Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity, not just gastric bypasses, which make up only one class of such operations.

Facts at a glance

• Gastric bypass surgery is performed with keyhole surgery
• The surgery has a higher complication rate than Gastric banding surgery
• Weight loss is much faster than Gastric banding surgery
• Hospital stay is on average (7-10) days
• Return to work is usually with in (4) weeks
• Long term follow up is essential for nutritional monitoring
• No adjustments are required post operatively

A gastric bypass first divides the stomach into a small upper pouch and a much larger, lower “remnant” pouch and then re-arranges the small intestine to allow both pouches to stay connected to it. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different GBP names. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and psychological response to food. The resulting weight loss, is typically dramatic, associated with markedly reduction in comorbidities.

Gastric bypass is indicated for the surgical treatment of morbid obesity, a diagnosis which is made when the patient is seriously obese, has been unable to achieve satisfactory and sustained weight loss by dietary efforts, and is suffering from co-morbid conditions which are either life-threatening or a serious impairment to the quality of life.

In the past, serious obesity was interpreted to mean weighing at least 100 pounds (45 kg) more than the “ideal body weight”, an actuarially determined body weight at which one was estimated to be likely to live the longest, as determined by the life insurance industry. This criterion failed for persons of short stature.

In 1991, the National Institutes of Health sponsored a consensus panel whose recommendations have set the current standard for consideration of surgical treatment, the body mass index (BMI). The BMI is defined as the body weight (in kilograms), divided by the square of the height (in meters). The result is expressed as a number usually between 20 and 70, in units of kilograms per square meter.

The Consensus Panel of the National Institutes of Health (NIH) recommended the following criteria for consideration of bariatric surgery, including gastric bypass procedures:

• People who have a body mass index (BMI) of 40 or higher. Or,
• People with a BMI of 35 or higher with one or more related comorbid conditions.

The Consensus Panel also emphasized the necessity of multidisciplinary care of the bariatric surgical patient, by a team of physicians and therapists, to manage associated co-morbidities, nutrition, physical activity, behavior and psychological needs. The surgical procedure is best regarded as a tool which enables the patient to alter lifestyle and eating habits, and to achieve effective and permanent management of their obesity and eating behavior.

Since 1991, major developments in the field of bariatric surgery, particularly laparoscopy, have outdated some of the conclusions of the NIH panel. In 2004, a Consensus Conference was sponsored by the American Society for Bariatric Surgery (ASBS), which updated the evidence and the conclusions of the NIH panel. This Conference, composed of physicians and scientists of many disciplines, both surgical and non-surgical, reached several conclusions, amongst which were:

• Bariatric surgery is the most effective treatment for morbid obesity
• Gastric bypass is one of four types of operations for morbid obesity.
• Laparoscopic surgery is equally effective and as safe as open surgery.
• Patients should undergo comprehensive pre-operative evaluation, and have multi-disciplinary support, for optimum outcome.

Surgical techniques

The gastric bypass, in its various forms, accounts for a large majority of the bariatric surgical procedures performed. It is estimated that 200,000 such operations were performed in the United States in 2008.[4] An increasing number of these operations are now performed by limited access techniques, termed “laparoscopy”.

Laparoscopic surgery is performed using several small incisions, or ports, one of which conveys a surgical telescope connected to a video camera, and others permit access of specialized operating instruments. The surgeon actually views his operation on a video screen. The method is also called limited access surgery, reflecting both the limitation on handling and feeling tissues, and also the limited resolution and two-dimensionality of the video image. With experience, a skilled laparoscopic surgeon can perform most procedures as expeditiously as with an open incision — with the option of using an incision should the need arise.

