CMMC now offers both the Roux-en-Y Gastric Bypass (open and laparoscopic) and the Laparoscopic Adjustable Gastric Band (LapBand) procedures.
The American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:
- Restrictive procedures that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.
To read about each of our weight management procedures, click here for view a PDF guide.
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.
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Laparoscopic Adjustable Gastric Banding (LAGB) (This procedure is offered by CMMC Bariatric Surgery Center)
The LAGB (LapBand or Realize Band) is designed to induce weight loss by restricting food consumption, and is a variation of the Vertical Banded Gastroplasty (VBG).
An adjustable elastic band is placed around the upper stomach to create a small 15cc (one half ounce) pouch with a narrowed outlet. The outlet size can be adjusted by injecting saline into a small reservoir (port) placed under the skin at the time of surgery, and connected to the band by an I.V. tubing. The pouch fills quickly with solid food and empties slowly to relieve hunger and produce a feeling of fullness. Overeating results in pain or vomiting to limit food intake.
Advantages
- That no cutting or stapling of the stomach is required
- The outlet size can be adjusted in the office by injecting saline into the band to loosen or tighten the opening.
- The band is more easily reversible with restoration of normal stomach anatomy after band removal.
Risks
- Risk of slippage of the band around the stomach to an abnormal position, Erosion of the band into the stomach, or Port or tubing problems or Mechanical malfunction of the band.
All of these are known to occur in 10-22% of patients, and many require another operation to correct the condition .The LAGB is not a permanent device and will require replacement or removal at some point in the future.
Just as with the VBG, the band does not limit intake of high calorie liquids or sweets. This procedure can be accomplished laparoscopically as an outpatient with return to full activity in 7-10 days.
With that in mind, the REALIZE(tm) Personalized Banding Solution gives patients the REALIZE mySUCCESS(tm) program, which provide support to help patients successfully achieve long-term weight loss with the REALIZE Band.
Through REALIZE my SUCCESS(tm), patients and physicians can set
goals and continuously watch the patient's progress together -
especially for the first three years, as the patient adjusts to his/her
new lifestyle. Through this program, patients and physicians can
establish a tailored progress plan to develop new health habits in the
areas of physical activity, nutrition and emotional well-being.
"REALIZE my SUCCESS(tm) works closely with our bariatric team," said
Adam Dungey, CBN, the state's first certified Bariatric nurse and nurse
manager of the Comprehensive Weight Management Center. "The information
provided is comprehensive yet specific to the needs of a gastric band
patient."
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The vertical sleeve gastrectomy, more simply called the sleeve gastrectomy, is an operation in which the left side of the stomach ("greater curvature") is surgically removed. This results in a new stomach that is roughly the size and shape of a banana. Since this operation does not involve any "rerouting" or reconnecting of the intestines, it is a simpler operation than the gastric bypass or the duodenal switch. Unlike the LAP-BAND® procedure, the sleeve gastrectomy does not require the implantation of an artificial device inside the abdomen.
In some cases, the sleeve gastrectomy is performed as a definitive therapy for obesity. For certain patients, in particular those with a body mass index greater than 60, the sleeve gastrectomy may be the first part of a 2-stage operation.
Advantages
- Since the stomach reduces to about 150 cc in volume, it results in a restrictive weight loss. The patients feel full and satisfied after a very small amount of food, and therefore, lose weight because they eat less. What's more, they are happy eating less.
- A very important fact is that the operation preserves the pylorus, the valve that regulates emptying of the bowels. This valve acts as a "nature's band" and allows food to stay in the stomach for a while, thus making the person feel full while the food trickles out.
Risks
- Potential for inadequate weight loss or weight regain. While this is true for all procedures, it is theoretically more possible with procedures that do not have an intestinal bypass.
- Higher BMI patients will most likely need to have a second stage procedure later to help lose the rest of the weight. Remember, two stages may ultimately be safer and more effective than one operation for high BMI patients. This is an active point of discussion for bariatric surgeons.
- Soft calories such as ice cream, milk shakes, etc can be absorbed and may slow weight loss.
- This procedure does involve stomach stapling and therefore leaks and other complications related to stapling may occur.
- Because the stomach is removed, it is not reversible. It can be converted to almost any other weight loss procedure.
- Considered investigational by some surgeons and insurance companies.
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Vertical Banded Gastroplasty (VBG) is a purely restrictive procedure. In this procedure the upper stomach near the esophagus is stapled vertically for about 2-1/2 inches (6 cm) to create a smaller stomach pouch. The outlet from the pouch is restricted by a band or ring that slows the emptying of the food and thus creates the feeling of fullness.
Advantages
- The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order. That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body.
- After 10 years, studies show that patients can maintain 50% of targeted excess weight loss.
Risks
- Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection. This may require prolonged hospitalization with antibiotic treatment and/or additional operations.
- Staple-line disruption may also, in the long-term, lead to weight gain. For these reasons, some surgeons divide the staple-line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple-line disruption.
- The band or ring applied may lead to complications of obstruction or perforation, requiring surgical intervention.
- Characteristically, these procedures, while creating a sense of fullness, do not provide the necessary feeling of satisfaction that one has had "enough" to eat.
- Because restrictive procedures rely solely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or of the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.
- Around 40% of patients undergoing these procedures have lost less than half their excess body weight.
- As is the case with all weight loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.
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While these operations also reduce the size of the stomach, the stomach pouch created is much larger than with other procedures. The goal is to restrict the amount of food consumed and alter the normal digestive process, but to a much greater degree. The anatomy of the small intestine is changed to divert the bile and pancreatic juices so they meet the ingested food closer to the middle or the end of the small intestine.With the three approaches discussed below, absorption of nutrients and calories is also reduced, but to a much greater degree than with previously discussed procedures. Each of the three differs in how and when the digestive juices (i.e., bile) come into contact with the food.
Since food bypasses the duodenum, all the risk considerations discussed in the gastric bypass section regarding the malabsorption of some minerals and vitamins also apply to these techniques, only to a greater degree.
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BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb." All the food moves through this segment, however, not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.
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This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above.
Advantages
- These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
- These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
- In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
- Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.
Risks
- For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
- Abdominal bloating and malodorous stool or gas may occur.
- Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
- Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
- Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.
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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.
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The Comprehensive Weight Management Center at Central Mississippi Medical Center is among the first in the state of Mississippi to offer the REALIZE(tm) Adjustable Gastric Band, a device that is surgically implanted around the stomach to help people with morbid obesity lose weight and improve obesity-related health conditions including type 2 diabetes, sleep apnea and high cholesterol.
In the clinical trail that led to its FDA approval, REALIZE(tm) Band patients lost an average of 50 pounds or 40% of their excess body weight within the first year of surgery and maintained that weight loss over three years.
"Gastric band patients are able to lose a significant amount of weight and improve their overall health status in a relatively short period of time considering many have been morbidly obese for years prior to surgery," said Ken Cleveland, M.D., medical director of the Comprehensive Weight Management Center at CMMC. "And, while the surgery is among the most effective treatments for morbid obesity, it is just one step along the patient's journey. Patients must make changes to their diet and lifestyle after surgery to help achieve long term success."
For more information on this procedure, contact the Comprehensive Weight Management Center at 601-376-2474 or 1-877-544-4898.
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