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
Restrictive vs. Malabsorptive Procedures ©Miller K.
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.
- 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.
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.
to the high rate of complications VBG is not performed in our clinic
Gastric Restrictive Procedure -
Adjustable Gastric Banding
Gastric Restrictive Procedure -
Gastric Sleeve Resection
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.
Biliopancreatic Diversion (BPD)
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.
Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E)
RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it fewer operative risks by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects.
Biliopancreatic Diversion with "Duodenal Switch"
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.
- 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.
- 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.
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.
- 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.
- 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.
Frequently Asked Questions about Gastric Bypass Surgery
What is gastric bypass surgery?
Gastric bypass is a surgical method used to help people
with morbid obesity lose weight and reverse other health problems associated
with being overweight, such as high blood pressure and Type II diabetes. The
Roux-en-Y gastric bypass, creates a small pouch in the top of the stomach to
which the small intestine is connected. With a smaller stomach, the patient
feels "full" sooner and is less likely to overeat. Depending upon what is best
for each individual patient, the bypass is performed as an "open" procedure, or
with a minimally invasive technique using laparoscopes.
Can anyone who is overweight have gastric bypass
The surgery is not a cosmetic procedure, but rather, a
course of last resort for people who are at least 100 pounds over their ideal
weight and have a body mass index (BMI) of over 40. Patients with a slightly
lower BMI may be considered for the procedure if they have other obesity-related
problems such as Type II diabetes, cardiovascular disease, or sleep apnea.
Gastric bypass is also generally reserved for patients who have been unable to
lose weight through weight reduction programs and exercise.
What are the risks of gastric bypass surgery?
As is true with any operation, there are complications
associated with gastric bypass surgery. One of the most serious is leakage where
the stomach pouch meets the small intestine.
With no treatment, approximately one in four gastric
bypass patients will develop gallstones following surgery. That is why a bile
thinning medication is prescribed after surgery.
Some other complications include abdominal hernia in
open traditionally surgery, wound infection, and bowel obstruction. There is
also the possibility of lung-related conditions, such as pulmonary embolism, and
additional stress on the cardiac system; for these reasons, the patients are
closely monitored during the post-surgical hospital stay. In very rare
situations, a patient may even die as a result of the surgery or one of its
Gastric bypass surgery reduces stomach capacity quite
significantly. Does the stomach ever stretch back to a larger size?
Surgery reduces the stomach capacity by about 90 percent.
Immediately after surgery, the pouch can hold approximately two ounces.
Gradually, the stomach pouch does stretch somewhat and the capacity increases,
but not to its original size
How effective a procedure is the Roux-en-Y gastric
The results are very encouraging. But the surgery is not
a magic "cure all" in itself: Eating healthy foods and exercising regularly are
the other parts of the equation for success.
How long does recovery from gastric bypass surgery
Patients can expect to be out of bed by evening of the
same day of the surgery, with a total hospitalization stay of about 4-6 days in
our hospital. The surgical recovery period averages between 3-5 weeks.
How many pounds can someone expect to lose after
surgery, and how long does it take to achieve the desired weight loss?
Every person's weight loss experience is different. As a
rule of thumb, the heavier the patient, the more weight they are likely to lose.
Most patients can expct to lose two-thirds of their excess weight. Most of that
weight loss will occur within the first 12 months. That loss is almost always
followed by a slight weight gain while the body is stabilizing, and is followed
by another period of weight loss.
Losing the weight is only part of the picture, however.
The difficulty can be in keeping it off. That is where gastric bypass surgery
has proven to be so effective. Five years after surgery, 95% of all patients
have maintained a loss of more than 50% of their excess weight. Keep in mind
that on average, with a traditional diet-based weight loss program, only about
1% of morbidly obese persons maintain their weight loss at that level.
Do patients ever have to "diet" again following
gastric bypass surgery?
The patient will have to adopt a healthy eating plan and
an exercise program for the rest as well as vitamin suppliments of his or her
What is "dumping syndrome"?
When large amounts of high-calorie foods (especially
those containing sugar) pass quickly from the stomach pouch into the intestine,
fluid rushes into the small intestine to dilute the high concentration of sugar.
The patient may feel faint, break out in a cold sweat, and have intestinal
cramps followed by diarrhea. Fortunately, "dumping syndrome" can be averted
simply by the patient avoiding high intakes of sweets.
What happens if someone "cheats" on the recommended
Usually, "cheating" cures itself, as the consequences
can be quite uncomfortable for the patient. Eating high-calorie foods can bring
on "dumping syndrome," which results in cold sweats, a feeling of faintness,
intestinal cramps, and diarrhea. It is such an unpleasant experience that most
people do not keep on "cheating."
How does gastric bypass surgery affect which
medications a patient is able to take?
Patients should avoid aspirin or aspirin-containing
medications and anti-inflammatory drugs; they can irritate the intestinal
tract’s inner lining and sometimes cause ulcers. For the same reason, alcohol
and tobacco products should be avoided, as well.
Is pregnancy possible following gastric bypass
Many obese women of childbearing age do not have
menstrual periods, a condition known as amenorrhea, and thus, are unable to
become pregnant. After the surgery and subsequent weight loss, regular menstrual
cycles typically resume. Barring other fertility-related problems, these women
are able to become pregnant. However, it is not
advisable to attempt a pregnancy until 18 months after the surgery.
Before then, the rapid weight loss and nutritional deficiencies can harm a
When the waiting period is over, these women–with proper
pre-natal care and monitoring by their obstetrician and bariatric team–can go on
to have uneventful pregnancies and healthy babies. Despite the reduced size of
her stomach, the mother-to-be can still intake sufficient calories for both the
fetus and herself.
If I want to pay for the surgery myself, in the event
my insurance won't cover it, how much can I expect to pay?
If you are interested in paying out-of-pocket for the procedure, the fees at
the Hospital Hallein are in the approx. $ 7,000 to $ 12,000 range (depending
upon the different operations and services needed) and are payable in full prior
to the surgery.
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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