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Surgery in the Treatment of Obesity (cont.)

Operative Procedures for Bariatric Surgery

Gastric bypassRoux-en-Y gastric bypass is the most commonly performed weight loss procedure in the United States. This operation both restricts food intake and limits absorption of food. A part of the stomach is closed off, creating a small pouch. This restricts the amount of food that you can eat at one time. The small pouch of the stomach is connected directly to the small bowel. As the name implies, food bypasses the stomach and the first portion of the small intestine. Because a part of the small bowel is bypassed, less food is absorbed. Most people find they can eat less than 1 cup of food at a time after the operation. Food must be chewed very well. Overeating or not chewing food finely will result in cramping, nausea, and vomiting.

Laparoscopic adjustable gastric bindingThis is a purely restrictive procedure. It involves placing an inflatable silastic band around the uppermost part of the stomach. This results in a smaller upper stomach pouch and a narrow opening between the upper and lower parts of the stomach. This induces and early feeling of fullness and thereby decreases food intake. It is adjustable by changing the volume of saline in a surgically placed subcutaneous reservoir, thereby tightening or loosening the band.

Biliopancreatic diversion Biliopancreatic diversion (BPD) is a malabsorptive procedure with some restrictive component. A part of the stomach is removed and the remaining part is attached directly to the small intestine near its end. BPD is used much less often than Roux-en-Y because it has a greater risk of complications.

Vertical banded gastroplastyVertical banded gastroplasty (VBG, stomach stapling) is a restrictive procedure that traditionally was done by applying bands or staples to the stomach. This procedure is rarely performed today due to the high failure rate. More information about these procedures can be obtained by visiting the American Society for Bariatric Surgery or the Bariatric Multidisciplinary Institute.

Benefits and Risks of Weight-Loss Surgery

Like all surgical procedures, weight-loss operations have benefits and risks. No one should decide to have surgery without being completely informed of both the pros and cons. This is a decision that you make with your family members, your health care provider, and your surgeon.

Benefits of weight-loss surgery

  • Weight loss: Most patients begin to lose weight right away. Some gain some of the weight back, but most are able to keep the weight off for long periods.
    • In general, combined restrictive and malabsorptive procedures (like gastric bypass) are more successful than restrictive procedures (like adjustable gastric banding) at promoting weight loss.
      • Gastric bypass is the most successful procedure. In the first 2 years after gastric bypass, average weight loss is 65% of excess weight. On the other hand, average weight loss with AGB is 35% of excess weight.
      • With gastric bypass, no band is introduced into the body. Also, it is a good operation for a sweet eater because eating sugar makes the patient feel ill (referred to as "dumping").
      • The lap-band system has the advantages of being less invasive, providing a faster recovery, and avoiding alteration of anatomy of the gastrointestinal tract. It is adjustable and reversible with normal stomach restoration. No opening of the stomach or intestines occurs that could cause a leak.
    • People who undergo one of these procedures are much more likely to reach their goal and keep weight off if they also adopt a plan of healthy eating and regular exercise.
  • Improved health: Most obesity-related medical conditions improve drastically after surgery, especially diabetes, sleep apnea, and hypertension.
    • After surgery mortality rate is reduced and improvements are seen in many of the health risks associated with obesity.
    • Overall, quality of life, self image, and mobility are reported to be better.

Risks of weight-loss surgery

All surgical procedures have complications. Talk to your surgeons about this and make sure that your surgeons are specialists in bariatric surgery.

  • Disadvantages of gastric bypass - A patient who has gastric bypass may develop the following complications:
    • "Dumping syndrome" - Patients experience nausea, abdominal cramping, and diarrhea after eating sugar. Other symptoms include weakness or faintness.
    • Narrowing or ulcer formation or leak at the stomach to intestine connection - These may require reoperation.
    • Incisional hernia - This is more common in open bariatric surgery.
    • Blood clot in the leg - This may migrate to the lung.
    • In addition to surgical complications, long-term consequences of the malabsorption arise if patients with gastric bypass do not take supplemental vitamins, iron, and calcium. These nutritional deficiencies include the following:
      • Vitamin deficiencies (A, B-12, D, E, and K) - Deficiencies of vitamin B-12, folate, and iron can cause anemia.
      • Mineral deficiencies (calcium, iron, and folic acid) - Calcium deficiency is a concern because it may lead to osteoporosis and other bone disorders.
  • Disadvantages of adjustable gastric band
    • The lap-band system is not the operation of choice in sweet eaters or patients with severe gastroesophageal reflux disease (GERD).
    • There is a low possibility of port leak or infection, as well as slippage, erosion, or migration of the band. This may require re-operation. High conversion rates of band to gastric bypass have been reported in American studies and may reflect patient selection.

In experienced hands, the benefits of surgery are typically viewed to outweigh the risks. The immediate operative mortality rate for both adjustable gastric band and Roux-en-Y gastric bypass is about 1%.

Weight regain after bariatric surgery

Some patients may regain weight after bariatric surgery. This may be due to many factors, among them the following:

  • Noncompliance with postoperative diet
  • Noncompliance with postoperative exercise
  • Stretching of the stomach pouch
  • Communication between the pouch and the rest of the stomach
  • Band problems

Costs of weight loss surgery

Surgery seems to be much more expensive than other treatments for obesity, but is cheaper than the treatment of all the complications of obesity. However, rates vary depending on choice of surgeon and hospital and region in which you live. Check with your carrier to see whether such operations are covered. Surgery may be covered by Medicare or Medicaid; check with your regional office.

Postoperative Care for Bariatric Surgery

If you undergo weight loss surgery, you will continue to receive close medical care for the rest of your life. Laparoscopic adjustable gastric banding will require more frequent visits for band adjustment. Postoperative dietary (including vitamin, mineral, and possibly liquid protein supplementation), exercise, and lifestyle changes should be reinforced by counseling, support groups, and working with your primary care physician. Postoperative care may include planning for reconstructive operations after weight stabilization for certain patients.

Medically reviewed by John A. Daller, MD; American Board of Surgery with subspecialty certification in surgical critical care


"Surgical management of severe obesity in adolescents"

Medically Reviewed by a Doctor on 7/27/2016
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