At the Association of South Bay Surgeons, we've harnessed the collaborative power of multiple specialists and sub specialists into one comprehensive team of expert surgeons. For more than 10 years, we've provided quality care for our patients while paving the way for future medical innovations. Since the practice was formed in 1995, our surgeons have performed countless procedures. You can feel confident that our physicians have the experience needed to provide patients with the best possible care. And now, many of these surgeries can be performed using minimally-invasive techniques. This benefits patients in many ways - smaller scars, less bleeding, less pain and quicker recovery.

Overview

Obesity is defined as a "life-long progressive, life-threatening, costly, genetically related, multi-factorial disease of excess fat storage." Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Overweight and obese individuals are at increased risk for type 2 diabetes, heart disease, hypertension, stroke, obstructive sleep apnea, respiratory problems, gallbladder disease, osteoarthritis, endometrial, breast, prostate, & colon cancers, poor female reproductive health, & depression. Obesity is estimated to lead to 400,000 deaths annually. Diet and exercise only works for 1 in 20 people. Gastrointestinal surgery is the best option for people who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems. The surgery promotes weight loss by restricting food intake and, in some operations, interrupting the digestive process. As in other treatments for obesity, the best results are achieved with healthy eating behaviors and regular physical activity.

People who may consider gastrointestinal surgery include those with a body mass index (BMI) above 40—about 100 pounds overweight for men and 80 pounds for women (see table 1 for a BMI conversion chart). People with a BMI between 35 and 40 who suffer from type 2 diabetes or life-threatening cardiopulmonary problems such as severe sleep apnea or obesity-related heart disease may also be candidates for surgery.

Table 1: Body Mass Index

Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. Then look to find your weight group.

Body Mass Index (BMI)

BMI =	weight (kg)
	height (m)²

World Health Organization Classification	BMI
Ideal weight	20-24.9
Overweight	25-29.9
Moderate obesity (class I)	30-34.9
Severe obesity (class II)	35-39.9
Morbid obesity (class III)	40-49.9
(Super obesity)	50+

U.S. Obesity Prevalence

The concept of gastrointestinal surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine. Because patients undergoing these procedures tended to lose weight after surgery, some physicians began to use such operations to treat severe obesity. The first operation that was widely used for severe obesity was the intestinal bypass. This operation, first used 40 years ago, produced weight loss by causing malabsorption. The idea was that patients could eat large amounts of food, which would be poorly digested or passed along too fast for the body to absorb many calories. The problem with this surgery was that it caused a loss of essential nutrients and its side effects were unpredictable and sometimes fatal. The original form of the intestinal bypass operation is no longer used.

The Normal Digestive Process

Normally, as food moves along the digestive tract, digestive juices and enzymes digest and absorb calories and nutrients (see figure 1). After we chew and swallow our food, it moves down the esophagus to the stomach, where a strong acid continues the digestive process. The stomach can hold about 3 pints of food at one time. When the stomach contents move to the duodenum, the first segment of the small intestine, bile and pancreatic juice speed up digestion. Most of the iron and calcium in the foods we eat is absorbed in the duodenum. The jejunum and ileum, the remaining two segments of the nearly 20 feet of small intestine, complete the absorption of almost all calories and nutrients. The food particles that cannot be digested in the small intestine are stored in the large intestine until eliminated.

How Does Surgery Promote Weight Loss?

Gastrointestinal surgery for obesity, also called bariatric surgery, alters the digestive process. The operations promote weight loss by closing off parts of the stomach to make it smaller. Operations that only reduce stomach size are known as "restrictive operations" because they restrict the amount of food the stomach can hold.

Some operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as malabsorptive operations.

What Are the Surgical Options?

There are several types of restrictive and malabsorptive operations. Each one carries its own benefits and risks.

Restrictive Operations

Restrictive operations serve only to restrict food intake and do not interfere with the normal digestive process. To perform the surgery, doctors create a small pouch at the top of the stomach where food enters from the esophagus. Initially, the pouch holds about 1 ounce of food and later expands to 2-3 ounces. The lower outlet of the pouch usually has a diameter of only about ¾ inch. This small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only ¾ to 1 cup of food without discomfort or nausea. Also, food has to be well chewed.

Restrictive operations for obesity include laproscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG).

• Lap Adjustable Gastric Banding. In this procedure, a silastic band with an inner balloon is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach (figure 2). The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution. If needed, the band can be removed and the surgery reversed.

• Vertical Banded Gastroplasty. VBG has been the most common restrictive operation for weight control. As figure 3 illustrates, both a band and staples are used to create a small stomach pouch.

