Laparoscopic Roux en Y Bypass
(Figure #1)

Lap-Band
(Figure# 2)

Other surgeries for obesity involved bypassing much of your small intestine. When you bypass the small intestine, the body's ability to absorb calories is decreased. The problem is that if you bypass too much intestine, you can become extremely malnourished and develop life-threatening illnesses like liver failure. Surgery to bypass this much small intestine is therefore not done anymore.

Gastric bypass surgery combines a little of both the above procedures, but should be considered to be primarily one that produces restriction. In this procedure, the stomach is made extremely small (1-2 ounces), and then that small stomach is reconnected or bypassed to a point lower down on your small intestine (see enclosed figure #1). Another surgery that is offered at UMass/Memorial is called the Lap-Band (see figure #2). In the Lap-Band procedure a small silicone band is placed around the top portion of the stomach to create a small stomach pouch and more restriction to food passing (more on this procedure later).

Important to remember is that with either surgery, you will have a new relationship with food. Due to the smaller stomach, you will no longer be able to sit down at a meal and have a large or even averaged sized portion. For gastric bypass, the food you eat will not be completely absorbed due to the bypass of part of the small intestine.

The initial time period (up to 12 months) after the surgery is when weight loss is easiest. Therefore, during this time it is of utmost importance that you focus on developing and solidifying new, healthy eating and exercise habits and work hard to eradicate old overeating patterns. Remember you should not go into this surgery thinking that this drastic surgery will ever allow you to eat like you do now and still lose weight. If you keep pushing the stomach pouch to accept significant volumes of food, then over time you will stretch your stomach and regain your weight.

In addition to improving overall quality of life, many post operative patients will see improvement or even resolution of medical illness brought on by obesity (including sleep apnea, diabetes, high blood pressure, and arthritis). Most will enter into a category of weight (BMI<35) in which the risk of major illnesses or sudden death is not much higher than in the general population.

You will be closely followed in the postoperative weeks, months, and years. You must be committed to these follow up appointments with medical, surgical, behavioral, and nutritional staff. Not only is safe weight loss dependent on these follow-ups, but so is your also your ability to permanently keep the weight off. Bypass surgery can finally give you the capacity to avoid food and begin the weight loss process, but long- term success will be dependent on modifications in your behavior, nutrition, and physical activity.

Risks can be classified as intraoperative (during the operation), early postoperative (first week), and late postoperative (after leaving the hospital).

• Intraoperative risks

Intraoperative risks are similar to that for any surgery. They involve risks related to the anesthesia, bleeding that may require transfusions, and injury to surrounding abdominal structures that can occur with surgery. Most of these injuries are non-life threatening, but may delay your recovery significantly.

• Early postoperative risks

Early postoperative risks may include death, bleeding, wound or intra-abdominal infection, lung problems including pneumonia, heart problems including heart attack, and blood clots. One of the more serious and recognized problems with this surgery is called anastomotic leak. Any place that the bowel is cut and then fashioned back together is called an anastomosis. A leak of bowel contents is possible from any of these places. Leaks may be managed with bowel rest (nothing to eat) and antibiotics, or they may require another operation to fix the problem. In our extensive experience at UMass/Memorial the incidence of death is <0.5%, with other major complications including leak around 2%.

• Late postoperative risks

Late postoperative risks can be from many sources. The wounds still carry a risk for infection or hernia. You may have significant problem with your ability to tolerate solid foods due to pain, nausea, or vomiting. You may develop reflux, ulcers, bowel obstructions, gallbladder stones, diarrhea or strictures (narrowings) of the anastomosis (areas where the stomach or small intestine are sutured or stapled together). Many problems can be corrected, but some may require a second operation. Many will experience nutritional disturbances in the postoperative period (malnutrition, vitamin deficiency, calcium deficiency, anemia). Most are controlled with supplements, diet change and close follow up.

• Other complications

Other complications/risks include:

1. Kidney stones

2. Abdominal cramping/gas

3. Dumping syndrome - inability to tolerate sugar and/or simple carbohydrates in anything but small quantities. The condition is seen in about 70-80% of patients in their first year after surgery. Patients may experience a range of symptoms including abdominal pain, bloating and cramps, diarrhea, weakness, dizziness, headache, and low blood sugar levels. Dumping tends to function as an aid to weight loss for many patients because of the foods they will need to avoid. Most (but not all) patients eventually resolve dumping symptoms by 2 years.

4. Neuropathy - from poor absorption of certain vitamins

5. Osteoporosis - from poor absorption of calcium

6. Miscarriage or birth defects – females of child bearing age need to avoid pregnancy during the period of acute weight loss (at least 18 months). After that period, it will be safe for you and your fetus to sustain a normal pregnancy.

7. Liver function abnormalities

8. Redundant skin folds from weight loss - a very common condition that may need to be dealt with by another operation (plastic surgery). This surgery may be classified as cosmetic and not necessarily covered by insurance.

The procedure is called gastric banding and it is frequently done laparoscopically (you may see it described on the internet as the LAP-BAND). To learn about the procedure in detail click here.

In brief, it involves placing an inflatable silicone band around the upper stomach (see figure A). When progressively inflated over a span of many months, it effectively creates a small stomach pouch with a very narrow emptying site (like a tight belt). The inflation of the band takes place by placing a small needle into a port under the skin in your upper abdomen. It has been used for many years internationally with fair to good results. It has been available in the United States since June 2001. The good news is that the operation does not involve cutting your stomach or rearranging your anatomy, therefore there is decreased operative and post-operative risk associated with the LAP-BAND compared with bypass. It is also a shorter operation that can be more easily reversed, and does not carry concerns about malabsorption of certain vitamins or other nutritional problems. There also is a much shorter recovery period compared with bypass.

For many people, the LAP-BAND will be a good choice and can be done very safely. It is, in general, not recommended for people who are big sweet eaters as the liquid calories (ice cream, shakes, chocolate, etc.) will easily pass through the narrow outlet created by the band and sabotage weight loss (and there is no “dumping syndrome” created with a LAP-BAND to help avoid sugar calories). The band is also less recommended in our program for people who have much more weight to loose (BMI>55) or are tremendously disabled because of their weight.

The down side for some is that the overall weight loss is much slower and potentially not as good as the gastric bypass. There are also many more visits in the first 6-8 months (4 to 6 visits) in order to adjust the band properly for weight loss. It is, however, a viable option offered here at Umass/Memorial for the right person. You can find more information about the LAP-BAND at the following web sites:

http://www.inamed.com

http://www.becapprovalsite.com

• John J. Kelly, MD
  Assistant Professor of Surgery
  Department of Surgery
  UMass/Memorial Medical Center
  67 Belmont Street
  Worcester, MA 01605

• Richard A. Perugini, MD
  Assistant Professor of Surgery
  Department of Surgery
  UMass/Memorial Medical Center
  55 Lake Avenue North 
  Worcester, MA 01655

• Donald R. Czerniach, MD
  Assistant Professor of Surgery
  Department of Surgery
  UMass/Memorial Medical Center
  67 Belmont Street
  Worcester, MA 01605