In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight-loss surgery for thousands of patients. The Roux-en-Y gastric bypass surgery combines the malabsorptive and restrictive approach to surgery. Food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients.  The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight-loss surgery.  It is one of the most frequently performed weight-loss procedures in the United States.

The bariatric surgical procedures performed by Surigcal Associates are the Roux-en-Y gastric by-pass and placement of the adjustable LapBand^® System. Most of the time, these can be completed using a surgical camera laparoscopically.

Malabsorptive Procedures.

Malabsorptive weight-loss procedures are the most common gastrointestinal surgeries for weight loss. They restrict both food intake and the amount of calories and nutrients the body absorbs. 

Malabsorptive procedures produce more weight loss than restrictive procedures, and are more effective in reversing the health problems associated with severe obesity. Patients who have malabsorptive operations generally lose two-thirds of their excess weight within two years.

However, it is important to note that the risk of complications and side effects from the surgery, including nutritional deficiencies, increase with the lengthening of the small intestine bypass. Patients with extensive  bypasses of the normal digestive process require close monitoring and life-long use of special foods, supplements, and medications.

Types of malabsorptive procedures include:

• Roux-en-Y (RGB)
• Biliopancreatic Diversion (BPD)
• Distal RY
• Duedenal Switch

Roux-en-Y (RGB) -- The Roux-en-Y procedure changes the original shape of the stomach, the capacity to hold food, and time emptying the stomach of food, and re-routes the direction of food, leaving the "new" stomach.

In this procedure, stapling creates a small stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption.

This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine, creating the “y” shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.

The average excess weight loss in the Roux-en-Y procedure is generally higher in a patient who follows the dietary guidelines and exercise regime set forth by the doctor than patients who have just had restrictive procedures. One year after surgery, weight loss can average 77% of excess body weight. Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients and 96% of certain associated health conditions (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.

Of course, there are risks associate with the surgery. Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and predisposition to iron deficiency anemia.  This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids.  Bypassing the duodenum has also caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hipbones.  All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements. A chronic anemia due to Vitamin B12 deficiency may occur.  The problem can usually be managed with Vitamin B12 pills or injections.

A condition known as “dumping syndrome,” can occur as the result of rapid emptying of stomach contents into the small intestine.  This is sometimes triggered when too much sugar or large amounts of food are consumed.  While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating.  Some patients are unable to eat any form of sweets after surgery. In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30ml.

The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using x-ray or endoscopy if problems such as ulcer, bleeding or malignancy should occur.

Biliopancreatic Diversion -- BPD is an invasive technique developed and performed primarily in Italy. Approximately 3/4 of the stomach is removed to produce both restriction of food intake and reduction of acid output. The small intestine is then divided and a common channel created. Weight loss is achieved but at the expense of multiple surgical complications as well as unacceptable nutritional deficiencies. This type of operation can be converted to a standard RYGB.

Distal RY -- Distal RY creates a stapled small gastric pouch, leaving the remainder of the stomach in place. A long limb of small bowel is attached to the stomach to divert bile and pancreatic juices, which produces a malabsorptive effect.

Duodenal Switch -- The duoneal switch is a variation of the BPD, which does include stomach resection, but leaves a "sleeve" of stomach. The duodenum is closed so pancreatic and bile drainage is bypassed. Food joins with bile and pancreatic juice in a bowel segment called a "common limb."

In addition to increased operative risk and increased potential nutritional deficiencies, the malabsorptive procedures may have side effects including abdominal bloating and malodorous stool and flatus. Close monitoring, nutritional supplements, vitamins and life-long medical surveillance are imperative in maintaining health.

Restrictive Procedures.

Restrictive procedures deal with restricting the amount of food you intake. During restrictive weight-loss surgery, the surgeon creates a smaller upper stomach pouch that initially has the capacity to hold about 1 ounce of food and later expands to 2-3 ounces. The pouch is connected to the rest of the stomach through the stoma. This procedure does not interfere with the normal digestion of food.

Quite simply, the idea is that when you feel full, you are less likely to feel hungry. When you don't feel hungry, you're not as likely to eat as much, nor will you feel deprived. With a reduced stomach size, it takes much less food to make you feel full.

During recovery from restrictive weight-loss surgery, you must adhere to strict dietary guidelines and restrictions as directed by your surgeon. Once you have graduated to eating "regular" food, you must learn to adapt to a new way of eating. For example, at each meal you may eat 3/4 to 1 cup of food, and after that much, you may be uncomfortably full.

Although restrictive operations lead to weight loss in almost all patients, they are less successful than malabsorptive procedures in achieving substantial, long-term weight loss. Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. 

Success of the surgery depends on learning to eat slowly, eating less, and not drinking too many fluids, particularly carbonated beverages. If your eating habits return to intaking high calorie, high fat foods, the stomach pouch and stoma outlet may be stretched, defeating the purpose of the surgery.

Types of restrictive procedures include:

• Vertical Banded Gastroplasty
• Gastric Banding
• Inflatable Gastric Banding

The primary advantage of this restrictive procedure is that a reduced amount of well-chewed food enters and passes through the digestive tract in the usual order.  That allows the nutrients and vitamins (as well as the calories) to be fully absorbed into the body. After 10 years, studies show that patients can maintain 50% of targeted excess weight loss.

Postoperatively, stapling of the stomach carries with it the risk of staple-line disruption that can result in leakage and/or serious infection.  This may require prolonged hospitalization with antibiotic treatment and/or additional operations. Staple-line disruption may also, in the long-term, lead to weight gain.  For these reasons, some surgeons divide the staple line wall of the pouch from the rest of the stomach to reduce the risk of long-term staple disruption. The band or ring applied may lead to complications to obstruction or perforation requiring surgical intervention.

Characteristically, these procedures while creating a sense of fullness, do not provide the necessary feeling of satisfaction that one has had “enough” to eat. Because restrictive procedures rely solely on a small stomach pouch to reduce food intake, there is the risk of the pouch stretching or of the restricting band or ring at the pouch outlet breaking or migrating, thus allowing patients to eat too much.

Around 40% of patients undergoing these procedures have lost less than half their excess body weight. As is the case with all weight-loss surgeries, readmission to a hospital may be required for fluid replacement or nutritional support if there is excessive vomiting and adequate food intake cannot be maintained.

Gastric Banding -- Gastric banding is a simple restrictive operation where a band of synthetic material is placed around the stomach near the upper end. Generally, experience with foreign materials in contact with the GI tract has been unfavorable. This operation is used on an extremely limited basis in the United States.

Inflatable Gastric Band -- While widely used in Europe, this procedure is considered experimental and is undergoing FDA trials in this country. With consideration of previous banding experience and noted European results and complications, we currently have no plans to offer or endorse this procedure.