Variations of the gastric bypass

Gastric bypass, Roux en-Y (proximal)

This variant is the most commonly employed gastric bypass technique, and is by far the most commonly performed bariatric procedure in the United States. It is the operation which is least likely to result in nutritional difficulties. The small bowel is divided about 45 cm (18 in) below the lower stomach outlet, and is re-arranged into a Y-configuration, to enable outflow of food from the small upper stomach pouch, via a “Roux limb”. In the proximal version, the Y-intersection is formed near the upper (proximal) end of the small bowel. The Roux limb is constructed with a length of 80 to 150 cm (31 to 59 in), preserving most of the small bowel for absorption of nutrients. The patient experiences very rapid onset of a sense of stomach-fullness, followed by a feeling of growing satiety, or “indifference” to food, shortly after the start of a meal.

Gastric bypass, Roux en-Y (distal)

The normal small bowel is 600 to 1,000 cm (20 to 33 ft) in length. As the Y-connection is moved farther down the Gastrointestinal tract, the amount of bowel capable of fully absorbing nutrients is progressively reduced, in pursuit of greater effectiveness of the operation. The Y-connection is formed much closer to the lower (distal) end of the small bowel, usually 100 to 150 cm (39 to 59 in) from the lower end of the bowel, causing reduced absorption (mal-absorption) of food, primarily of fats and starches, but also of various minerals, and the fat-soluble vitamins. The unabsorbed fats and starches pass into the large intestine, where bacterial actions may act on them to produce irritants and malodorous gases. These increasing nutritional effects are traded for a relatively modest increase in total weight loss.

Loop Gastric bypass (“Mini-gastric bypass”)

The first use of the gastric bypass, in 1967, used a loop of small bowel for re-construction, rather than a Y-construction as is prevalent today. Although simpler to create, this approach allowed bile and pancreatic enzymes from the small bowel to enter the esophagus, sometimes causing severe inflammation and ulceration of either the stomach or the lower esophagus. If a leak into the abdomen occurs, this corrosive fluid can cause severe consequences. Numerous studies show the loop reconstruction (Billroth II gastrojejunostomy) works more safely when placed low on the stomach, but can be a disaster when placed adjacent to the esophagus. Thus even today thousands of “loops” are used for general surgical procedures such as ulcer surgery, stomach cancer and injury to the stomach, but bariatric surgeons abandoned use of the construction in the 1970s, when it was recognized that its risk is not justified for weight management.

The Mini-Gastric Bypass, which uses the loop reconstruction, has been suggested as an alternative to the Roux en-Y procedure, due to the simplicity of its construction, which reduced the challenge of laparoscopic surgery.

The Laparoscopic Gastric Bypass, Roux-en-Y, first performed in 1993, is regarded as one of the most difficult procedures to perform by limited access techniques, but use of this method has greatly popularized the operation, with benefits which include shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.

Essential features

The gastric bypass procedure consists in essence of:

• Creation of a small, (15–30 mL/1–2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach (about 400 mL and variable). This restricts the volume of food which can be eaten. The stomach may simply be partitioned (typically by the use of surgical staples), or it may be totally divided into two parts (also with staplers). Total division is usually advocated, to reduce the possibility that the two parts of the stomach will heal back together (“fistulize”), negating the operation.
• Re-construction of the GastrointestinalI tract to enable drainage of both segments of the stomach. The technique of this reconstruction produces several variants of the operation, which differ in the lengths of small bowel used, the degree to which food absorption is affected, and the likelihood of adverse nutritional effects.

Frequently Asked Questions

What hospitals do we operate at for this procedure?

•  The Valley Private – Mulgrave
•  Knox Private – Wantirna

What appointments are required prior to surgery?

•  (2) weeks prior you will have a consultation with the dietitian
•  (2) weeks prior you will have a consultation with our counsellor
•  (1) week prior a consultation with the pre-admission nurse of the hospital
•  (1) week prior a final consultation with your surgeon

What appointments will I need following surgery?

We will make an appointment for you to have a consultation with our dietitian around the 2-3 weeks post surgery to discuss you dietary requirements.

