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Laparoscopic Gastric Bypass

Recent advances in the field of minimally invasive surgery have made laparoscopic gastric bypass surgery possible in certain individuals. The laparoscopic approach involves placement of usually about six trocars through separate ½ to 1 inch incisions instead of the usual eight to ten inch incision necessary for the open procedure. Dissection and anastamoses (connecting the bowel) are performed with special instruments inserted through these small incisions. The basic operation, however, is essentially the same as that done open.

Because the laparoscopic approach to gastric bypass is new, the advantages or disadvantages over the open approach are not known. However, we anticipate decreased post-operative pain, a shorter hospital length of stay, quicker recovery, and decreased incidence of ventral hernia. Likewise, we anticipate risks of surgery to be equivalent to the open procedure, but can not be sure. As with any laparoscopic operation, conversion to an open procedure is possible and will likely occur occasionally.

Morbid Obesity

Obesity is a very common condition affecting between 20 and 30% of the U.S. population. In fact it is the most common nutritional disorder in our nation. A person is considered obese when they are about 30% over their ideal body weight. The term “morbid obesity” is used to describe people who are about twice the weight they should be or 100% over their ideal body weight. A formula based upon height and weight is used to determine if someone is morbidly obese.

Weight in Kg/(Height in meters)2 = Body Mass Index

A BMI Calculator can be found on the right hand side of this page.

If this number, the Body Mass Index, or BMI, is 40 or greater, a person is considered morbidly obese and may be a candidate for surgery.

Rationale for treatment

A number of health problems are directly related to obesity. They include atherosclerosis affecting the heart vessels and other vessels, congestive heart failure since the heart has to pump to such a large distribution, hypertension, and severe back and knee arthritis due to the tremendous weight these joints have to bear. Adult onset diabetes is often brought on by obesity. In fact over 50% of massively obese individuals have diabetes. Diabetes is a leading risk factor for heart disease and a leading cause of premature death. Because fat cells affect the metabolism of estrogen, many morbidly obese females have irregular periods or may even have trouble conceiving. Obesity is also thought to be a risk factor for the development of uterine cancer. In addition to the known health risks, morbidly obese people may suffer from other less obvious but no less troubling psychosocial problems including diminished career opportunities, social maligning, and difficulty in public places such as mass transit vehicles, and airliners.

If we plot the incidence of these and other obesity related conditions as a function of weight, we would see that as the average weight of a population increases, so does the incidence of these co-morbid conditions. Likewise, if we plot the life expectancy of a population as a function of their average weight, we see life expectancy decline. When the average weight of the population reaches about twice the average ideal body weight, i.e., the point at which we say someone is morbidly obese, the two curves we plotted begin to change exponentially. Simply put, the problems associated with obesity begin to mount rapidly when a person enters the realm of morbid obesity.

While weight loss may not correct all of these problems, it has been shown to improve many. In this era of preventative medicine, we realize that the best “treatment” for heart disease is to prevent its occurrence in the first place. Diabetes and hypertension control are improved with weight loss. In fact some individuals who require insulin when they are morbidly obese, no longer require it after losing weight. Arthritis sufferers generally have less pain after losing weight, and those individuals who do not yet have arthritis may be able to prevent it by losing weight.

But, while weight loss improves the outlook of many individuals, some actually have difficulty adapting to their “new bodies.” We have seen familial and marital discord develop likely as a result of families and friends thinking their loved one has changed, and indeed they have.

However, this is not a “cosmetic” operation. And while we define success as losing 50% or more of your excess body weight, not everyone achieves that.

Treatment Options

Many patients claim, “I hardly eat anything,” and while the literature suggests obese people may indeed be more efficient with the calories they ingest, for the most part, you simply cannot be overweight without overeating. In general, obesity is best treated by taking in fewer calories than you burn. While this may sound simple, adhering to that dictum is difficult. The National Institute of Health studies estimate the success of dieting for weight loss at about 3%. In fact, it may be lower than that for morbidly obese people. Diet pills seem to help some, and perhaps a few more individuals are successful with these. However, regaining weight after stopping the diet pills often proves to be problematic.

Surgical treatment of obesity, called bariatric surgery, has evolved over the years. We currently perform the gastric bypass operation. The stomach is partitioned by placing a line of staples along the upper aspect creating a very small gastric pouch. It is designed to hold 1 to 2 tablespoons only. The GI tract is rerouted such that food empties from the upper gastric pouch into a six-foot intestinal conduit before mixing with the digestive enzymes which emanate from the pancreas. Gastric bypass, therefore, attacks the problem of obesity from two angles. The small stomach produces early satiety, and the gastrointestinal bypass decreases the efficiency of the GI tract. It is likely this double-edged approach has enabled the gastric bypass to become the “state of the art” in bariatric surgery.

Side Effects

The point of the operation is to drastically limit how much a patient can eat. It is life style changing. Many people experience frequent vomiting after the procedure which is generally secondary to overeating. Fatigue, especially during the period of active weight loss, is common. Vitamin and micronutrient deficiencies, such as iron, and calcium are common, and it is mandatory that you take a multivitamin with iron daily for the rest of your life, as well as a calcium supplement. Vitamin B12 absorption is particularly affected and requires supplementation in the form of an injection four times per year. Ultimately it can be replaced with a daily oral supplement if you prefer. You may experience hair loss which coincides with weight loss or sometimes protein deficiency. This is usually self-limited, but is concerning for some patients. Some patients develop certain food aversions which are unique and unpredictable. Foods you once liked may no longer have the same appeal. Diarrhea or constipation sometimes ensue, and may be aided with a daily fiber supplement such as Metamucil, Citrucel, or Fibercon.

Risks

Gastric bypass is a major operation, and as such is associated with significant risks. Complications can and do occur commonly. They may be minor or major, and may include bleeding, wound infection, or intra-abdominal abscess. Disruption of the surgical wound or disruption of the connection between the stomach and intestine or between the two limbs of intestine may occur. Bowel obstruction either early on or years later, development of an abdominal wall hernia, pneumonia, or heart attack are possible complications related to surgery. Because of the proximity of the stomach to the spleen, it can be injured during the operation and necessitate splenectomy. Formation of clots in the legs that can break free and clog the vessels going to the lungs resulting in sudden death has been known to occur. Some complications may require re-operation and women of child-bearing age should avoid pregnancy during the 12 to 24 months after surgery when weight loss is most rapid. These are only some of the possible problems. Others can occur. In fact, estimates put the risk of death related to surgery at about 1 in 100 patients. Laparoscopic gastric bypasses may need to be converted to open for various reasons.

Indications for Operation

People with a body mass index (BMI) of 40 or greater (Click Here to calculate), and not over the age of 50 years, who have tried and failed conservative weight loss measures preferably including physician directed methods are considered for operation. Rarely people with a lower BMI but with severe co-morbid obesity related conditions such as diabetes are considered.

Contraindications for Operation

Patients with severe heart conditions, angina pectoris, bleeding problems such as hemophilia, or unrealistic expectations of surgery (see below) are generally not surgical candidates. There may be other reasons to exclude patients from surgical consideration as well, and your surgeon can discuss these with you when he takes your medical history.

Find out more about Gastric Bypass with the following links.

Nondiscrimination Statement:

Cahaba Valley Surgical Group, P.C. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

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