Types of Bariatric Surgery


 

What is StomaphyX?

The StomaphyX device is an endoluminal fastener and delivery system that consists of an ergonomic, flexible fastener delivery device and sterile polypropylene fastener implants.

The procedure to insert the StomaphyX device is the first FDA-approved non-invasive bariatric procedure for weight loss.

Using a fiberoptic gastroscope the esophagus and stomach are easily accessed. The StomaphyX device is designed to go down into the stomach with the fiberoptic endoscope. Once inside the stomach pouch, the StomaphyX tool pleats and staples the stomach to make the pouch smaller.

StomaphyX may benefit:

  • Gastric Bypass patients who have regained weight or want to lose more weight
  • Duodenal Switch patients who want more restriction
  • Sleeve Gastrectomy patients who want more restriction in the remaining stomach

StomaphyX features include:

  • Transoral insertion
  • Delivers unlimited fasteners with single insertion
  • Adjustable and /or revisable transorally
  • No abdominal incisions
  • No internal incisions


What is The Duodenal Switch Procedure?

The Duodenal Switch procedure is a major surgery that rearranges the intestines so that the majority of food calories are not absorbed, resulting in progressive, long-term weight loss in most obese persons. It is important to be aware that many physical, social, and emotional changes occur as a result of this surgery.

The risks, as well as the benefits, must be understood.

Our staff will gladly discuss variations for your individual situation, along with any other questions you may have.

Normal Digestion - How Our Bodies Process Food

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The complex fats, proteins, and carbohydrates are broken down into simpler fatty acids, amino acids, and sugars. Only the simple "building blocks" are then absorbed as they continue to pass through the small intestine. These basic end products of digestion are then absorbed as they continue to pass through the small intestine. These basic end products of digestion are then used for fuel or stored as fat.The food you ingest first enters your stomach, where hydrochloric acid and some enzymes begin the digestive process. In the next stage, the food enters the duodenum, the first portion of the small intestine, where it mixes with bile and additional enzymes produced by the intestinal lining and the pancreas.

How the Duodenal Switch Procedure is Performed

  1. The duodenum is divided to the point where it connects to the stomach and where it connects to the bile ducts. The purpose is to divert pancreatic juice and bile. The lower end of the duodenum is then closed.
  2. A portion of the stomach is removed to create a pouch with a capacity of about six ounces.
  3. A segment of the small intestine is divided. Note that no portion of the intestine is removed. Using this separated section of small intestine, a new connection is made to the open end of the duodenum.
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  1. The remaining end of the divided small intestine is reattached approximately 30 inches from the colon. This biliopancreatic segment now carries the digestive enzymes and bile. Thus, food travels along one section of intestine and the digestive juices (enzymes and bile) travel along a separate section of the intestine. The food and digestive juices now mix in a short 30-inch section of the intestine where most of the digestion and absorption of nutrients will take place. This significantly reduces the amount of fat emulsification and absorption and reduces calories absorbed as well.
  2. The food then moves into the large intestine (colon). Absorption of calories has been essentially completed; mainly water is absorbed during this final stage.
  3. The gallbladder is removed if still present because many people who don't already have a diseased gallbladder tend to form gallstones while they lose weight.
  4. The appendix, if present, is often removed. Note that the gallbladder, appendix and a portion of the stomach cannot be put back as they are permanently removed. However, none of the small or large intestines is removed, and therefore the intestinal rearrangement is completely reversible.

How Does the Surgery Work?

The immediate result of the surgery is a restriction of food intake due to the smaller stomach size; this assists the initial weight loss. Within 18 months the stomach pouch will gradually stretch to hold a normal-size meal. Weight loss will taper off and stabilize. An added benefit of stomach size reduction is decreased stomach acid production, thereby reducing the chances of ulcer formation.

Additionally, fewer calories are absorbed in the abbreviated 30-inch section of small bowel where food and digestive juices combine. This results in continued weight loss due to malabsorption. In the first 18 months after surgery, fats are incompletely absorbed, proteins are somewhat more absorbed, and simple sugars are completely absorbed. As the bowel naturally accommodates the surgery, fats will continue to be incompletely absorbed, but both protein and carbohydrate absorption generally increase over time.

Beneficial Effects

Besides the previously listed effects, blood levels of cholesterol and triglycerides will be reduced, often to normal or even lower levels, due to the reduced absorption of fats. In diabetes, blood sugar levels will often become normal, and insulin requirements reduced or eliminated altogether. Similarly, medication for high blood pressure can often be discontinued as weight is lost.

All abdominal operations carry the risks of bleeding, infection in the incision, thrombophlebitis of legs (blood clots), lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks, anesthetic complications, and blockage or obstruction of the intestine. These risks are greater in morbidly obese patients. Effective medical and nursing procedures used during and after the surgery have contributed to a successful outcome in the majority of obese patients.