Although restrictive operations lead to weight loss in almost all patients, they are less successful than malabsorptive operations in achieving substantial, long-term weight loss. About 30 percent of those who undergo VBG achieve normal weight, and about 80 percent achieve some degree of weight loss. Some patients regain weight. Others are unable to adjust their eating habits and fail to lose the desired weight. Successful results depend on the patient's willingness to adopt a long-term plan of healthy eating and regular physical activity.

Restrictive Procedures
Weight Loss Related To:
Surgery Factors	Patient Factors
Meal size restriction	Caloric intake
	Caloric expenditure

A common risk of restrictive operations is vomiting, which is caused when the small stomach is overly stretched by food particles that have not been chewed well. Band slippage, erosion, and saline leakage have been reported after AGB. Risks of VBG include wearing away of the band and breakdown of the staple line. In a small number of cases, stomach juices may leak into the abdomen, requiring an emergency operation. In less than 1 percent of all cases, infection or death from complications may occur.

Malabsorptive Operations

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

• Biliopancreatic Diversion (BPD). In this more complicated malabsorptive operation, portions of the stomach are removed (see figure 4). The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure successfully promotes weight loss, it is less frequently used than other types of surgery because of the high risk for nutritional deficiencies. A variation of BPD includes a "duodenal switch" (see figure 5), which leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway.

Malabsorptive operations produce more weight loss than restrictive operations, 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 2 years.

In addition to the risks of restrictive surgeries, malabsorptive operations also carry greater risk for nutritional deficiencies. This is because the procedure causes food to bypass the duodenum and jejunum, where most iron and calcium are absorbed. Menstruating women may develop anemia because not enough vitamin B12 and iron are absorbed. Decreased absorption of calcium may also bring on osteoporosis and metabolic bone disease. Patients are required to take nutritional supplements that usually prevent these deficiencies. Patients who have the biliopancreatic diversion surgery must also take fat-soluble (dissolved by fat) vitamins A, D, E, and K supplements.

Combined Procedures (Restrictive & Malabsorptive Operations)

• Roux-en-Y Gastric Bypass (RYGB). This operation, illustrated in figure 6, is the most common and successful surgical procedure for long-term weight loss. First, a small portion of the upper stomach is used to create a "pouch" which now acts as the stomach reservoir. This restricts food intake. Next, a portion of small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (first segment of the small intestine) and the first portion of the jejunum (second segment of the small intestine). This bypass reduces the amount of calories and nutrients the body absorbs.

The RYGB is considered the "gold standard" of weight loss surgery. Two years after surgery, 75% of patients have lost excess weight. In addition, 50% of patients maintain weight loss 10 years after the procedure.

RYGB
Weight Loss Related To:
Surgery Factors	Patient Factors
Meal size restriction	Caloric intake
Some malabsorption	Caloric expenditure
Decreased appetite

Surgical complications after gastric bypass surgery are related to technique as well as underlying patient disease. Intestinal leakage, acute gastric remnant dilation, obstruction, as well as cardiopulmonary complications such as heart attacks, pulmonary embolus (blood clot to the lung), and pneumonia may occur. The mortality rate after RYGB is 0.5%.

Long-term complications for malabsorptive or combined procedures include weight regain, anemia, and vitamin/mineral deficiency. Short-term complications include hair loss, kidney stones, nausea and vomiting, gallstones, internal hernias and bowel obstruction, and peripheral neuropathy.

RGB and BPD operations may also cause "dumping syndrome." This means that stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and sometimes diarrhea after eating. Because the duodenal switch operation keeps the pyloric valve intact, it may reduce the likelihood of dumping syndrome.

The more extensive the bypass, the greater the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require close monitoring and life-long use of special foods, supplements, and medications. The mortality rate with the Biliopancreatic Diversion (BPD) is the highest of any bariatric procedure at 1.1%.

How Are Outcomes Measured?

Weight Loss
% of Excess Body Weight (EBW) lost
EBW = Actual weight - Ideal weight
BMI before and after
Improvement in obesity related co-morbidities
Quality of life improvement

Laparoscopic Bariatric Surgery

Laparoscopic surgery utilizes a camera and long slender instruments placed within the abdomen to perform a particular operation. It is a means of access to the abdomen. This is in contrast to the traditional open incision, which is usually a large cut down the middle of the abdomen.

Because of the smaller incisions used with laparoscopic surgery, postoperative pain is less. Patients are also able to get up and ambulate faster since they have less pain and are most often able to go home from the hospital sooner. In addition, with the smaller incisions, the body perceives less injury and less stress hormones are released that can be detrimental to healing.

