Millions of Americans turn to diet, fitness, and medication first to treat their obesity. Unfortunately, studies indicate that people will not achieve long-term weight loss through dietary and behavior modification regimens alone. Morbidly obese people have an even greater challenge when it comes to sustaining weight loss and resolving their health conditions. Surgery may remain the best hope for these individuals to lose weight and keep it off.
The two most common weight loss surgical procedures are Gastric Banding and Gastric Bypass. There is a newer procedure gaining popularity called Sleeve Gastrectomy.
The gastric band system also known as the LAP-BAND® System is designed to help you lose excess body weight for resolution of obesity-related health conditions. This approach eliminates many of the known associated operative risks and provides unique benefits compared to other obesity surgeries. This effort has resulted in the gastric band system, the only adjustable and reversible obesity surgery that does not require cutting and stapling of the stomach or gastrointestinal re-routing to bypass normal digestion.
Patient benefits include reduced surgical trauma, complications, pain, and scarring, as well as shorter hospitalization and recovery time compared to other obesity surgeries.
Gastric Band Overview
The body gets energy from food while it passes through the alimentary canal, which consists of the mouth, esophagus, stomach, and small and large intestines. Digestion starts in the mouth with chewing and the addition of saliva. After food passes through the esophagus, this process continues in the stomach. The stomach then provides temporary storage for food. Gastric juices, which contain enzymes, break down the food so that it can be absorbed and the energy can be carried through the body by the blood.
The gastric band system is a silicone elastomer ring designed to be placed around the upper part of the stomach and filled with saline on the inner surface. This creates a new small stomach pouch and leaves the larger part of the stomach below the band so the food storage area in the stomach is reduced, and the pouch above the band can hold only a small amount of food. The band also controls the stoma (stomach outlet) between the two parts of the stomach. The size of the stoma regulates the flow of the food from the upper to the lower part of the stomach. When the stoma is smaller, you feel full sooner and have a feeling of satiety so you are not hungry between meals.
The band is connected by tubing to an access port that is placed beneath the skin during surgery. Later, the surgeon can change the stoma size by adding or subtracting saline inside the inner balloon through the access port. This adjustment process helps drive the rate of weight loss. If the band is too loose and weight loss inadequate, adding more saline can reduce the size of the stoma to further restrict the amount of food that can move through it, if the band is too tight, the surgeon will remove some saline to loosen the band and reduce the amount of restriction.
Gastric Band Placement
The gastric band system is usually placed laparoscopically under general anesthesia. First the surgeon makes a few small incisions in the abdominal wall for the insertion of long, thin surgical instruments. A narrow camera is also passed through a port so the surgeon can view the operative site on a nearby video monitor. A small tunnel is made behind the top of the stomach to let the band through and allow it to be wrapped around the upper part of the stomach, almost like a wristwatch. The band is then locked securely in a ring around the stomach. The gastric band is usually left empty or only partially inflated for the first 4-6 weeks after surgery.
Gastric Band Weight-Loss Results
The gastric band system is a tool to help you achieve sustained weight loss by limiting how much you can eat, reducing your appetite, and slowing digestion. Remember, though, the the gastric band system by itself will not solve morbid obesity, nor will it ensure that you reach your goal weight or even that you lose weight at all. The amount of weight you lose depends both on the band and on your motivation and commitment to a new lifestyle and eating habits. Below is a sample of published results from around the world:
|A Sample of Published Results From Around The World:
||% of Excess Weight Lost
||Years of Patient Follow Up
||# of Patients Studied
|Rubenstein, et al, Us
|O'Brien et al, Australia
|Nehoda et al, Austria
|Forestieri et al, Italy
|Fielding et al, Australia
Some people lost more than others, and though you may never reach your ideal weight, chances are good that with weight loss our health and self-image will improve.
Gastric Band Removal
If there is a problem with the band, if you can't lose enough weight or can't adjust to the new eating habits, your surgeon may suggest removal of the band. This decision will come after your surgeon consults with you. Generally after gastric band system removal, your stomach will be restored to its original form, and the digestive tract should function normally. Please keep in mind that when the band is removed your weight will likely increase.
Gastric Band Advantages
- Least invasive surgical option
- No intestinal re-routing
- No cutting or stapling or the stomach wall or bowel
- Small incisions and minimal scarring
- Reduced patient pain, length of hospital stay and recovery period
Fewer Risks and Side Effects
- Significantly lower mortality risk compared to other obesity surgeries
- Low risk of nutritional deficiencies associated with BPD and Gastric Bypass
- Reduced risk of hair loss
- No "dumping syndrome" with certain dietary elements
- Allows individualized degree of restriction for ideal, long-term weight-loss rate
- Adjustments performed without additional surgery
- Supports pregnancy by allowing stomach outlet size to be opened to accommodate increased nutritional needs
- Removable at any time
- Stomach and other anatomy are generally restored to their original forms and functions
Effective Long-Term Weight Loss
- More than 100,000 gastric bandS placed worldwide
- Standard of care for hundreds of surgeons around the world
- Academic publication with up to 7 years of follow-up
Gastric Band Candidates
You may be eligible for gastric band system surgery if:
1. You are at least 18 years old.
2. Your BMI is > 40 or you weigh at least 100 pounds more than your ideal weight.
3. You have been overweight for more than 5 years.
4. Your serious weight-loss attempts have only had short-term success.
5. You are not suffering from any other disease that my have caused your obesity.
6. You are prepared to make substantial changes in your eating habits and lifestyle.
7. You are willing to continue being monitored by the specialist treating you.
8. You do not drink alcohol in excess.
If you do not meet the BMI or weight criteria, you still may be considered for surgery if your BMI is over 35 and you are suffering from serious health problems causes by your weight. Your surgeon may have additional criteria to those listed above.
Gastric Band Contraindications
The gastric band system is not right for you if:
- You have an inflammatory disease or condition of the gastrointestinal tract, such as ulcers, severe esophagitis.
- You have severe heart or lung disease that makes you a poor candidate for surgery.
- You have some other disease that makes you a poor candidate for surgery.
- You have a problem that could cause bleeding in the esophagus or stomach. This might include esophageal or gastric varices (a dilated vein). It might also be something such as congenital or acquired intestinal telangiectasias (dilation of a small blood vessel).
- You have portal hypertension.
- Your esophagus, stomach, or intestine is not normal (congenital or acquired). For instance you might have a narrowed opening.
- You have or have experienced an intra-operative gastric perforation at or near the location of the intended band placement.
- You have cirrhosis.
- You have chronic pancreatitis.
- You are pregnant. (If you become pregnant after the gastric band system has been placed, the band may need to be deflated. The same is true if you need more nutrition for any other reason, such as becoming seriously ill. In rare cases, removal may be needed).
- You are addicted to alcohol or drugs.
- You are under 18 years of age.
- You have an infection anywhere in your body or one that could contaminate the surgical area.
- You are on chronic, long-term steroid treatment.
- You cannot or do not want to follow the dietary rules that come with this procedure.
- You might be allergic to materials in the device.
- You cannot tolerate pain from an implanted device.
- You or someone in your family has an autoimmune connective tissue disease. That might be a disease such as systemic lupus erythematosus or scleroderma. The same is true if you have symptoms of one of these diseases.
Your surgeon will not do the operation unless he or she knows you understand the problems your excess weight is causing. Also, your surgeon will make sure you know that you have responsibilities, such as adopting new eating patterns and a new lifestyle. If you are ready to take an active part in reducing your weight, your surgeon will consider the treatment. You should be well-informed about the advantages, disadvantages, and risks involved. Be sure to investigate whether this treatment is right for you.
Bypass, Roux en-Y:
The Gastric Bypass, Roux en-Y is considered the "gold standard" of modern weight loss surgery, the benchmark to which other operations are compared, for evaluation of their quality and effectiveness.
The objective of Gastric Bypass, Roux en-Y surgery is to make a very small pouch (thumb-sized) out of the upper stomach, to restrict the amount of food which can be eaten. That pouch is separated from the rest of the stomach, which is bypassed, by creating a new pathway into the intestines. This pathway is called a “Roux en-Y” (named after the French surgeon, Dr. Roux, who first described this reconstruction in the 1800's). The bowel is cut, and reconstructed in a Y configuration, so that two parts of the GI tract can feed into one.
operation achieves its effects by creating a very small
stomach pouch (thumb-sized, actually), from which the
rest of the stomach is permanently divided and separated.
The small intestine is cut about 18 inches below the stomach,
and is re-arranged so as to provide an outlet to the small
stomach, while maintaining the flow of digestive juices
at the same time. The lower part of the stomach is bypassed,
and food enters the second part of the small bowel within
about 10 minutes of beginning the meal. Click
here to view an animation of the procedure.
Although the reconstructed "Y" configuration creates some malabsorptive traits, there is very little interference with normal absorption of food.
The Gastric Bypass provides an excellent tool for gaining long-term control of weight, without the hunger or craving usually associated with small portions, or with dieting. Weight loss of 80 - 100% of excess body weight is achievable for most patients, and long-term maintenance of weight loss is very successful, but does require adherence to a simple and straightforward behavioral regimen.
Of patients who have undergone laparoscopic gastric bypass surgery; weight loss averages over 80% of excess body weight, one year after surgery, and is usually maintained over 80% for over 5 years. Over 95% of all health problems (co-morbidities) associated with their obesity have been resolved following surgery. Patients enjoy a normal-style diet, and are satisfied to eat smaller portions.
There is very
little interference with normal absorption of food - the
operation works by reducing food intake, and reducing
the feeling of hunger. The result is a very early sense
of fullness, followed by a very profound sense of satisfaction.