Surgical Benefits

1. Long term maintenance weight loss
2. Possible control or remission of serious illness associated with obesity including:
   • Raised Blood Pressure
   • Diabetes
   • Sleep Apnoea
   • Depression
3. Improved Quality of life, relinquish of stress of always being on a diet
4. Able to participate in family activities eg swimming, playing sport chasing the kids
5. Ability to purchase clothes in mainstream shops

Risks Associated with Laproscopic Gastric Bypass

Anastomotic leakage

An anastomosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a water-tight connection by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the healing power of the body, and its ability to create a seal like a self-sealing tire, to succeed with the surgery. If that seal fails to form, for any reason, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastomosis can occur in about 2% of gastric bypass procedures, usually at the stomach-bowel connection. Sometimes leakage can be treated with antibiotics, and sometimes it will require immediate re-operation. It is usually safer to re-operate if an infection cannot be definitely controlled immediately.

Anastomotic stricture

As the anastomosis heals, it forms scar tissue, which naturally tends to shrink (“contract”) over time, making the opening smaller. This is called a “stricture”. Usually, the passage of food through an anastomosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction.

Anastomotic ulcer

Ulceration of the anastomosis occurs in 1-16% of patients. Five possible causes of such ulcers are:

• Restricted blood supply to the anastomosis (compare to the blood supply available to the original stomach)
• Anastomosis tension
• Gastric acid
• Helicobacter pylori
• Smoking
• Use of Non-steroidal anti-inflammatory drugs

This condition can be treated as follows:

• Use of Proton pump inhibitors, e.g., Nexium
• Use of a Cytoprotectant and acid Buffering agent, e.g., Sucralfate
• Temporary restriction of the consumption of solid foods

The post What you should know about Laparoscopic Gastric Bypass appeared first on South Florida Bariatric Surgery.

 How the LAP-BAND® Adjustable Gastric Banding System Works: 

The LAP-BAND® System was developed to facilitate long-term weight loss and reduce the health risks associated with severe and morbid obesity.  Unlike gastric bypass, it does not involve stomach cutting, stapling or intestinal re-routing. , ,   Using laparoscopic surgical techniques, the device is placed around the top portion of the patient’s stomach, creating a small pouch.  By reducing stomach capacity, the LAP-BAND® System can help achieve long-term weight loss by creating an earlier feeling of satiety.  The LAP-BAND® System is adjustable, which means that the inflatable band can be tightened or loosened to help the patient achieve a level of satiety while maintaining a healthy diet.  It is also reversible and can be removed at any time.

Key Benefits of the LAP-BAND®System over Gastric Bypass:

Safer, Less Invasive Surgical Option:

1. The LAP-BAND® System can be applied to the top portion of the stomach laparoscopically using “keyhole” surgery, which offers the advantages of reduced pain, length of hospital stay and recovery period1,2
2. The LAP-BAND® System procedure has a lower severe complication rate perioperatively (less than 1 percent) and lower mean short-term mortality rate (0.05 percent, approximately 1/10 the mortality rate of gastric bypass)3
3. The LAP-BAND® System carries fewer risks of vitamin and mineral deficiencies than gastric bypass
4. The LAP-BAND® System has non-surgical adjustments that help the patient attain and maintain a healthy satiety level and minimize the potential for weight regain
5. The LAP-BAND® System is reversible and it can be removed at any time

LAP-BAND®System Effectiveness:

1. In clinical studies of severely obese patients, the LAP-BAND® System has been demonstrated to be an effective surgical method for weight loss, improving co-morbid conditions such as Type 2 diabetes and hypertension and reducing the use of medication to treat those conditions
2. Adjustibility helps patients sustain long-term weight loss benefits

Surgical Risks

These will be discussed with in detail with you PRIOR to the operation. Possible complications include but are not limited to:

• Band Slippage or dilatation of the upper pouch – Occurs in about 10% of cases. Usually means another operation, usually a keyhole operation again and just overnight in hospital.
• Band erosion – Rare, less than 1.0%. Requires another operation, usually keyhole surgery
• DVT (blood clots in the leg or pelvic veins). Rarely, but occasionally fatal if clots spread to lungs.
• Respiratory complications, such as pneumonia.
• Damage to other organs during procedure – risk is common to all laparoscopic surgery but very rare.
• Open surgery – on rare occasions it may be impossible to insert the band with keyhole surgery and a large incision may be needed.
• Longterm band failure is about 10%

