“Roux-en-Y” gastric bypass surgery is a procedure where most of the stomach is bypassed and a small stomach pouch is made. It is the most commonly performed weight loss surgery today, accounting for about 80% of all weight loss surgery in the US
Roux-en-Y gastric bypass surgery has two parts. First the stomach is divided into a large portion, and a much smaller portion. The small part of the stomach is then sewn or stapled together to make a small pouch (this part is sometimes called “stomach stapling”). The small stomach pouch can only hold a cup or so of food. With such a small stomach, people feel full quickly and eat less. Then the new, small stomach pouch is disconnected from the first part of the small intestine (the duodenum) and reconnected to a portion of intestine slightly further down (the jejunum). This surgical technique is called a “roux-en-Y.”
Roux-en-Y gastric bypass is typically performed laparoscopically (using tools inserted through small incisions in the belly). When laparoscopy is not possible, gastric bypass can be open (laparotomy). This involves a large incision in the middle of the belly. The procedure is performed under general anesthesia. After gastric bypass surgery, people typically stay in the hospital for two to three days and return to normal activity in two to three weeks. Weight loss after gastric bypass surgery is often dramatic. On average, patients lose 60% of their extra weight. For example, a 350-pound person who is 200 pounds overweight would lose about 120 pounds.
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Laparoscopic Adjustable Gastric Banding Surgery
Laparoscopic gastric banding is the second most common weight loss surgery, after gastric bypass. Using laparoscopic tools, the surgeon places an adjustable silicone band around the upper part of the stomach. Squeezed by the silicone band, the stomach becomes a pouch with about an inch-wide outlet. After banding, the stomach can only hold about an ounce of food. A plastic tube runs from the silicone band to a device just under the skin. Saline (sterile salt water) can be injected or removed through the skin, flowing into or out of the silicone band. Injecting saline fills the band and makes it tighter. In this way, the band can be tightened or loosened as needed. This can reduce side effects and improve weight loss.
Laparoscopic adjustable gastric banding leads to loss of about 40% of excess weight, on average. For example, someone who is 200 pounds overweight could expect to lose an average of 80 pounds after gastric banding. However, these results vary widely. Gastric banding is considered the least invasive weight loss surgery. It is also the safest. The
procedure can be reversed if necessary, and in time, the stomach generally returns to its normal size. Gastric banding surgery also has a low complication rate.
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Sleeve gastrectomy is a surgical weight-loss procedure in which the stomach is reduced to about 25% of its original size by surgically removing a large portion of the stomach along the greater curvature. This results in a sleeve or tube like structure. The procedure permanently reduces the size of the stomach and is irreversible, although there could be some dilatation of the stomach later on in life. Sleeve Gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, Sleeve Gastrectomy may reduce the amount of “hunger hormone” produced by the stomach which may contribute to weight loss after this procedure. A sleeve gastrectomy is generally performed laparoscopically. This involves making five or six small incisions in the abdomen and performing the procedure using a video camera and long instruments that are placed through these small incisions.
Sleeve gastrectomy was originally performed as a modification to another bariatric procedure, the duodenal switch, and then later as the first part of a two-stage gastric bypass operation on extremely obese patients for which the risk of performing gastric bypass surgery was deemed too large. The initial weight loss in these patients was so successful it began to be investigated as a stand alone procedure.
Today sleeve gastrectomy is the fastest growing weight loss surgery option in North America and Asia. In many cases, but not all, sleeve gastrectomy is as effective as gastric bypass surgery, including weight independent benefits on glucose homeostasis. The precise mechanism(s) that produce these benefits is not known. The procedure takes one to two hours to complete and is performed under general anesthesia.
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The duodenal switch procedure, also known as biliopancreatic diversion with duodenal switch, is a weight loss surgery procedure that is composed of a restrictive and a malabsorptive aspect. The restrictive portion of the surgery involves removing approximately 70% of the stomach along the greater curvature. The malabsorptive portion of the surgery reroutes a lengthy portion of the small intestine, creating two separate pathways and one common channel. The shorter of the two pathways, the digestive loop, takes food from the stomach to the common channel. The much longer pathway, the biliopancreatic loop, carries bile from the liver to the common channel. The common channel is the portion of small intestine, usually 75-150 centimeters long, in which the contents of the digestive path mix with the bile from the biliopancreatic loop before emptying into the large intestine. The objective of this arrangement is to reduce the amount of time the body has to capture calories from food in the small intestine and to selectively limit the absorption of fat. As a result, following surgery, these patients only absorb approximately 20% of the fat they intake.
The primary advantage of duodenal switch surgery is that its combination of moderate intake restriction with substantial calorie malabsorption results in a very high percentage of excess weight loss for obese individuals, with a very low risk of significant weight regain. Type 2 diabetics have had a 98% “cure” (i.e., became euglycemic) almost immediately following surgery which is due to the metabolic effect from the intestine switch. The results are so favorable that some surgeons are performing the surgery on non-obese patients for the benefits of curing the diabetes. The following observations were reported on the resolution of obesity related comorbidities following the duodenal switch: type 2 diabetes 99%, hyperlipidemia 99%, sleep apnea 92%, and hypertension 83%.
Because the pyloric valve between the stomach and small intestine is preserved, people who have undergone the duodenal switch do not experience the dumping syndrome common with people who’ve undergone the Roux-en-Y gastric bypass surgery. Much of the production of the hunger hormone, ghrelin, is removed with the greater curvature of the stomach. Diet following duodenal switch surgery is more normal and better tolerated than with other surgeries. The malabsorptive component of the duodenal switch is fully reversible as no small intestine is actually removed, only re-routed. The procedure takes one to two hours to complete and is performed under general anesthesia.
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