Weight Loss Surgery Options
The American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

1. Restrictive procedures that decrease food intake.
2. Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.

Restrictive Procedures
Laparoscopic Adjustable Gastric Band

The most commonly performed restrictive procedure is adjustable gastric banding. This involves placement of an inflatable balloon around the upper stomach to create a very small virtual pouch. The balloon is 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, and the REALIZE Band System are each available at CRH Bariatric Center.

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.

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Sleeve Gastrectomy
Sleeve gastrectomy is a newer procedure that is restrictive in nature. In this procedure, approximately 90% of the stomach is removed, leaving a tubular sleeve between the esophagus and the 1st portion of the small intestine. The remaining stomach holds only about 150 cc's. This procedure induces significant satiety and a long lasting feeling of fullness which leads to profound weight loss.

Advantages

• There is no implanted device with sleeve gastrectomy, so there is no risk for erosion or device- related infection.
• There is no need for adjustments with the sleeve.
• Unlike the gastric bypass, there is no malabsorption with sleeve gastrectomy., so the long term risk of nutritional deficiency is lower than with gastric bypass or other malabsorptive procedures.
• The gastric sleeve is technically a simpler procedure than gastric bypass.
• Weight loss following the sleeve gastrectomy is reliable and relatively rapid. In studies of gastric sleeve patients, patients lost an average of 55-65% of their excess body weight over the first 18 months. Weight loss following sleeve gastrectomy is somewhat superior to adjustable gastric banding, and approaches that of gastric bypass.
• It may be the ideal choice for patients with a BMI >60, as it can be used wither as a primary procedure, or occasionally as a staged procedure, the first step toward a bypass or duodenal switch.

Risks associated with sleeve gastrectomy include obstruction (1-2%), leak (1%), bleeding (1-2%), and death (0.1%). These risks are intermediate in severity between adjustable gastric banding and gastric bypass.

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Combined Restrictive & Malabsorptive Procedure - Gastric Bypass Roux-en-Y
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% of excess body weight.
• Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
• A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.

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 15-30cc.
• 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.