Ki H. Oh, M.D., FACS.

Thomas Hirai, M.D.

200 S 333rd St., Suite 150
Federal Way, WA 98003
Phone: 253-275-6030
Fax: 253-946-0428
Clinic Manager: Ginger Rhodes

Types of Surgeries
The American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:

• Restrictive procedures that decrease food intake.
• Mal-absorptive procedures that alter digestion, causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.

Roux-En-Y Gastric Bypass—Proximal, Medial and Distal
Adjustable Gastric Band (LAP-BAND, Realize Band)
Duodenal Switch
Sleeve Gastrectomy
Laparoscopic Gastric Bypass

Roux-En-Y Gastric Bypass
Considered the “gold standard” of modern obesity surgery, Roux-En-Y gastric bypass offers an excellent combination of maximum weight control and minimum nutritional risk. This operation achieves its effectiveness by creating a very small pouch (thumb-sized) from which the rest of the stomach is permanently divided and separated. The small intestine is cut and rearranged to provide an outlet to the small stomach, while maintaining the flow of digestive juices at the same time. The lower part of the stomach is bypassed and food enters the second part of the small bowel within ten minutes of the beginning of a meal.

The operation reduces food intake, reduces the feeling of hunger, and with mal-absorption of the nutrients that are eaten, reduces the caloric intake even further.

This procedure provides an excellent tool for gaining long-term control of weight without the hunger or cravings usually associated with small portions or with dieting. Weight loss of 80 percent to 100 percent of excess body weight is achievable for most patients. Long-term maintenance is very successful with adherence to a simple and straightforward behavior regimen. This procedure is the most common of the gastric bypass procedures. It can be done laparoscopically or with an open incision.

 Three types of Roux-En-Y gastric bypass are available:

Proximal: The most common surgical weight loss procedure today, this is the least aggressive gastric bypass. It reduces absorptive capacity of the small intestine by 20 percent. Five-year weight loss averages 50 to 75 percent in most studies.

Medial: This moderately aggressive gastric bypass reduces the absorptive capacity of the small intestine by 50 percent. Five-year weight loss averages 70-80 percent in most studies.

Distal: This most aggressive gastric bypass reduces the absorptive capacity of the small intestine by 70-80 percent. More than half of calories ingested are not absorbed. In a study conducted by Surgical Weight Loss Clinic in Tacoma, patients had lost 89 percent of excess weight after five years. The distal patient must take more vitamin, mineral and protein supplements than other bypass patients. The five year weight loss averages 75 to 85 percent.
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 Adjustable gastric band (AGB, LAP-BAND®, Realize Band^TM)
The newest obesity surgery technology, approved by the Food and Drug Administration in June 2001, is the adjustable gastric band (AGB). Gastric band is a variation of gastroplasty, in which the stomach is neither opened nor stapled. In the AGB procedure, a restrictive band is placed around the upper part of the stomach so that the patient feels full after just a few bites of food. The band is made of implantable silicone rubber and contains an adjustable balloon. This allows adjustment of the band without another operation. Advantages of this procedure include:

• It can be inserted laparascopically without a large incision
• It does not require any opening in the gastrointestinal tract, reducing the risk of infection
• There is no staple line to come apart
• It is adjustable. By increasing or decreasing the size of the band, the doctor can control the amount of food able to pass between the two parts of the stomach, according to each patient’s individual weight loss needs.

The AGB is the least invasive, most reversible of the surgical weight loss procedures, and results in an average 75 percent weight reduction after three years.

In roughly 97 percent of cases, the operation is done laparascopically (using several small incisions in the abdominal wall) on an outpatient basis. People who have this procedure typically check into the hospital in the morning, have surgery, and return home the same day or the next morning. The band can be removed if complications arise.

Duodenal Switch
This complex and less-often performed procedure generates weight loss through restriction and mal-absorption. In duodenal switch, most (85 percent) of the stomach is permanently removed, creating a pouch with about a six-ounce capacity. While a segment of the small intestine is divided and rearranged, no portion of the intestine is removed. Advantages of this procedure include:

• It is very effective in patients with a high BMI (greater than 55)
• There is no dumping syndrome—the pylorus remains intact

Significant mal-absorption can cause anemia, protein deficiency and metabolic bone disease; thus this procedure is generally limited to very morbidly obese patients whose compromised health warrants the higher risks associated with this procedure.
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Sleeve Gastrectomy
This is the newest available weight loss procedure. It creates weight loss by restricting food intake. It is usually performed on highly obese or at-risk patients, to provide weight loss and allow for a second surgery—a gastric bypass or duodenal switch—to be performed later. However, it may also be used on its own, as both risk and weight loss are more moderate compared with other surgeries. A little over half of the stomach is removed laparascopically, leaving the remaining stomach in the shape of a sleeve. Most patients will lose 30-50 percent of their excess body weight over a 6-12 month period with gastric sleeve alone. If further surgery is desired, gastric sleeve may be followed by a gastric bypass or duodenal switch, typically 6-18 months following initial surgery.

 Laparoscopic gastric bypass (LGB)
One of the most time-tested procedures for long-term weight loss is gastric bypass surgery where surgeons create a pouch within the stomach, then attach one half to one third of the small intestine to it, bypassing the rest of the stomach.

Digestion occurs about two thirds of the way into the intestine, so a large part of what the patient eats remains undigested and the calories are not absorbed.

Once done mostly through traditional, open surgery, this procedure can now be done laparascopically, usually performed as day surgery with an overnight stay. The procedure offers a faster recovery time with excellent outcomes. Celebrities Al Roker, Carnie Wilson and Anne Wilson all have had the LGB procedure.
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