A History of Obesity Surgery:
(Patients are encouraged visit the link to the ASBS website and read the full text of "The Story of Obesity Surgery")
The history of bariatric surgery begins in the 1950’s when two surgeons, Dr. Kremen and Dr. Linner performed a procedure known as the jejuno-ileal bypass.
The procedure consisted of connecting a segment of the upper small bowel to the lower small bowel and bypassing the middle portion and reducing the area available for calories to be absorbed. A number of problems occurred with this bypass including profuse diarrhea, gallstones, calcium deficiencies, neuropathy, night blindness, hair loss, anemia, kidney failure, liver failure and many other problems. This procedure is no longer popular.
The biliopancreatic diversion or “Scopinaro” differed from the jejunoileal (JIB) bypass by not having a portion of bowel that was a “dead end” like the JIB did. This procedure had significantly fewer problems with liver failure, involved a limited gastrectomy that reduced the amount of food a patient could eat, and a bypass of much of the small bowel which resulted in a significant malabsorptive component (food couldn’t be processed by the intestine). The difficulties with this technique were that patients had significant problems with loose stools, protein malnutrition, excessive and smelly flatus (gas), strong body odor and ulcers at the site where the bowel was connected to another portion of bowel. This procedure has not been particularly popular in the U.S. A modification of this procedure is the “duodenal switch” which has is thought to produce fewer and less profound problems than the original biliopancreatic diversion.
Old Loop Bypass
One of the most influential surgeons studying weight loss surgery is Dr. Edward Mason. He was involved in many of the innovations and developments that have occurred since 1966, and one of these, a type of bypass that created a smaller gastric pouch to limit food intake and a “loop” of small intestine that was attached downstream to the small bowel to limit the ability of the bowel to absorb calories. This approach was very successful however the “loop” was created in such a way that bile from the liver flowed across this connection to the gastric pouch and one of it’s major criticisms was that it caused bile reflux into the stomach pouch and esophagus.
Vertical Banded Gastroplasty
Since that time there have been a number of modifications to the gastric surgery. One of these was the vertical banded gastroplasty. This involved a staple line on the stomach that created a partitioning of the stomach and in effect a smaller reservoir to hold food. This approach has a number of variations including a prosthetic band, which strengthens the integrity of the base of the pouch, and an adjustable device that can vary the size of the pouch. Although this was a relatively uncomplicated surgery technically it has become associated with a significant incidence of weight gain a few years after the surgery since the pouch can stretch back to a significant size and there is no malabsorption aspect to this surgery. Long term results are not yet available but they are expected to be similar to the vertical banded gastroplasty.
Roux-en-Y Bypass
Another modification to the gastric bypass was the creation of the Roux-en-Y gastric bypass. This procedure entailed making a small gastric pouch high in the abdomen and just below the esophagus. A segment of small bowel is divided and attached to this pouch, sometimes behind the colon and remainder of the stomach if there is difficulty reaching the pouch. The remainder of the small bowel is then attached to the bowel leading from the liver and pancreas in a shape that resembles a Y. This is probably the most common bypass being done today. It too has had a number of problems and is a technically more difficult procedure. There is a significant risk of narrowing at the connection between the stomach pouch and the small intestine and may require stretching the opening. There is a risk of the “Roux stasis syndrome” which is a slowing down of the emptying of the pouch and small bowel causing nausea and vomiting. The limbs of the Y can become involved with an obstruction of the bowel and anemia, calcium and vitamin deficiency can result.
Mini Gastric Bypass
Dr. Robert Rutledge developed the “Mini” gastric bypass in 1997. This bypass creates a small gastric pouch much lower in the abdomen than previous techniques of this kind and incorporates a “loop” anastamosis (connection) with the small bowel that provides for a malabsorption effect similar to that, which is used in the Roux-en-y bypass. Some of the beneficial effects of the “Mini” are similar to the Roux-en-Y bypass. A patient with the “Mini” must still be followed carefully for calcium and iron deficiencies just as the Roux patient must be followed. There are some similar risks to the operations such as leak, bowel obstruction, pulmonary embolus (blood clot going to the heart), pneumonia, and others.
Laparoscopic Gastric Bypass
The Roux-en-y gastric bypass is the procedure to which other obesity surgery is often compared. It is the most common obesity surgery performed and is considered by many as the "standard of care" in weight loss surgery. There are two varieties of roux-en-y procedures, the proximal and distal roux. The proximal bypass is described above and represents a more "restrictive procedure" in vastly limiting the amount of food a patient can eat while providing a more limited "malabsorptive procedure" that decreases the ability for food to be absorbed. The distal roux combines the small gastric pouch with a more lengthly bypass and thus a greater "malabsorptive procedure".
Some of the difficulties of the roux-en-y have included the technical problems involved in creating the small gastric pouch located high in the abdomen near the gastro-esophageal junction. This is a more difficult area to reach surgically and can be challenging to make the small bowel extend to in certain individuals. Other problems have included the Roux stasis syndrome as described above, weight regain over time, and the technical difficulties involved in the revision of these procedures due to their location high in the abdomen and the associated scarring in this relatively confined region. By combining a moderate length distal bypass with a slightly elongated gastric pouch, the malabsorptive component of the procedure becomes more prominent and keeps the connection (anastamosis) between the stomach pouch and the small bowel more accessible in the abdomen should laparoscopic revision/reversal be considered.
