifelong follow-up with the surgeon and dietitian are crucial for ongoing success. The weight loss journey is not just about the weight loss; the maintenance, and lifestyle change are major parts of the journey as well.

Laparoscopic gastric banding

This operation has gained in popularity over the past several years, since the LAP-BAND was approved in 2001 by the FDA. Currently, there are two bands available in the United States, the LAP-BAND and the REALIZE band which was approved by the FDA in 2007. Both bands are similarly effective at weight loss with minor differences.

The band is made of silicone and placed around the upper part of the stomach. (Fig. 2) The band has an inflatable balloon that cinches around the stomach and allows patients to be less hungry and to eat less at each meal. The band balloon is inflated with saline using a needle that goes thru the skin into the band port. The port is secured under the skin so that nothing is visible. Percent of excess weight loss at five years is 50-55%. Follow-up is crucial with the band as adjustments are usually necessary the first year and sometimes in the second year as well.

Complications may include infection, bleeding, gastric prolapse or band slippage and band/tubing problems. Reoperation may be necessary to address some of these complications. In my hands, these complications are decreased and less than the national average, but they still can occur.

Laparoscopic Duodenal Switch

In this operation, part of the stomach is removed as well as a significant bypass of the intestines (Fig. 3). Because of the magnitude of the intestinal bypass, the patient is at risk for malnutrition and is on many vitamin and protein supplements. This operation is very good for long-term weight loss but the patient needs to be monitored lifelong with bloodwork every six months. These patients are at high risk for brittle bone disease, night blindness, and liver problems. This is only an operation for someone committed to the risks and understands the need for compliance in follow-up as well as in taking the nutritional supplements.

Risks of this operation can include leak, infection, bleeding, pancreatitis in the short term and can include reoperations long term for malnutrition or for possible bowel obstruction. On average, the duodenal switch takes off up to 80% of your excess weight at 10 years.

Laparoscopic Sleeve Gastrectomy

This operation is also known as vertical gastrectomy, and approximately 80% of the stomach is removed (Fig 4). This is a newer operation, performed since 2001 as the first stage of the Duodenal Switch operation in patients who had over 200 lbs to lose. Because these patients were considered super, super morbidly obese, it was felt they would not tolerate a long operation. Doing the stomach resection first is a shorter procedure. The idea was to make their stomachs smaller and have them lose weight, and then perform the duodenal switch operation when it was safer for them to tolerate the rest of the operation. When these original patients were a year out, we found that some of them did not need a second stage of the duodenal switch, that they were losing weight still with just the sleeve gastrectomy. Because of that, many of us started doing sleeve gastrectomy as a primary weight loss procedure. This procedure is now covered by most insurance policies with some exceptions including Medicare.

Risks of the sleeve gastrectomy include infection, bleeding and leak. Long-term, the risk of bowel obstruction is unlikely given that only the stomach is operated on. Average excess weight loss at five years is about 50-55%. Because the stomach that produces ghrelin, a hormone that impacts hunger, is removed, patients may experience significantly less hunger after this operation.