Good Samaritan Hospital is currently offering the Laparoscopic and Open Gastric Bypass and the Laparoscopic Adjustable Gastric Band (LAP-BAND).

Gastric Bypass Roux-en-y

According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.

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.

LAP-BAND®

Approved by the FDA in June 2001, the BioEnterics® LAP-BAND Adjustable Gastric Banding System is the newest and the only adjustable surgical treatment for morbid obesity in the United States. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed. Since its clinical introduction in 1993, more than 100,000 LAP-BAND procedures have been performed around the world.



Minimally Invasive Approach
During the procedure, surgeons usually use laparoscopic techniques (using small incisions and long-shafted instruments), to implant an inflatable silicone band into the patient's abdomen. Like a wristwatch, the band is fastened around the upper stomach to create a new, tiny stomach pouch that limits and controls the amount of food you eat. It also creates a small outlet that slows the emptying process into the stomach and the intestines. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. In turn, this results in weight loss.

Least Traumatic Procedure
Since there is no cutting, stapling or stomach re-routing involved in the LAP-BAND System procedure, it is considered the least traumatic of all weight loss surgeries. The laparoscopic approach to the surgery also offers the advantages of reduced post-operative pain, shortened hospital stay and quicker recovery. If for any reason the LAP-BAND System needs to be removed, the stomach generally returns to its original form.

Adjustable Treatment
The LAP-BAND System is also the only adjustable weight loss surgery. The diameter of the band is adjustable for a customized weight-loss rate. Your individual needs can change as you lose weight. For example, pregnant patients can expand their band to accommodate a growing fetus, while patients who aren't experiencing significant weight loss can have their bands tightened.



To modify the size of the band, its inner surface can be inflated or deflated with a saline solution. The band is connected by tubing to an access port, which is placed well below the skin during surgery. After the operation, the surgeon can control the amount of saline in the band by entering the port with a fine needle through the skin.


The LAP-BAND System

The LAP-BAND® System Advantage

Minimal Trauma

Least invasive surgical option

No intestinal re-routing

No cutting or stapling of the stomach wall or bowel

Reduced patient pain, hospital length-of-stay and recovery period

Fewer Risks and Side Effects

Significantly lower mortality risk than other obesity surgery procedures¹

Low risk of nutritional deficiencies associated with gastric bypass

Reduced risk of hair loss

No “dumping syndrome” related to dietary intake restrictions

Adjustable

Allows individualized degree of restriction for ideal, long-term weight loss

Adjustments performed without additional surgery

Supports pregnancy by allowing stomach outlet size to be opened for increased nutritional needs

Reversible

Removable at any time

Stomach and other anatomy are generally restored to their original forms and functions

Effective Long-Term Weight Loss

More than 100,000 cases performed worldwide

Standard of care for hundreds of practices around the world

Academic publications with up to 7 years of follow-up

Transforming Lives
The LAP-BAND System is an effective treatment for morbid obesity and can help you achieve lasting results by limiting food intake, reducing appetite and slowing digestion. But the pounds do not come off by themselves. It is important to understand that you play an active role in the weight-loss process and ultimate success of the procedure. LAP-BAND system patients should expect gradual weight loss, approximately 1-2 pounds per week on average over the first year. Your individual weight-loss results may vary.

A Sample of Published Results From Around the World	% of Excess Weight Lost	Years of Patient Follow Up	# of Patients Studied
Rubenstein, et al, US2	53.6%	3	63
Dargent, France3	64%	3	500
O’Brien et al, Australia4	68.2%	4	302
Nehoda et al, Austria5	72%	1	250
Forestieri et al, Italy6	88.5%	2	62
Fielding et al, Australia7	68%	3	620

Contraindications
The LAP-BAND® System is not right for you if:

You have an inflammatory disease or condition of the gastrointestinal tract, such as ulcers, severe esophagitis, or Crohn's disease.

You have severe heart or lung disease that makes you a poor candidate for surgery.

You have some other disease that makes you a poor candidate for surgery.

You have a problem that could cause bleeding in the esophagus or stomach. This might include esophageal or gastric varices (a dilated vein). It might also be something such as congenital or acquired intestinal telangiectasia (dilation of a small blood vessel).

You have portal hypertension.

Your esophagus, stomach, or intestine is not normal (congenital or acquired). For instance you might have a narrowed opening.

