Weight Loss Surgery. My name is Dr. Kevin Krause. I am the division chief of bariatric surgery for Beaumont Health System. I am going to discuss the different options available for weight loss surgery. One of the most important advances in surgery has been the transition to minimally invasive or laparoscopic techniques. With laparoscopy, small incisions are utilized to perform the same tasks that required a large laparotomy incision in the past. These minimally invasive techniques result in less pain, lower risks of infection, better cosmetic appearance, improved recovery, shorter hospital stay, fewer complications, and an overall lower mortality rate. This requires an experienced surgical team and hospital system. At Beaumont Health System, we offer all 3 main bariatric operations. All operations are performed with laparoscopic or minimally invasive techniques.
From left to right on this slide, the choices include laparoscopic gastric bypass, laparoscopic sleeve gastrectomy, and LAP-BAND. The first operation that I will speak about is laparoscopic gastric bypass. The illustration on the right side depicts gastric bypass. For this procedure, the surgeon will measure down approximately 2 inches from the junction of the esophagus and the stomach. In this location the stomach is divided and separated.
The upper portion forms a small gastric pouch of less than 1 ounce. This will be the new functional stomach. The remainder of the stomach is left in place, but will no longer fill up with food. The second step of the surgery involves the intestinal bypass. The small intestine is measured a specific length and divided. The end of the small intestine is then brought up to connect to the small gastric pouch. This enables food to fill the upper portion of the stomach and then proceed directly into the small intestine, bypassing the remainder of the stomach and the upper portion of the small intestine.
The operation produces weight loss primarily by creating a small pouch that will fill up with small portions of food. Additional weight loss is created by limiting the ability to absorb all the calories consumed. Finally, the bypass alters hormone levels that lead to diminished hunger and improvement of diabetes and cholesterol profiles. As with all of the laparoscopic bariatric operations, bypass results in a relatively short hospital stay and quick return to activity for most patients. Bypass has the longest track record of success and safety. It has the greatest effect on diabetes. In addition, bypass has the greatest effect on cholesterol and heartburn. Bypass produces the highest weight loss of 65-80% of the patient's excess body weight. The major complication rate is 3.2% which remains relatively low. It is reversible, though this is rarely performed. Overall, bypass does have the highest complication rate.
The operation increases risk for ulcers and therefore is a poor choice for smokers. In addition, anti-inflammatory medications such as aspirin, Aleve, Motrin, and Mobic should be avoided for their risk of ulceration. Most patients can tolerate low-dose aspirin if absolutely necessary. Bypass also has a higher incidence of vitamin and mineral deficiencies. The next operation that I will speak about is laparoscopic sleeve gastrectomy. For this operation, the surgeon measures back a couple of inches from the outlet of the stomach to the small intestine. The blood supply to the outer curvature is then divided. A sizing catheter that is less than 1 inch is passed down the esophagus to the end of the stomach. A stapling device is then used to staple along the sizing catheter from the bottom all the way up to the top. This results in a long narrow sleeve. The portion in light pink on the illustration is then removed from the abdomen. This operation creates restriction of food intake by forming the narrow high-pressure sleeve.
There is no intestinal bypass with this operation allowing food and nutrients to be absorbed normally. This surgery does influence hormone levels by removing many Ghrelin cells, resulting in diminished hunger. Sleeve gastrectomy also has a short hospital stay and quick return to activity for most patients. Patients are able to take all medications including anti-inflammatory drugs without restriction. Fewer vitamin and mineral deficiencies are associated with this operation. It has a high excess weight loss typically in the range of 60-70%. Overall, weight loss is within 5-10% of gastric bypass. The major complication rate is 2.6%, slightly lower than gastric bypass. The operation is not reversible.
Weight Loss Surgery. Given the presence of a long high pressure staple line, it is associated with a higher leak rate. This refers to the potential for the staple line to breakdown allowing food and bacteria to escape out of the stomach and cause a potentially serious abdominal infection. Overall, this risk is approximately 2%. Finally, sleeve gastrectomy is a newer operation and long-term results beyond 5 years are lacking, though it is unlikely that a significant change in results would be noted beyond this timeframe. Both gastric bypass and sleeve gastrectomy have similar weight loss patterns. A majority of weight loss will be achieved in the first 9-12 months. This chart shows typical weight loss at 10 days around 10-15 pounds, 6 weeks around 25-40 pounds, 3 months typically 40-60 pounds, and ultimately resulting in weight loss from 80-100 pounds or more. Overall weight loss for sleeve gastrectomy is typically 5-10% lower than gastric bypass.
A lap band is a soft silicone device wrapped around the upper portion of the stomach. The device is placed high on the stomach to leave a half ounce capacity stomach above the band. It is sutured in this position. The device is then connected by a tubing to a portal. The portal is secured to the abdominal wall muscle below the skin and subcutaneous tissue. By accessing the port with a specialized needle in the future, fluid may be added or withdrawn to tighten or loosen the band around the stomach. The operation produces restriction of food intake by creating a small pouch in the upper stomach and is adjustable. There is no intestinal bypass with this operation allowing food and nutrients to be absorbed normally. The pressure of the band does appear to diminish overall hunger. LAP-BAND has a very low major complication rate of less than 1%. It has the shortest hospital stay and return to activity. Patients may take anti-inflammatory medications. Vitamin deficiencies rarely occur with this surgery. The band is reversible and may be removed surgically if necessary. The band does require a more restricted diet and some solid foods may be difficult. It requires more intense office follow-up for adjustments typically every month in the first year and less frequently after that time. It may create problems with heartburn. Weight loss is less predictable. Weight loss with lap band is more gradual averaging 1-2 pounds per week. Most patients can achieve approximately 40% excess weight loss in the first year. Weight loss with Lap Band is highly variable ranging from poor to excellent. Overall long-term results are close to 50% excess weight loss. The operation may not be effective enough in patients with a BMI over 50. Up to 20% of patients may require surgery to repair problems with the device. Up to 10% of patients may choose revision to an alternate surgery or simply removal of the device.
