About the Surgery
Comments on Bariatric Surgery by Dr. Todd
The Roux-en-Y Gastric Bypass is generally considered to be the best surgical procedure for the treatment of morbid obesity. Weight loss is achieved by reducing the functional portion of the stomach to a pouch one ounce or less in size, and by creating a stoma, a small opening between the stomach and the intestine.
The small size of the stomach pouch causes the patient to have a sensation of fullness after eating only a small portion of food. The small stoma delays stomach emptying, making the sensation of fullness last longer. These are called the Restrictive components of the procedure.
The limb of intestine coming down from the small pouch is called the Roux limb. The limb of intestine coming down from the bypassed portion of the stomach can be called the Biliary or Bypassed limb. The remaining portion of the intestine is called the Common Channel. Food does not pass down the Bypassed limb, only the Roux limb and the Common Channel. The longer the Bypassed limb, the less the length of intestine actively working to absorb nutrients from the food that is eaten. Digestive juices that normally help absorb nutrients from the food enter the Bypassed limb from the larger portion of the stomach, the liver, and the pancreas, and pass down the Bypassed limb to the Common Channel. These juices do not mix with the food while it is passing down the Roux limb. The longer the Roux limb, the longer the portion of intestine trying to absorb nutrients without the benefit of these digestive juices. Both of these changes result in less absorption of nutrients and contribute to weight loss, and are called the Malabsorptive components of the procedure.
Exactly how the operation is done for an individual patient depends on their individual anatomy, their general health status, whatever changes they may have from prior surgeries, and what they hope to achieve from the operation. The stomach compartments can be completely divided from each other or simply partitioned, the small stomach pouch and the intestinal limbs may be connected to each other with either staples or sutures, a small band may be placed around the stomach pouch, and the two intestinal limbs may be made longer or shorter. The drawing below depicts the Roux-en-Y Gastric Bypass operation. Note that the two portions of the stomach are completely divided from each other. This is my preferred way of making the pouch, as simply partitioning the stomach instead of completely dividing it may entail a higher risk of the two parts connecting themselves back together, which would defeat the operation. Some very fine surgeons prefer to just partition the stomach and not to divide it completely, and I may choose to do the operation that way from time to time.
My preferred length for each of the intestinal limbs is approximately 100 cm, or 3 feet. These are reasonable lengths of intestine to bypass from the food stream and to isolate from the flow of digestive juices, but still leaves enough (approximately 14 feet) intestine in the Common Channel to allow for adequate nutritional intake. Making the limbs longer will increase the amount of malabsorption, and increase the potential weight loss. But increasing the length of the limbs also increases the requirement for dietary supplementation of vitamins, minerals and protein, increases the incidence of side effects such as diarrhea, and increases the potential for excessive weight loss.
Patients will be on a clear liquid diet for the first few days immediately following surgery, and then advance to a pureed diet. These foods will be very soft, so as to pass through the small, newly formed pouch and stoma. One of the main issues during this period will be adequate fluid intake, and dehydration can be a problem for patients recovering from this surgery. We will ask patients to take in at least 32 ounces of liquid a day before leaving the hospital. Approximately one month after surgery the patients can expect to advance to a transitional diet. They begin to take more regular table foods, but will often still go back to eating the pureed foods that they have tolerated well. They will still be learning how to eat right, including chewing food carefully, learning to drink most of their liquids between rather than with meals, and learning that eating the wrong foods, such as sweets or fatty foods, can make them ill. Patients experience the most rapid weight loss during this period. They are often thrilled to see the weight coming off, sometimes at the rate of 20 pounds a month, but it is not an easy time. Patients feel the loss of calories taken in, and are sometimes low in energy. Their small pouch will make them uncomfortable when they eat too much or too fast. They may have diarrhea, which can usually be controlled by avoiding certain foods or by taking medication. They may experience hair loss, though the hair usually begins to grow back within a few months.
At 6 months the patients will probably be on their long-term maintenance diet, which is more or less what and how they will eat for the rest of their lives. The maintenance diet for the most part consists of regular table foods, but in small portions. Most patients describe their meals as child sized, and they often do not finish what they are served. The patients generally become comfortable eating these small meals, and almost always say the loss of the ability to enjoy large meals or certain foods is more than compensated for by being able to successfully control their weight. Patients may expect to lose approximately 70% of their excessive body weight during the first 2 years following surgery. An approximately 10% weight regain is sometimes seen between years 2 and 5, perhaps because the small pouch increases several ounces in size, and perhaps because the patients learn how to take in extra calories without making themselves sick. The surgical community involved in weight loss surgery is very concerned about this late 10% or any other weight regain.
