Α. Restrictive procedures

Restrictive procedures make the stomach smaller to limit the amount of food intake.

Restrictive procedures reduce the amount of food intake during a single meal to increasingly create an early feeling of satiety. Sleeve gastrectomy is the most common and up-to-date restrictive surgery. Other less frequent alternative procedures are considered to be gastric band, gastric balloon, gastric plication, and vertical band gastroplasty.

Gastric band

The gastric band (adjustable gastric band or “lap band”) is a silicone device placed around the top portion of the stomach, which is thus divided into two parts. The gastric tube (sleeve) created in this way has very small capacity, thus reducing the amount of food consumed.

Its placing technique is easy and is performed laparoscopically. In the past, it was excessively performed by surgeons, without strictly complying with indications; this resulted in poor long term results and high failure rates regarding the desired weight loss.

This method tends to be abandoned and most bariatric surgery centers now turn to other procedures. This is due to the poor results in maintaining the weight loss but also to the band placement complications. Such complications may be severe and dangerous and include gastric pouch dilation (which results in vomiting, regurgitation, gastric content aspiration), esophagus dilation, bad slippage or stomach perforation, stomach twisting, adjacent organ erosion, mechanical problems related to the device (inflammation at the point of entry, tube rupture, port-valve displacement, etc.). Both the occurrence of the above complications and failure to achieve weight loss, often make its removal necessary. This may be doubled or not with a concurrent procedure or restrictive or malabsorptive type. Band removal may become technically difficult at times. Opinions differ regarding the appropriate time to perform a second procedure (e.g. sleeve gastrectomy) when a gastric band is already in place.

• At our center we implement the laparoscopic technique of simultaneous gastric band removal of sleeve gastrectomy during the same surgical procedure with spectacular results, provided that the band did not erode or rupture the stomach wall.

Sleeve gastrectomy

The laparoscopic longitudinal / vertical sleeve gastrectomy (VSG) is the procedure that has lately gained widespread popularity for the treatment of morbid obesity, offering better immediate and long-term results. In sleeve gastrectomy the fundus and the bigger part of the body are resected and the stomach is reduced to a narrow tube (“sleeve”) with very small capacity. By reducing the size of the stomach, this procedure also limits the amount of food ingested and increases postprandial satiety, thus decreasing appetite and the feeling of hunger.

Sleeve gastrectomy presents many advantages and strengths:

• It is an absolutely safe procedure with extremely rare complications.
• Patients can lose up to 70% of their excess weight at 1 year following surgery.
• There are no foreign objects implanted in the body.
• It does not affect vitamin or nutrient absorption.
• Ghrelin levels are lower after resection of the fundus, therefore decreasing the feeling of hunger.
• It also minimizes the chance of developing ulcers and can be successfully performed in patients with co-morbidities.
• Patients have shorter hospital stay; they soon return to their normal daily activities and easily adjust their diet accordingly.
• Even in the very rare case of unsuccessful surgery, there is still the option of switching to another procedure type.

Three-port sleeve gastrectomy

The laparoscopic longitudinal gastrectomy is traditionally performed via 5-7 ports-trocars. Pain and the risk of hernias are minimized by reducing the number of trocars. Recently, a new technique has been described at international conferences and applied, helping us reduce the number of ports to 3, one of which is made inside the navel and is practically invisible. Esthetic results are better and so is postoperative pain.

According to this technique, a stitch is introduced under direct laparoscopic viewing on the right crus of the diaphragm, which improves the surgical field. Moreover, the stomach is divided before the major arc is detached thus making the additional trocar unnecessary. These are two technical details that do not alter the main operative times; they eliminate the need of two additional incisions, therefore performing the operation via 3 small ports in total. It should be noted that surgeons need to be highly experienced and familiar with advanced laparoscopic surgery to achieve the desired results safely for the patient.

B. Malabsorption procedures

Malabsorption procedures drastically limit calorie and energy uptake from the intestine. Digestive tract anatomy is modified in order to cause malabsorption, i.e. limit the capacity of the intestine to absorb nutrients. The stomach is linked to the terminal portion of the small intestine and this way food passes through a small part of the gastrointestinal tract only. This reduces the nutrients absorption significantly and the patient has an early feeling of satiety. This also separates the path of food and the path of the digestion peptides. Likewise, daily calorie intake may be reduced even by 30%. Malabsorption procedures achieve higher weight loss. They have, however, the most serious adverse effects such chronic diarrhea, vitamin, ferrum and calcium deficiency. They include enterectomy and intestinal by-pass.

C. Mixed procedures

They reduce the capacity of the stomach but mainly the absorption of nutrients in food. Thus, they are quite effective regarding weight loss. However, these are much more complicated procedures with higher risk of complications such as liver failure, cirrhosis, anemia, nephrolithiasis, vitamin insufficiency and cholelithiasis.

Gastric bypass, long and mini, and biliopancreatic diversion techniques also belong in this category of procedures.

Roux en-Y gastric by-pass

It consists of creating a new stomach pouch (of a stomach portion), which is directly connected to the small intestine. This way, food bypasses the remaining part of the stomach, the pylorus and duodenum. It combines characteristics typical of both restrictive and malabsorptive procedures as it bypasses a large part of the intestine where carbohydrates and fat are absorbed. It is the procedure of choice for a number of conditions, such as diabetes mellitus and other metabolic disorders.  This is a rather complicated and long surgical procedure because in comprises two anastomoses. Moreover, patients should receive food supplements for the rest of their lives due to vitamins and minerals malabsorption, and they should be regularly followed by a nutritionist. Dumping syndrome is another potential adverse effect that follows consumption of food rich in carbohydrates and fats.

Mini gastric by-pass

It is a variation of the gastric bypass. The procedure is simpler and consists of creating a single anastomosis (omega loop anastomosis). A small gastric sleeve is created which connects the part of the small intestine that is located at a distance of 2 meters approximately before the end of the duodenum.

Biliopancreatic diversion with or without duodenal switch

It is considered as a mixed procedure, but is mainly a malabsorptive procedure due to the extensive bypass and the relatively large gastric stump. Biliopancreatic diversion (Scopirano’s procedure) consists of an extensive partial gastrectomy that leaves a stomach remainder of 150-250 ml and a reconstruction of the digestive tract. The stomach stump undergoes a terminolateral anastomosis with ileum forming a gastric curvature measuring 2.5 m in length. The remaining small intestine (2-3 m) forms the biliopancreatic curvature. This curvature is anastomosed with the terminal ileum 50 cm away from the ileocecal valve. This procedure comprises of preventive cholecystectomy and occasionally appendicectomy. Biliopancreatic diversion by Scopirano creates serious fat malabsoprtion and lower carbohydrate and protein malabsorption.

Duodenal switch consists of a vertical gastrectomy and digestive tract reconstruction, pylorus sparing and intestinal loop anastomosis with the proximal duodenum and creation of a common canal, 50-100cm long, by connecting the intestinal to the biliopancreatic loop. Pylorus preservation limits the dumping syndrome implications (diarrhea, vomiting).

Despite the good results these procedures have achieved in weight loss, they are serious surgical procedures with serious metabolic complications such as malnutrition, severe vitamin malabsorption, need for long term food supplements, steatorrhea, even liver failure.

CONCLUSIONS

• There is no ideal method – they all have advantages and disadvantages.
• All procedures for treating obesity are now laparoscopically performed.
• We recommend longitudinal sleeve gastrectomy for the majority of cases, provided that it will be performed by an experienced surgeon with minimum number of incisions (3 incisions).