Weight Loss Surgery Options - Everything you need to know

Surgical Weight Loss Options

Sleeve Gastrectomy / Vertical Sleeve Gastrectomy

LAP-BAND® System Adjustable Gastric Band

REALIZE? Adjustable Gastric Band

Roux-en-Y Gastric Bypass

Duodenal Switch

What is Bariatric Surgery?

Bariatric surgery is a surgical procedure performed for treatment of morbid obesity.  The word "bariatric" comes from the Greek: Baros which means weight and Iatreia which means medical treatment. Bariatric surgery has existed since the 1960's, having gone through significant evolution from the early days of the jejunoileal or jejunocolic bypass operations and the horizontal gastroplasty or original "stomach stapling." Other procedures that are no longer performed include the silastic ring vertical gastroplasty and the vertical banded gastroplasty. Modern day procedures are usually performed by skilled laparoscopic surgeons and include the Vertical Sleeve Gastrectomy, the LAP-BAND® or REALIZE? Adjustable Gastric Band procedures, the transected Roux-en-Y Gastric Bypass, and the Duodenal Switch.

All the procedures significantly reduce stomach size. This is accompanied by an altered physiological and psychological response to food. The Vertical Sleeve Gastrectomy, the LAP-BAND® or REALIZE? Adjustable Gastric Band procedures, and the Roux-en-Y Gastric Bypass reduce the size of the stomach well over 90%. The Duodenal Switch also reduces the stomach size but not as much.  The Duodenal Switch procedure also and mainly decreases the body's ability to absorb fat calories and nutrients to aid in successful weight loss.  None of the surgeries affect the absorption of carbohydrates. The normal stomach can stretch sometimes over 1000ml. The stomach pouch in these operations is usually formed from the part of the stomach which is least susceptible to stretching. When the patient ingests a small amount of food, mainly solid protein, the patient feels a sensation of fullness. The patient learns quickly that subsequent bites of food must be eaten slowly and carefully to avoid increasing discomfort and sometimes vomiting.  In the Duodenal Switch, meals high in fat calories cause significant, oily, frequent diarrhea and discomfort.

Remember, bariatric surgery is only a tool. The patient must eat the right foods with vitamins and supplements to feel full enough in order to avoid eating carbohydrates and excessive fatty foods to lose their excess weight in a healthy, nutritional manner with close follow-up.  Exercise, drinking plenty of liquids and support from Dr. Feng, his multidisciplinary bariatric team, and other patients alike are critical in this process.  Eating the wrong foods, not taking the recommended vitamins and minerals, not exercising can lead to multiple problems that can result in an unhealthy, malnourished individual who is still obese.

Dr. Feng specializes in minimally invasive, advanced laparoscopic bariatric surgery (weight loss surgery) with expertise in minimally invasive robotic surgery to optimize surgical precision and 3D visualization.  Dr. Feng is dedicated to patient care. With his comprehensive surgery and multispecialty programs, he and his team are here to make you feel comfortable.

Surgical Weight Loss Options

• Vertical Sleeve Gastrectomy / Sleeve Gastrectomy
• LAP-BAND® System Adjustable Gastric Band
• REALIZE?Adjustable Gastric Band
• Roux-en-Y gastric bypass
• Duodenal Switch

Restrictive Operations

Restrictive operations mainly limit the amount of food intake and do not interfere with normal digestive or nutrient absorption process

• Vertical Sleeve Gastrectomy / Sleeve Gastrectomy
  
• LAP-BAND® System Adjustable gastric band
• REALIZE? Adjustable Gastric Band

Vertical Sleeve Gastrectomy / Sleeve Gastrectomy

This restrictive option has an expected Weight loss of 60-80% of excess body weight

Description of the Vertical Sleeve Gastrectomy or Sleeve Gastrectomy

Most common weight loss surgery performed in the U.S.

This is the most modern weight loss procedure that induces weight loss by restricting food intake, invented back in 1999 but modified and refined by Dr. Feng in 2002 to an optimal smaller size to become a well-established, most popular, stand-alone procedure.

The Vertical Sleeve Gastrectomy (VSG) is also commonly known as the Sleeve Gastrectomy, Restrictive Vertical Gastroplasty, or just Vertical Gastrectomy (VG).  The Vertical Sleeve Gastrectomy is essentially a newer, better version of the vertical banded gastroplasty, a procedure that has been abandoned by virtually all weight loss surgeons, due to high failure rates and complications.  Dr. Feng surgically reduces the stomach in size to a long narrow, tube like, vertical pouch, between 1-4 ounces in size, keeping the valves of the stomach at the entry and exit of food into the stomach which helps maintain normal function.

There is no intestinal bypass performed, avoiding many of the problems associated with malabsorption of nutrients. In the past, the procedure was usually reserved for high risk patients or super obese patients with the intention of performing another surgery at a later date. If necessary, the second procedure would be either a duodenal switch or gastric bypass.

