Roux-en-Y Gastric Bypass

RYGB restricts food intake. RYGB also decreases how food is absorbed. Food intake is limited by a small pouch similar in size to the pouch created with AGB. Also, sending food directly from the pouch into the small intestine affects how the digestive tract absorbs food. The food is absorbed differently because the stomach, duodenum, and upper intestine no longer in contact with food.

Biliopancreatic Diversion with a Duodenal Switch

BPD-DS, usually referred to as a “duodenal switch,” is a complex bariatric surgery that includes three features. One feature is to remove a large part of the stomach. This step makes patients feel full sooner when eating than they did before surgery. Feeling full sooner encourages patients to eat less. Another feature is re-routing food away from much of the small intestine to limit how the body absorbs food. The third feature changes how bile and other digestive juices affect the body’s ability to digest food and absorb calories. This step also helps lead to weight loss.

In removing a large part of the stomach, the surgeon creates a more tubular “gastric sleeve” (also known as a VSG, discussed later). The smaller stomach sleeve remains linked to a concise part of the duodenum, directly linked to a lower part of the small intestine. This surgery leaves a small part of the duodenum available to absorb food and some vitamins and minerals.

However, when the patient eats food, it bypasses most of the duodenum. The distance between the stomach and colon becomes much shorter after this operation, limiting how food is absorbed. BPD-DS produces significant weight loss. However, a decrease in the amount of food, vitamins, and minerals absorbed creates long-term problems.

Some of these problems are anemia (lower than the normal count for red blood cells) or osteoporosis (loss of bone mass that can make bones brittle).

Vertical Sleeve Gastrectomy

VSG surgery restricts food intake and decreases the amount of food used. Most of the stomach is removed during this surgery, which may decrease ghrelin, a hormone that prompts appetite. Lower amounts of ghrelin may reduce hunger more than other purely restrictive surgeries, such as AGB.

VSG has been performed in the past mainly as the first stage of BPD-DS (discussed earlier) in patients who may be at high risk for problems from more extensive types of surgery. These patients’ high-risk levels are due to body weight or medical issues. However, more recent research indicates that some patients who have VSG can lose a lot of weight with VSG alone and avoid a second procedure. Researchers do not yet know how many patients who have VSG alone will need a second stage procedure.

What are the side effects of these surgeries?

Some side effects may include bleeding, infection, leaks from the site where the intestines are sewn together, diarrhea, and blood clots in the legs that can move to the lungs and heart.

Examples of side effects that may occur later include poorly absorbed nutrients, especially in patients who do not take their prescribed vitamins and minerals. In some cases, if patients do not address this problem promptly, diseases may occur along with permanent damage to the nervous system. These diseases include pellagra (caused by lack of vitamin B3—niacin), beriberi (caused by lack of vitamin B1—thiamine), and kwashiorkor (caused by lack of protein).

Other late problems include strictures (narrowing the sites where the intestine is joined) and hernias (part of an organ bulging through a weak muscle area).

Two kinds of hernias may occur after a patient has bariatric surgery. An incisional hernia is a weakness that sticks out from the abdominal wall’s connective tissue and may cause a blockage in the bowel. An internal hernia occurs when the small bowel is displaced into pockets in the lining of the abdomen. These pockets occur when the intestines are sewn together. Internal hernias are thought to be more dangerous than incisional ones and need prompt attention to avoid serious problems.

Some patients may also require emotional support to help them through body image changes and personal relationships that occur after the surgery.

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Medical Costs

Bariatric procedures, on average, cost from $20,000 to $25,000. Medical insurance coverage varies by state and insurance provider. In 2004, the U.S. Department of Health and Human Services reduced barriers to obtaining Medicare coverage for obesity treatments. Bariatric surgery may be covered under these conditions:

• If the patient has at least one health problem linked to obesity
• If the procedure is suitable for the patient’s medical condition
• If approved surgeons and facilities are involved

Patients can contact staff at their regional Medicare, Medicaid, or health insurance office to determine if the procedure is covered and obtain facts about options.