There is a national effort underway to keep patients involved in support groups and in follow-up with their doctors to reinforce what they had been taught after surgery, and what had worked for them the first 2 years. Long term success with this operation requires a team effort of both the patients and their doctors. Gastric Bypass patients take in less food and absorb less of what they take in, and they are at risk for developing nutritional deficiencies. They must also make a life long commitment to taking vitamin, mineral, and possibly protein supplements, and may become very ill if they don’t. These supplements will cost about $30.00 a month, sometimes more, sometimes less, and can be purchased almost anywhere.
This represents the briefest introductory description of one of the operations involved in weight loss surgery, and there are many important issues not addressed here. Please see and discuss this further with your doctor, our office, or any number of good organizations (asbs.org, ObesityHelp.com, etc.) dedicated to helping patients who wish to pursue this effective and long term means of weight loss. -Michael A. Todd, MD, FACS
Results of Bariatric Surgery
Bariatric surgery usually results in the loss of 50-80% of one’s excess weight. Most of this takes place within one year of surgery. In addition to this, however, surgery has also been found to either cure or greatly reduce the following health problems associated with being overweight. It is from helping patients with these problems below that the greatest clinical benefits of bariatric surgery arise.
Weight loss surgery was developed using two different approaches- a restriction technique that limits the intake of calories as well as a absorption approach that restricted the amount of calories absorbed by the body. As a result of attempted procedures, an array of procedures were developed- The Duodenal Switch, Bilio Pancreatic Diversion and Gastric Bypass. These procedures incorporate both malabsorption and restriction which allowed surgeons to bypass a smaller portion of the intestines which reduces the risk of nutritional deficiencies from the bypass in addition to the reduced stomach size which physically limited the amount people could eat. The Sleeve was a procedure that derived from the separation of two stages of the Duodenal Switch. The first stage was to reduce the size of the stomach and the second stage would be done after a patient has lost weight which included bypasses some of the intestines to reduce calorie absorption. Patients would come back after the first stage and had lost so much weight that the second procedure wasn't necessary.
Benefits of Gastric Bypass
Weight will be lost.
-70%-85% is the average excess body weight people will lose 18 months after surgery.
-You will absorb less calories from food because of the bypassed intestines.
-You will eliminate or improved type 2 diabetes.
-You will not be able to eat large meals because of the reduced stomach size and restricted pouch.
-You nay get sick from eating too much sugar which is known as dumping syndrome.
-Because of the weight loss, your hormones may adjust improving metabolism.
The surgery will be a tool that will cause you to have more energy, more confidence and an improved quality of life.
Potential Gastric Sleeve Benefits
-50-65% is the average excess body weight people will lose 18 months after surgery.
-Shorter operating time in comparison to the Gastric Bypass.
-May reduce hunger because of the reduced amount of ghrelin which is a hormone found in the stomach that induces hunger.
-No dumping syndrome. Although dumping syndrome may be a tool to reinforce good eating habits it is not a pleasant experience,
-Unlike the Lap Band there are no adjustments needed.
Specific conditions improved by Bariatric Surgery
Hypertension, or high blood pressure, causes a number of problems, most of which are associated with damage to blood vessels. These vessels are not fixed plumbing, but rather dynamic passage ways that actively expand or contract upon proper stimulus. Persistent hypertension damages their ability to function and, along with high cholesterol, makes them more susceptible to plaque formation. These plaques can break off to form emboli which can flow down stream and lodge elsewhere, causing heart attacks and stroke. Hypertension can also lead to chronic heart failure, where the heart attempts and ultimately fails to cope with a increased work load. Obesity makes it harder for individuals to exercise, an important blood-pressure lowering activity. Obesity is also associated with higher levels of cholesterol and lipids in the blood. These interfere with the ability of blood vessels to expand and contract at the proper times, leading to higher baseline pressure levels. Weight loss is a major factor in the control of hypertension.
Overweight persons are 10 times more likely to develop Type II Adult-Onset Diabetes than those who are not overweight. Diabetes is the condition of insulin not working well. The body needs insulin in order for cells to take up glucose. After eating a meal, your digestive system breaks carbohydrates in the meal down into sugar which enters the blood stream. Insulin is also released into the blood. Insulin acts as the key to allow glucose into the cells. To work, it must bind to insulin receptors on the cell surface, which act like a lock. Diabetes Type II (about 95% of all diabetes) results from cells not being able to maintain enough functioning insulin receptors to bind with insulin. Another name for this is insulin resistance. For reasons not fully understood, obesity is strongly associated with insulin resistance. Diabetic persons losing weight experience a strong reduction in diabetic symptoms.