Nowadays, no other surgeries are needed at all anymore since patients loose as much as a gastric bypass patient would. In general, all qualified obese patients are considered and recommended for undergoing this procedure.  Most patients can lose 60 to 80% of their excess body weight over 6-12 months with sleeve gastrectomy alone.

Advantages of Vertical Sleeve Gastrectomy Procedure

• Usually done laparoscopically (minimally invasive) with robotic-assistance in patients.
• Allows patients of any weight, including the super super obese and high risk patients, to undergo surgery with small incisions
• Rapid weight loss
• Patients do not experience diarrhea or significant ?Dumping Syndrome? symptoms
• The portion of the stomach producing hunger-stimulating hormones (Grehlin) is removed
• The smaller stomach maintains normal function with no rearrangement of the intestines, reducing risks of protein and vitamin deficiency and thus no significant "Dumping Syndrome" symptoms
• Minimal patient effort to lose and maintain weight loss
• Better weight loss than the Adjustable Gastric Band procedures
• Safe in patients needing long term aspirin, NSAID such as Motrin, Advil, naprosyn, steroid use

Disadvantages of Vertical Sleeve Gastrectomy Procedure

• Successful results depend on willingness to adopt long-term lifestyle changes
• Weight loss may be slower than more malabsorption procedure type like the duodenal switch

Risks of Vertical Sleeve Gastrectomy Procedure

• Leakage
  
• Nausea/vomiting
• Acid reflux
• Weight regain
• Rarely, allows for second surgery for more weight loss
• Gallstones

LAP-BAND® or REALIZE? Adjustable Gastric Band

This restrictive option has the least expected weight loss of 40-55% of excess body weight.

Description of the LAP-BAND® System or REALIZE? Adjustable Gastric Band

The LAP-BAND® System or REALIZE? Adjustable Gastric Band is placed laproscopically around the upper part of the stomach.  The band divides the stomach into a small pouch above the band and larger pouch below the band.  The smaller pouch limits the amount of food the patient can eat with the result of fullness after eating a small amount of food.

The opening of the stomach can be increased or decreased by injecting or removing saline from the band.  Dr. Feng or his staff can later control or adjust the amount of saline in the band that is a unique feature of the Lap-Band® or REALIZE? system and is a normal part of follow-up post the procedure.

Dr. Feng no longer recommends adjustable gastric band procedures due to the poor weight loss compared with the sleeve gastrectomy, gastric bypass or duodenal switch, in addition to higher than expected incidence of severe complications.

Advantages of LAP-BAND® System or REALIZE? Adjustable Gastric Band Procedures

• Only procedure that can be reversed if necessary
  
• Usually done laparoscopically (minimally invasive)
  
• Easier to perform and generally safer than other weight loss options
  
• Outpatient surgery
  
• Results in fewer nutritional deficiencies

Disadvantages of LAP-BAND® System or REALIZE? Adjustable Gastric Band Procedures

• Successful results depend on the willingness to adopt long-term lifestyle changes more than all the other surgeries, and even the number of visits made after surgery
  
• Patients may have numerous visits with Dr. Feng during the first year to ensure proper band adjustment
• Requires the most effort from the patient to lose and maintain weight loss
  
• Weight loss is usually slower than the other surgeries and may take 2-3 years to lose the predicted weight loss
• Weight loss is less than all the other surgeries: sleeve gastrectomy, gastric bypass, or duodenal switch
• Patients must avoid aspirin, NSAIDs such as ibuprofen, Motrin, Advil, naprosyn to avoid band erosion into the stomach
• Patients must always avoid large meals to minimize risk of causing band slippage or excessive esophagus stretching and abnormal widening

Risks of LAP-BAND® System or REALIZE? Adjustable Gastric Band Procedures

• Nausea/vomiting
• Food getting stuck, needing deflation of band
• Overstretched, abnormally widened esophagus
• Excessively tightened
• Infection
  
• Inadequate weight loss
• Weight regain
• Device malfunction
  
• Balloon, tube access port breakage
• Access port flipping over
• Slippage of down along the stomach causing vomiting
• Erosion of the silicone band creating a hole in the stomach
• Gallstones

 

Combined Restrictive/Mal-absorption Operations

Combined operations restrict the amount of food intake and thus restricting calories, but also limit absorption of certain nutrients. These operations may also be more effective in improving health problems related to obesity compared with some restrictive-only operations, but at higher risk of short and long-term side effects and complications.

• Roux-en-Y Gastric Bypass
• Duodenal Switch

Roux-en-Y Gastric Bypass Procedure

This combined mostly restrictive and some mal-absorption option, the Roux-en-Y Gastric Bypass procedure, has an expected weight loss of 60-80% of excess weight, similar to the vertical sleeve gastrectomy.

Description of the Roux-en-Y Gastric Bypass

Second most common weight loss surgery performed in the U.S. (less than half as much as sleeve gastrectomy) and was previously considered the gold standard of weight loss surgery.

