Surgical Options: U.S. Incidence = 5% (Brethauer Clev Clin J Med 2006)

• Weight loss: 70% EWL
• Operative mortality: 1%
• Operative morbidity: 5%
• Long-term complications: diarrhea, malodorous stools and flatus, vitamin, mineral and nutrient deficiencies, in particular, protein deficiency
  Buchwald J Am Coll Surg 2005

Advantages

Disadvantages

• Superior weight loss
• Most durable weight loss
• Most difficult to beat

• Protein and calcium malnutrition
• Most complicated
• Malodorous stool and flatulence

Surgical Options: U.S. Incidence = 5% (Brethauer Clev Clin J Med 2006)

• Weight loss: 50-60% EWL
• Plateau in weight loss reached at 2 years
• Operative mortality: 0.1%
• Operative morbidity: 5%
• Longterm complications: vomiting, outlet obstruction, erosion, staple line dehiscence
  Buchwald J Am Coll Surg 2005

Advantages

Disadvantages

• Easier to perform
• Shorter operative time

• Poor operation for sweet eaters
• Restrictive only
• Nonadjustable
• Staple line disruption
  and leaks

Surgical Options: U.S. Incidence = 10% (Brethauer Clev Clin J Med 2006)

• Weight loss: 50% EWL at 2 years
• Operative mortality: 0.1%
• Operative morbidity: 5%
• Long-term complications: gastric prolapse, stomal obstruction, esophageal and gastric pouch dilation, gastric erosion and necrosis, access port problems - Buchwald J Am Coll Surg 2005

Advantages

Disadvantages

• Simple to perform
• Adjustable
• Lowest mortality
• Minimally invasive
• Shortest operative time
• No need for vitamin and mineral supplementation

• Foreign body
• Slower weight loss
• Lower overall weight loss
• Higher failure rate
• Poor operation for sweet eaters

• A silicone band is placed around the upper part of the stomach
  • A small pouch is created
  • Stomach holds less food
  • Induces feeling of satiety
  • Shorter OR time
  • Overnight hospital stay
  • Return quickly to work
  • Evaluated every 6-8 weeks for gradual tightening if necessary

Laparoscopic Adjustable Gastric Banding Video

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• Adjustability is the most important attribute
  • Filled with a saline solution
  • By adding or removing the saline, can be made tighter
• Use it freely
  • Adjust as necessary to support gradual, steady weight loss
  • Often 5-6 times in the first year
• Keep it simple
  • Place reservoir on anterior rectus sheath
  • Palpate, mark the site, no-touch technique
  • Office procedure, rarely needs radiology

• First performed as part of Duodenal Switch procedure 1988 (Marceau/Hess)
• First performed in laparoscopic isolated form 1999 (Gagner)
• 15 published reports in the surgical literature describing clinical outcomes in 775 patients
• Risk appears to be low even in high risk patients
• Complication rates between 0%-24%
• Overall mortality rate: 0.39%
• No consensus of optimal dilator size
• No study provides data beyond 3 years postoperatively
• BMI treatment range 35-69
• %EWL range 33%-83%
• Comorbidity resolution 1-2 years reported in 345 patients demonstrating resolution of diabetes, HTN, sleep apnea, dyslipidemia comparable to other restrictive surgeries

Surgical Options: U.S. Incidence = 80% (Brethauer Clev Clin J Med 2006)

• Weight loss: 65-70% EWL
• Weight loss plateaus at 1-2 years
• Operative mortality: 0.5%
• Operative morbidity: 5% (pulmonary emboli, anastomotic leak, bleeding, wound infection)
• Long-term complications: Dumping syndrome, stomal stenosis, marginal ulcers, staple line disruption and internal hernias
  Life-long Vitamin B12, iron, folate, and calcium supplementaion
  Ventral hernia formation is more prevelant after open gastric bypass
  Buchwald J Am Coll Surg 2005

Advantages

Disadvantages

• Gold standard operation in the U.S.
• Dumping syndrome
• Less malabsorption
  than BPD/DS
• Rapid weight loss

• Technically more complicated than restrictive operations
• Need for permanent vitamin and mineral vitamin supplementation

Advantages

Disadvantages

• Shorter operative time
• Less OR costs

• Incisional hernia
• Wound infection
• Higher pulmonary complications
• Cosmesis
• Pain
• Longer hospital stay
• Slower return to work
• Lifting restrictions

Advantages

Disadvantages

• Minimally invasive
• Shorter hospital stay
• Faster return to work and activity
• Lower incidence of pulmonary complications
• Cosmetic

• Increased OR costs
• Steep learning curve

• Compared with open procedures, laparoscopic gastric bypass has a higher rate of intraabdominal complications; whereas duration of hospitalization is shorter, wound complications are lower, and postoperative patient comfort is higher
  Buchwald J Am Coll Surg 2005

• The gastric pouch is formed with the use of a stapler below the GE junction
• Pouch size measures 15cc (½ ounce)

• The small intestine is divided 40-75 cm from the ligament of Treitz

• Jejunojejunostomy is created of variable distance from the end of the Roux limb
• BMI<50 Roux =75cm
• BMI>50 Roux=150cm

• The Roux is attached to the pouch to create the gastrojejunostomy
• Can be done
  • Hand sewn
  • Linear stapler
  • Circular stapler

Complications of Laparoscopic Gastric Bypass

StomaphyX

Can be used to plicate the gastric pouch to dramatically reduce the stomach size Can indirectly reduce the size of a dilated anastomosis Device is place through the mouth under direct endoscopic vision The wall of the stomach is suctioned into the device and a prolene H-shaped fastener is fired creating approximation of the stomach Can be done as an outpatient or short stay procedure Reports of 50%-90% reduction in stomach size No major complication reported How does it Work? Tissue is drawn into the tissue chamber Serosafuse deployed through the plication StomaphyX Experience Procedures are easy 20 - 40 minute cases Typically14 to 16 fasteners Overnight hospital stay or outpatient procedure Can create multiple large tissue folds

• Laparoscopic Roux-en-Y Gastric Bypass
• Laparoscopic Adjustable Gastric Banding
• Open Roux-en-Y Gastric Bypass
• Laparoscopic Sleeve Gastrectomy
• StomaphyX