Apnea means “without breathing” Overweight individuals (more likely men than women), may develop fatty deposits in the neck that restrict breathing during the night. Individuals with sleep apnea may go many seconds without breathing. They may typically wake up, gasp for air, and then return to sleep, sometimes repeating the process hundreds or even thousands of times during an evening. The most prominent result of this is chronic daytime fatigue and drowsiness. People with sleep apnea may lack the energy to function normally and are much more likely to fall asleep while driving. Sleep apnea of often but not Anecessarily associated with snoring. Sleep apnea generally vanishes in individuals who return to normal body weight.
This syndrome was named after a character in one of Charles Dickens’ works (Dickens was a 19th century English writer who wrote Great Expectations and other works). One character of his, Mr. Pickwick, had a peculiar type of labored breathing which 20th century clinicians recognized as being associated with sleep apnea. The three clinical components of Pickwickian syndrome are day time sleepiness, lack of oxygen and excess carbon dioxide in the blood. This disorder, if left unchecked, can eventually lead to heart failure.
Obesity Hypoventilation Syndrome
This condition occurs primarily in the very severely obese — over 350 lbs. It is characterized by episodes of drowsiness, or narcosis, occurring during awake hours, and is caused by abnormalities of breathing and accumulation of toxic levels of carbon dioxide in the blood. It is often associated with sleep apnea, and may be hard to distinguish from it because it presents with the same effects, but is a non-obstructive disorder of ventilatory drive.
Those who are obese find that exercise causes them to be out of breath very quickly. The lungs are decreased in size, and the chest wall is very heavy and difficult to lift. The demand for oxygen is greater with any physical activity. This condition prevents normal physical activities and exercise and often interferes with usual daily activities Respiratory insufficiency can be completely disabling. Weight loss cures this condition.
Heart Disease and Stroke
Heart disease and stroke are the leading causes of death and disability for both men and women in the United States. Severely obese persons are approximately 6 times as likely to develop heart disease as those who are normal-weighted. Coronary disease is pre-disposed by increased levels of blood fats, and the metabolic effects of obesity. Increased load on the heart leads to early development of congestive heart failure. Severely obese persons are 40 times as likely to suffer sudden death, in many cases due to cardiac rhythm disturbances. Being overweight also contributes to angina (chest pain caused by decreased oxygen to the heart) and sudden death from heart disease or stroke without any signs or symptoms. The good news is that losing a small amount of weight can reduce your chances of developing heart disease or a stroke. Reducing your weight by 10 percent can decrease your chance of developing heart disease by lowering your levels of blood cholesterol and triglycerides and improving how your heart works.
High Blood Cholesterol
Cholesterol levels are commonly elevated in the severely obese — a factor predisposing to development of heart and blood vessel disease. Cholesterol is a waxy, fat-like substance that is present in every cell in your body. Some cholesterol is needed for your body to function. Your liver produces enough cholesterol for your body. Certain foods provide additional amounts of cholesterol, which may be more than your body needs. While some cholesterol in your blood is essential to your health, too much can be harmful. A healthy artery has a smooth, even surface. When too much cholesterol builds up on the walls of your arteries, however, thick deposits, called plaque, form. The buildup of plaque narrows the artery, so your heart must work harder to force blood through. Plaques can limit or block the blood flow in the artery. They can also rupture and form blood clots. When either happens in a major artery supplying the heart or in a major artery supplying brain, the blood flow can be completely blocked. The result can be a heart attack or stroke. There are many reasons for a high cholesterol level. These include diet and family history and obesity. With weight loss, cholesterol levels decrease.
GERD – Gastroesophageal Reflux Disease (Heartburn) and Reflux Nocturnal Aspiration
Acid belongs in the stomach, and seldom causes any problem when it stays there. When it escapes into the esophagus the result is called “heartburn”, or “acid indigestion”. One of the leading causes is obesity, where the weight presses on the valve at the top of the stomach, causing dysfunction of that valve. The problem is not with digestion, but with the burning of the esophagus by the powerful stomach acid. When one belches, the acid may bubble up into the back of the throat, causing a burning feeling there as well. Often this occurs at night, especially after a large or late meal. If one is asleep when the acid regurgitates, it may actually be inhaled, causing a burning of the airway. GERD is dangerous, because of the possibility of pneumonia or lung injury. The esophagus may become scarred and constricted, causing problems with swallowing. Approximately 10 – 15% of patients with even mild sporadic symptoms of heartburn will develop a condition called Barrett’s esophagus, which is a pre-malignant change in the lining membrane of the esophagus, a cause of esophageal cancer.
