Gastric Bypass and Other Bariatric Surgeries

Gastric Bypass Surgery

Gastric bypass and related weight loss surgeries are not cosmetic procedures; they are procedures of last resort for morbid obesity. Morbid obesity is usually defined as being 100 pounds over ideal weight. Ideal weight and an individual's body mass index (BMI) should be determined by a patient's physician. Morbidly obese individuals are at risk for early death or other debilitating illnesses such as diabetes, cardiovascular disease, musculo-skeletal problems and respiratory problems. Because of these risks, for individuals who are at least 100 pounds overweight, surgery should be viewed as alleviation of a debilitating disease.

Bariatric surgery is the term most often used to describe procedures that restrict a person's intake of food and produce malabsorption in the digestive tract, which further reduces daily caloric intake. Bariatric surgery has proven to be an effective means of achieving drastic weight loss and thereby controlling morbid obesity and reducing associated diseases. To learn more about the basics of morbid obesity and bariatric surgery, you can visit the American Society for Bariatric Surgery's website.

There are many serious risks and complications associated with bariatric procedures. These risks include perforation of the stomach or intestine, internal bleeding, severe infection, fluid in lungs, blood clots in legs or lungs, acute kidney failure, liver failure, anemia, and malnutrition. Despite these risks, gastric bypass surgery has become the new frontier for elective surgical procedures. Recently, there has been a proliferation of gastric bypass advertisements by surgeons across the country, relying on extensive internet information and testimonials in support of the drastic weight loss procedure. For example, the Wall Street Journal, on March 31, 2008, printed an article, "Industry Giants Push Obesity Surgery", referring to medical device makers, venture capitalists and surgeons' newfound interest in gastric bypass surgery. Furthermore, the American Society for Bariatric Surgery (ASBS) reported approximately 25,000 to 30,000 procedures, including gastric bypass, roux-en-Y bypass and vertical band bypass in 1995, and up to 200,000 procedures in 2007. Clearly, more and more people are running to surgery as a fix for obesity. It also appears that insurers are being persuaded that the costs associated with obesity are far more extensive and long lasting than payment for bypass surgery which, if successful, reduces weight and goes a long way to towards reducing the medical ailments associated with morbid obesity.

Currently, there are many bariatric procedures available for weight loss. These procedures can be divided into the following categories: gastric restriction operations; malabsorptive procedures; and combined restrictive and malabsorptive procedures.

Gastric banding is the simplest restrictive operation. A band made of synthetic material is placed around the stomach near the upper end, creating a small upper pouch and a narrow passage into the larger lower portion of the stomach. The stomach is not cut, stapled or entered and the digestive tract remains in normal sequence for digestion and absorption. The intended effect of the procedure is a reduction in capacity to intake food. The small pouch and narrow outlet create a feeling of fullness that in a cooperative, compliant patient induces behavioral changes which leads to less caloric intake and resulting weight loss. Since the stomach is not cut or stapled, gastric banding has a lower risk of infection than alternative procedures and there is no possibility of staple-line disruption. Another advantage is that the operation is easy to revise and is the only completely reversible technique. Potential risks of this procedure include the risk of injuring the esophagus or stomach when placing the band, and the possibility that the stomach may slip under the band after the surgery, causing distention of the pouch and poor emptying. The band may also cause scar tissue to build up and reduce the outlet, or the band may loosen and no longer restrict eating.

Other restrictive procedures, such as vertical gastroplasties, also reduce food intake by stapling the stomach in order to create a small stomach pouch. Due to the stapling of the stomach, these procedures carry more risk than gastric banding because postoperatively, staple-line disruption may result in leakage or serious infection. According to the ASBS, the primary advantage of all restrictive procedures is that well-chewed food still enters and passes through the digestive tract in proper order so that iron, calcium, vitamin and nutrient absorption is maintained.

