Surgical Options - Weight loss surgery

  • Weight loss surgery changes the way your digestive system works by closing off parts of the stomach. Making the stomach smaller means that you feel full after eating a small amount of food.

    Operations that reduce stomach size are known as restrictive operations because they restrict the amount of food the stomach can hold.

    Some operations combine restriction with a partial by pass of the small intestine (where food and nutrients are absorbed into the body). By creating a detour around part of the intestine, less food is absorbed. Operations that use this mechanism to enhance weight loss are called malabsorptive operations.

    There are a number of different restrictive and malabsorptive operations being done in our center,but each of these has its unique advantages and disadvantages.

    No single procedure is right for everyone. When you meet with our surgical weight loss team, we will help you determine which procedure is best for you.

    We not just do the Bariatric Surgery, we know Bariatric Surgery !

Weight Loss Surgery

Gastric Band

Gastric Plication

Mini Sleeve

Gastric Banded Plication

LPJB-SG

LDJB-SG

Sleeve Gastrectomy

Roux-en-Y Gastric Bypass

Gastric Band

During the procedure, surgeons typically use laparoscopic

techniques and instruments to implant an inflatable silicone band

around the upper portion of the stomach. The band creates a new,

tiny pouch that limits and controls the amount of food consumed.

The band also creates a small outlet that slows the emptying

process into the stomach and the intestines allowing the patient to

experience an earlier sensation of fullness and increased satisfied

with smaller amounts of food. This ultimately results in weight loss.

The laparoscopic adjustable gastric banding patient can expect a

reduced hospital stay of one to two days; in some instances there

may be an increased stay if the surgery required an abdominal

incision or complications occurred. Patients may resume normal

activities in one to two weeks; again, expect a delay if there is an

abdominal incision or complications occurred.

The lap band surgery procedure (also commonly referred to as a

"lap band") requires no cutting or stapling of the stomach and bowel

and is considered the least invasive weight loss surgery available.

The band is also adjustable and can be modified by inflating or

deflating the inner surface with distilled water. The surgeon can

control the amount of distilled water in the band using a fine needle

through the skin. The adherence to monthly appointments for band

adjustments the first 6-12 months after surgery is very important to

achieve optimal results. Once the band is adjusted properly, the

duration between visits can be lengthened. The adjustments are

made in the surgeon’s exam room and patients have minimal

discomfort. Finally, should the band need to be removed, the

stomach will return to its original form and function.

Gastric Plication

How Is Gastric Plication Performed?

We perform the gastric plication as a laparoscopic procedure. This

involves making five or six small incisions in the abdomen and

performing the procedure using a video camera (laparoscope) and

long instruments that are placed through these small incisions.

Laparoscopic gastric plication, involves sewing one or more large

folds in your stomach. During the laparoscopic gastric plication the

stomach volume is reduced about 70% which makes the stomach

able to hold less and may help you eat less. There is no cutting,

stapling, or removal of the stomach or intestines during the Gastric

Plication. The gastric plication may potentially be reversed or

converted to another procedure if needed. The gastric plication

procedure is minimally invasive and takes approximately one to two

hours to complete. Most patients stay in the hospital for 1-2 days

after the procedure.

How Does Gastric Plication Cause Weight Loss?

Gastric plication is a restrictive procedure. It greatly reduces the

size of your stomach and limits the amount of food that can be

eaten at one time. It does not cause decreased absorption of

nutrients or bypass your intestines. After eating a small amount of

food, you will feel full very quickly and continue to feel full for

several hours. Gastric plication may also cause a decrease in

appetite.

Mini Sleeve

Mini-LSG

Gastric Banded Plication

Laparoscopic gastric plication has emerged as a new bariatric

procedure with promising results. This paved the path for further

innovation and conception of a new procedure known as

“Laparoscopic Adjustable Gastric Banded Plication”. This dual

restrictive procedure involves gastric greater curvature placation or

infolding of the stomach to form a gastric sleeve followed by

placement of an adjustable band in the upper part of the stomach.

Combination of Gastric plication and gastric banding makes it dual

restrictive with powerful weight loss comparable to sleeve

gastrectomy and gastric bypass surgery. The rationale behind this

surgery is that the plication “switches on” the initial weight loss

process. Then adjustment of band further initiates the second phase

of weight loss and maintains the success through serial

adjustments. In addition to quicker weight loss from gastric

plication, far less adjustments are required than with just having the

band alone. In LAGBP, the disadvantages of gastric banding and

gastric plication are taken off by each other. Gastric band doesn’t let

plication to dilate over a period of time and gastric band doesn’t slip

now because of the plicated stomach.