Asthma and Bronchitis
Asthma is a breathing problem which results from spasm (bronchospasm) of the muscles surrounding the walls of the lung airways (bronchi). Airways are breathing passages that allow air to move in and out of the lungs. Alveoli are tiny sac-like stuctures at the end of the airways where oxygen enters the bloodstream. Bronchospasm causes narrowing of the airways which leads to shortness of breath, wheezing, coughing, and congestion. Airways can also be narrowed in asthma from accumulated mucus and swelling that is caused by inflammation of the bronchi. Asthma is a respiratory disorder affecting an estimated 10-15 million people. More than 4,000 people in the U.S. die of asthma each year. Asthmatics have difficulty exhaling. Obesity does not itself cause asthma, or bronchitis, directly. However, it does interfere with breathing, aggravating any attack of asthma and may cause severe bronchitis.
Gallbladder disease occurs several times as frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem. When stones form in the gallbladder, and cause abdominal pain or jaundice, the gallbladder must be removed. Gallstones are formed by cholesterol and pigment (bilirubin) in bile. Bile is produced in the liver and stored in the gallbladder. Risk factors for cholesterol gallstones include age, obesity, female gender, multiple pregnancies, birth control pills, and heredity. The most common symptom of gallstones is pain in the upper abdomen. Diagnosis of gallstones is usually made with ultrasound of the abdomen. Cholecystitis (inflammation and infection of the gallbladder) is a complication of gallstones. Some patients with gallstones have no symptoms, and need no treatment. Patients with mild and infrequent symptoms may consider oral medication to dissolve gallstones. Surgery (standard or laparoscopic) is considered for patients with severe symptoms and for patient with cholecystitis.
Stress Urinary Incontinence
A large heavy abdomen, and relaxation of the pelvic muscles, especially associated with the effects of childbirth, may cause the valve on the urinary bladder to be weakened, leading to leakage of urine with coughing, sneezing, or laughing. This condition is strongly associated with being overweight, and is usually relieved by weight loss.
Degenerative Disease of Lumbo-Sacral Spine The entire weight of the upper body falls on the base of the spine, and overweight causes it to wear out, or to fail. The consequence may be accelerated arthritis of the spine, or “slipped disk”, when the cartilage between the vertebrae squeezes out. Either of these conditions can cause irritation or compression of the nerve roots, and lead to sciatica — a dull, intense pain down the outside of the leg.
Degenerative Arthritis of Weight-Bearing Joints
The hips, knees, ankles and feet have to bear most of the weight of the body. These joints tend to wear out more quickly, or to develop degenerative arthritis much earlier and more frequently, than in the normal-weighted person. Eventually, joint replacement surgery may be needed, to relieve the severe pain. Unfortunately, the obese person faces a disadvantage there too — joint replacement has much poorer results in the obese. Many orthopedic surgeons refuse to perform the surgery in severely overweight patients.
Venous Stasis Disease
The veins of the lower legs carry blood back to the heart, and they are equipped with an elaborate system of delicate one-way valves, to allow them to carry blood “uphill”. The pressure of a large abdomen may increase the load on these valves, eventually causing damage or destruction. The blood pressure in the lower legs then increases, causing swelling, thickening of the skin, and sometimes ulceration of the skin. The loss of weight brought by WLS can improve or cure venous stasis disease.
The obese face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, ridicule and remarks from strangers, lack of self- esteem, social rejection, loss of job potential, inappropriate coping strategies, depression and anxiety. They often experience discrimination at work, and cannot fit into theatre seats, or a ride in a bus or airplane. There is no wonder that anxiety and depression might accompany years of suffering from the effects of a genetic condition — one which many thinner people believe should be controlled easily by will power. Seriously obese persons suffer inability to qualify for many types of employment, and discrimination in employment opportunities, as well. They tend to have higher rates of unemployment, and a lower socioeconomic status. Ignorant persons often make rude and disparaging comments, and there is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness. Many severely obese persons find it preferable to avoid social interactions or public places, choosing to limit their own freedom, rather than suffer embarrassment.