In addition, several problems related to this specific surgical procedure are possible, although uncommon. One of these is the injury to the spleen during surgery, which could require removal of the spleen. Leakage of fluid from the stomach or intestine through the staples or sutures may occur which may result in abdominal infection; this could require additional surgery for repair and for drainage of infection. Narrowing of intestinal connections may occur, which could require a second surgery to widen the opening.

Possible late complications related to this surgery could include peptic ulcer; intestinal obstruction due to adhesions; vitamin deficiencies or anemia from insufficient absorption of iron or vitamins, low blood proteins from malabsorption, resulting in fluid retention; a hernia in the abdominal incision; temporary hair thinning due to changes in protein metabolism. Specific diet, physical activity, vitamin supplements, and medications may be recommended.

Morbidly obese patients are at higher risk for all surgical and anesthetic complications. Accordingly, extra precautions are taken before, during, and after the operation. Historic data show an approximately 0.5% (1 in 200) chance of death from obesity surgery nationally.


Vertical Gastrectomy

Anatomy

The Vertical Gastrectomy creates a banana shaped stomach by resecting the lateral aspect of the stomach. This reduces the stomach capacity from about 16 ounces to less than 4 ounces in size. The pylorus, vagus nerves and antral pump are all intact preserving the functional integrity of the stomach.

How it Works

VG1

Similar to the DS, the patients lose weight related to the reduced stomach size. Patients may then be able to adjust their eating behavior and maintain this weight loss, however, if they start to gain weight due to the expansion of the stomach over time, discussion of conversion to the DS can then be entertained.

Advantages

This is purely a restrictive procedure and as such, one does not have to take additional vitamins and supplements except a multivitamin. Like the DS, normal gastric emptying is maintained and dumping does not occur. Marginal ulcers also do not occur and these patients tolerate aspirin and NSAIDS, which are commonly not tolerated with conventional RGB. It is also an operation which can be performed laparoscopically in about 1 hour, giving the highest risk patients the ability to proceed with weight loss surgery when the other more involved procedures would be contraindicated.

Risks

Although the same risks are present, the chance of a leak is extremely low as there are no anastomoses done. In addition, most postoperative problems are related to the length of surgery, blood loss, fluid shifts, etc. In this procedure, because of its simplicity, the risks of these complications are reduced.


Jejuno-Illeal Bypass Surgery 

According to the American Society of Bariatric Surgery, the first report of a procedure designed to induce weight loss was published in 1954. Two surgeons by the name of Kremen and Linner described a procedure which involved connecting the upper part of the small intestine to the lower part of the small intestine. Essentially, this meant that food would "bypass" a large amount of the small intestine, including sections called the jejunum and the ileum. Patients could eat as much as they wanted, but only a small amount of the calories and nutrients would be absorbed by the body. The jejunoileal bypass (JIB), as it was called, pioneered the concept of malabsorption. Shortening the nutrient absorptive circuit remains the most powerful bariatric technique used today.

Unfortunately, the JIB can also be blamed for the negative or fearful attitude some people still have towards weight loss surgery. By the late 1960s and early 1970s, the procedure had become quite popular in the United States due to the dramatic and sustained weight loss it produced. But after long-term data accumulated, physicians discovered that it carried several distressing and even life-threatening complications. Patients regularly experienced diarrhea, electrolyte imbalances, anemia, vitamin deficiencies, malnutrition, gallstones, and a number of other adverse effects. But more frighteningly, some patients developed severe kidney and liver failure, leading to a number of deaths. As a result of its high risk, the JIB procedure was abandoned in favor of safer techniques. The procedure is no longer performed in the United States.


Biliopancreatic Diversion for Surgical Weight Loss

By the late 1970s, surgeons had learned from the JIB experience and gained an idea of what not to do for surgical weight loss. The next major bariatric surgical weight loss procedure to emerge came out of Italy in 1976. Dr. Nicola Scopinaro of the University of Genoa revised the JIB procedure so that most of the small intestine remained intact, thus reducing the chances of liver or kidney problems.

To achieve maximum weight loss, Scopinaro's procedure used two components instead of one. First, approximately 2/3 of the stomach was removed to moderately restrict the amount of food that can be consumed at one time. Then the outlet of the stomach was connected to the final segment of the small intestine. By diverting food through this new "limb," the nutrients were effectively separated from the bile and pancreatic enzymes that would break them down. As a result, BPD greatly reduced nutrient absorption and caloric intake.

The first to combine the restriction of food intake and malabsorption, BPD is also the first procedure to remain in usage (albeit limited) more than two decades after its advent. In 1996, Scopinaro reported that after 18 years of follow-up, his patients maintained an excess weight loss of 72%.2 According to the American Society of Bariatric Surgery, BPD has yielded the best long-term results published to date.

