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Weight Loss Surgery: An Overview 

Introduction
Weight loss surgery may be recommended for people that are extremely obese and have medical conditions that may improve with weight loss.  Severe obesity is referred to as "morbid obesity" because it is associated with health problems that are considered dangerous and can be deadly.  Type 2 Diabetes, heart attack, heart disease, high cholesterol, sleep apnea, and some types of cancer are associated with morbid obesity. 

Weight loss surgery is not a type of cosmetic surgery and does not surgically remove fat from the body.  Weight loss surgery reduces the size of the stomach to restrict the amount of food that is eaten, re-routes the digestive system to change the way that food is absorbed, or both.  Following weight reduction surgery, a commitment to lifelong healthy eating and exercise is required.  Depending on the type of weight loss surgery, rates of 40% to 85% of excess weight loss may be achieved.  It is possible for health problems to resolve or become more manageable after weight loss is achieved.
 
Candidates
 
Doctors may recommend gastric banding for people with:
• Body Mass Index (BMI) of 40 or more
• Body Mass Index of 35 or more and a serious medical condition that might improve with weight reduction, such as type 2 diabetes, heart disease, high blood pressure, arthritis, or sleep apnea.
 
Candidates should not smoke or be dependent on drugs or alcohol.  Candidates should be mentally stable.

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Anatomy
When you eat, your tongue moves chewed food to the back of your throat.  When you swallow, the food moves into the opening of the esophagus.  Your esophagus is a tube that moves food from your throat to your stomach.  Muscles in your esophagus wall slowly squeeze the food toward your stomach. 

A ring of muscles is located at the bottom of the esophagus.  It is called the lower esophageal sphincter (LES).  The LES opens to allow food to enter the stomach.  The LES closes tightly after the food enters.  This prevents stomach contents and acids from backing up into the esophagus.  The esophagus does not secrete mucus that protects it from stomach acids. 

The stomach secretes mucus to protect the lining of the stomach from the acids.  Your stomach produces acids to break down food for digestion.  Your stomach processes the food you eat into a liquid form.  The processed liquid travels from your stomach through the pyloric valve to your small intestine.

The small intestine is a tube that is about 20-22 feet long and 1 ½ to 2 inches around.  The duodenum is the first part of the small intestine.  It is a short C-shaped structure that extends off the stomach.  The jejunum and the ileum are the middle and final sections of the small intestine.

Your gallbladder works with your liver and pancreas to send bile and digestive enzymes to the first part of your small intestine.  Your small intestine uses these digestive products to break down the liquid from your stomach even further so your body can absorb the nutrients from the food that you ate.  The remaining waste products from the small intestine travel to the large intestine.

Your large intestine, also called the large bowel or colon, is a tube that is about 5 feet long and 3 or 4 inches around.  The lower GI tract is divided into sections, including the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, anal canal, and anus.  The appendix is located on the cecum, but it does not serve a purpose in the digestive process. 
 
The first part of the colon absorbs water and nutrients from the waste products that come from the small intestine.  As the colon absorbs water from the waste product, the product becomes more solid and forms a stool.  The large intestine moves the stool into the sigmoid colon, where it may be stored before being traveling to the rectum.  The rectum is the final 6-inch section of your digestive tract.  No significant nutrient absorption occurs in the rectum or anal canal.  From the rectum, the stool moves through the anal canal.  It passes out of your body through your anus when you have a bowel movement.

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Treatment
Laparoscopic Gastric Banding

Laparoscopic gastric banding reduces the size of the stomach.  Individuals lose weight because laparoscopic gastric banding restricts the amount of food that they eat.  Some types of bands are adjustable and can change the stomach size after surgery.
 
Laparoscopic gastric banding surgery is less complicated and safer than other types of weight loss surgeries.  The surgery is reversible by removing the band.  Gastric banding is a restrictive type of weight loss surgery.
 
The Procedure

There are a few types of gastric banding procedures, but for many, laparoscopic surgery methods are preferred over open surgeries. A laparoscope is a thin viewing instrument that guides the surgeon during surgery.  During surgery, the surgeon inserts the laparoscope and thin surgical instruments through several small incisions. 
 
During laparoscopic gastric banding, the surgeon places a band around the stomach.  Filling the band with saline solution divides the stomach into two parts.  One part, the new stomach, is a small pouch about the size of an egg. 
Following laparoscopic gastric banding, the food content in the pouch empties slowly into the larger section of the stomach.  This allows people to feel full sooner and less hungry.  Because only small incisions are used, recovery is faster and less complicated than with weight loss procedures that use an open surgery technique.
 
