Procedures
- Roux-en-Y Gastric Bypass Surgery
- Laprascopic Adjustable Gastric Band
- Vertical Sleeve Gastrectomy
- Transoral Surgery
Roux-en-Y Gastric Bypass Surgery
The purpose of the operation is to reduce the size of the stomach to roughly two ounces, as opposed to its former size of about two quarts. This drastic reduction limits the stomach’s ability to hold food, making the patient feel full and satisfied after eating only a small amount. Bypassing most of the stomach reduces hormones that induce hunger so patients may not have the cravings for food. Additionally, because most of the stomach and some of the small intestine has been bypassed, some of the nutrients and calories in your foods will not be absorbed. However, most of the effect of this surgery is in helping with volume control.
For the surgery to be successful, lifelong dietary and behavior modifications of eating habits and exercise are required.
Step One
The stomach is stapled just below the esophagus, forming a 20 to 30cc (1 ounce) stomach pouch above the staples, severely restricting the amount and kind of food or liquid that can be consumed at one time.
Step Two
The small bowel is divided about four feet below the stomach (points A and B). Then a new 1.5 centimeter opening (stoma) is created in the stomach pouch (Point C).
Step Three
The open end of the small bowel at Point B is attached to the new opening at Point C. Food and fluids can now pass from the stomach pouch into the small bowel. The remaining end of the small bowel (Point A) is attached at Point D, creating a "Y-shaped" intestinal junction. An opening is made at Point D to allow digestive juices from the bypassed part of the stomach to flow into the small bowel.
Adapted from Bray, G.A., Gray, D.S. Obesity, Part I. Pathogenesis. West J. Med. 1988: 149:429-41.
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Laprascopic Adjustable Gastric Band
Laparoscopic adjustable gastric banding is a restrictive weight loss surgery. The gastric band is an inflatable silicone prosthetic device which is placed around the top portion of the stomach creating a small pouch. On eating, food is now stored in the upper part of the stomach giving the sensation of fullness with a small amounts. The band can be adjusted (tightened or loosened) via a small access port placed under the skin. Most of the effect of this operation is with volume control.
For the surgery to be successful, it requires lifelong dietary and behavior modifications of their eating habits and exercise. Average weight loss of patients undergoing a laparoscopic adjustable band is 40% of their excess body weight over a 12 month period.
How does the Lap-Band promote weight loss?
The Lap-Band restricts the amount of food your stomach can hold and extends the feeling of being full and satisfied after eating a small amount of solid food. The success of this procedure, however, depends on how motivated you are to change your eating behaviors. Patients should eat three small high protein, low carb meals daily with no snacking. Eating too fast or too much can cause vomiting. No fluid should be taken with meals because it will cause the stomach to empty quickly. High-calorie beverages such as non-diet sodas, fruit juice, milkshakes, and smoothies must be avoided because they will impair weight loss. The same is true of high-calorie snack foods such as candy, ice cream and chocolate.
How does the surgery differ from gastric bypass
The Lap-Band procedure requires no stapling or cutting of the stomach and no surgery on the intestine. No intestinal bypass is done, so there is no change in the amount of calories and nutrients absorbed in the intestine. Lap-Band patients do not experience dumping syndrome after consuming high-sugar foods or beverages. The tightness of the Lap-Band is adjusted to suit your individual situation and it can be removed if necessary. If done laparoscopically, which is the case for most patients, the Lap-Band procedure takes about one hour in the operating room and usually one night in the hospital. In 5% of cases, the Lap-Band placement cannot be completed laparoscopically. This would extend the hospital stay. Gastric bypass is a longer, more complex surgery that usually requires a stay of two or more nights.
How much weight can I expect to lose with the Lap-Band?
A weight loss of 2-3 pounds a week is possible during the first year, but this depends on the patient's commitment to new eating habits and regular exercise.
Weight loss is usually at a slower rate than weight loss after gastric bypass surgery. Studies show the average weight loss after Lap-Band surgery is about 15 points on the body mass index scale within 18-24 months after the surgery.
