Weight Loss Surgery

Weight-loss surgery, or bariatric surgery, describes the area of surgery that specializes in altering the size and structure of several organs in the digestive tract to allow severely obese people to permanently lose weight. It is not cosmetic surgery. Instead, the operations performed, limit either the amount of food a person can eat or how much of the food is absorbed or a combination of both. The surgeries that are performed include:

• {L} Laparoscopic adjustable gastric banding
  
• {L} Roux-en Y gastric bypass
  
• {L} Biliopancreatic diversion with duodenal switch
  
• Vertical banded gastroplasty
   

*{L}=laparoscopic

Surgery for weight loss at NYU Medical Center utilizes an integrated approach that focuses on caring for the severely obese patient. The surgical staff is trained in the most advanced techniques of laparoscopic bariatric surgery. Nutritional, psychologic and medical support is provided both before and after surgery by a dedicated team of physicians and therapists.

Physicians who perform this surgery:

• Michael Edye, M.D.
  
• Thomas Gouge M.D.
  
• Christine J. Ren M.D.
  

 
Why have surgery to lose weight? - the rationale for bariatric surgery

Diets and drugs have failed to assure permanent weight loss in the nutritionally challenged population. By remaining obese this group is at increased risk of the complications of hypertension, heart disease, diabetes, cancer, degenerative joint disease and many other conditions. Weight loss results in increased longevity and a reduction in premature death. Significant quality of life improvements and reduction of complications can be achieved by relatively modest degrees of permanent weight loss.

There is a growing acceptance by the medical profession and health authorities that the risk and expense of surgical treatment for weight are justified by these benefits. The National Institute of Health (NIH) recommends that surgery is an acceptable therapy when the weight/height ratio (known as the BMI, explained later) is 40 kg/m 2or more. This corresponds to a weight of 225 lb in a female of 5'3" or 270 lb in a male of 5'9". In individuals who suffer other serious disorders (known as co-morbidities) such as hypertension, diabetes, heart disease etc, a lower threshold for surgery (35 kg/m 2) is allowed.

While there are increased risks associated with surgery in the obese, they are vastly outweighed by the cumulative risks of remaining obese, staying unwell and dying prematurely. As with all surgical procedures there are risks associated with anesthesia, the surgery itself and post-operative care.

Weight loss surgery is now known to consistently correct type II diabetes. As soon as weight loss begins, the need for drugs to reduce blood sugar diminishes as well. However, because of the largely restrictive mechanism for the weight loss procedures described below, by consuming enough high calorie foods in liquid or semi-solid form (ice cream, chocolate etc) it is possible to maintain or regain weight thereby negating the purpose of the surgery.

PROCEDURES

Gastric Bypass

A little background: Also known as Roux en Y Gastric bypass after César Roux. This Swiss surgeon first described a neat intestinal plumbing trick that involved cutting the small intestine near where it begins after the duodenum. This created two arms, upstream and downstream. The upstream end was plugged into the side of the downstream arm about 18 inches from the cut end (this can be hard to visualize so look at the drawing and play with a piece of string to get the idea). This creates a "Y" like configuration of the intestine. One arm of the "Y" comes from the stomach, liver and pancreas, called the biliopancreatic limb. The other arm (the "Roux" limb) was available to attach to any other hollow organ that carries food or produces fluid. Traditionally this was made at least 18 inches (1.5 foot) long to prevent backflow but can be made longer depending on the purpose of the operation being performed as will be described below. This plumbing change meant that by using the Roux limb, a blockage could be bypassed or the stomach removed, yet food or secretions would continue to pass through the intestinal tract in the normal way. It was observed that many patients with this arrangement after removal of the stomach would lose weight.

The operation of gastric bypass begins by creating a small pouch, of roughly one ounce capacity, with surgical staplers in the top of the stomach. The surgeon then attaches a long (3-4.5 foot) Roux limb to the pouch to allow food to continue on down through the gut. This takes food past almost all of the stomach (hence Gastric bypass) and shortens the intestine slightly causing some calories to be poorly absorbed.

Effects: Only small quantities of food can be ingested with comfort at any time, an effect known as restriction . Because food mixes further down the intestine with juices made by the liver and the pancreas, nutrient absorption changes. The complex set of digestive reflexes normally initiated by food entering the stomach is also permanently altered by this fundamental "plumbing" change. If concentrated, sugary foods are eaten, many patients will suffer from an uncomfortable reflex known as dumping due to rapid movement of food out of the stomach causing sudden fluid shifts into the intestine. Those who suffer this phenomenon learn to avoid high calorie foods. The end result is progressive weight loss due mostly to restriction and to a lesser extent though malabsorption . Weight loss continues for 12 to 18 months or more. This amounts on average to 70% of excess body weight. Vitamin and mineral micronutrient supplements are necessary for life.

Advantages of gastric bypass

The operation is permanent (although reversal can be achieved under certain circumstances). Weight loss is relatively predictable. By avoiding a large incision in the belly, laparoscopy is followed by much less pain, more rapid return of action of the intestine and shorter hospital stay. The weight loss results of laparoscopic compared with conventional surgery are identical. There are fewer serious complications after laparoscopic surgery than conventional surgery.

