Surgical Weight Loss: LAP-BAND®® and Gastric Bypass procedures in Los Angeles

presented by the Coastal Center for Obesity for residents of Bellflower, Beverly Hills, Brentwood, Carson, Cerritos, Culver City, Downey, Glendale, Hermosa Beach, Hollywood, Hollywood Hills, La Mirada, Lakewood, Lawndale, Long Beach, Los Altos, Los Angeles, Marina del Rey, Norwalk, Palms, Paramount, Pasadena, Playa del Rey, Playa Vista, Rancho Palos Verdes, Redondo Beach, Rolling Hills Estates, San Pedro, Santa Monica, Torrance, Venice, West Hollywood, West Los Angeles, Westchester, and Whittier

Surgical weight loss operations performed at Coastal Center for Obesity Coastal Center for Obesity include laparoscopic, open Roux-en-Y gastric bypass and the LAP-BAND® procedure. We do not perform the duodenal switch procedure or the biliopancreatic diversion. We feel these operations are associated with more short and long term complications and therefore are not currently performing them.

Comparison between the LAP-BAND® and Gastric Bypass procedures

LAP-BAND®

• Less invasive
• Outpatient surgery
• Reversible Adjustable
• No rearrangement of anatomy
• Slower weight loss
• Not endorsed by NIH
• Less well studied in US
• More follow-up required
• More dietary compliance required

Gastric Bypass

• More invasive Inpatient surgery
• Not easily reversible
• Not adjustable
• Anatomy rearranged
• Faster weight loss
• Endorsed by NIH
• Well studied in US
• Less follow-up required
• Less dietary compliance required

Roux-en-Y Gastric Bypass

In the gastric bypass procedure, a 15-20cc stomach pouch is constructed (usual stomach approximately 1500cc or greater). The remainder of the stomach is separated from the new stomach pouch and stapled closed. This part of the stomach is not removed. The new stomach pouch is then connected to the small intestine. This is done by dividing the intestine approximately 40cm from the stomach and attaching the distal part to the stomach pouch. The proximal part of the divided intestine is then connected to the side of the intestine that was previously attached to the pouch. The roux limb is that part of the intestine between the stomach pouch and the connection to the proximal small intestine.

The difference between short limb (or proximal) and long limb (or distal) gastric bypass is the length of the roux limb. Long limb gastric bypass results in more malabsorption than short limb gastric bypass.

Laparoscopic vs Open

The most significant recent advance in bariatric surgery is the technique of laparoscopy. Using laparoscopy, Roux-en-Y gastric bypass can be done with five small incisions rather that one large incision. Otherwise the laparoscopic procedure is the same as the open procedure. The laparoscopic approach results in less pain, quicker recovery, shorter hospital stay, less scarring, and quicker return to normal activity. Complications related to the incision, such as infections and hernias, are nearly eliminated with the laparoscopic approach.

Despite these benefits of laparoscopic surgery, only a small percentage of gastric bypasses are currently being done laparoscopically. This is because the laparoscopic approach is new and is difficult to learn. Research completed by Dr. Oliak demonstrated the difficulty of learning laparoscopic gastric bypass. Dr. Oliak found that complication rates and operative times are much higher during a surgeon's first 75 laparoscopic gastric bypasses. Complication rates and operative times stabilize at low rates beyond 75 procedures. The importance of this is that an experienced laparoscopic gastric bypass surgeon is essential for good outcomes. Dr. Owens, Dr. Hajduczek and Dr. Oliak have combined experience of well over 600 laparoscopic bariatric procedures, operations, and bypasses (including laparoscopic revisions). Not all patients are appropriate for laparoscopy. Open gastric bypass is probably better for patients with BMI's of 60 or higher (more than 200 pounds overweight). Other research completed by Dr. Oliak demonstrates that serious complications occur more often in patients with BMI's of 60 or higher after the laparoscopic approach. Open surgery is likely safer in this group of patients.

Results of Gastric Bypass

* One-two years after surgery, weight loss averages 65-80% of excess weight.
* 10 years after surgery, weight loss averages 55% of excess weight.
* Associated medical problems, such as diabetes, hypertension, sleep apnea, joint pain, and heartburn are improved or resolved in more than 90% of patients.

Risks of Gastric Bypass

Adjustable Gastric Banding (LAP-BAND®)

Adjustable gastric banding operations have been performed for the treatment of obesity in Europe and Australia for many years with proven effectiveness and safety . The LAP-BAND®, a type of adjustable gastric band, was recently approved (June 2002) for use in the United States. It is an attractive procedure because it is less invasive than a gastric bypass, adjustable, and reversible.

Operation

The LAP-BAND® consists of a silicone inflatable band and an attached access port (see picture). The band is placed around the top part of the stomach (like a belt) to form a narrow constriction. This functionally divides the stomach into a small (15cc) proximal gastric pouch and the large remainder of the stomach. Eating small amounts fills the pouch and causes a feeling of fullness. The access port is implanted under the skin of the abdomen and connected to the band via a small tube. After surgery the tightness of the band can be adjusted for optimal weight loss by injecting or removing saline from the access port. The operation is performed laparoscopically using five small incisions. The operation takes about an hour and patients can usually go home the day of surgery or the morning after.

Results

* Long-term weight loss 40-60% of excess weight
* Weight loss 1-2 pounds per week after surgery

Risks

* Vitamin and mineral deficiencies (usually can be prevented by taking supplements)
* Infection, bleeding, blood clots, band slippage, and band erosion

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