Outcome
 
Following surgery, individuals consume a liquid diet initially and transition to small portions of healthy food.  Patients must commit to lifelong lifestyle changes, including dietary and exercise recommendations, for the program to be successful. Laparoscopic gastric banding can result in a 40% to 60% loss of excess weight over the first three years.  The amount of weight loss is not as dramatic as with other types of weight loss surgeries. 

Advantages Laparoscopic Gastric Banding
 
• Small portions of healthy table food can be eaten
• The laparoscopic ring is adjustable and removable
• Laparoscopic surgery is associated with a fast recovery time.  People typically return to work in a week.
• 40% to 60% loss of excess weight over the first three years
 

Laparoscopic Gastric Bypass Surgery

Laparoscopic Gastric Bypass Surgery, also referred to as Roux-en-Y, is one of the most effective and commonly performed weight loss surgeries. Laparoscopic gastric bypass surgery creates a 95% smaller stomach.  The smaller stomach size causes people to eat less food.   The small intestine is rerouted so food bypasses the first two sections, which prevents the absorption of calories and nutrients.  People lose weight because they eat less and the body absorbs less of the food. Laparoscopic Gastric Bypass surgery is both a restrictive and malabsorptive type of weight loss surgery.

The Procedure
 
Gastric bypass surgery can be an open surgery, but laparoscopic methods are appropriate for many people. A laparoscope is a thin viewing instrument that guides the surgeon during the weight loss procedure.  The surgeon performs laparoscopic gastric bypass surgery by inserting the laparoscope and thin surgical instruments through several small incisions. 
 
The surgeon creates a small pouch, about the size of an egg, at the top part of the stomach. The small pouch acts as the "new stomach." The pouch attaches to the middle part of the second section of the small intestine (jejunum), bypassing the first part of the intestine (duodenum & first part of the jejunum).  Now, the contents of the pouch will empty slowly into the last section of the small intestine (second part of jejunum and ileum). 
 
The small stomach size allows people to feel full after eating just two tablespoons of food.  Because food bypasses the first sections of the small intestine, gastric juices and food are separated for a period of time during which calories and nutrients cannot be absorbed by the body.
 
Outcome

Following surgery, individuals consume a liquid diet and progress to eating small amounts of table food.  People typically lose 50% to 66%, and some up to 75%, of their excess weight within the first few years.  About a 10% weight gain may occur between years two and five, if the small pouch increases in size. 
 
Advantages of Laparoscopic Gastric Bypass Surgery
 
• Laparoscopic gastric bypass surgery uses small incisions and presents fewer risks than other types of weight loss surgeries that remove a portion of the stomach.
• Small portions of table food can be eaten
• Greater amounts of weight can be lost with laparoscopic gastric bypass surgery than with restrictive weight loss surgeries. 
• Laparoscopic gastric bypass surgery is more effective in reversing health problems associated with severe obesity than restrictive weight loss surgeries.

Biliopancreatic Diversion (BPD)

Biliopancreatic diversion (BPD) surgery creates a smaller stomach size and reroutes the path of food directly to the last part of the small intestine.  People lose weight with biliopancreatic diversion because they eat less, feel fuller, and the body only absorbs a limited amount of calories and nutrients.
 
Biliopancreatic diversion is a complicated surgery and not used as often as other types of weight loss surgeries because of the risk of nutritional deficiencies.  Biliopancreatic Diversion (BPD) is both a restrictive and malabsorptive weight loss surgery.

The Procedure

Biliopancreatic diversion surgery is an open surgery using a large incision or laparoscopic surgery using small incisions.  The surgeon removes a large portion of the stomach to decrease its size.  The surgeon connects the new small stomach to the last part of the small intestine (ileum).  Now, food bypasses the first sections of the small intestine (duodenum & jejunum). 

Outcome

Most people lose as much as 75% to 80% of their excess weight and remain at their new weight.  People with biliopancreatic diversion are at risk for anemia, vitamin deficiencies, and dumping syndrome.  When food moves too quickly through the stomach and intestines too fast, the body "dumps" it causing nausea, diarrhea, sweating, and fainting soon after eating.

Advantages of biliopancreatic diversion (BPD)
 
• Significant loss of excess weight
• Maintenance of weight loss
 

Biliopancreatic Diversion with Duodenal Switch (BPD/DS)
 
Biliopancreatic diversion with duodenal switch (BPD/DS) removes part of the stomach and reroutes the small intestine.  People lose weight with biliopancreatic diversion with duodenal switch because they eat less and the body absorbs less calories and nutrients.  Biliopancreatic diversion with duodenal switch is both a restrictive and malabsorptive weight loss surgery.

