Gastric Bypass

The gastric bypass has been performed since the 1960’s, and in high numbers since the 1990’s.  It is a time tested procedure that is still performed frequently today.  In the 1970’s, the procedure choice that patients contemplating bariatric surgery had was between the jejunal-ileal bypass and the gastric bypass.  Few of you have heard of the jejunal-ileal bypass, and for good reason – it’s not performed any more.  In the 1980’s and 1990’s, your surgical options included the gastric bypass, the vertical banded gastroplasty and the Bilopancreatic Diversion.  Early this century, the two most frequent surgeries performed were the adjustable gastric band and the gastric bypass, and today, most people decide between the sleeve gastrectomy and the gastric bypass.  This brief history lesson points out that many Bariatric Surgeries have come and gone over the last fifty years, but the gastric bypass has always been an option because of its high success rate and low rate of both long and short term complications.

The gastric bypass operation effectively reroutes your intestines from a straight line into a “Y” shape.  Of the two upper limbs of the “Y,” one contains the food that you eat while the other houses the digestive enzymes.  At the crotch of the “Y,” the two limbs come together and the food mixes with the enzymes.  This delay in the mixing of food with enzymes (typically this occurs immediately after food leaves the stomach) changes the contents of the first portion of the intestine.  The food cannot be broken down and absorbed by the first portion of the intestine since enzymes are required for this process.  For reasons that we don’t fully understand, this change tricks your brain into burning off your fat stores.  The surgery also divides the stomach into two parts.  The first part, referred to as your pouch,  is approximately the size of your thumb and connects to the top part of one limb of the “Y.”  The second part, referred to as the gastric remnant, just sits inside your abdomen and continues to make acid and digestive hormones despite the fact that no food ever flows through it.  There is no need to remove the gastric remnant since it causes very few problems and removing it is unnecessarily risky.

Approximately 40% of all the weight loss surgeries performed in 2014 were gastric bypass procedures.  The Sleeve Gastrectomy has risen in popularity quickly and has become more popular, however the pendulum is beginning to swing back toward the Gastric Bypass.  The weight loss is typically very good after Gastric Bypass and the serious complication rate runs between 2-3% for most patients.  This surgery can be completed through small incisions (laparoscopically) more than 99% of the time.  The surgery typically takes between 1-2 hours and requires a hospital stay between 1-3 nights.

The Gastric Bypass is a very powerful set point lowering surgery.  It typically results in greater weight loss than the sleeve gastrectomy.  Even more importantly, the gastric bypass is probably a more durable operation than the sleeve gastrectomy, allowing patients to maintain their weight loss for a longer period of time after surgery.  This point is heavily debated and points out the lack of quality long term data we have on Bariatric Surgery despite the tens of thousands of published articles we have to draw from.  While I don’t have any high quality published articles that support the Gastric Bypass as the more durable operation, my clinical experience strongly supports this claim.  While most of us look at long term compliance with the recommended postoperative diet as being the sole responsibility of the patient, my personal observations as well as an emerging body of research demonstrate that postoperative compliance is more complicated than we’ve been led to believe.

When we look at Bariatric Surgery as a hormonal, setpoint lowering procedure, rather than one that works by anatomically restricting your food intake or inducing the malabsorption of nutrients, our perspective on post-operative compliance changes.  Because the surgery works by adjusting your hunger and metabolism to drive weight loss, patients who have less hunger after surgery have a much easier time following the postoperative rules.  As we’ve already discussed, the degree of success after surgery varies significantly from individual to individual, as does the amount of hunger that patients have.

Because the Gastric Bypass offers a more powerful hormonal effect than the sleeve gastrectomy, patients after gastric bypass surgery often have an easier time following our Pound of Cure plan postoperatively.  Most patients after gastric bypass surgery have a strong preference for fruit, vegetables, nuts, seeds and beans and develop a dislike for greasy or sugary processed foods.  Many patients will develop abdominal pain or nausea after eating heavily processed foods.  The Gastric Bypass will change your relationship with food and encourage you to not only eat less, but also to choose healthier foods.  The simplest way that I explain the difference between the two surgeries is that the Sleeve Gastrectomy will nudge you toward eating a better diet while the Gastric Bypass will shove you toward healthier eating.

If you are already a healthy eater prefer nutrient dense foods like those recommended on the Pound of Cure plan, then this added effect of the Gastric Bypass is unnecessary.  However, if you have a difficult time making changes to your diet preoperatively, then you should strongly consider the Gastric Bypass since it will offer you the help you need to change your diet after surgery.  Some people are attracted to the idea of a surgery that punishes you for eating poorly, while others do not want to be so influenced.  This is a personal choice that should be considered when you decide on which surgery to have.

When deciding on which surgery to undergo, it comes down to doing a thorough investigation of the risks of each procedure in comparison to the benefits.  The benefits, as described, include significant, durable weight loss, a change in your taste preferences and improvement of Diabetes, GERD and many other medical conditions.  The recovery is surprisingly fast and most patients experience only minimal pain and are able to return to work within 2-3 weeks after surgery.  However, with all surgeries, there is the risk that things don’t go as planned and you suffer a complication after surgery.

I will leave an exhaustive discussion of every possible complication to your surgeon and will just focus on the problems that are commonly seen or discussed.  While things can go terribly wrong after gastric bypass surgery, this is very uncommon and is only a serious concern for patients who are at high risk for surgery due to advanced age, a heart condition, severe diabetes or limited mobility.  Pregnancy and childbirth carry a similar risk of death to gastric bypass surgery for normal risk patients.  While the risk of serious complications runs between 2-3% for most patients, these complications are typically straightforward problems that can be very frightening, but are rarely life threatening.  While most patients’ fears of dying on the operating room table or ending up in the Intensive Care Unit for months are understandable, these are extremely uncommon events.  When you examine your risks closely, most patients have a decreased risk of death after surgery when the results are averaged over three to five years.  While the surgery carries a small risk up front, the benefits of the procedure will decrease your risk of dying from other causes over the long run.

The primary concern with gastric bypass surgery is not what happens within the first month after surgery since these risks are exceptionally low.  The primary issues with gastric bypass surgery are problems that can occur years or even decades after surgery.  While less than 5% of gastric bypass patients experience significant long term complications related to the surgery, these problems do occur and must be considered by any patient considering this surgery.

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