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Roux-en-Y Gastric Bypass

The Roux en-Y Gastric Bypass has long been considered the “gold standard” for obesity surgery; all other procedures are compared to this when establishing their effectiveness. It is primarily a “restrictive” procedure with some, minimal, malabsorption of digested food.

This operation accomplishes weight loss through satiety (fullness), achieved by creating a one to two ounce pouch out of the old stomach. The small intestine is divided some 70 to 90 cm downstream from the stomach, and is reconnected to the stomach with a double-stapled anastomosis, which is buttressed with additional sutures. The other end of the bowel is reconnected to itself at a point approximately 75 cm downstream via a stapled connection. Food flows from point-to-point, where it mixes with digestive enzymes from the stomach, small bowel, liver, and pancreas. These enzymes then work to break down food for digestion. The real key to weight loss is in the radically-reduced volumes of food that can be eaten at any one meal. All of this is accomplished with very rare, if ever, sensations of hunger during the first 6 to 12 months after surgery.

The result is a very early sense of fullness, followed by a very profound sense of appetite satisfaction, with the most minimal meal volumes. Most patients are full on one to two ounce meal portions originally. After six months, they are satisfied with three to five ounce servings—still quite small. Even though the portion size may be small, there is rarely hunger, and no feeling of having been deprived. When truly satisfied, you feel indifferent to even the choicest of foods. Patients continue to enjoy eating – but they enjoy eating less volume.

The Gastric Bypass provides an excellent tool for gaining long-term control of weight. Now, without the hunger or craving usually associated with small portions or with dieting, it is entirely normal for patients to lose 75-100% of their excess weight… often as early as the first anniversary after surgery. Long-term success is dependent on accepting new rules for eating and food selection that will be taught in the pre-operative and follow-up periods, before and after surgery. Your new-found energy levels and activity interests will lead to increased planned exercise and a more active lifestyle.

We perform this procedure as a minimally-invasive (laparoscopic) procedure—small incisions to allow access to the abdominal cavity though inserted tubes. On very rare occasions, a planned laparoscopic procedure will have to be converted to an “open” procedure, for safety reasons. Both approaches have similar risks and complications; both have excellent long-term success potential. We have performed over 1500 such procedures and our conversion to open rate in our last 500 cases is far less than 1/2%!

Laparoscopic Adjustable Gastric Banding (Lap-Band® and Realize ® Band):

Gastric Banding is a variation on the banded gastroplasty, in which the stomach is neither opened nor stapled—a band is placed around the outside of the upper stomach, and creates an hourglass-shaped stomach. It also produces a narrow, controlled and adjustable outlet that allows for management of the rate at which food travels from the upper to the lower stomach. Patients are satisfied with smaller meals that easily fill the small upper stomach. The Band constriction causes food to slowly pass through the outlet and maintain stretch on the upper pouch – leading to a prolonged sense of fullness and lack of hunger. The Band is made of a non-reactive, durable elastomer that can be surgically implanted during a relatively short laparoscopic procedure (less than an hour, on average). The inflation port, which is placed under the skin below the patient’s ribs, allows for periodic adjustments to the volume of the outlet; making it tighter, if weight loss is too slow, or looser, if weight loss is too fast. These adjustments can almost always be done in our office, without the need for anaesthetic, and with the utmost of safety.

Advantages of the Band are:

• It can virtually always be inserted laparoscopically, without a large, open incision.
• It does not require any opening in the gastrointestinal tract, so infection risk is reduced.
• There are no staple lines to come apart. It is adjustable. If necessary, it is reversible (the Band can be removed).
• The Band devices (Lap-Band® and Realize ® Band) have now been approved by the Food and Drug Administration (FDA) for use in the United States. One-hundred thousand have been implanted here and abroad, and the track record of safety is well-established.
• This procedure may be particularly suited to persons who may wish to have a quicker recovery, less surgical-related risk, and the ability to undergo a surgical procedure with a slower (less “obvious”) weight-loss. Most can return to work quickly, and dietary changes are less obvious. Although the results may not be as profound or rapid as the gastric bypass, the risks of the procedure are less, and the recovery time is the shortest. (Note: in our program, the absolute difference in weight loss is only about 10% between the two procedures.)
• The Band is also an excellent tool in the treatment of morbid obesity. In the latest study out of the journal of Obesity Surgery (Rubenstein, 2002), the average weight loss, with the Lap-Band®, at three years was approximately 54%, range: 21-94%. The resolution of comorbidities (weight-related illness and injury) in the same interval was similar to the Gastric Bypass procedure. (Note: in our program, we are seeing these results in 1 year—about 3x as fast!!)

What is the difference between the Lap-Band® and Realize® Band?

This is a question that we are going to be seeing a lot of as the Realize® Band has recently been FDA approved (2008) and the Lap-Band® was approved about 4 years earlier. The powerhouse companies that make these bands (Ethicon for Realize® Band and Allergan for Lap-Band®) have a big investment in their success and the marketing and advertising is going to catch fire in June 2008. I think both are reasonable options if you are considering a Band. Both have essentially the same benefits and limitations for the patients. There ARE some differences in placement and surgical decision-making. But, these have minimal impact on the patient. First, you need to understand the differences. The Lap-Band® is a restrictive device that utilizes a “high-pressure” restrictive mechanism. The pressure at the band is what restricts food from passing through it. The Realize® Band utilizes a “low-pressure” system that relies on the length of the channel through which the food passes and “lower” restriction pressures on the stomach. And… no one has ever shown me that the outcomes or complication rate is lower with either. But, watch the marketing machine on this!

As of June 2008, I am considering both as viable options. But, to fully disclose to you my personal biases, I have done over 700 Lap-Band® procedures and am just starting to use the Realize® Band in a “study” fashion. I work closely with Allergan, the company that makes the Lap-Band® and train surgeons for them. In addition, I am on their Regional Advisory Board. All of this aside, I believe that in the long run BOTH are reasonable options for those who desire a Band procedure.

 

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