Carolinas HealthCare System

Weight Loss Procedures

Weight loss procedures provided by Carolinas Weight Loss Surgery include adjustable gastric band, gastric bypass and gastric sleeve.

A History of Obesity Surgery

(Patients are encouraged to visit the link to the American Society for Metabolic and Bariatric Surgery (ASMBS) and read the full text of “The Story of Obesity Surgery.”)

The history of bariatric surgery begins in the 1950s when two surgeons, Dr. Kremen and Dr. Linner, performed a procedure known as the jejuno-ileal bypass.

The procedure consisted of connecting a segment of the upper small bowel to the lower small bowel and bypassing the middle portion, reducing the area available for calories to be absorbed. A number of problems occurred with this bypass including profuse diarrhea, gallstones, calcium deficiencies, neuropathy, night blindness, hair loss, anemia, kidney failure, liver failure and many other problems. This procedure is no longer popular and in some surgeon’s opinions should be reversed or converted to another procedure.

The Biliopancreatic Diversion or “Scopinaro” differed from the jejunoileal (JIB) bypass by not having a portion of bowel that was a “dead end” like the JIB did. This procedure had significantly fewer problems with liver failure, involved a limited gastrectomy that reduced the amount of food a patient could eat, and a bypass of much of the small bowel which resulted in a significant malabsorptive component (food couldn’t be processed by the intestine).

The difficulties with this technique were that patients had significant problems with loose stools, protein, mineral, or vitamin malnutrition, excessive and smelly flatus (gas), strong body odor and ulcers at the site where the bowel was connected to another portion of bowel. This procedure has not been particularly popular in the U.S.A.  Modification of this procedure is the “duodenal switch” which is thought to produce fewer and less profound problems than the original biliopancreatic diversion. It is now currently offered laparoscopically.

Old Loop Bypass

One of the most influential surgeons studying weight loss surgery is Dr. Edward Mason. He was involved in many of the innovations and developments that have occurred since 1966. One of these was a type of bypass that created a small gastric pouch to limit food intake that attached to a downstream “loop” of small intestine, which limited the ability of the bowel to absorb calories. This approach was successful, however the “loop” was created in such a way that bile from the liver flowed across the connection to the gastric pouch. This lead to one of its major criticisms being that it caused bile reflux into the stomach pouch and esophagus. This approach was abandoned for that reason.

Vertical Banded Gastroplasty (VBG)

Since that time there have been a great number of modifications to weight loss surgery. One of these was the vertical banded gastroplasty. This involved a staple line on the stomach that created a partitioning of the stomach and in effect a smaller reservoir to hold food. This approach has a number of variations including a prosthetic band, which strengthens the integrity of the bottom of the pouch. Although this was a relatively uncomplicated surgery technically, it has become associated with a significant incidence of weight gain a few years after the surgery.

This is because of a number of reasons: The pouch can stretch back to a significant size when not accompanied by careful dietary coaching and supervision, there is no malabsorption aspect to this surgery, the partitioning method can break down over time and allow the original capacity of the stomach to become available, and avoidance of dense foods because the tightness of the constricting band can lead patients to pick poor food choices high in caloric content. The VBG is no longer supported by Medicare and many insurance companies.

The Roux-en-Y Gastric Bypass

Another modification to the gastric bypass was the creation of the Roux-en-Y gastric bypass. This procedure entailed making a small gastric pouch high in the abdomen and just below the esophagus. A segment of small bowel is divided and attached to this pouch, sometimes behind the colon and remainder of the stomach if there is difficulty reaching the pouch. The remainder of the small bowel is then attached to the bowel leading from the liver and pancreas in a shape that resembles a Y.

This is probably the most common bypass being done today. As with any of these procedures there are potential problems and it is a technically more difficult procedure. Leakage of bowel contents can occur after the initial surgery and results in further surgery. There is a risk of narrowing at the connection between the stomach pouch and the small intestine and this may require stretching the opening. There is a risk of the “Roux stasis syndrome” which is a slowing down of the emptying of the pouch and small bowel causing nausea and vomiting.

The limbs of the Y can become involved with an obstruction of the bowel requiring further surgery. There is also a risk of anemia, calcium and vitamin deficiency but it's rare that this cannot be treated with supplementation. The portion of the stomach that is bypassed is no longer accessible by endoscope from the mouth, and other means of access to it and the region of the common bile duct are necessary. No stomach tissue or small bowel is removed in this operation.

Mini Gastric Bypass

Dr. Robert Rutledge developed the “Mini” gastric bypass in 1997. This bypass creates a small gastric pouch much lower in the abdomen than previous techniques of this kind (like Dr. Mason’s) and incorporates a “loop” anastomosis (connection) with the small bowel that provides for a malabsorption effect similar to that which is used in the Roux-en-y bypass. Some of the beneficial effects of the “Mini” are similar to the Roux-en-Y bypass. A patient with the “Mini” must still be followed carefully for calcium and iron deficiencies just as the Roux patient must follow. There are some similar risks to the operations such as leaks, bowel obstruction, pulmonary embolus (blood clot going to the heart), pneumonia and others. 

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