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What You Need to Know About Weight Loss Surgery Facts P.2
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Malabsorptive Procedures:

Weight loss surgeries that alter the digestive process are referred to as malabsorptive procedures. There are more than a few different types of malabsorptive weight loss surgery. Several of these techniques involve a by-pass of the small intestine, thus limiting the absorption of calories. Malabsorptive weight loss surgery decreases the amount of intestine that comes in contact with food so that the body absorbs smaller quantity calories.

Biliopancreatic Diversion (BPD) : BPD removes approximately 3/4 of the stomach to produce both restriction of food intake and reduction of acid output. Leaving enough upper stomach is important to maintain proper nutrition. The small intestine is then divided with one end attached to the stomach pouch to create what is called an "alimentary limb." All the food moves through this segment, however, not much is absorbed. The bile and pancreatic juices move through the "biliopancreatic limb," which is connected to the side of the intestine close to the end. This supplies digestive juices in the section of the intestine now called the "common limb." The surgeon is able to vary the length of the common limb to regulate the amount of absorption of protein, fat and fat-soluble vitamins.

Extended (Distal) Roux-en-Y Gastric Bypass (RYGBP-E) : RYGBP-E is an alternative means of achieving malabsorption by creating a stapled or divided small gastric pouch, leaving the remainder of stomach in place. A long limb of the small intestine is attached to the stomach to divert the bile and pancreatic juices. This procedure carries with it fewer operative risks by avoiding removal of the lower 3/4 of the stomach. Gastric pouch size and the length of the bypassed intestine determine the risks for ulcers, malnutrition and other effects.

Biliopancreatic Diversion with "Duodenal Switch" :  This procedure is a variation of BPD in which stomach removal is restricted to the outer margin, leaving a sleeve of stomach with the pylorus and the beginning of the duodenum at its end. The duodenum, the first portion of the small intestine, is divided so that pancreatic and bile drainage is bypassed. The near end of the "alimentary limb" is then attached to the beginning of the duodenum, while the "common limb" is created in the same way as described above.

Advantages

These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard Roux-en-Y gastric bypass procedure.
These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
In one study of 125 patients, excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years, and 91% at five years was achieved.
Long-term maintenance of excess body weight loss can be successful if the patient adapts and adheres to a straightforward dietary, supplement, exercise and behavioral regimen.

Risks

For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence.
Abdominal bloating and malodorous stool or gas may occur.
Close lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. As well, lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment.
Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder.
Re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers.

Combined Procedures:

Gastric Bypass Roux-en-Y is a recently developed procedure that utilizes the principles of both restrictive and malabsorptive weight loss surgeries. Consistent with the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric by pass is the most frequently performed weight loss surgery in the United States. This method engages the creation of a small stomach pouch with the remainder of the stomach completely stapled shut and divided from the pouch. Another point we care that the outlet from the pouch than empties directly into the lower portion of the jejunum, therefore bypassing calorie absorption. By inserting malabsorption to a restrictive weight loss procedure, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The consequence is an early sense of fullness, together with a sense of satisfaction that reduces the desire to eat.

Advantages

The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
One year after surgery, weight loss can average 77% of excess body weight.
Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.

Risks

Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
A condition known as "dumping syndrome " can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur.

Laparoscopic or Minimally Invasive Surgery 

For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still "experimental." In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.

When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.

 The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.

Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures.

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