The BPD is also unique because it is the only current procedure that allows you to eat normal quantities of food and still achieve excellent weight loss. But there's a catch. The procedure still carries some of the malabsorptive complications of JIB, including loose stools, malodorous gas, and serious deficiencies in protein and minerals such as calcium. BPD patients must take vitamin supplements for the rest of their lives to avoid malnutrition and bone demineralization.

In 1993, a group of Canadian doctors published the first results of a modification of the BPD procedure known as the biliopancreatic diversion with duodenal switch (BPDDS).3 The BPDDS preserves the pyloric valve that connects the stomach to the beginning portion of the small intestine. In addition, physicians increase the length of the small intestine left intact. As a result of these adjustments, this variant reportedly carries fewer complications but with comparable or greater weight loss.

Nonetheless, BPD is the still the most complicated and extreme bariatric surgical weight loss procedure in use. While it produces profound weight loss, it also carries a high risk of nutritional and metabolic problems. This led researchers to continue searching for an even safer approach for surgical weight loss. Presently, the BPD remains in use, especially in Europe, but is less popular in than some of the newer procedures available in the United States.


Gastroplasty (Stomach Stapling)

The science of "stapling" surgeries originated in World War II. To provide a rapid method of dealing with injuries sustained on the battlefield, the Russians developed surgical instruments which could staple body tissue together. Later, these instruments were refined into what's used today.

Gastroplasty, or "stomach stapling," represented the next wave of weight loss surgery in the early 1980s. Surgeons could now reduce the volume of the stomach without removing any portion of it. Instead, a staple line would hold the stomach tissue together to create a new wall. Three staples would be removed from the center of the line, however, to allow for a narrow passageway into the lower stomach. The pouch fills quickly and empties slowly with solid food, producing a feeling of fullness. Overeating results in pain or vomiting.

As a result, patients became full after eating only small amounts of food, due to the reduced stomach size and slower passage of food through the new, narrow stomach outlet, or stoma as a result of stomach stapling surgery. Those who had early gastroplasty-called horizontal gastroplasty-lost weight over the first few months, but at a certain point, doctors observed that they stopped losing weight or even regained weight. Doctors quickly determined that the stoma was stretching out over time in many patients.

To address this problem, Dr. Edward Mason at the University of Iowa developed a modification known as vertical banded gastroplasy (VBG) and published the first results in 1982. Mason decided to make the stapling line vertical instead of horizontal to capitalize on the thickest areas of the stomach wall-those least likely to stretch. In addition, he imposed strict measurements for the stomach pouch and placed a polypropylene band around the stoma to reinforce it. As a result, the rate of stoma enlargement decreased.

Compared to its predecessor, the VBG produced better results and fewer complications. Within a matter of time, it became the preferred method of gastroplasty. Because there is no malabsorptive component, patients do not generally encounter serious metabolic side effects or nutritional deficiencies. Weight loss-which can exceed 50% of excess body weight-occurs solely due to the restriction of food intake.

Unfortunately, despite the many improvements over the years, VBG still comes with a risk of weight regain as a late complication. Staple line disruption and shifting of the band can allow the stoma to expand years after surgery. Although not nearly as popular as it once was, the VBG remains in use today.

 

Minimal Incision Gastric Bypass

There are different approaches to accomplish operations. These approaches have been adapted for procedures in the abdomen as well as other areas of the body, such as the chest. They are:

Traditional Open Surgery

Minimally Invasive Surgery

- Laparoscopic

- Minimal Incision

The Minimal incision approach falls within the category of minimally invasive surgery, as does Laparoscopic surgery. Both approaches minimize the incision length and thus reduce trauma and thus minimizes recovery time and postoperative pain. In minimal incision bariatric surgery, the same operation is accomplished as with traditional open surgery, however the incision size is greatly reduced, and are on the order of about 4 inches or 10 cm. The total length of the multiple small incisions used for laparoscopy and the length of the single small incision used for minimal incision surgery are about the same, and therefore the amount of pain and recovery time from both approaches are comparable.

Typically patients that have had their bariatric surgery through the minimal incision approach will leave the hospital on the 3rd hospital day (post-op day #2), which is as good or better than those that have the operation through the laparoscopic approach.

  

Adjustable Gastric Banding (Lap Band)

In the early 1990s, bariatric surgeons in Europe and Scandinavia were in the early stages of investigating another procedure that would eventually become the least invasive and traumatic bariatric surgery to date. For the first time, surgeons explored the idea of implanting a restrictive device instead of cutting or stapling the stomach to reduce its capacity.

