Bariatric Surgery

Who Qualifies for Bariatric Surgery*

1. BMI ≥ 40, or more than 100 pounds overweight.

2. BMI ≥35 and at least one or more obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.

3. Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.

*Insurance coverage may vary. This is just a guideline. At your consult we will discuss finance options.

How Can Bariatric Surgery Help Me?

When combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long term weight-loss and help you increase your quality of health. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, hyperlipidemia, sleep apnea and more. Frequently, individuals who improve their weight find themselves taking less and less medications to treat their obesity-related conditions.

Significant weight loss through bariatric surgery may also pave the way for many other exciting opportunities for you and your family due to improvements in physicial health, quality of life and psychosocial health.

 

Adjustable Gastric Band (Band)

The Band procedure involves the placement of an inflatable band around the upper portion of the stomach, creating a small stomach pouch above the band, and leaving the remainder of the stomach below the band. 

How Does it Work?

The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.

Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that the food is digested and absorbed as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

 Advantages

1. Reduces the amount of food the stomach can hold

2. Induces excess weight loss of as much as 40 – 50 percent

3. Involves no cutting of the stomach or rerouting of the intestines

4. Usually requires a shorter hospital stay, and patients can often go home the same day

5. Is reversible and adjustable

6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures

7. Has the lowest risk for vitamin/mineral deficiencies.

 Disadvantages

1. Slower and less early weight loss than other bariatric surgical options

2. Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to other bariatric surgery options

3. Requires a foreign device to remain in the body

4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients

5. Can have mechanical problems with the band, tube or port in a small percentage of patients

6. Can result in dilation of the esophagus if the patient overeats

7. Requires strict adherence to the postoperative diet and to postoperative follow-up visits

8. Highest rate of re-operation.

 

Sleeve Gastrectomy (Sleeve)

The Sleeve is performed by removing approximately 65-80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

How Does It Work?

This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.

Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggests the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the associated weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-Y gastric bypass.

While every patient is different, on the whole, this is a highly effective weight loss surgery, especially for those patients with few comorbidities.

 Advantages

1. Restricts the amount of food the stomach can hold

2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%

3. Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)

4. Involves a relatively short hospital stay of approximately 2 days (my patients typically stay overnight only)

5. Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages

1. Is a non-reversible procedure

2. Has the potential for long-term vitamin deficiencies

3. Has a higher early complication rate than the AGB

4. Can sometimes worsen reflux disease.

 

Roux-en-Y Gastric Bypass (Gastric Bypass)

The gastric bypass is considered the ‘gold standard’ of weight loss surgery.

How Does It Work?

There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably some degree less absorption of calories and nutrients.

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reduces the incidence of type 2 diabetes.

Advantages

1. Produces significant long-term weight loss (60 to 80 percent excess weight loss on average)

2. Restricts the amount of food that can be consumed

3. May lead to conditions that increase energy expenditure

4. Produces favorable changes in gut hormones that reduce appetite and enhance satiety

5. Typical maintenance of >50% excess weight loss.

Disadvantages

1. Is technically a more complex operation than the band or sleeve procedure, and therefore has the potential for increased rates of complications

2. Can lead to long-term vitamin/mineral deficiencies, particularly deficits in vitamin B12, iron, calcium, and folate

3. Generally has a longer hospital stay than the band procedure

4. Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and strict compliance with post-operative instructions.

 

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

The Biliopancreatic Diversion with Duodenal Switch – abbreviated as BPD/DS – is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed.

How Does It Work?

The duodenum, or the first portion of the small intestine, is divided just past the outlet of the stomach. A segment of the distal (last portion) small intestine is then connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. Roughly three-fourths of the small intestine is bypassed by the food stream.

The bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream. Similar to the other bariatric surgical options, the BPD/DS initially helps to reduce the amount of food that is consumed; however, over time this effect lessens and patients are able to eventually consume near “normal” amounts of food. Unlike the other procedures, there is a significant amount of small bowel that is bypassed by the food stream.

