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Operative Procedures
In the United States, about 95% of all morbid obesity operations are gastric restrictive (literally, stomach-reducing) procedures. That is, they involve the creation of a small (30 to 40 ml), less than 1/2 a cup, upper gastric pouch that drains through a small outlet (0.75 to 1.2 cm), about 1/2 inch, setting in motion the body's satiety mechanism. This procedure can be done as an open procedure or laparoscopically.
Of these gastric restrictive procedures, about half involve a technique for gastric bypass, with the upper gastric pouch draining into a Roux-en-Y segment of jejunum. The other half of these restrictive procedures include vertical banded gastroplasty with the upper gastric pouch draining into the remainder of the stomach, and the LAP-BAND® System. The gastric bypass and vertical banded gastroplasty have been used for about 20 years have proven to be safe and successful. The other 5% of morbid obesity operations done in the United States usually involve gastric restrictive surgery combined with a malabsorptive procedure, which divides small intestinal flow into a biliary-pancreatic conduit and a food conduit joined 50 cm proximal to the ileocecal valve (e.g., duodenal switch procedure).
At the University of Minnesota Obesity Surgery Center, we routinely perform the gastric bypass, the vertical banded gastroplasty, duodenal switch procedure, and the LAP-BAND® System. The selection of the operation to be employed is made by the patient, in consultation with his or her personal physician and with the surgeon. For certain patients, a combination of a gastric restrictive procedure with a malabsorptive procedure may be suggested.
Gastric Bypass
In addition to the potential complications of any abdominal operation, gastric bypass is associated in some patients with the dumping syndrome. Gastric bypass patients require vitamin B12 supplementation and possibly oral iron supplementation.
In addition to the potential complications of any abdominal operation, vertical banded gastroplasty is associated in some patients with vomiting and early postoperative intolerance of certain foods, notably red meats, as well as the necessity for chewing food adequately.
A duodenal switch procedure (DS) has two parts to it – removal of a portion of stomach and the formation of a bypass of the small intestine. The greater curvature of the stomach is completely removed during surgery; however, the pyloric sphincter is left in place and functions normally. This eliminates the risk of dumping syndrome. Dumping syndrome is a reaction in which you can experience cramps, nausea, diarrhea, sweating, weakness and light headedness. A bypass of the small intestine is made to prevent some food from being absorbed into your body. A common channel is created just before the small intestine enters into the colon or large intestine. The “common channel” is the only portion where complete digestion and absorption of food takes place.
In addition to the potential complications of any abdominal operation, the long-term complications with DS are malnutrition, dehydration, liver abnormalities, out-eating the surgery, osteoporosis, diarrhea, and flatulence. These problems are preventable.
The “laparoscopic” approach to obesity surgery is different from the traditional “open” approach only in the method of accessing the stomach and intestines. In other words, the operations are exactly the same except in the laparoscopic procedure there are five to six small incisions (¼ to ½ inch) instead of the 10 to 12 inch abdominal incision in the open procedure. In a laparoscopic procedure, the laparoscope which is connected to a video camera is inserted through the small abdominal incisions, giving the surgeon a magnified view of the patient’s internal organs on a television monitor. The surgical specialized laparoscopic instruments are inserted into separate incisions. The entire operation is performed “inside” the abdomen after gas has been inserted to expand the abdomen.
The laparoscopic Roux-en-Y gastric bypass (Lap RNY) operation is consists of a horizontal, 4-row staple line dividing the stomach into the upper gastric pouch (30 to 40 ml) and the gastric remainder. The upper pouch is drained through a small outlet (0.75 to 1.2 cm) into a 75-150 cm Roux-en-Y jejunal limb to the jejunum, approximately 75 cm distal to the ligament of Treitz.
Possible adverse effects of the Lap RNY include dumping syndrome, wound infections, wound breakdown, leaks from staple-line breakdown, stomal stenosis marginal ulcers, various pulmonary problems, and blood clots in the legs. Gastric bypass patients require vitamin B12 supplementation and possibly oral iron supplementation.
Most reports indicate 66-80% loss of excess body weight for the gastric bypass procedure. The patient’s success with weight loss is dependent on appropriate food choices and a consistent exercise program.