About the Gastric Bypass Surgery

There have been many operations done over the past forty years to assist patients in controlling their weight. Some have proven to be more effective than others, and some have more side effects. Today in the United States, the two most commonly performed operations are gastric bypass surgery and the vertical banded gastroplasty. I, like most bariatric surgeons, now exclusively perform the gastric bypass surgery because it has proven, in the long term, to provide greater weight loss with minimal side effects.

     The Gastric Bypass Surgery

The gastric bypass surgery has been performed with minor variations since 1968. It has been shown to be effective in controlling morbid obesity in the long term.

The gastric bypass operation is designed to limit the amount of food you eat. This is done by stapling and dividing the stomach (A) (stomach stapling). The "new stomach", also called the pouch, is only about 5-10% the size of the "old stomach" and holds less food. The pouch (B) is about the size of a golf ball as opposed to a normal stomach, which is about the size of a football. The pouch is designed to be permanent, although it is reversible. I do not remove any part of the stomach or other tissue while doing the gastric bypass operation.

When food enters the pouch, it must have a way to leave. An opening is made from the pouch to the small intestine (C). This opening is called a stoma and is about the size of a dime. The opening is made small so that food empties slowly and the sensation of being full or satisfied lasts longer. Because the opening leaving the pouch is small, you must cut your food into small pieces and chew it well for food to be able to pass easily.

It is possible to damage the pouch and stoma by overeating. This could result in stretching the pouch and dilating the stoma. If this occurs, your weight loss and long term results will not be as good. I know this may happen, so I initially make the pouch and stoma extra small to compensate for some stretching and dilation. I simply ask you to do your best to take care of your new pouch and stoma.

In the type of gastric bypass procedure I perform, a type of intestinal connection is created (C & D). This is called a Roux-en-Y. The part of the small intestine that is attached to the pouch , does not metabolize refined sugars well. Approximately 50% of people who undergo this operation may have difficulty with foods or liquids high in refined sugar (table sugar). If you are one of those people, after the operation if you consume a large amount of refined sugar (chocolate bar/cheesecake/syrup), you may not feel well for 5-20 minutes. When large amounts of sugar enter the pouch attached to the intestine, a signal goes to the pancreas to secrete insulin. Insulin lowers your blood sugar and this can give patients what is called "dumping syndrome." Symptoms may include a cold sweat, an ill stomach, and/or possible diarrhea. In general, this is unpleasant and people would not intentionally experience it again. This mechanism assists in keeping patients from consuming large amounts of calorie rich sugar and helps in weight reduction. The normal amount of sugar in what is not considered desserts or snack food will generally not cause these symptoms.

The bottom part of the stomach is not removed (see diagram E) and continues to function. The bottom part of the stomach will secrete the gastric juices as before and they empty into the small intestine to mix with the food and assist in digestion.

The three mechanisms by which patients lose weight after the gastric bypass surgery are:

1. The pouch is very small and holds only a tiny portion of food.
2. The size of the opening, called the stoma, allows food to empty only slowly from the pouch.
3. A large number of patients have the inability to tolerate large amounts of refined sugar.

As mentioned before, this operation has been performed for over 35 years and at present there is no evidence of a higher rate of gastric cancer, but the incidence after 35 years is not known.

Your weight loss begins immediately after the operation. The majority of people will continue to lose weight for approximately 12 months. The amount of weight a patient will lose every month will vary depending upon the height and weight prior to surgery. A reasonable expectation is to expect to lose 50% or more of your excess body weight and many patients will get to within 30-40 pounds of their ideal body weight. In general, the weight loss is complete within 12 months and may plateau unless you institute an exercise program. The percent of weight loss among different patients varies and depends upon a number of factors such as exercise, food choices, and daily calorie requirements.

When people lose large amounts of weight, there are three areas of the body that may have excess skin. These are the tummy, the back of the upper arms, and the thighs. While an exercise program will help tone muscle and assist in reducing the amount of redundant skin, it may not completely solve the problem. The most common area to be affected is the tummy. I recommend that patients wait until their weight loss is complete and should this be a problem, I write the insurance companies for approval to remove the excess skin and perform a tummy tuck. I have had good success in getting approval to perform this procedure in the past. However, it is more difficult to get insurance approval for the upper arm and the thighs, though this is much less frequently a problem.

This operation also assists in weight loss by creating a small pouch. It does not involve any intestinal connection. It has been popular in the past and I have also performed this procedure, but have had been less satisfied with the total weight lost by my patients and have noticed a most troublesome tendency for weight gain 2-3 years after the operation. Two problems with this procedure are a tendency for the staples to disrupt, allowing patients to consume larger quantities of food, and no intolerance for refined sugars.