Malabsorptive procedures are operations that also reduce the size of the stomach to restrict meal size by removing a large part of the stomach or stapling it to create a small pouch. The difference between a malabsorptive procedure and a restrictive procedure is that a malabsorptive procedure results in a change in the anatomy of the small bowel. During a malabsorptive surgery, the small bowel is divided. One end is attached to the stomach pouch, creating what is typically called the alimentary limb. Ingested food moves through the alimentary limb, but not much of it is absorbed. Bile and pancreatic juice, both necessary for the absorption of fats, are diverted through a bypassed segment of the small intestine, called the biliopancreatic limb, which connects to the intestine near its end. These juices join the ingested food in a bowel segment called the common limb. Instead of meeting the bile and pancreatic juice early on in the digestive process, ingested food does not encounter the enzymes until the end of the small intestine. This causes increased weight loss by reducing the absorption of nutrients and calories. Unfortunately, the absorption of many important vitamins and minerals, including calcium, iron and B-12, is also reduced.

As the name may suggest, a combined restrictive and malabsorptive operation involves creating a small pouch and narrow outlet to restrict food intake, as well as changing the anatomy of the small bowel in order to bypass most of the stomach and the duodenum. The Roux-en-Y gastric bypass (RYGBP), one of the most frequently performed operations for morbid obesity in the United States, is an example of a combined restrictive and malabsorptive procedure. The stomach is stapled in order to create a pouch the same size as other pure restrictive operations. The difference between a restrictive procedure and a RYGBP is that during a RYGBP the stomach is completely stapled shut and the outlet of the pouch opens into the intestine instead of into the rest of the stomach.

Additionally, there is the option of undergoing a less invasive laparoscopic operation. A laparoscopic operation employs the same surgical principals as "open" gastric banding, vertical gastroplasties and gastric bypass procedures. The difference is that a laparoscopic operation is performed using a laparoscope, a fiberoptic tube and a light source connected to a small video camera, which displays the abdominal organs on a TV monitor. Surgical instruments are inserted through small incisions in the abdominal wall, making the procedure less invasive and recovery more rapid than in open bariatric procedures. However, laparoscopic surgery requires an advanced level of skill which not all surgeons possess and the procedure still carries the risk that postoperative complications will occur.

Although bariatric surgery may help you look better, feel better, and may lead to an increased enjoyment of life, there is no quick fix for obesity. Bariatric surgery requires a lifelong change in eating habits, and is associated with nutritional risks and complications. Therefore, a prospective candidate for the surgery must clearly understand the procedure, the associated risks, and the requisite post-operative life changes before deciding to go under the knife.

Since gastric bypass surgery did not exist when many surgeons trained as residents, many of those who perform these procedures have learned the techniques at seminars which are taught over three to five days—or less. Thus, when considering the procedure, it is imperative that you make sure that the surgeon is qualified to perform the surgery and that the hospital where it will be performed has been certified by the ASBS. It is also important to make sure that the hospital has the proper protocol to deal with bariatric surgical patients. When choosing a surgeon, ask about his or her experience, number of cases performed, average length of the operation and hospitalization, results in terms of weight loss, side-effects of the surgery and whatever other concerns you may have. A patient may have only one choice of procedure if a surgeon performs only one type of operation and believes that this operation is the best for all patients. However, it is important for a prospective patient to ask about the different types of bariatric surgeries and to learn how the procedures work. Knowing how the chosen operation works and complying with its requirements will help a patient make the operation a success.

The ASBS also recommends discussing the chances of having to be hospitalized due to complications or metabolic problems and the risk of needing further operations either to solve these problems or for failure to satisfactorily lose weight. Finally, remember to ask about how the operation can be undone, how your digestive system would function thereafter and the consequences for the future if reversing the operation becomes necessary.

Most importantly, when considering bariatric surgery it is crucial to remember that you are not electing a cosmetic procedure, you are making a life changing decision that should not be taken lightly. Your surgeon will provide information about the operation recommended for you. Be sure to ask questions and understand the answers. Learn about the changes that will be made to the stomach and intestine and the effects the procedure will have. According to the ASBS, it is also beneficial to consult more than one physician and to talk to patients who have undergone similar operations. Finally, before signing a permission form for your surgery, make sure that you are aware of what will be done, what you will need to do to live well with the operation, and any signs or symptoms of complications that may occur later.