Treatment of obesity entails weight loss and weight loss maintenance. The co-morbid conditions are resolved or ameliorated with the weight loss and maintenance. Currently, non-surgical treatments are usually effective in inducing weight loss but rarely weight loss maintenance. Weight regain and return of co-morbid conditions are the norm.
Surgery, bariatric surgery, offers the only modality that provides long term weight loss and weight loss maintenance. Surgery is a tool and as such it is very limited at best. Surgical weight loss is based on the principles of decreased caloric intake and/or malabsorption of calories in the gastro-intestinal tract.
FOBI POUCH GASTRIC BYPASS- The Fobi Pouch Gastric Bypass is a modification of an operation, over a hundred years old, now applied to the management of the severe recalcitrant medical problem of obesity. The operation has an operative mortality of less than .02% and significant morbidity of less than 10%. It is 95% effective with greater than 50% excess weight loss that is maintained for more than five years of follow up. Long term related complications are limited to Fat soluble vitamin deficiencies, Calcium, Iron, B12, and Folic Acid deficiencies with the resultant anemia. All of these can either be prevented or corrected. There are occasional problems with frequent vomiting, diarrhea and meat intolerance. The operation is completely reversible if the need does arise.
The Fobi Limiting Proximal Gastric Pouch consists of a less than 30 cc pouch of the proximal stomach on the lesser curvature, a silastic ring around the stomach that functions as a stoma. The band is 5.5 – 6.5 cm long. A gastroenterostomy to a Roux-y limb of the jejunum completes the operation. A gastrostomy tube is placed to decompress the distal stomach perioperatively. The gastrostomy site has a silastic ring marker to facilitate percutaneous radiological evaluation of the distal stomach if the need arises.
The only foreseeable complications from this operation are Vitamin A, D and E, Calcium, Iron, B12 and Folic Acid deficiencies and the associated anemia. These problems are preventable and correctable.
Roux-en-Y Gastric Bypass – This operation has been available for almost 20 years. Designed to allow ingestion of almost any type of food, but limiting in the amount, this operation is conducive to healthy eating habits. In constrast to malabsorbtive procedures, the Roux-en-Y Gastric Bypass does not promote diarrhea, gas problems or malnutrition.
The Roux-en-Y Gastric Bypass is usually performed through an incision 3-4 inches in the upper part of the abdomen. It takes about 90 minutes and hospital stay varies between two and four days. By creation of a small stomach pouch, patients eat less and get "full" faster.
LAPBAND (Banded Gastric Bypass) - Here a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the absorption of nutrients and thereby reduces the calorie intake.
Distal Roux-en-Y Gastric Bypass- This operation is often confused with the Roux-en-Y Gastric Bypass. It is however, much closer to the biliopancreatic diversion. This operation attempts to combine a gastric restrictive and malabsorbtive procedure. A small gastric pouch is formed and over 50% of the small intestine is bypassed. This lends itself to a higher degree of protein-calorie malabsorbtion and marginal ulcer formation than the biliopancreatic diversion. Fortunately, in this case, the stomach pouch will continue to increase in size as long as the patient is encouraged to overeat.
Biliopancreatic diversion with duodenal switch (BPD/DS) – Biliopancreatic diversion with duodenal switch (BPD/DS) is similar to gastric bypass. Instead of a small stomach pouch, the surgeon creates a sleeve-shaped stomach. The surgeon then attaches the final section of the small intestine to the stomach sleeve. The small intestine absorbs calories and nutrients. Bypassing all but the last section of the small intestine ensures that far fewer calories are absorbed.
To learn more about BPD/DS, visit the website of the American Society for Metabolic and Bariatric Surgery (ASMBS).
- Sleeve Gastrectomy – Sleeve gastrectomy is a restrictive bariatric surgery. During this procedure, the surgeon creates a small, sleeve-shaped stomach. It is larger than the stomach pouch created during Roux-en-Y bypass and is about the size of a banana.
Sleeve gastrectomy is typically considered as a treatment option for bariatric surgery patients with a BMI of 60 or higher. It is often performed as the first procedure in a two-part treatment. The second part of the treatment can be gastric bypass.
Co-morbid condition resolution 12 to 24 months after sleeve gastrectomy has been reported in 345 patients. 24 Sleeve gastrectomy patients experienced resolution rates for type 2 diabetes, high blood pressure, high cholesterol, and obstructive sleep apnea that were similar to resolution rates for other restrictive procedures such as gastric banding.