The intestinal bypass, as the name implies, bypasses all but two feet of the intestine. Many patients lost large amounts of weight, but suffered problems such as: diarrhea 10-15 times per day, electrolyte abnormalities, dehydration, kidney stones, and liver problems. This is an operation no longer performed today. I recommend against it and have reversed many patients who have had this operation and converted them to gastric bypass.

This is a relatively new operation developed by Dr. Scopinaro and others in Europe. It involves removing part of the stomach and bypassing much of the small intestine. It appears to be effective in controlling weight, but at the cost of malnutrition. I would at this time recommend against this operation.

This is an operation that reduces the size of the stomach and bypasses a large part of the small intestine. In lay terms it`s like a hybrid of the biliopancreatic/intestinal bypass and a gastric stapling procedure. The hope here is to provide a patient the advantages of other procedures and at the same time to eliminate the side effects of the same procedures. It appears to provide reasonable weight loss and to some extent lessen though not eliminate the metabolic side effects of bypassing the intestine. This is not a procedure that has been done for nearly as long as the gastric bypass operation. I would also recommend against this operation to my patients at this time.

The First Step

The first visit is an information session in our Lexington, KY office. I go over the operation in detail and perform an in-depth history and physical exam. This also affords you an opportunity to have all questions addressed. This usually takes 45 minutes with the me. Then you meet with my staff who discuss with you the approval process as well as the pre-op testing.

The Second Step

The second step involves a psychological evaluation. This is done to make sure that candidates for the operation are psychologically stable, they understand the procedure, and are capable of appropriate follow-up in the office.

The Third Step

Most, if not all, insurance companies require prior written authorization of the operation prior to hospitalization. This means a summary letter must be sent to your insurer which includes both the history and physical examination results along with the psychological evaluation. This can be time consuming and may take 4-6 weeks. In addition, if your insurance company requests further information, this will take additional time. I understand that it can be difficult to be patient, but I have found that persistence and patience are generally well rewarded. When we hear from your insurance company we will contact you immediately and if an approval has been received, I can generally perform the operation within two weeks. This can be scheduled as conveniently as possible for you.

Gastric Bypass Hospital Stay

The vast majority of patients are admitted the morning of surgery and would be discharged three days after the day of surgery. Exceptions to this would be patients who are over 400 pounds and who have severe fluid retention. These patients may need to be admitted 1-2 days prior to the day of surgery to treat the fluid retention and improve their breathing capacity. These patients may also need to be in the hospital 1-2 days longer after surgery, but most patients are in the hospital a total of four days.

Any operation, no matter how big or small, has the potential for complications. This is a major operation and the potential complications include, but are not exclusive to: wound infection, incisional hernia, bleeding, blood clots in the legs or lungs, heart failure, heart attack, abscess, bowel obstruction, and other potentially serious complications. Minor complications include: wound infection, mild pneumonia, blood clots in the legs, and wound healing problems. With a severe complication, death could result. I have been involved in bariatric surgery since 1986. It is rare for my patients to have a major or even minor complication. We do everything surgically and medically to prevent these things from happening. You need to understand that any surgical procedure involves some risks before proceeding with the proposed operation.

After your stay in the hospital, you will be sent home when I am satisfied that you are doing well and can either care for yourself or have made appropriate arrangements for some assistance at home for a few days. I will see you back in the office, approximately 10 days after discharge. At that time, I normally will remove your skin staples and usually tell people they can drive provided they have power steering, power brakes and automatic transmission. During the ten days you are home before your first office visit, you will be on a liquid diet which includes Popsicles, broth, jello, fruit juices, fruit punch, and decaffeinated tea or coffee. After your first visit, you will be started on a full liquid diet which includes cooked cereals, strained soups, skim milk, plain yogurt, juices and other foods. I will see you back in the office 10-14 days later and at that time start you on a pureed diet which includes fruits, vegetables, cooked meats, poached eggs, toast and crackers, etc. I will see you back in the office approximately two weeks after that and at which time you will be started on a regular diet. Recovery time is generally 4 to 6 weeks. I recommend that all of my patients take a multivitamin with minerals once a day, every day for life.

The first year after surgery, I would like to see you every three months to answer any questions that you might have and to make sure that your weight loss continues. The second year, I would like to see you twice and then, if possible, once a year every year thereafter.

E-mail us with any questions or to set up an appointment for a gastric bypass consultation at The Bariatric Institute of Kentucky in Lexington, KY.