Unlike other bariatric surgery procedures, there is no stapling

involved with LAGBP. No part of the stomach or intestines is cut or

removed either. They are just folded from within followed by band

placement. LAGBPcan be reversed to normal anatomy or revised to

any other procedure.

Facts about LAGBP

Dual Restrictive

Reversible

No Stapling

No Cutting

What to Expect During and After LAGBP?

Your recovery begins almost immediately after the surgery as you

gradually begin to get used to your new way of eating. This starts

with a two-week liquid diet that likely will include water, milk,

coconut water, fruit juice and lime juice. The next few weeks will

involve thicker liquids such as soup with some vegetables, and

eventually you can try yogurts and fruits. After this, you will be able

to eat all foods in restricted amounts. We start Band adjustments 3

months after the surgery.

What are the benefits of LAGBP?

Potentially Reversible

Obviates the need for GI resection or anastomosis

Obviates the need for intestinal bypass and future mal-absorption

Provides a “bi-phasic” restrictive effect

Combines benefits of adjustability of gastric band and quick weight

loss of gastric plication

Reduces the need of frequent band adjustments

What Are the Risks of Laparoscopic Adjustable Gastric banded

Plication?

When we discuss the risks of any bariatric surgery, they must be

compared to the serious risks associated with obesity. Risks of

gastric plication include bleeding, blood clots, infection, and injury to

other organs.

Other LAGBP-specific risks may include:

Stomach leakage from the fold

Blockage of the stomach from swelling or a fold that is too tight

Fundal herniation

Band Slippage or infection

Do I need to take bed rest after the surgery?

We encourage you to walk 2-3 hours after the surgery as being

active and mobile reduces the risk of deep vein thrombosis. On

third day, you are discharged from the hospital and you can return

to work within a week.

Will I ever regain weight after this surgery?

Yes you can if you are not careful with the intake of high calorie

liquids or junk food as consumption of them could lead to increased

caloric intake. With any bariatric procedure, restriction is only for

solid food but not for high calorie liquids or sweets. Good healthy

eating habits and regular exercise form the cornerstones of success

after bariatric surgery.

What will be my diet after the surgery?

You will need to be on a liquid diet for first 14 days after the surgery.

This is followed by 7 days of semi-solid foods and then you

progress onto solids. Within 1 months you can have all kinds of

foods though in limited quantities.

LPJB-SG

In this process bypassing a short segment of proximal intestine

directly ameliorates type 2 diabetes, independently of effects on

food intake, body weight, malabsorption, or nutrient delivery to the

hindgut. These findings suggest that a proximal intestinal bypass

could be considered for diabetes treatment and that potentially

undiscovered factors from the proximal bowel might contribute to

the pathophysiology of type 2 diabetes.

The LPJB-SG may serve as a middle ground between RYGB and

SG. It is technically easier to perform;

provides better eating quality than RYGB due to less restriction; and

allows better weight loss and antidiabetic

effect than SG due to some malabsorption. However, long-term

results and further prospective

studies are still needed to confirm the effect of this operation.

This procedure only requires a jejuno-jejunal anastomosis

with only one mesenteric defect, hence technically simpler to

perform compared to RYGB. Our series showed most of the

procedure to be completed within two hours. It may also be

easily converted to a duodenojejunal bypass with sleeve

gastrectomy

or RYGB if complications or insufficient weight loss

occur. However, there are concerns for blind loop syndrome

or less efficient anti-diabetic effect. Until present, we have

not had any incidence of blind loop syndrome in our series,

but we continue to observe for it. As bypassing only the proximal

jejunum is done, the anti-diabetic effect may not be as

impressive as other operations that exclude the duodenum

LDJB-SG

LOOP DUODENOJEJUNAL BYPASS WITH SLEEVE

GASTRECTOMY(LDJB-SG)

Loop duodenojejunal bypass with sleeve Gastrectomy (LDJB-SG)

was started to achieve Type 2 diabetes remission and to avoid the

drawbacks of RYGB. It is safe, feasible, and shows good efficacy in

terms of glycemic control or long term remission of type 2 diabetes,

due to several hormonal changes such as reduced

ghrelin,increased GLPI and peptide YY. Adding intestinal diversion

to sleeve increases its efficacy and reduces problem related with

gastric bypass.Bilio-pancreatic diversion with duodenal switch is the

most effective metabolic surgery since hormonal changes are

maximum.

