OBESITY SURGERY

The Center for Obesity Surgery has been performing obesity surgery since 1983 with over 3000 cases successfully completed to date. Our results have been excellent. There have been remarkable advances in obesity surgery during the last few years and we are very proud to have contributed to some of them. The operations are very safe and effective.

There are several types of operations done in this country to treat obesity. They can be classified into three types: restrictive, malabsorptive and a combination of restrictive and malabsorptive.

In 1991 the National Institutes of Health held a consensus conference on surgery for obesity and recommended the Vertical Banded Gastroplasty, (VBG), and the Roux-en Y Gastric Bypass (Roux-en Y) for the treatment of severe obesity. At the Center for Obesity Surgery the primary procedure is the Roux-en Y which experience shows has the best results and least post-operative complications.

The Roux-EN-Y Gastric Bypass is a restrictive procedure combined with a modified gastric bypass that moderately limits calorie and nutrient absorption and may lead to altered food choices. The Roux-en Y works by decreasing food intake, limiting the amount of food the stomach can hold by closing off a significant portion of the stomach and delaying the emptying of the stomach (gastric pouch).

ROUX-EN-Y GASTRIC BYPASS

In this operation the stomach is divided into two compartments with several rows of titanium staples. The newly created stomach pouch is measured at less than 30 cc's. The small intestine is then divided in the proximal jejunum and the lower end brought up and joined to the new small stomach compartment. The pouch initially holds about 1 ounce of food and expands to 2-3 ounces with time. The pouch's lower outlet usually has a diameter of about 1/2-inch. The small outlet delays the emptying of food from the pouch and causes a feeling of fullness. After an operation, the person usually can eat only 5 to 10 bites of food before feeling full. With time, the capacity may increase to half to a whole cup of food that may be consumed without discomfort or nausea. Food has to be well chewed. For most people, the ability to eat a large amount of food at one time is lost, and some of the food consumed will not be absorbed due to the bypass segment of the operation.

They are more interested in lighter and healthier food. Most patients report that their tastes change after surgery. Many patients experience the "dumping syndrome" in which foods; usually those high in fat and/or sugar are not well tolerated. In the dumping syndrome stomach contents move too rapidly through the small intestine. Symptoms include nausea, weakness, sweating, faintness, and, occasionally, diarrhea after eating these foods. Patients find that this negative incentive helps them to eliminate high caloric foods and sweets from their diets.

At the Center for Obesity Surgery we recommend the Proximal Roux-En-Y gastric Bypass and we do it through a small midline incision (mini-lap), 4-5 inches, and the skin is closed with sutures under the skin (plastic surgery closure).

In our opinion, based on 21 years of experience this operation optimizes safety and effectiveness of the proximal Roux-En-Y Gastric Bypass through:

1. Excellent cosmetic result (small incision)
2. Short operating time (Average 1.5 hours)
3. Short hospital stay (Average 2 days)
4. Less pain (Use of narcotics 2-3 days)
5. Fast recovery (Back to work in 10-12 days)
6. Safety (less complication rate)

ADVANTAGES

• Greatly controls food intake
• Dumping syndrome - eliminates high calorie foods and sweets from diet
• Decrease appetite
• Limit Caloric Absorption
• Reversible in an emergency - though this procedure should be thought of as permanent

DISADVANTAGES

• Staple line failure (Less than 5%)
• Narrowing/blockage of the stomach (Less than 1%)
• Vomiting if food is not properly chewed or if food is eaten too quickly

Other less common procedures include

ADJUSTABLE GASTRIC BANDING (AGB)

In this procedure, a silicone band is placed around the upper part of the stomach to create a small stomach pouch, which can hold only a small amount of food. The lower, larger part of the stomach is below the band. These two parts are connected by a small outlet created by the band. Food will pass from the upper stomach pouch to the lower part more slowly, and one will feel full longer. The diameter of the band outlet is adjustable.

ADVANTAGES

• Simple
• Short recovery period
• Major complication rate is low
• No altering of the natural anatomy

DISADVANTAGES

• Patient non-compliance causes high failure rate
• Complications include :
  • Balloon leakage
  • Band erosion/migration
  • Deep infection
  • Identifying patients who will not "eat through" the operation is difficult
  • Weight loss is 15-25% less than Roux-En-Y Gastric Bypass

VERTICAL BANDED GASTROPLASTY (VGB)

This, along with the RNY, is one of the two major types of operations recognized by the NIH for the treatment of clinically severe obesity. It is a purely restrictive procedure with no malabsorptive effect. The goal of this procedure is to severely restrict the patient's capacity to eat certain foods.

ADVANTAGES

• Completely reversible
• No dumping syndrome
• No nutritional deficiencies

DISADVANTAGES

• Needs strict patient compliance to diet
• No malabsorbtion
• Vomiting if food is not properly chewed or if food is eaten too quickly
• Conversion to RYGB is common
• Weight loss is 15-20% less than the Roux-En-Y Gastric Bypass

DUODENAL SWITCH - DS

There is a significant malabsorptive component that acts to maintain weight loss long term. The patient must be closely monitored to guard against severe nutritional deficiencies. This procedure, unlike the Bilio Pancreatic Diversion, keeps the pyloric valve intact. That is the main difference between the BPD and the DS.

ADVANTAGES

• More "normal" absorption of many nutrients than with BPD, including calcium, iron and vitamin B12
• Better eating quality when compared to other WLS procedures.
• Eliminates or greatly minimizes most negative side effects of the original BPD
• Essentially eliminates stomal ulcer and dumping syndrome

DISADVANTAGES

• Greater chance of chronic diarrhea
• Significant malabsorptive component
• More foul smelling stools and flatus but less than with the BPD alone
• High risk of nutritional deficiencies.

