Surgeons first began to recognize the potential for surgical weight loss while performing operations that required the removal of large segments of a patient's stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the last decade these procedures have been continually refined in order to improve results and minimize the risks. Today's bariatric surgeons have access to a substantial body of clinical data to help them determine which surgeries should be used and why.

Malabsorptive Proceedures

Restrictive Proceedures

• Vertical Banded Gastroplasty
• Adjustable Gastric Banding

Combined Restrictive and Malabsorptive procedures

• Roux en Y Gastric Bypass (the "Gold Standard" in North America) 

Jejunoileal Bypass (JIB, not performed any more)

The procedure involves bypassing large parts of the absorptive capacity of the gut. JIB is generally considered to be of historical interest, rarely undertaken today due to its unacceptably high morbidity and mortality rates. People are affected by the malabsorption of carbohydrate, protein, lipids, minerals and vitamins. Other complications of JB include:

• diarrhea due to irritation of the colon by bile acid and fat usually absorbed in the small intestine
• increased risk of cholesterol stones in the gallbladder
• hepatic cirrhosis
• osteoporosis
• osteomalacia
• neuropathy; and night blindness associated with mineral and vitamin deficiency.

As a consequence, this procedure is not recommended; people with such a procedure still intact are carefully monitored and early reversal is considered.

IF YOU HAD THIS PROCEDURE PERFORMED, CONSULT AN EXPERIENCED BARIATRIC SURGEON.

Biliopancreatic Diversion (Scopinaro's operation)

Biliopancreatic diversion was first reported in 1978 by Dr. Nicola Scopinaro and has become popular in Europe. It involves cutting out half the stomach to limit oral intake, followed by the construction of a long limb Roux en Y anastomosis with a short, common, alimentary channel of 50-100 cm in length. This causes malabsorption to maintain weight loss. As the procedure does not defunctionalise any part of the small intestine, fewer liver problems are observed. Biliopancreatic diversion is considered to be a technically demanding procedure with an operative mortality of 1-2% and a major perioperative morbidity of 10%.

Complications of the procedure include:

• loose stools
• stomal ulcers
• offensive body odor
• foul smelling stools
• flatus
• anastomotic ulceration
• protein malnutrition
• hypoalbuminaemia
• anemia
• edema
• asthenia
• alopecia

Biliopancreatic Diversion with Duodenal Switch (Quebec city operation)

In an attempt to overcome these complications, particularly stomal ulceration and diarrhea, several variants of the procedure have been developed. Sleeve resection of the stomach maintains continuity of the gastric lesser curve, while the duodenal switch maintains continuity of the gastroduodeno jejunal axis. Despite the complications, it is considered to be an attractive option as patients may remain on a totally free diet in all instances.

Complications of the procedure include:

• loose stools
• stomal ulcers
• offensive body odor
• foul smelling stools
• flatus
• anastomotic ulceration
• protein malnutrition
• hypoalbuminaemia
• anemia
• edema
• asthenia
• alopecia

Gastroplasty involve the partitioning of the stomach into two parts. Using surgical staples, a small segment at the top of the stomach is partially separated from the remainder of the stomach, with only a small gap remaining. The intention is to cause the individual to have the sensation of fullness from a limited intake of food, a consequence of the reduced capacity of the small upper segment of the stomach and the slow emptying through the small gap into the remainder of the digestive system. In addition, a polypropylene band is used around the lower end of the vertical pouch to prevent stretching. This procedure has the advantage of being a restrictive procedure with no malabsorption component or dumping. Postoperative mortality rates are relatively low (1%). Revision rates requiring further surgical intervention are often high at approximately 30%.

Specific complications include:

• bolus obstruction
• anemia
• calcium or vitamin deficiencies
• leakage of the staple line
• stenosis of the outlet
• ulcer at the outlet
• staple line disruption
• pouch dilation
• band erosion
• incisional hernia
• wound infection

Adjustable Gastric Banding

Adjustable Gastric banding limits food intake by placing a constricting ring completely around the stomach below the junction of the stomach and esophagus. While early bands were non adjustable, those used currently incorporate an inflatable balloon within their lining to allow adjustment of the size of the stoma to regulate food intake. Today, gastric bands are placed through laparoscopic surgery, decreasing wound complication rates and time spent in hospital to one day, with patients returning to work within 7 days. Adjustment is undertaken without the need for surgery by adding or removing an appropriate material through a subcutaneous access port. As a restrictive procedure, Gastric Banding avoids the problems associated with malabsorptive techniques such as anemia, dumping and vitamin/mineral deficiencies.

Complications associated with Gastric Banding include:

• splenic injury
• esophageal injury
• wound infection
• band slippage
• reservoir deflation/leak
• persistent vomiting
• failure to lose weight
• acid reflux.

 Roux-en-Y Gastric Bypass (the "Gold Standard" in North America)

The Roux en Y gastric bypass procedure combines restriction and malabsorption techniques, creating both a small gastric pouch and a bypass that prevents the patient from absorbing all they have eaten. The Roux en Y procedure involves the partition of the upper part of the stomach using surgical staples to create a small pouch with a small outlet (gastroenterostomy stoma) to the intestine that is attached to the pouch. The Roux en Y technique is used to avoid loop gastroenterostomy and bile reflux that may ensue. Adaptations of the procedure include lengthening of the Roux en Y limb to 100-150 cm to increase both malabsorption and weight loss. Often, a prosthetic band, such as a Silastic ring or Gortex band, is positioned above the junction of the gastric pouch and small intestine to stabilize the gastroenterostomy, preventing late stretching of the opening and improving long term weight control

Complications associated with the surgery include: failure of the staple partition

• leaks at the junction of the stomach and small intestine
• acute gastric dilatation
• lung failure
• blood clots
• wound infections
• fluid collection
• vomiting caused by narrowing of the stoma
• wound hernia
• intestinal obstruction
• anemia
• vitamin B12 and calcium deficiency
• dumping syndrome (rapid heart beat, nausea, tremor, a faint feeling and diarrhea)