Surgical benefits

1. Long term maintenance weight loss
2. Possible control or remission of serious illness associated with obesity including:
   • Raised Blood Pressure
   • Diabetes
   • Sleep Apnoea
   • Depression
3. Improved Quality of life, relinquish of stress of always being on a diet
4. Able to participate in family activities eg swimming, playing sport chasing the kids
5. Ability to purchase clothes in mainstream shops

Frequently Asked lap Band Questions

How long do I have to wait to have my surgery?

From the time you have your first consultation to the date of surgery providing you are assessed as suitable to go ahead approximately 6 – 8 weeks.  Should you need further investigations as required by our physician we will instigate these as soon as possible in order for you to have your surgery as soon as possible.  What you need to remember is that we do not want to put you at risk by rushing the process – it’s in your best interest to wait until our physician has given the go ahead to proceed.

How long am I in hospital for?

The average stay in hospital is overnight but should you not be well enough to return home the day after your surgery we will keep you in hospital for on more night.  In the event that your procedure is not straight forward then a longer stay can be anticipated.

How long am I off work for?

You can be expected to be off work for approximately 10- 14 days following your surgery.  Should you require a medical certificate to cover your time off work please ensure you request it from the hospital prior to going home.

What follow up appointments are required?

You will require an appointment with our nurse specialist at 10 days post operatively, then our Dietitian at 3 weeks post operatively and your first adjustment of the LapBand® at approximately 5 weeks.  Following these appointments your may require 3-5 visits to adequately adjust your band to obtain restriction.

What is my diet pre-operatively and post operatively?

You will be expected to have Optifast shakes for 2 weeks pre-operatively and then following your surgery your diet will consist of “mushy” food which will be built up to resume solid foods by the 5th week.

When can I exercise?

If you plan to join a gym following your surgery you will need to wait 4-6 weeks.  If you already had a gym membership and have suspended it you can restart your cardio exercise after 2 weeks and weights at 4 weeks.  Walking can be resumed after 1 week and cycling at 2 weeks.

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Surgical Procedure

Sleeve Gastrectomy surgery is a restrictive surgical procedure. It is restrictive in the sense that it “restricts” how much food the stomach can hold.

Patients with excessively high BMI’s (over 55), are at increased risk for Bariatric surgery. Therefore, your surgeon may recommend performing the sleeve gastrectomy as the first part of a two part surgery. This enables the patient to lose weight for the first year prior to the second surgery where bypass is performed to assist the patient with the remaining weight loss. Because the patient loses weight from the sleeve gastrectomy, there is less risk associated with the second surgery to do the bypass. Highly motivated patients may not require the second stage of surgery if adequate weight loss is achieved by sleeve gastrectomy alone.

In a sleeve gastrectomy surgery, the left side of the stomach is removed leaving a smaller sleeve or tube that is shaped like a banana. This surgery is performed laparoscopically and involves stapling of the stomach upon removal of the left side of the stomach.

How long will I be in hospital?

On average your stay in hospital will be approximately (5) days.

How long will I need to be off work?

You will require approximately (2) weeks - should you require a medical certificate please ensure you request one from the hospital prior to discharge.

What can I eat following surgery?

You will be required to have fluid/soft food for the first couple of weeks and then progress to solid foods as instructed.

Which hospitals do we operate at?

•  The Valley Private Hospital – Mulgrave
•  Knox Private Hospital – Wantirna

Disadvantages

• Potential is higher for inadequate weight loss or weight regain compared to intestinal bypass surgeries.
• Irreversible
• Considered investigational by some surgeons and insurance companies
• Considered a temporary treatment for obesity unless second stage (bypass) is performed
• Potential for dilation of the sleeve affecting weight loss
• Long term results have not been evaluated

As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages

It is important that you are informed of these risks before the surgery takes place.