You have or have experienced an intra-operative gastric injury, such as a gastric perforation at or near the location of the intended band placement.

You have cirrhosis.

You have chronic pancreatitis.

You are pregnant. (If you become pregnant after the BioEnterics LAP-BAND System has been placed, the band may need to be deflated. The same is true if you need more nutrition for any other reason, such as becoming seriously ill. In rare cases, removal may be needed.)

You are addicted to alcohol or drugs.

You are under 18 years of age.

You have an infection anywhere in your body or one that could contaminate the surgical area.

You are on chronic, long-term steroid treatment.

You cannot or do not want to follow the dietary rules that come with this procedure.

You might be allergic to materials in the device.

You cannot tolerate pain from an implanted device.

You or someone in your family has an autoimmune connective tissue disease. That might be a disease such as systemic lupus erythematosus or scleroderma. The same is true if you have symptoms of one of these diseases.

Your Motivation
While the LAP-BAND System is an effective treatment for morbid obesity, the pounds do not come off by themselves. The LAP-BAND System is an aid to support you in achieving lasting results by limiting food intake, reducing appetite and slowing digestion. However, your motivation and commitment to adopt a new lifestyle are extremely important for long-term weight loss. New eating habits must be adhered to for the rest of your life. Exercise is an equally important component of a changed lifestyle.

Risk Information

A brief description of relevant contraindications, warnings and adverse events of the LAP-BAND® System

Indications: The LAP-BAND System is indicated for use in weight reduction for severely obese patients with a Body Mass Index (BMI) of at least 40 or a BMI of at least 35 with one or more severe co-morbid conditions, or those who are 100 lbs. or more over their estimated ideal weight.

Contraindications: The LAP-BAND System is not recommended for non-adult patients, patients with conditions that may make them poor surgical candidates or increase the risk of poor results, who are unwilling or unable to comply with the required dietary restrictions, or who currently are or may be pregnant.

Warnings: The LAP-BAND System is a long-term implant. Explant and replacement surgery may be required at some time. Patients who become pregnant or severely ill, or who require more extensive nutrition may require deflation of their bands. Patients should not expect to lose weight as fast as gastric bypass patients, and band inflation should proceed in small increments. Anti-inflammatory agents, such as aspirin, should be used with caution and may contribute to an increased risk of band erosion.

Adverse Events: Placement of the LAP-BAND System is major surgery and, like any surgery, death can occur. Possible complications include the risks associated with the medications and methods used during surgery, the risks associated with any surgical procedure, and the patient’s ability to tolerate a foreign object implanted in the body.

Band slippage, erosion and deflation, obstruction of the stomach, dilation of the esophagus, infection, or nausea and vomiting may occur. Reoperation may be required.

Rapid weight loss may result in complications that can require additional surgery. Deflation of the band may alleviate excessively rapid weight loss or esophageal dilation.

Not all contraindications, warnings or adverse events are included in this brief description. More detailed risk information is available at http://www.lap-band.com or 1-877-LAP-BAND.

REFERENCES

1. Executive summary: Laparoscopic adjustable gastric banding for the treatment of obesity (Update and Re-appraisal). The Australian Safety and Efficacy Register of New Interventional Procedures - Surgical (ASERNIPS) 2002: 1. (Laparoscopic adjustable gastric banding surgery, like the LAP-BAND surgery, is associated with a mean short-term mortality rate of around 0.05% compared to 0.50% for Gastric Bypass and 0.31% for Vertical Banded Gastroplasty.)
2. Rubenstein R. Obes Surg 2002; 12: 380-384.
3. Dargent J. Laparoscopic adjustable gastric banding: lessons from the first 500 patients in a single institution. Obes Surg 1999 Oct; 9 (5): 446-52.
4. O’Brien PE et al. Propsective study of a laparoscopically placed, adjustable gastric band in the treatment of morbid obesity. Br J Surg 1999 Jan: 86(1): 113-8.
5. Nehoda H et al. Results and complications after adjustable gastric banding in a series of 250 patients. Am J Surg 2001 Jan; 181(1): 12-5.
6. Forestieri P et al. Two years of practice in adjustable silicone gastric banding (LAP-BAND): evaluation of variations of body mass index, percentage ideal body weight and percentage excess body weight. Obes Surg 1998 Feb; 8(1): 49-52.
7. Fielding G. LAP-BAND® Experience with 620 Cases over Forty-Five Months. Obes Surg 2000; 10: 143.