The Procedure

Biliopancreatic Diversion with Duodenal Switch is performed as an open surgery or laparoscopically.  The surgeon reduces the size of the stomach, but a larger part of the stomach remains than with a biliopancreatic diversion.  Unlike some other types of weight loss surgery, the pyloric valve and a small section of the first part of the small intestine (duodenum) remain.  The surgeon connects the first part of the small intestine (duodenum) to the last part of the small intestine (ileum).  Now, food will not pass through the middle part of the small intestine (jejunum).  Because food is separated from digestive fluids and bile, the body absorbs a limited amount of calories and nutrients.  
 
Outcome
 
Biliopancreatic diversion (BPD) with duodenal switch is associated with successful long-term weight loss.  Most people lose as much as 75% to 80% of their excess weight and remain at their new weight.  People with biliopancreatic diversion are at risk for anemia and vitamin deficiencies.   Biliopancreatic diversion (BPD) with duodenal switch has a lower risk of dumping syndrome than biliopancreatic diversion.

Advantages of biliopancreatic diversion (BPD) with duodenal switch
 
• Achieves and maintains best long-term weight loss
• Unlike Biliopancreatic Diversion (BPD) the valve (pyloric valve) between the stomach and small intestine is intact and eliminates such complications as dumping syndrome, ulcers, and blockages.
• Allows for more absorption of nutrients than other weight loss procedures
• Larger amounts of food can be eaten than with gastric bypass surgery
 
Sleeve Gastrectomy (Verticle Gastrectomy)
 
Sleeve gastrectomy, also called a Verticle Gastrectomy, removes part of the stomach and reshapes it into a narrow tube that is about 15% of its original size.  People lose weight because the stomach is smaller, and they eat less.  In most cases, sleeve gastrectomy is the first in a series of weight loss procedures for people with a body mass index of 40 or more and that a gastric bypass or duodenal switch procedure presents too great of a risk.  If weight loss ceases after the sleeve gastrectomy, then a gastric bypass or duodenal switch may be performed. Sleeve gastrectomy is a restrictive type of weight loss procedure.

The Procedure
 
Most sleeve gastrectomies are performed with minimally invasive laparoscopic techniques.  During the procedure, the surgeon staples to stomach to create a thin sleeve about the size of a banana.  Sleeve Gastrectomy only decreases the size of the stomach and allows for the regular digestive process to occur.
 
Outcome
 
Sleeve gastrectomy is associated with weight losses averaging 55% of the excess weight.
 
Advantages of sleeve gastrectomy

• Research studies demonstrate that sleeve gastrectomy, followed by a second type of weight loss procedure has been successful for people with a BMI greater than 50 or those at high-risk for weight loss surgery. 
• With laparoscopic sleeve gastrectomy, individuals usually can resume regular activities in 2 weeks and are fully recovered in 3 weeks.

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Prevention
Weight loss surgery is not appropriate for people with psychological disorders or those who smoke or use alcohol or drugs.  Weight loss surgery is not recommended for people that weigh less than twice their ideal weight.

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Complications
Certain complications are associated with any surgery and weight loss surgery.  Your doctor will discuss possible complications with you prior to your weight loss surgery.  You should understand both the risks and benefits of weight loss surgery before making your decision.  Additionally, you should realize that the success of weight loss surgery depends on a lifelong commitment to healthy diet, lifestyle, and exercise.

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This information is intended for educational and informational purposes only. It should not be used in place of an individual consultation or examination or replace the advice of your health care professional and should not be relied upon to determine diagnosis or course of treatment.

The iHealthSpot patient education library was written collaboratively by the iHealthSpot editorial team which includes Senior Medical Authors Dr. Mary Car-Blanchard, OTD/OTR/L and Valerie K. Clark, and the following editorial advisors: Steve Meadows, MD, Ernie F. Soto, DDS, Ronald J. Glatzer, MD, Jonathan Rosenberg, MD, Christopher M. Nolte, MD, David Applebaum, MD, Jonathan M. Tarrash, MD, and Paula Soto, RN/BSN. This content complies with the HONcode standard for trustworthy health information. The library commenced development on September 1, 2005 with the latest update/addition on April 13th, 2016. For information on iHealthSpot’s other services including medical website design, visit www.iHealthSpot.com.

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