The average weight loss in the Lap-Band U.S. clinical trials was approximately 40% of excess weight, but some patients were able to lose much more. The majority of Lap-Band patients do not reach their ideal weight range; however, they enjoy a tremendous improvement in their health, appearance, energy level and ability to enjoy physical activities.
What are the risks?
Lap-Band surgery carries the same risks as other laparoscopic surgical procedures and much less risk than gastric bypass surgery. Only 1-3% of patients experience bleeding, infection inside the abdomen, blood clots in the leg that can travel to the lungs, perforation of the stomach or esophagus during surgery, spleen or liver damage and death (less than 1%). There also are possible complications related specifically to the Lap-Band. Over time, it is possible for the band to slip out of position, block the outlet from the stomach or erode into the lining of the stomach, which would require an additional surgery to repair.
If the band needs to be removed or replaced, it would require an additional surgery. Problems that can occur after Lap-Band placement include nausea, vomiting, acid reflux, heartburn, stomach ulcer, gastritis, gas bloat, trouble swallowing, dehydration, diarrhea, constipation and weight regain. The band may deflate if a leak occurs in the tubing, port or the band itself. In the first Lap-Band study in the U.S., 25% of the patients had the band removed for a variety of reasons. Since that time, surgical techniques have been improved to reduce the risk of complications.
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Vertical Sleeve Gastrectomy
The operation and how it works
The Vertical (Sleeve) Gastrectomy is an operation that causes weight loss by restricting food intake. In this procedure, the surgeon removes about 60% of the stomach, so that the stomach is the shape of a narrow tube or "sleeve". This allows the person to experience a sense of fullness after a small meal. Many people have less hunger, too. This operation is permanent, to help people sustain their weight loss. The normal pathway of food digestion is preserved.
In most patients, this procedure is done laparoscopically. It takes about an hour in the operating room, and people typically leave the hospital on the day after surgery.
Complications
Complications from the Laparosopic Vertical Gastrectomy procedure include leakage, along the staple line where the stomach was removed. People who have weight loss surgery are particularly vulnerable to blood clots in the leg, called deep venous thrombosis (DVT), which can travel to the lungs, called pulmonary embolism. Because the Laparoscopic Vertical Gastrectomy procedure is shorter than the Gastric Bypass, the risk of DVT is slightly less.
Benefits
The most recent data suggest that patients who have undergone Laparoscopic Vertical Gastrectomy surgery will lose 40-50% of their excess body weight, at about one year post-operatively.
At this time, not all insurance companies are authorizing this type of surgery. While there are significant advantages to this operation, particularly for people who take many medications for diseases that are unlikely to improve with weight loss (such as mental illness or rheumatoid arthritis), there remain some questions regarding the long-term weight maintenance. There are a few recent scientific articles that address this, and the outlook is promising, but many insurance companies are waiting for more information.
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Transoral Surgery
Surgical treatment can be done with the help of endoscopes, long flexible tools that can be introduced through natural openings. We are using these endoscopic techniques with increasing frequency as new tools have become available that allows the surgeons to treat patients through these less invasive methods.
Revisional surgery following Roux-en-Y gastric bypass:
Years after gastric bypass surgery, a small percentage of patients may experience a profound change in the amount of food they can eat before feeling full.
Regain weight may have a number of causes:
Other factors
After a thorough re-evaluation, patients with a structural problem to their gastric bypass may benefit from endoscopic surgery. Issues with stoma or pouch dilatation may be possible to address with endoscopic plication (gathering) of the tissues to reduce the size of either the pouch, the stoma (opening) or both.
Endoscopic revisional surgery is performed under general anesthetic. The endoscope and the plicating device is introduced through the mouth and esophagus to the small stomach area and the plication or gathering is then done around the area of the previous gastric bypass. Following the procedure, patients need to be on a liquid diet for several days while the surgery heals. The effect of the endoscopic surgery may vary depending on the individual anatomy and previous surgery.
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