MedStar Health: Bariatric Surgery Center Baltimore

The laparoscopic sleeve gastrectomy, often called the “sleeve,” is performed by removing approximately 80 percent of the stomach. The portion of the stomach that remains is the size and shape of a banana.

How it Works

The procedure limits the stomach’s ability to hold food and liquid, helping reduce the amount of food (and calories) that are consumed. By removing the portion of the stomach that produces most of the “hunger hormone,” the surgery effects metabolism. It decreases hunger, increases fullness, and allows the body to reach and maintain a healthy weight, as well as control blood sugar. The potential for complications in the small intestine is minimal.

Advantages

1. Technically simple procedure requiring only a short amount of time in the operating room
2. Can be performed for certain patients with high-risk medical conditions
3. May be performed as the first step for patients with severe obesity
4. May be used as a bridge to gastric bypass or SADI-S procedures
5. Effective weight loss and improvement of obesity related conditions

Disadvantages

1. Non-reversible procedure
2. May worsen or cause new onset reflux and heart burn
3. Less impact on metabolism compared to bypass procedures

The Roux-en-Y Gastric Bypass, often called the “gastric bypass,” has been performed for more than 50 years, and the laparoscopic approach was refined in 1993. It is one of the most common operations and is very effective in treating obesity and obesity-related diseases. The name is a French term meaning “in the form of a Y.”

The Procedure

1. First, the stomach is divided into a smaller top portion (pouch) which is about the size of an egg. The larger part of the stomach is bypassed and will not be able to store or digest food following the surgery.
2. The small intestine is also divided and connected to the new stomach pouch to allow food to pass. The small bowel segment, which empties the bypassed or larger stomach, is connected into the small bowel approximately 3-4 feet downstream, resulting in a bowel connection resembling the shape of the letter Y.
3. Eventually, the stomach acids and digestive enzymes from the bypassed stomach and first portion of the small intestine will mix with food that is consumed.

How it Works

Like many bariatric procedures, the newly-created stomach pouch is smaller and able to hold less food, which means fewer calories are consumed. Additionally, the food does not come into contact with the first portion of the small bowel and this results in decreased absorption. Most importantly, the modification of the food routed through the gastrointestinal tract has a profound effect to decrease hunger, increase fullness, and allow the body to reach and maintain a healthy weight. The impact on hormones and metabolic health often results in improvement of adult-onset diabetes even before any weight loss occurs. The operation also helps patients with reflux (heart burn) and often the symptoms quickly improve. Along with making appropriate food choices, patients must avoid tobacco products and non-steroidal anti-inflammatory drugs.

Advantages

1. Reliable and long-lasting weight loss approach
2. Effective for remission of obesity-associated conditions
3. Refined and standardized technique

Disadvantages

1. Technically more complex compared to sleeve gastrectomy or gastric band procedures
2. More vitamin and mineral deficiencies than sleeve gastrectomy or gastric banding
3. There is a risk for small bowel complications and obstruction
4. There is a risk of developing ulcers, especially for non-steroidal and anti-inflammatory drug user, and/or tobacco uses
5. May cause “dumping syndrome” (a feeling of sickness after eating or drinking, especially sweets)

The Biliopancreatic Diversion with Duodenal Switch (BPD-DS) begins with creation of a tube-shaped stomach pouch similar to the sleeve gastrectomy. It resembles the gastric bypass, where more of the small intestine is not used.

The Procedure

1. Following creation of the sleeve-like stomach, the first portion of the small intestine is separated from the stomach.
2. A part of the small intestine is then brought up and connected to the outlet of the newly created stomach, so that when the patient eats, the food goes through the sleeve pouch and into the latter part of the small intestine.

How it Works

The smaller stomach, shaped like a banana, allows patients to eat less food. The food stream bypasses approximately 75 percent of the small intestine-the most of any commonly-performed approved procedures. This results in a significant decrease in the absorption of calories and nutrients. Patients must take vitamins and mineral supplements after surgery. The BPD-DS effects intestinal hormones in a manner that reduces hunger, increases fullness, and improves blood sugar control. This procedure is considered to be the most effective approved metabolic operation for the treatment of Type 2 diabetes.

Advantages

1. Among the best surgical procedure for overcoming obesity
2. Affects bowel hormones to result in less hunger and more fullness after eating
3. It is the most effective procedure for treatment of Type 2 diabetes

Disadvantages

1. Has slightly higher complication rates than other procedures
2. Highest malabsorption and greater possibility of vitamins and micro-nutrient deficiencies
3. Reflux and heart burn can develop or get worse
4. Risk of looser and more frequent bowel movements
5. More complex surgery requiring more operative time

The Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy, referred to as the SADI-S, is the most recent procedure to be endorsed by the American Society for Metabolic and Bariatric Surgery. While similar to the BPD-DS, the SADI-S is simpler and takes less time to perform, as there is only one surgical bowel connection.

The Procedure

1. The operation starts the same way as the sleeve gastrectomy, making a smaller tube-shaped stomach.
2. The first part of the small intestine is divided just after the stomach.
3. A loop of intestine is measured several feet from its end and is then connected to the stomach. This is the only intestinal connection performed in this procedure.

How it Works

When the patient eats, food goes through the pouch and directly into the latter portion of the small intestine. The food then mixes with digestive juices from the first part of the small intestine. This allows enough absorption of vitamins and minerals to maintain healthy levels of nutrition. This surgery offers good weight loss along with less hunger, more fullness, blood sugar control, and diabetes improvement.

Advantages

1. Highly-effective for long-term weight loss and remission of Type 2 diabetes
2. Simpler and faster to perform than gastric bypass or BPD-DS
3. Excellent option for a patient who already had a sleeve gastrectomy and is seeking further weight loss

Disadvantages

1. Vitamins and minerals are not absorbed as well as in the sleeve gastrectomy or gastric band
2. Newer operation with only short-term outcome data currently available
3. Potential to worsen or develop new-onset reflux
4. Risk of looser and more frequent bowel movements