In recent years, better clinical understanding of procedures combining
restrictive and malabsorptive approaches has increased the choices
of effective weight loss surgery for thousands of patients. By
adding malabsorption, food is delayed in mixing with bile and
pancreatic juices that aid in the absorption of nutrients. The
result is an early sense of fullness, combined with a sense of
satisfaction that reduces the desire to eat.
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.
For the last decade, laparoscopic procedures
have been used in a variety of general surgeries. Many people
mistakenly believe that these techniques are still "experimental."
In fact, laparoscopy has become the predominant technique in some
areas of surgery and has been used for weight loss surgery for
several years. Although few bariatric surgeons perform laparoscopic
weight loss surgeries, more are offering patients this less invasive
surgical option whenever possible.
When
a laparoscopic operation is performed, a small video camera is
inserted into the abdomen. The surgeon views the procedure on
a separate video monitor. Most laparoscopic surgeons believe this
gives them better visualization and access to key anatomical structures.
The camera and surgical instruments are inserted through small
incisions made in the abdominal wall. This approach is considered
less invasive because it replaces the need for one long incision
to open the abdomen. A recent study shows that patients having
had laparoscopic weight loss surgery experience less pain after
surgery resulting in easier breathing and lung function and higher
overall oxygen levels. Other realized benefits with laparoscopy
have been fewer wound complications such as infection or hernia,
and patients returning more quickly to pre-surgical levels of
activity.
Laparoscopic procedures for weight loss surgery employ the same
principles as their "open" counterparts and produce similar excess
weight loss. Not all patients are candidates for this approach,
just as all bariatric surgeons are not trained in the advanced
techniques required to perform this less invasive method. The
American Society for Bariatric Surgery recommends that laparoscopic
weight loss surgery should only be performed by surgeons who are
experienced in both laparoscopic and open bariatric procedures.