Disadvantages of gastric bypass

This is a major abdominal procedure in individuals who often have important co-morbid conditions that add to the risks. Intestine and stomach are cut with staplers. Staple lines can leak or narrow due to scarring. Leaks after surgery are particularly dangerous as they can be hard to identify early in obese individuals. Reoperation may be the only way to make the diagnosis and is often necessary if a leak can be identified. Overall the mortality of gastric bypass surgery is around 1%. Intestinal obstruction due to twists, kinks, adhesions or internal hernias can occur. Narrowing of the join between the small stomach pouch and the intestine occurs in 5-15% of patients. To improve swallowing, dilatation (stretching) of the narrowing by endoscopy may be necessary. Nutritional deficiencies can arise if supplements are omitted or follow-up is inadequate. Open surgery is complicated by a 25 % incidence of hernia in the abdominal wound (incisional hernia). Although laparoscopy does not eliminate incisional hernia completely, the hernias are smaller and less frequent. Apart from the obvious short-term benefits of laparoscopic surgery, many surgeons see the reduction in the incidence and severity of incisional hernia as the main long-term benefit.

Adjustable Gastric Banding-the "Band"

Contrary to what some insurers claim, this is not an experimental procedure. The Lapband device (formerly made by Bioenterics, now called Inamed) was approved for clinical use by the Food and Drug Administration in April 2001.

The operation: A tunnel is created around the top part of the stomach through which the Band is threaded, locked and fixed with stitches. A small reservoir linked by tubing to the Band is secured to the muscles of the abdomen that is accessed with a needle after the stomach has healed. In this way the amount of fluid within the collar of the Band can be increased or decreased according to the patient's needs. Once correctly adjusted, firstly by adding fluid, hunger is reduced and it is very uncomfortable if large quantities of food are consumed, or eaten too quickly. Weight loss should be of the order of 5-10 pounds a month but may be minimal until the correct adjustment is achieved. If the Band is too tight, vomiting is frequent. If the Band is too loose, little restriction is experienced, hunger is a problem and weight will not be lost.

Advantages of the adjustable gastric band:

This is a purely restrictive procedure. Stomach and intestine are not cut and joined as in gastric bypass. The operation is quicker and safer. Dangers are mostly due to the increased risk of an obese person undergoing general anesthesia. Only three deaths complicating 100,000 implantations worldwide are known.

Disadvantages of the adjustable gastric Band:

Obstruction: Stomach can slip under the Band causing a kink in the food channel, resulting in difficulty or inability to swallow. This usually occurs toward the end of the first year when weight loss has caused the fat between the Band and the stomach to diminish. Revision of the position or removal of the Band may be necessary.

Device related problems: Infection of the reservoir or Band will require removal. Leakage from the tubing due to a crack will need repair. Kinked tubing needs repositioning. If the reservoir or Band leaks it will need to be replaced.

Erosion: This is a rare but serious complication in which the Band migrates though the wall of the stomach. Weight gain or failure to lose weight may be the only clue. The diagnosis can be made by endoscopy when part of the Band can be seen on the inside of the stomach. Removal (a minor operation) is necessary and the patient is usually unsuited for the Band again.

Overall, about 15% of patients require some form of surgical procedure to correct a problem with the Band: removal, replacement, repositioning, revision or repair.

Around 5-7 adjustments may be necessary in the first year after implantation to achieve appropriate weight loss results. Experience shows that close follow-up and frequent adjustments result in better weigh loss. This continues more slowly than after gastric bypass but there are reports that by two years the weight loss after bypass and Band is equivalent.

WHAT IS BEST FOR ME?

The hallmark of the Band is safety. The price for safety is the relatively high incidence of device related problems requiring more surgery, the need for adjustments and the slower early weight loss. Some insurers do not cover the cost of the device (about $3500) which will need to be paid for by the patient.

Gastric bypass is followed by more rapid, even weight loss without the nuisance of device related problems with the Band. It is a far more major procedure with a reported mortality in the United States is about 1%.

What operation is recommended will depend strongly on your personal preference and comfort with the various risks and inconveniences of the methods available. There is no reliable way to know which is best for any given individual. It is known that patients whose excess calorie sources include simple carbohydrates in large quantities ("sweet eaters") do not lose weight well after the Band. Eliminating simple carbohydrates requires the sort of behavioral change that has been unsuccessful in the failed diets that regularly precede bariatric surgery. Ice cream, chocolate, and other high calorie liquifiable foods can pass straight through the banded stomach and will prevent weight loss if this type of eating behavior is not curbed. These are serious considerations when deciding which operation to have.

BMI Calculator Body Mass Index: Weight alone is insufficient to define obesity. Height must be added to the mix.
 
Use this calculator to determine your Body Mass Index (BMI).

 
DEFINITIONS:

Body Mass Index: Weight alone is insufficient to define obesity. Height must be added to the mix.

BMI=Weight (kg)/Height 2(meter)= Weight (pound)/Height 2(inches)x704

Obesity: BMI > 30 kg/m 2

Morbid obesity: BMI > 40 kg/m 2

Superobesity: BMI>50 kg/m 2

Very muscular individuals with low body fat will have a BMI in the obesity range e.g. a lean body builder 220 pounds/5'9" tall has a BMI 32.5.

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