LRYGB and BPD-DS are procedures with higher rates of T2DM

remission and long-term complications. The aim of metabolic

surgery is to produce remission of T2DM with more physiological

aspects and minimal morbidity and mortality. In our center, LDJB-
SG , a novel surgical procedure was invented as a proposed

technique for treatment of T2DM to reach the goal of metabolic

surgery.

Operative techniques

Under general anesthesia, a 5-port laparoscopic surgery was used

to access the abdominal cavity. We then performed a standard

sleeve gastrectomy with endostaplers. Two centimeters distal to the

pylorus, we did the dissection of the duodenum. We transected

duodenum 2 cm from the pylorus, pancreas, and major vessels in

the area. And then we measured 2–300 cm of the jejunal loop from

the ligament of Treitz. We then performed side to side isoperistaltic,

totally hand-sewn, one layered duodeno-jejunal anastomosis with

absorbable sutures. After the anastomosis, we placed one anti-
torsion suture in the antrum and upper jejunum, 4 cm proximal to

the duodenojejunostomy. We put one Jackson-Pratt drain behind

the duodenojejunal anastomosis reaching the sleeve and end the

procedure.

Advantages of LDJB-SG

Exclusion of duodenum may ease the abnormal glycemic control

and insulin resistant. Scientists found proximal bowel diversion,

which was done on rat models, would not decrease food intake or

weight loss but may improve diabetes instead. As previous

elucidation, that’s the reason why LSG only resolved partial T2DM.

Rubino et al. demonstrated when bypassing duodenum and

proximal jejunum, amelioration of T2DM will occur without any

change on food intake, body weight, malabsorption, or nutrient

delivery to the hindgut.

LDJB-SG has higher satisfied T2DM resolution rates than LSG

(remission rate for 1 year follow up: 62% vs. 32%). For diabetes

patients, surgery preserving the pylorus may cause delaying gastric

emptying and then reduce postprandial glucose excursions. LDJB-
SG is a good option for revision when intractable dumping

syndromes happened after LRYGB. LDJB-SG also eliminates the

risk of remnant gastric cancer, an important issue in Asia where

gastric cancer is very common. Based on our experience, the

resolution of co-morbidities was similar in both LDJB-SG and

LRYGB for BMI
LDJB-SG has longer operative time and length of stay than LRYGB,

however, it has no inferior rate than LRYGB on postoperative one-
year improvement of body weight loss, fasting plasma glucose and

%HbA1c. The level of HOMA-%B at 12 months was even

significantly higher in the LDJB-SG than in the LRYGB. However,

further studies on change of gut hormones and long-term results

compared with RYGB, LDJBSG is still needed to be investigated in

the future.

Sleeve Gastrectomy

How Does Sleeve Gastrectomy Cause Weight Loss?

Sleeve gastrectomy is a restrictive procedure. It greatly reduces the

size of your stomach and limits the amount of food that can be

eaten at one time. It does not cause decreased absorption of

nutrients or bypass your intestines. After eating a small amount of

food, you will feel full very quickly and continue to feel full for

several hours.

Sleeve gastrectomy may also cause a decrease in appetite. In

addition to reducing the size of the stomach, sleeve gastrectomy

may reduce the amount of "hunger hormone" produced by the

stomach which may contribute to weight loss after this procedure.

Who Do We Offer Laparoscopic Sleeve Gastrectomy?

This procedure is primarily used as part of a staged approach to

surgical weight loss. Patients who have a very high body mass

index (BMI) or who are at risk for undergoing anesthesia or a longer

procedure due to heart or lung problems may benefit from this

staged approach. Sometimes the decision to proceed with a two-
stage approach is made before surgery due to these known risk

factors. In other patients, the decision to perform sleeve

gastrectomy (instead of gastric bypass) is made during the

operation. Reasons for making this decision intraoperatively include

an excessively large liver or extensive scar tissue that would make

the gastric bypass procedure too long or unsafe.