Gastric Banding
Another way to limit food intake is to place a constricting ring completely around the top end (fundus) of the stomach, creating an hour-glass effect, just like your Microsoft cursor! Except that the ring has to be placed near the upper end of the stomach, just below the junction of stomach and esophagus. This idea of gastric banding has been around for quite a number of years, and was pursued in Europe and Scandinavia particularly. Initially, readily available materials such as arterial graft was used for the band. The results, however, were not as good as RGB or VBG and the concept has only become popular with the development of modern bands designed for the task and techniques to measure the size of the "stoma" created under the band and associated pressures. An ingenious variant, the inflatable band was developed by Dr Kuzmak (Kuzmak, Yap et al. 1990) who devised a band with an inflatable balloon as its lining. This balloon was connected to a small reservoir which is placed under the skin of the abdomen, through which, the balloon can be inflated, thus reducing the size of the stoma, or deflated thus enlarging the stoma. Even more ingenious, has been the development of models which can be inserted laparoscopically, thus saving the patient the discomfort of a large incision. Since the hour glass configuration only constricts the upper stomach, with no malabsorptive effect, it acts as a pure restrictive operation. Like VBG, the favorable consequences are absence of anemia, dumping and malabsorption, while the disadvantages include the need for strict patient compliance. Long term results of this device are not yet available, but logic would suggest they are likely to be comparable to VBG results with an unknown additional effect due to manipulation of the inflatable balloon. At the present time there are two devices on the world market. The LapBand manufactured by Bioenterics, Carpenteria, California and the Obtech device produced in Sweden by Obtech Medical AG. At this time only the LapBand is freely available in the USA at this time, having completed U.S. trials and been approved for use by the FDA.It is now produced by a company named Inamed.
Listing of Complications Following Gastric Banding
Operative:
Splenic Injury
Esophageal Injury
Conversion to Open Procedure
Wound Infection
Late:
Band slippage
Reservoir deflation/leak
Failure to lose weight
Persistent vomiting
Acid reflux
Significant debate continues as to which obesity surgery is preferred.
How to Proceed from Here
1) Am I a candidate?
Between the ages of 20 and 62 years old (exceptions are possible).
BMI (body mass index) of greater than 40 (or > 35 with co-morbid conditions)
BMI = [weight (pounds) x 703] / [height (inches) x height (inches)]
No previous major upper abdominal surgery (gallbladder OK)
No active drug or alcohol addiction history
No medical contraindication to anesthesia or surgery
No major psychiatric history that can’t be OK’d by your psychiatrist
Active: either employed attending school or by avocation (keeping a family running obviously counts)
2) What do I need?
A primary care doctor who will follow you post-operatively and who is already familiar with caring for patients whom have undergone these procedures. When you come for your visit you should bring a letter to this affect with you as well as his/her records concerning you. (If you don’t have a medical doctor we can find one with you). It is important that your doctor is well versed in the care of weight loss surgery patients and the potential metabolic as well as nutritional issues.
Make sure your insurance covers these kinds of procedures. We will supply a letter of medical necessity if it’s appropriate and if it’s required. Insurance companies sometimes don’t recognize how your good health benefits them and it may require material from us pointing out how it’s better for them in the long run as well. The cost of the surgical fee for either the bypass or the Lap-Band is currently $4875 as well as the hospital charge which is approximately $16000 for the Roux-en-y and somewhat less for the Lap-Band at our hospital (Northeast Medical Center). If you wish to pay for this without insurance these arrangements can be made at the time of your first visit. (A deposit will be necessary)
The commitment to start a new way of living. Once you’ve had the surgery not only your eating habits but also your lifestyle habits must be changed forever. You should have a formal exercise plan set up.
Support. Going through this will require a close friend, relative, mate to help you through the recovery period. Your family or significant other must understand what you are undergoing. They must accompany you on either your first or second visit.
Contact with previous patients. When you come we will supply you with a list of our patients who you can contact. It is very important to have talked with previous patients to know what to expect.
Understand the dangers of alcohol post operatively.
An upper gastrointestinal x-ray series: a study involving drinking a liquid visible by
x-ray and the evaluation of your esophagus, stomach and first portion of small bowel as well as its dynamics (the ability to propel food contents through the upper intestinal tract).
Appropriate lab work which will be determined by your doctors but should include complete blood count, comprehensive chemistries, and iron studies. Further testing may be required depending upon your health and age and can sometimes include cardiac and pulmonary evaluation.
A psychological screening as suggested by the National Institute of Health.
A nutritionist who will follow your course post-operatively (and can help pre-operatively as well) and guide you with instructions, suggestions and help to keep track of what should become routine check-ups in the years to come. We are biased towards our own nutritionist who has years of experience and who has been outstanding as well as essential to the success of our program.
Fill in the Patient Information Form and e-mail it back to our office with the Submit button.
The above elements are necessary to have completed before the surgery can be scheduled. These can be done prior to your appointment with us in order to shorten the time between your first appointment with us and the time of your surgery. If you wish to have us help you arrange these components of your workup we would be happy to help after your first appointment. After sending your form you should receive a confirmation that your information has been received and that your next step is to call to either make an appointment or to be placed on the waiting list. |
