Which procedure to choose

Dr Atalla has extensive training and experience in a variety of laparoscopic bariatric procedures as well as general surgery.  He will be happy to help you select the right procedure to suit your needs and your desired outcome, whilst taking into consideration any other medical issues you may have.

Sleeve Gastrectomy

The Procedure

Gastric sleeve surgery is a restrictive type of procedure that permanently reduces the size of the stomach, thereby limiting food intake as well as the sensation of hunger. The remaining stomach is a tubular pouch that resembles a banana. It works through several mechanisms:

  1. The smaller volume new stomach pouch (average 150-200mls) holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed each time (you will feel full and satisfied after a small meal).
  2. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger and satiety maintaining the fullness sensation longer (feel full for most of the day after meals).

Short term studies show that the sleeve is as effective as the gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

Sleeve Gastrectomy

Advantages

  1. Restricts the amount of food the stomach can hold
  2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. 
  3. Requires no foreign objects as in gastric band and no bypass or re-routing of the food stream 
  4. Involves a relatively short hospital stay of approximately 1-2 days
  5. Causes favourable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages

  1. Is a non-reversible procedure
  2. Has the potential for long-term vitamin deficiencies
  3. Has a higher early complication rate than gastric band

Gastric Bypass: Roux-en-Y

The Procedure

The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard’ of weight loss surgery.

There are two components to the procedure. First, small stomach pouch is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach will eventually mix with the food. 

The gastric bypass works through several mechanisms. Firstly, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, therefore, there is, to some degree, less absorption of calories and nutrients. 

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Gastric Bypass

Advantages

  1. Produces significant long-term weight loss (60 to 80 percent excess weight loss)
  2. Restricts the amount of food that can be consumed
  3. Produces favourable changes in gut hormones that reduce appetite and enhance satiety
  4. Typical maintenance of >50% excess weight loss

Disadvantages

  1. Is technically a more complex operation and potentially could result in greater complication rates
  2. Can lead to long-term vitamin deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
  3. Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

Gastric Bypass: Single Anastomosis/mini/omega loop

The Procedure

The procedure works both by restricting the amount of food that can be eaten at any one time, and altering gut hormones involved in appetite control.  MGBP was first used in the late 1960s but abandoned in the 1970s.  Today, because of developments in laparoscopic (“keyhole”) surgery, MGBP has started to come back into fashion and is being promoted as a quick and effective alternative to standard gastric bypass. 

A longer thinner gastric pouch which is similar to a sleeve gastrectomy, however, the small bowel is attached to the bottom of the sleeve.  This bypasses about 1.5-2.5 metres of the small bowel. This operation is extremely good for diabetic patients.

Gastric Bypass – Single

Adjustable Gastric Band

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band.

The Procedure

The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.

Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

Gastric Band

Advantages

  1. Reduces the amount of food the stomach can hold
  2. Induces excess weight loss of approximately 40 – 50 percent
  3. Involves no cutting of the stomach or rerouting of the intestines
  4. Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
  5. Is reversible and adjustable
  6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
  7. Has the lowest risk for vitamin/mineral deficiencies

Disadvantages

  1. Slower and less early weight loss than other surgical procedures
  2. Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed
  3. Requires a foreign device to remain in the body
  4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients
  5. Can have mechanical problems with the band, tube or port in a small percentage of patients
  6. Can result in dilation of the esophagus if the patient overeats
  7. Requires strict adherence to the postoperative diet and to postoperative follow-up visits
  8. Highest rate of re-operation

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)

The Biliopancreatic Diversion with Duodenal Switch – abbreviated as BPD/DS – is a procedure with two components. First, a smaller, tubular stomach pouch is created by removing a portion of the stomach, very similar to the sleeve gastrectomy. Next, a large portion of the small intestine is bypassed.

The Procedure

The duodenum, or the first portion of the small intestine, is divided just past the outlet of the stomach. A segment of the distal (last portion) 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 a newly created tubular stomach pouch and empties directly into the last segment of the small intestine. Roughly three-fourths of the small intestine is bypassed by the food stream.

The bypassed small intestine, which carries the bile and pancreatic enzymes that are necessary for the breakdown and absorption of protein and fat, is reconnected to the last portion of the small intestine so that they can eventually mix with the food stream. Similar to the other surgeries described above, the BPD/DS initially helps to reduce the amount of food that is consumed; however, over time this effect lessens and patients are able to eventually consume near “normal” amounts of food. Unlike the other procedures, there is a significant amount of small bowel that is bypassed by the food stream.

Additionally, the food does not mix with the bile and pancreatic enzymes until very far down the small intestine. This results in a significant decrease in the absorption of calories and nutrients (particularly protein and fat) as well as nutrients and vitamins dependent on fat for absorption (fat soluble vitamins and nutrients). Lastly, the BPD/DS, similar to the gastric bypass and sleeve gastrectomy, affects guts hormones in a manner that impacts hunger and satiety as well as blood sugar control. The BPD/DS is considered to be the most effective surgery for the treatment of diabetes among those that are described here.

Duodenal Switch

Advantages

  1. Results in greater weight loss than RYGB, LSG, or AGB, i.e. 60 – 70% percent excess weight loss or greater, at 5 year follow up
  2. Allows patients to eventually eat near “normal” meals
  3. Reduces the absorption of fat by 70 percent or more
  4. Causes favourable changes in gut hormones to reduce appetite and improve satiety
  5. Is the most effective against diabetes compared to RYGB, LSG, and AGB

Disadvantages

  1. Has higher complication rates and risk for mortality than the AGB, LSG, and RYGB
  2. Requires a longer hospital stay than the AGB or LSG
  3. Has a greater potential to cause protein deficiencies and long-term deficiencies in a number of vitamin and minerals, i.e. iron, calcium, zinc, fat-soluble vitamins such as vitamin D
  4. Compliance with follow-up visits and care and strict adherence to dietary and vitamin supplementation guidelines are critical to avoiding serious complications from protein and certain vitamin deficiencies

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