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Research

In 2003, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the NIH partnered with researchers to create the Longitudinal Assessment of Bariatric Surgery or LABS. LABS researchers are experts in bariatric surgery, obesity research, internal medicine, behavioral science, and related fields. Their mission is to plan and conduct studies that will lead to more knowledge about bariatric surgery and its impact on patients’ health and well-being with extreme obesity. More information about LABS is available at http://www.niddklabs.org.

To help determine if bariatric surgery is appropriate for youth, NIH launched Teen-LABS in 2007. From 2007 to 2012, the multicenter study is collecting data from teens who plan to have surgery. The data will help to evaluate bariatric surgery’s benefits and risks. Researchers are collecting data about medical problems related to obesity, other health risk factors, and quality of life from these patients before surgery and 2 years after surgery. Researchers will then compare the teen outcomes to data from adults. These websites offer more information about Teen-LABS: http://www.nih.gov/news/pr/apr2007/niddk-16.htm and http://www.cincinnatichildrens.org/teen-LABS. 

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Resources

The following list of publications, websites, and organizations may be used for patients or health care providers discussing bariatric surgery.

ADDITIONAL READING FROM THE WEIGHT-CONTROL INFORMATION NETWORK

Active at Any Size. This fact sheet provides ideas and tips on how people considered to be overweight or obese can be physically active. It focuses on overcoming common barriers and setting goals. Available at http://www.win.niddk.nih.gov/publications/active.htm.

Binge Eating Disorder. This fact sheet provides information and resources for patients who may have binge eating disorder. Available at http://www.win.niddk.nih.gov/publications/binge.htm.

Dieting and Gallstones. This fact sheet explains what gallstones are, how they form, and the roles obesity and rapid weight loss play in developing gallstones. Available at http://www.win.niddk.nih.gov/publications/gallstones.htm.

Weight Loss for Life. This booklet describes ways to lose weight and encourages healthy eating habits and regular physical activity. Available at http://www.win.niddk.nih.gov/publications/for_life.htm.

ADDITIONAL READING FOR HEALTH CARE PROVIDERS

Pharmacological and Surgical Treatment of Obesity: Evidence Report/Technology Assessment: Number 103. Shekelle PG, Morton SC, Maglione M, et al. Agency for Healthcare Research and Quality (AHRQ). AHRQ Publication Number 04–E028–1; 2004. Rockville, MD. This report reviews the scientific evidence on weight-loss drugs and bariatric surgery among children, youth, and adults. Available at http://archive.ahrq.gov/clinic/epcsums/obesphsum.pdf [PDF – 441 Kb].

ADDITIONAL RESOURCE

American Society for Metabolic and Bariatric Surgery
100 SW 75th Street
Suite 201
Gainesville, FL 32607
Phone: 352-331–4900
Fax: 352-331–4975
Internet: http://www.asmbs.org/ 

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Weight-control Information Network

1 WIN Way
Bethesda, MD 20892–3665
Phone: 202-828–1025
Toll-free number: 1–877–946–4627
Fax: 202–828–1028
Email: win@info.niddk.nih.gov
Internet: http://www.win.niddk.nih.gov

The Weight-control Information Network (WIN) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, the Federal Government’s lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103–43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information on weight control, obesity, physical activity, and related nutritional issues.

Both NIDDK scientists and outside experts review publications produced by WIN. Walter Pories also reviewed this fact sheet, M.D.‚ FACS‚ Professor of Surgery and Biochemistry‚ Brody School of Medicine at East Carolina University; and Thomas Inge‚ M.D.‚ Ph.D.‚ FACS‚ FAAP‚ Assistant Professor of Surgery and Pediatrics and Surgical Director‚ Comprehensive Weight Management Center‚ Cincinnati Children’s Hospital Medical Center.

This text is not copyrighted. WIN encourages unlimited duplication and distribution of this fact sheet.

1. Inge TH‚ Krebs NF‚ Garcia VF‚ et al. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics. 2004 Jul;114(1):217–23.
2. Wilson ST‚ Thomas HI‚ Randall SB. Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome. Archives of Pediatrics & Adolescent Medicine. 2007;161(3):217–221.