Additionally, the food does not mix with the bile and pancreatic enzymes until very far down the small intestine. This results in a significant decrease in the absorption of calories and nutrients (particularly protein and fat) as well as fat soluble vitamins and nutrients. Lastly, the BPD/DS, similar to the gastric bypass and sleeve gastrectomy, affects guts hormones in a manner that impacts hunger and satiety as well as blood sugar control. The BPD/DS is considered to be the most effective surgery for the treatment of diabetes among the bariatric surgical options.

 Advantages

1. Results in greater weight loss than other bariatric surgical options (as much as 60 – 70% percent excess weight loss five years post-surgery)

2. Allows patients to eventually eat near “normal” size meals

3. Reduces the absorption of fat by 70 percent or more

4. Causes favorable changes in gut hormones to reduce appetite and improve satiety

5. Is the most effective of the bariatric surgical options to decrease the incidence of type 2 diabetes.

Disadvantages

1. Has higher complication rates and risk for mortality than the other bariatric surgical options

2. Requires a longer hospital stay than the band or sleeve procedure

3. Has a greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals such as iron, calcium, zinc, fat-soluble vitamins such as vitamin D, and therefore supplementation of these nutrients, vitamins, and minerals is required

4. Strict compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines is critical.

 

Revisional Bariatric Surgery

Revisional Bariatric Surgery is an umbrella term for many different types of bariatric surgery revisions. A revisional bariatric surgery is sometimes a surgical option for a patient who has undergone a previous bariatric surgery that failed.

Common revisional surgeries performed by Dr. Ditto include but are not limited to laparoscopic bands to laparoscopic sleeves, laparoscopic sleeves to laparoscopic gastric bypasses, gastric bypass pouch revisions and gastric bypass limb revisions.   

Why did my bariatric surgery fail?

There are many reasons for failure of a bariatric surgery which range from an inadequately performed initial surgery to poor patient compliance. Additionally, some bariatric surgeries fail for unknown reasons, or because of a patient's co-existing medical conditions (comorbidities). Failure can generally be divided into three main categories:

1. inadequate weight loss and/or weight regain

2. unresolved comorbidities

3. medical complications from the initial surgery.

Are there more risks involved?

Revisional surgery does carry a higher complication rate than initial bariatric surgery. Dr. Ditto will discuss your options with you prior to surgery, and will discuss your particular risks and benefits in light of your current and historical medical and surgical conditions. However, in general, revisional bariatric surgery results in 3-5 times more risks than initial bariatric surgery. One way Dr. Ditto attempts to mitigate the additional risks is to perform the revisional surgery in multiple steps. For example, he may suggest removal of a gastric band approximately three to six months before a second operation is performed to create either a sleeve or bypass.

What kind of results can I expect?

Every patient is different, and Dr. Ditto will discuss your particular risks and benefits with you individually. Revisional operations usually have different goals than that of the initial bariatric procedure. First and foremost, the number one goal is to restore the ability to eat without symptoms such as pain, nausea and emesis. Second, we want to restore both your psychological and emotional health. Lastly, the goal is to achieve a weight loss that is both desired by the patient and advantageous to the patient's health. It is a common misconception that weight loss is the same after a revisional operation as compared to your primary procedure. Patients undergoing a revisional bariatric surgery need to understand that weight loss after revisions is typically slower and the percentage of excess weight loss that is sustained is typically lower than that of an initial bariatric procedure.

**DISCLAIMER: The information and content provided herein is for informational purposes only, and is not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. All content, including text, graphics, images and information, contained on or available through this website is for general information purposes only. It does not establish a physician-patient relationship and should not be construed as medical advice.  The information is not intended to serve as a substitute for the consultation, diagnosis, and/or medical treatment of a qualified physician or healthcare provider.  Should you have any health care related questions, promptly call or consult a physician or healthcare provider. No information contained in this website should be used by any reader to disregard medical and/or health related advice or provide a basis to delay consultation with a physician or a qualified healthcare provider.  If you have a medical emergency, call your doctor or 911 immediately.

Author
Dr. Ditto

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