BILIOPANCREATIC DIVERSION (SCOPINARO PROCEDURE) BPD

This procedure is less food restrictive than the RNY. The stomach capacity is 8-10 ounces compared with RNY of around an ounce. There is a significant malabsorptive component, which acts to maintain weight loss long term. The patient must be closely monitored to guard against severe nutritional deficiencies.

ADVANTAGES

• Significant malabsorptive component
• Better chance of sustained weight loss
• Ability to eat larger quantities of food and still lose weight

DISADVANTAGES

• Greater chance of chronic diarrhea, stomal ulcers, more foul smelling stools and flatus
• Higher risk of nutritional deficiencies
• Higher chance of micronutrient deficiencies such as vitamins and calcium

THE LAP-BAND SYSTEM

A silicone band is placed around the upper part of the stomach. From this a small pouch is created making the stomach hold less food and including the feeling of satiety.

ADVANTAGES

• 10 x safer than Gastric Bypass
• Adjustable - customized per patient
• Least invasive option
• No stomach stapling, cutting or interstinal rerouting
• Reversible
• Lowest operative complication rate - no leaks
• Low malnutrition risk
• Satiety-including procedure
• OR time = 1 hour or less
• Overnight hospital stay in most cases

RISKS

As with any major abdominal surgery there are potential risks. These risks can be further complicated in operations on severely obese patients. It is important that you consider these potential risks, and discuss them with Dr. Afram and your own physician, when deciding whether to have surgery. Potential surgical risks include possible respiratory problems, infections, bleeding, bowel obstruction, leakage of the bowel connections, and obstruction of the stomach outlet. After performing over 3000 gastric bypass operations, Dr. Afram and his team have developed successful strategies for minimizing any potential risks.

POTENTIAL SIDE EFFECTS OF THE SURGERY

Due to the physical changes caused by the gastric bypass surgery, there are potential side effects that result from the surgery and your new way of eating. Due to restricted eating, there is a potential for deficiencies in protein, as well as certain vitamins and minerals. Use of an over-the-counter multivitamin, fortified with iron and calcium, and other nutritional supplements, determined on an individual basis, can help mitigate this risk.

Some patients experience nausea, food intolerance, changed bowel habits, transient hair loss, and loss of muscle mass. It is important to note that not all patients experience these side effects and these side effects are usually transitory. If you experience any of these post-operative side effects, Dr. Afram and the nutritionist are available for immediate consultation.

Gall bladder disease is a potential side effect due to the rapid weight loss most patients experience after the surgery. To minimize this risk Dr. Afram may prescribe medication, taken regularly for several months after surgery.

A word about pregnancy.

Infertility can be a significant co-morbidity for severely obese women. Many obese women experience irregular or non-existent menstrual cycles. Surgery for obesity often corrects these problems. Due to the increased nutritional needs of pregnancy, we recommend that patients not get pregnant for at least one to two years after surgery, when the initial rapid weight loss subsides. Patients should discuss birth control methods with their primary care physician or obstetrician/gynecologist. After the initial year, pregnancy is safe and many patients, who had suffered from infertility prior to surgery, have delivered healthy babies.

RESULTS

Most of our patients are very satisfied with the results of their operation. Overwhelmingly, patients have found that they lose 50 to 90 percent of their excess weight, and maintain that weight loss long-term.

Maximum effectiveness depends on the level of patient participation in the behavioral modification and nutritional programs, as well as an increase in physical activities and exercise on a regular basis. Other factors, such as age, sex, and initial weight at the time of surgery should also be considered. Weight loss surgery is not a magic bullet. It is, however, a powerful tool that has successfully helped many people achieve and maintain permanent weight loss. Your active participation in, and commitment to, the life style changes, exercise, and eating habits that weight loss surgery requires is a necessary component to your ultimate success.

Most medical diseases are improved or cured. Obesity related diseases are improved dramatically.

• High Blood Pressure can be often alleviated or eliminated by weight loss surgery
• High Blood Cholesterol in 80% of the patients can be alleviated or eliminated and in as little as 2-3 months post-operatively
• Heart Disease in obese individuals is certainly more likely to be experienced when compared to persons who are of average weight and adhere to a strict diet and exercise regimen. There is no hard and fast statistical data to definitively prove that weight loss surgery reduces the risk of cardiovascular disease, however, common sense would dictate that if we can significantly reduce many of the co-morbidities that we experienced as someone that is obese, we can likewise that our health may be much improved if not totally restored.
• Diabetes Mellitus can be cured or tremendously improved. Complications can be controlled based on many post gastric bypass studies.
• Abnormal Glucose Tolerance, or "Borderline Diabetes" is even more likely reversed by Gastric Bypass. Since this condition becomes diabetes in many cases, the operation can frequently prevent diabetes as well
• Asthma sufferers may find that they have fewer and less severe attacks, or sometimes none at all. When asthma is associated with gastroesophageal reflux disease, it is particularly benefited by gastric bypass.
• Sleep Apnea Syndrome sufferers can receive dramatic effects and many within a year or so of surgery find their symptoms were completely gone and they ever stopped snoring completely!
• Gastroesophageal Reflux Disease can be greatly relieved of all symptoms within as little as a few days of surgery
• Gallbladder Disease can be surgically handled at the time of weight loss surgery if your doctor has cause to believe that gallstones are present.
• Stress Urinary Incontinence responds dramatically to weight loss, usually by becoming completely controlled. A person who is still troubled by incontinence can choose to have specific corrective surgery later, with much greater chance of a successful outcome, with a reduced body weight.
• Low Back Pain and Degererative Disk Disease, and Degenerative Joint Disease can be considerable relieved with weight loss, and greater comfort may be experienced even after as few as 30 pounds are lost.
• Major improvement in the quality of life and improvement in self-esteem and self-confidence.