In patients who undergo LSG as a first stage procedure, the second

stage (gastric bypass) is performed 12 to 18 months later after

significant weight loss has occurred and the risk of anesthesia is

much lower (and the liver has decreased in size). Though this

approach involves two procedures, we believe it is safe and

effective for selected patients.

Laparoscopic sleeve gastrectomy can also be used as a primary

procedure. There is relatively little data regarding the use of LSG as

a stand-alone procedure in patients with lower BMI’s and it should

be considered an investigational procedure in this patient group. We

are offering this procedure to diabetic patients with a BMI between

30 and 40 as a part of a clinical trial that will better define the short

and long-term benefits of LSG in this group of patients.

What Are The Benefits Of Laparoscopic Sleeve Gastrectomy?

Depending on their pre-operative weight, patients can expect to

lose between 40% to 70% of their excess body weight in the first

year after surgery.

Many obesity-related comorbidities improve or resolve after bariatric

surgery. Diabetes, hypertension, obstructive sleep apnea and

abnormal cholesterol levels are improved or cured in more than

75% of patients undergoing LSG. Though long-term studies are not

yet available, the weight loss that occurs after LSG results in

dramatic improvement in these medical conditions in the first year

after surgery.

Complications of LSG

There are early and late complications of LSG. When comparing

with LRYGB, LSG is still a procedure with lower readmission and

re-operation rates. Staple line leaks, bleeding, and strictures are the

commonly reported complications following. Reported average rate

of LSG complications in a systemic review: approximately 3.57% of

bleeding rate, 12.1% of major complications, 1.17% of leak rate and

mortality rates between 0 and 3.3%. International Sleeve

Gastrectomy Expert Panel Consensus Statement 2011 [38]

showed: 1.06% of leak rate, 0.35% of stricture with 1.05–1.85% of

overall conversion rate and 3.66–5.1% of postoperative gastric

fistula. LSG which as a longer staple lines has comparable leak

rates to LRYGB which has shorter ones.

Gastroesophageal reflux disease (GERD) is the most common

chronic complications complained by the patients and usually need

to do revisional surgery which LRYGB is usually chosen. About 11–

33% patients have GERD reflux in long-term follow ups after LSG.

Until now, there were no sufficient evidences to show the

relationship between LSG and GERD. Chiu et al. reported a

systemic review showing no conclusive relationships on LSG to

GERD. implied when a relative narrowing of the middle stomach

combined with a dilated upper stomach after the LSG, GERD may

happen even without any complete obstruction. This functional

obstruction would result in severe esophageal dysmotility with reflux

symptom. Patients may reduce the incidence of GERD after LSG

when they concomitant repair of hiatal hernia (HH) during the LSG

operation. Preoperative evaluation of hiatal defects and repair of it

during the LSG is recommended . For the small hiatal defect which

is easily missed during preoperative panendoscopy examination,

can be revealed and repaired easily when the surgeon remembers

to exam the crura during LSG procedure and dissects left crura

during dissection angle .

Is Laparoscopic Sleeve Gastrectomy A Good Choice For Me?

Your surgeon may talk to you about LSG as an option if you have a

BMI over 60 or significant medical problems that increase your risk

for undergoing anesthesia or gastric bypass. Laparoscopic sleeve

gastrectomy may also be offered as part of a clinical investigation if

you have a lower BMI and diabetes.

You should discuss all of the available surgical procedures with your

surgeon and determine which procedure is best for you.

Roux-en-Y Gastric Bypass

Gastric bypass surgery is an operation that creates a small pouch

to restrict food intake and bypasses a segment of the small

intestine. In the gastric bypass procedure, a surgeon makes a direct

connection from the stomach pouch to a lower segment of the small

intestine, bypassing the duodenum (the first part of the small

intestine) and some of the jejunum (the second part of the small

intestine), delaying the mixing of ingested food and the digestive

enzymes.

Roux-en-Y gastric bypass is the most common type of bariatric

surgery. The surgeon begins by creating a small pouch by dividing

the upper end of the stomach. This restricts the food intake. Next, a

section of the small intestine is attached to the pouch to allow food

to bypass the duodenum, as well as the first portion of the jejunum.

The small intestine is re-connected 100 centimeters from the pouch

to allow ingested food and digestive enzymes to mix.

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(m)
(kg)
( Normal : 18.5 < BMI < 24.0 )
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