Mortality and complication rates are the same or better with laparoscopic surgery. The incidence of wound infections and hernias after laparoscopic surgery is neglible. This is in comparison to open surgery with hernia rates as high as 20% and wound infections of 13%. There is also a decrease in adhesion formation with less risk of bowel obstruction in the future with laparoscopic surgery.

Laparoscopic bariatric surgery provides comparable weight loss and similar resolution of co-morbidities to the traditional open surgery. The leak rate (< 1%) and risk of pulmonary embolus (0.5-1%) are equivalent. Whenever an operation is attempted laparoscopically there is always a risk of not being able to complete the procedure with the camera and the open incision may need to be made. The risk of conversion to the open method is approximately 10% depending of the patient's prior surgical history. The surgery is still completed at that time during the same anesthesia and the recovery would be expected to be similar to the open method.

Explore Benefits and Risks

Surgery to produce weight loss is a serious undertaking. Anyone thinking about surgery should understand what the operation involves. Patients and physicians should carefully consider the following benefits and risks:

Benefits

Right after surgery, most patients lose weight quickly and continue to lose for 18 to 24 months after the procedure. Although most patients regain 5 to 10 percent of the weight they lost, many maintain a long-term weight loss of about 100 pounds.

Co-Morbidities Resolved/Improved

Surgery improves most obesity-related conditions. For example, in one study blood sugar levels of 83 percent of obese patients with diabetes returned to normal after surgery. Nearly all patients whose blood sugar levels did not return to normal were older or had lived with diabetes for a long time.

Risks

Ten to 20 percent of patients who have weight-loss surgery require follow-up operations to correct complications. Abdominal hernia was the most common complication requiring follow-up surgery, but laparoscopic techniques seem to have solved this problem. Less common complications include breakdown of the staple line and stretched stomach outlets. Bloot clots and risk of pulmonary embolism are possible but rare (<1%). Pulmonary embolus is the most common cause of death after bariatric surgery.

Some obese patients who have weight-loss surgery develop gallstones. Gallstones are clumps of cholesterol and other matter that form in the gallbladder. During rapid or substantial weight loss, a person's risk of developing gallstones increases. Taking supplemental bile salts for the first 6 months after surgery can prevent gallstones. Nearly 30 percent of patients who have weight-loss surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies usually can be avoided if vitamin and mineral intakes are high enough. Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus; this is usually about 2 years.

Is the Surgery for You?

Gastrointestinal surgery may be the next step for people who remain severely obese after trying nonsurgical approaches. Candidates for surgery:

BMI of 40 or more
Life-threatening obesity-related health problem such as diabetes, severe sleep apnea, or heart disease and a BMI of 35 or more
Obesity-related physical problems that interfere with employment, walking, or family function.
No endocrine cause of obesity
Absense of drug or alcohol problems
Nonsmoker
No uncontrolled psychological conditions
Dedicated to life-style change and follow-up

If you fit the profile for surgery, answers to the following questions may help you decide whether weight-loss surgery is appropriate for you.

Are you:

unlikely to lose weight successfully with nonsurgical measures, including medically supervised programs?
well informed about the surgical procedures and the effects of treatment?
determined to lose weight and improve your health?
aware of how your life may change after the operation (adjustment to the side effects of the surgery, including the need to chew well and inability to eat large meals)?
aware of the potential for serious complications, dietary restrictions, and occasional failures?
committed to lifelong medical follow-up?

Remember: Not every sufferer is a candidate for surgery. Bariatric surgery is an elective operation and the benefits of surgery must outweigh the potential risks of surgery. There are no guarantees for any method, including surgery, to produce and maintain weight loss. Once the decision has been made to pursue surgery, treatment does not end with the operation. That is merely the beginning. Success is possible only with maximum cooperation and commitment to behavioral change and medical follow-up—and this cooperation and commitment must be carried out for the rest of your life.

The Next Step

Once your decision has been made to pursue surgical intervention for long-term weight loss and your medical doctors have deemed it safe you will need to be evaluated by the Bariatric team. A detailed and extensive medical and diet history as well as physical examination will be performed. There may be several tests that will need to be done in order to assess your surgical risks for complications. These may include but are not limited to Echocardiography, Stress tests, pulmonary function studies, sleep apnea studies, and endoscopy. A psychological evaluation and dietary consultation is required of all surgical candidates. In addition, you will meet with your surgeon for a comprehensive discussion of which surgery would be most appropriate for you. There will also be classes and support group meetings to attend in preparation for surgery.