The first device of this kind was the Swedish Adjustable Gastric Band (SAGB), patented in 1985 by Obtech Medical in Sweden. Essentially, a silicone band was placed around the upper stomach to create a tiny stomach pouch. As with VBG, the procedure restricted food intake by producing an earlier feeling of fullness. But unlike VBG, the new stomach outlet wasn't as susceptible to stretching, and the patient could have the band removed (thus reversing the procedure) if desired.

The earliest versions of Swedish Adjustable Gastric Banding required open surgery and carried some problems. In addition, the weight loss results were not as good as the prevalent restrictive procedure, VBG. But the adjustable gastric banding concept soon regained momentum thanks to a modified version that surfaced in 1990 and included an inflatable balloon on the inner surface of the band. Tubing connected the balloon to a reservoir of liquid positioned beneath the skin. Using a needle, physicians could add or withdraw liquid to adjust the size of the band and, consequently, the rate of weight loss.

With the unique attributes of reversibility and adjustability, the gastric banding concept garnered even more interest. An American company, INAMED Health (Santa Barbara, CA), with 25 years of silicone manufacturing expertise, designed a next-generation version called the BioEnterics® LAP-BAND® Adjustable Gastric Banding System that could be implanted laparoscopically. The new design included multiple sized bands and accessories. As a result, the procedure became more accessible and patient-friendly due to its minimal invasiveness and shortened recovery. Patients could potentially stay just one night in the hospital and be home the following day.

In this procedure, a hollow band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.


Laparoscopic Weight Loss Surgery

Laparoscopic operations are performed through several small incisions with the aid of a fiber-optic video camera and special instruments which can reduce the trauma and discomfort associated with a long open incision. Hospitalization, post-op pain, and recovery time is usually reduced compared to traditional surgery. Laparoscopic surgical obesity treatment operations have only been performed since 1993. Therefore the American Society of Bariatric Surgeons recommends choosing a surgeon who is experienced in both laparoscopic and open bariatric operations, and who understands the complexities of surgical treatment of obesity.


Restrictive Weight Loss Surgery Procedures

The theory is simple. When you feel full, you are more likely to have reduced feelings of hunger and will no longer feel deprived. The result is that you are likely to eat less. Restrictive weight loss surgery works by reducing the amount of food consumed at one time. It does not, however, interfere with the normal absorption (digestion) of food. In a restrictive procedure, the surgeon creates a smaller upper stomach pouch. The pouch, with a capacity of approximately 1/2 to 1 oz. (15 to 30 ml), connects to the rest of the stomach through an outlet known as a "stoma." In a cooperative and compliant patient, the reduced stomach capacity, along with behavioral changes, can result in consistently lower caloric intake and consistent weight loss.

During recovery, patients must adhere to the strict specific dietary guidelines and restrictions their surgeon prescribes. While these guidelines may vary from one surgeon to the next, it is important for each patient to follow the surgeon's guidelines. When the time comes to resume eating "regular" food, the patient must learn to adapt to a new way of eating. At each meal, they are restricted to consuming approximately 1/2 to a full cup of food before feeling uncomfortably full. Patients who see the best results from a restrictive procedure are those who learn to eat slowly, eat less, and avoid drinking too many fluids, particularly carbonated beverages.

If the patient fails to follow these guidelines, they can stretch the stomach pouch and/or the stoma outlet and defeat the purpose of the surgery. The effectiveness of a restrictive procedure is reduced by constant snacking or by drinking high-calorie, high-fat liquids. Failure to achieve the expected level of weight loss is usually the result of a patient failing to comply with the recommended dietary and behavior modifications, such as increased exercise and regular support group attendance.


Malabsorptive Weight Loss Surgery Procedures

It can be said that some of the restrictive approaches discussed have not always achieved the excess weight loss surgeons and patients anticipated. For this reason, weight loss surgery procedures that alter digestion, known as malabsorptive procedures, were developed to work in conjunction with restrictive approaches. Some of these weight loss surgery procedures involve a bypass of the small intestine, thus limiting the absorption of calories. On balance, malabsorptive or malabsorptive/restrictive weight loss surgery procedures have resulted in an overall increase in the loss of excess weight. The risk of complications and side effects generally increases with the lengthening of the small intestine bypass. You and your surgeon must determine the risks and benefits over your lifetime with the type of weight loss surgery procedures available.

  1. Basically, weight loss operations fall into three categories:
  2. Restrictive procedures make the stomach smaller to limit the amount of food intake.
  3. Malabsorptive techniques reduce the amount of intestine that comes in contact with food so that the body absorbs fewer calories.
  4. Combination operations take advantage of both restriction and malabsorption.
Location
Andrew Hargroder, MD
16851 Jefferson Highway, Suite 3B
Baton Rouge, LA 70817
Phone: 225-283-6806
Fax: 225-388-5382
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225-283-6806

Andrew Hargroder, MD
16851 Jefferson Highway
Suite 3B
Baton Rouge, LA 70817