Even though the portion size may be small, there is no
hunger, and no feeling of having been deprived: when truly
satisfied, you feel indifferent to even the choicest of
foods. Patients continue to enjoy eating - but they
enjoy eating a lot less.
Bypass provides an excellent tool for gaining long-term
control of weight, without the hunger or craving usually
associated with small portions, or with dieting. Weight
loss of 80 - 100% of excess body weight is achievable
for most patients, and long-term maintenance of weight
loss is very successful, but does require adherence
to a simple and straightforward behavioral regimen.
Gastric Bypass, Roux en-Y
for performing the Gastric Bypass by laparoscopy, or limited
access, was first performed in 1993. This operation duplicates
the anatomy and physiology of the standard, open procedure.
surgery first became available around 1990, when small,
light-weight, high-resolution video cameras were developed,
allowing surgeons to "see" into the abdomen
using a pencil-thin optical telescope, and to project
the picture from the video camera on a TV monitor at the
head of the operating table. The surgeon must develop
skills in operating by this new method, without being
able to feel tissue directly, and by learning to determine
where instruments are by seeing them on TV.
of the laparoscopic approach come from the very small
incisions which are necessary, which cause much less pain,
and very little scarring. Patients are able to get up
and walk within hours after surgery, can breath easier,
and move without discomfort. Bowel activity usually is
not affected, as it is with an open incision. Most persons
find they can return to normal activities within 10
12 days, or even sooner.
risks of surgery performed laparoscopically are
comparable to those the standard operation when
done by an experienced and skilled laparoscopic surgeon.
Some bariatric surgeons have been unable to master the
techniques of advanced laparoscopic surgery, and therefore
do not offer this method or may even try to claim
that it is less effective which is not true.
With the Gastric
Bypass procedures, using the laparoscopic technique, results
have been equal to, or better than, those obtained with
the open operation, but with major reduction of discomfort
and disability, and excellent cosmetic results as an additional
Of 500 patients
who have undergone laparoscopic surgery, weight loss averages
over 80% of excess body weight, one year after surgery,
and has been maintained over 80% for over 5 years. Over
95% of all health problems (comorbidities) associated
with their obesity have been resolved following surgery.
Patients enjoy a normal-style diet, and are satisfied
to eat smaller portions.
Laparoscopic Sleeve Gastrectomy (LSG) is the restrictive part of the more extensive mixed restrictive and malabsorptive operation, gastric bypass.
It generates weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption. With this procedure, the surgeon removes approximately 85 percent of the stomach laparoscopically so that the stomach takes the shape of a tube or "sleeve." This part of the procedure is not reversible. Unlike the gastric bypass, the outlet valve and the nerves to the stomach remain intact.
Because the modified stomach continues to function normally there are fewer restrictions on the types of foods which patients can consume after surgery. The quantity of food the patient can consume is greatly reduced. This is seen by many patients as being one of the benefits of the laparoscopic sleeve gastrectomy, as is the fact that the removal of the majority of the stomach also results in the virtual elimination of hormones (ghrenlin) produced within the stomach which stimulates hunger.
This procedure is usually performed on superobese or high risk patients with the intention of performing a full gastric bypass Roux en-Y at a later time. The stomach that remains is shaped like a thin sleeve and measures 35-60 cc or less, depending on the preference of the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. Note that there is no intestinal bypass or malabsorption with this procedure, only stomach reduction.
- No foreign body is used as in the adjustable gastric banding and thus no adjustment is required.
- If weight loss is inadequate, the patient has the option to have the second stage of the operation (gastric bypass).
- It does not involve any bypass of the intestinal tract and thus patients avoid the complications of intestinal bypass such as intestinal obstruction, anemia, osteoporosis, vitamin deficiency and protein deficiency.
- For lower BMI patients (35-42) who have complications (inadequate weight loss, band erosion, poor quality of life etc.) associated with gastric banding, LSG maybe a good alternative.
- It also makes it a suitable form of surgery for patients who are already suffering from anemia, Crohn's disease and a variety of other conditions that would place them at high risk for surgery involving intestinal bypass.
- It is one of the few forms of surgery which can be performed laparoscopically in patients who are super obese.
- Better quality of life with less late complications as compared to gastric banding.
- Inadequate weight loss or weight regain is possible with operations that do not include an intestinal bypass. This is true of any form of purely restrictive surgery, but is perhaps especially true in the case of the sleeve gastrectomy.
- The procedure requires stapling of the stomach and therefore leakage and of other complications directly related to stapling may occur.
- Patients who are super obese usually require second stage operations in order to lose the rest of the excess weight if their BMI remains larger than 45, although two stages may ultimately be safer and more effective than one operation for super obese patients.
- LSG is not reversible, but it can be converted to a gastric bypass.
- Long-term weight loss results are unknown.