Dr. Feng creates a small, upper stomach pouch about 1-2 ounces in size, dividing it from the lower stomach. This significantly restricts the volume of food that can be eaten if solid protein eaten first. This reduces the amount of calories that can be eaten. He then divides the small intestine to create a Y-shaped section to attach to the stomach pouch. The lower stomach and a portion of the small intestine is bypassed which causes malabsorption of certain nutrients, with no significant carbohydrate or fatty food malabsorption. The procedure minimally limits the nutrients the body can absorb because of the bypass.

Click Here to watch an interactive video of the Roux-en-Y Gastric Bypass Procedure

Advantages of Roux-en-Y Gastric Bypass Procedure

• May be more effective in in some studies in improving obesity-related health problems than some restrictive procedures
• Rapid weight loss
• The portion of the stomach producing hunger-stimulating hormones is bypassed, and thus less hunger is experienced in the first year after surgery but hunger usually returns after about 9 months after surgery
• Better weight loss than the Adjustable Gastric Band procedures

Disadvantages of Roux-en-Y Gastric Bypass Procedure

• Successful results depend on the willingness to adopt long-term lifestyle changes
• Patients may experience long-term nutritional deficiencies, more so than the restrictive procedures
• Decreased absorption of calcium may bring on osteoporosis and related bone diseases
• Decreased absorption of iron and vitamin B12 may lead to anemia
• Weight loss may be slower than more malabsorption procedure type like the duodenal switch
• ?Dumping Syndrome? reaction usually occurs when meals high in refined sugars, carbohydrates, or rich fatty foods are consumed
• Patients must avoid aspirin, NSAIDs such as ibuprofen, Motrin, Advil, naprosyn to avoid high risk of marginal ulcers that can cause bleeding, perforation, abdominal infection
• Possible risk of long-term permanent severe hypoglycemia episodes from nesidioblastosis, which may need high risk reversal

Risks of Roux-en-Y Gastric Bypass Procedure

• Leakage
• Infection
• Vitamin and mineral deficiencies
  
• Anemia
• Osteoporosis
• Strictures at the stomach pouch connection to intestine
• Intestinal ulcers at margin of connnection to stomach pouch
• Bowel Obstruction from internal intestinal scars, internal hernias or telescoping small intestine (intussusception)
  
• Dumping syndrome
• Gallstones
• Possible nesideoblastosis disease causing severe hypoglycemia issues
• Combined operations are more likely to lead to complications then restrictive operations
  
• Weight regain

Duodenal Switch

This combined less restrictive and more mal-absorption option, the Duodenal Switch, has an expected weight loss of 70-90% of excess body weight.

Description of the Duodenal Switch

This procedure offers the ability to eat larger portions foods than gastric bypass or adjustable gastric banding, and even the stand-alone vertical sleeve gastrectomy alone.  Weight loss can be long lasting. The patient may experience more frequent and number of loose, diarrheal bowel movements. Patients need to closely monitor vitamin, protein and mineral levels more than in any other surgery.

The stomach is reduced in size to a long, tube-like vertical sleeve gastrectomy pouch, 4-5 ounces in size with moderate restriction of food intake. The sleeve gastrectomy in the duodenal switich is considerably larger than when done as a stand-alone procedure since you have to eat more in the duodenal switch in order to get enough nutrients into your body, since the duodenal switch is so malabsoprtive, even causing very smelly gas.  Dr. Feng also divides the small intestine to separate food from the digestive juices, causing significant malabsorption.

This surgery is best for patients with BMI of 50 kg/m2 and above since sometimes too much weight is lost, and thus dangerous to perform in lighter, less morbidly obese patients.

Dr. Feng no longer recommends this procedure since the weight loss is similar to the sleeve gastrectomy (the way Dr. Feng does the surgery) and the gastric bypass but with much higher risk of complications and long term concerns about excessive weight loss and malnutrition.

Click Here to watch an interactive video of Duodenal Switch Procedure

Advantages of Duodenal Switch Procedure

• Patients are able to consume larger meals
• Rapid weight loss
• Stomach function remains intact with normal stomach emptying, and thus ?Dumping Syndrome? seldom occurs, like the sleeve gastrectomy
• The portion of the stomach producing hunger-stimulating hormones is removed, like the sleeve gastrectomy
• Better weight loss than the Adjustable Gastric Band procedures
• Safe in patients needing long term aspirin, NSAID such as Motrin, Advil, naprosyn, steroid use

Disadvantages of Duodenal Switch Procedure

• Successful results depend on the willingness to adopt long-term lifestyle changes
• Some patients lose too much weight
• May require lifetime use of special foods and medications
• Higher risk of long-term nutritional deficiencies due to more malabsorption
• More invasive surgery
• Foul-smelling stools/gas after surgery.
• Patients experience a higher incidence of complications than any other surgery

Risks of Duodenal Switch Procedure

• Excessive or too much weight loss
  
• Leakage
• Infection
• Diarrhea
  
• Anemia
  
• Bowel obstruction
  
• Gallstones
  
• More vitamin and mineral deficiencies
  
• Abdominal hernia
  
• Combined and more malabsorptive operations are more likely to lead to complications then restrictive operations
• Inadequate weight loss
• Weight regain