Most patients do not have complications after Sleeve Gastrectomy surgery; however complications can occur and depend on the patient’s health status.

Complications

Complications can be medical (general) or specific to Sleeve Gastrectomy . Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reaction to medications
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attack, strokes, kidney failure, pneumonia, bladder infections
• Complications from anesthesia
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death. (less than 1% cases)

Specific complications for Sleeve Gastrectomy surgery include:

• DVT (blood clot in the deep leg veins)
• Damage to adjacent organs
• Leakage of digestive contents from the staple line can lead to serious infection

Although every effort is made to educate you on Sleeve Gastrectomy surgery and take control, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any concerns you have about this surgery.

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Obesity is an excess of total body fat, which results from caloric intake that exceeds energy usage. A measurement used to assess health risks of obesity is Body Mass Index (BMI).

Obesity is the second leading cause of preventable death following smoking.

Causes of Obesity

Obesity could be a combination of the following:

• The genes you inherited from your parents
• How well your body turns food into energy
• Your eating and exercising habits
• Your surroundings
• Psychological factors
• Consequences of Obesity

If you are obese, severely obese, or morbidly obese, you may have:
Major health risks

• Shorter Life Expectancy
• Compared to people of normal weight, obese people have a 50% to 100% increased risk of dying prematurely
• Obese people have more risk for:
• Diabetes (type 2)
• Joint problems (e.g., arthritis)
• High blood pressure
• Heart disease
• Gallbladder problems
• Certain types of cancer (breast, uterine, colon)
• Digestive disorders (e.g., gastroesophageal reflux disease, or GORD)
• Breathing difficulties (e.g., sleep apnea, asthma)
• Psychological problems such as depression
• Problems with fertility and pregnancy
• Urinary Incontinence

Risks to psychological and social well-being

• Negative self-image
• Social isolation
• Discrimination
• Difficulties with day-to-day living

Normal tasks become harder when you are obese, as movement is more difficult
You tend to tire more quickly and you find yourself short of breath
Public transport seats, telephone booths, and cars may be too small for you
You may find it difficult to maintain personal hygiene
Treatment Options

Non-Surgical Treatment

Dieting, exercise, and medication have long been regarded as the conventional methods to achieve weight loss. Sometimes, these efforts are successful in the short term. However, for people who are morbidly obese, the results rarely last. For many, this can translate into what’s called the “yo-yo syndrome,” where patients continually gain and lose weight with the possibility of serious psychological and health consequences.

Recent research reveals that conventional methods of weight loss generally fail to produce permanent weight loss. Several studies have shown that patients on diets, exercise programs, or medication are able to lose approximately 10% of their body weight but tend to regain two-thirds of it within one year, and almost all of it within five years**. Another study found that less than 5% of patients in weight loss programs were able to maintain their reduced weight after five years*.

Surgical Treatment

Over the years, weight-loss surgery has proven to be a successful method for the treatment of morbid obesity#. Surgical options have continued to evolve and LAP-BAND surgery. This procedure is the least traumatic, adjustable and reversible obesity surgery available. The LAP-BAND System provides a unique tool that can help you achieve and maintain significant weight loss, improve your health, and enhance your quality of life.

Surgical Treatment options

:: Laparoscopic Adjustable Gastric Banding

:: Biliopancreatic Diversion BPD
:: Gastric Bypass

** American Association of Clinical Endocrinologists (AACE) / American College of Endocrinology. (ACE) Statement on the Prevention, Diagnosis, and Treatment of Obesity (1998 Revision).
AACE/ACE Obesity Task Force. Endocr Pract. 1998; Vol. 4 No. 5: 297-330.

* Kramer FM et al. Long-term follow-up of behavioral treatment for obesity: patterns of weight regain among men and women. Int J Obes 1989; 13:123-136.

# SAGES/ASBS Guidelines for Laparoscopic and Conventional Surgical Treatment of Morbid Obesity. American Society for Bariatric Surgery. http://asbs.org/html/guidelines.html

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