Thursday, March 25, 2010

Which Surgery Type Is Right For You?

There are several surgery types but there are four that are the most popular. I'll start with the top four from least invasive to most invasive. Keep in mind, the less invasive the surgery the less weight you will lose, statistically. The more risk you have for surgery the more you are likely to lose.

*****If you take nothing else away from this section of my blog please understand one thing, there is NO surgery type that fixes white carbs. No surgery type will prevent you from absorbing sugar, flour, rice, or pasta. That one is on us to change, not the surgery. Surgery is just a tool for us to lose our own weight. We can have surgery to limit the quantity of food we eat, we can have surgery to prevent us from absorbing all the calories that we consume but no surgery type prevents us from absorbing every white carb we consume.*****


Inamed, Inc originally came up with the Adjustable band and later sold the rights to the Lap Band System to Allergan who currently owns it. This band was approved by the FDA for use in the US in 2001.

The band is a restrictive only procedure meaning that it will limit the quantity of food you can consume at one time but you will not malabsorb nutrition or calories.

The Lap Band System was originally approved in Mexico in 1991. The Mexican doctors are the surgeons that perfected the surgical technique used today. Mexican surgeons were also the primary proctor surgeons (Proctors train other surgeons in a given procedure or technique.) that trained US surgeons in 2001. They still proctor many surgeons in the US and other countries. An interesting side note is that when Inamed owned the Lap Band System they had more strict requirements to be a proctor. You had to have at least 100 bands under your belt and low complication/morbidity stats before you could train another surgeon. Since Allergan took over they only require that a surgeon has performed 10 bands before they can teach another surgeon. The reality is that proctoring has "dumbed down" to "watch one, do one" and this is unfortunate. In order to be Allergan certified you must be proctored by another surgeon. When Inamed owned the rights to the Lap Band they would revoke a certification if the doctor proved to have a higher than normal level of complications. When Allergan took over they changed the policy, returned certifications to all surgeons that previously had high complication and morbidity stats. My personal opinion? They just want to sell bands and lots of them.

Johnson and Johnson decided they wanted a piece of the pie and their band, the REALIZE band was approved by the FDA in 2008. They claim big differences between REALIZE and Allergan Lap Band System but to be honest? They both work about the same way. The significant difference for patients is the port. I don't care for port placement of the REALIZE band but the Allergan is taller and tends to stick out more at goal.

About the band...

The band is a silicone band that goes around the upper part of your stomach creating a pouch. Your stomach takes on the shape of an hourglass. The whole idea is that you eat filling the upper pouch of your stomach and you can get full on a small quantity of food. There is a narrow pass through from your upper to lower stomach, it takes time for food to drain from your upper stomach to your lower stomach. There is a nerve at the top of your stomach called the Vegus nerve. This is the brain of your stomach, it basically tells your brain when you are full. So, you stay full on a small quantity of food for an extended period of time.

Three advantages of this surgery:

1) Least invasive
2) Removable
3) Up front surgery fees are more affordable than other surgery types

Three disadvantages of this surgery:

1) Slowest weight loss, least weight loss, highest regain, most mechanical problems of all main surgery types
2) Maintenance for life, hard to find follow up care if your surgeon moves, retires, etc.
3) Very high complication rate and costly for self pay folks


The VSG is a restrictive only procedure meaning that it will limit the quantity of food you can consume at one time but you will not malabsorb nutrition or calories.

The VSG (aka Sleeve) is where your surgeon will surgically make your stomach smaller. Your stomach has an elastic portion called the fundus. The fundus of your stomach can hold 18 cups of food. Clearly, this is not a benefit to those trying to lose weight. In the sleeve procedure your surgeon will remove the outer curvature of your stomach leaving a small, banana shaped portion of your stomach.

Studies show that obese people tend to produce three times the amount of Ghrelin as a naturally thin person. Ghrelin is a hormone that is mostly (but not all) produced by the stomach and Ghrelin is what tells your brain that you are hungry. People with the sleeve tend to lose the majority of their hunger. Doctors are not in agreement if Ghrelin will return later in life. Quantities of food vary from surgeon to surgeon but theoretically when your sleeve matures in 4-6 months you should be able to eat about 3oz of solid, dense protein such as steak or about 6oz of soft foods such as cottage cheese.

There is a bit of history with the Sleeve procedure. It used to be part one of a two part procedure. Today it is used as a stand alone procedure. If someone has a very large BMI they are often times too high risk for a full Gastric Bypass or DS surgery. So traditionally surgeons have performed a sleeve procedure and sent the patient home to lose enough weight to make a riskier and longer procedure safer. Later they come back and have the malabsorption added to their surgery type. Today they are making smaller stomachs and not doing the malabsorption for those that merely want restriction alone. The procedure itself is NOT new, what is new are the weight loss statistics since it was previously used as part one of a two part surgery.

There is a chance of a vitamin B12 deficiency. Your stomach produces an enzyme called Intrinsic Factor or IF. IF is needed to absorb Vitamin B12 via the stomach. Some people produce less IF after surgery and they need to take Vitamin B12 under their tongue instead of swallowing a tablet.

Three advantages of this surgery:

1) Safest surgery LONG term of all WLS types
2) Drastic reduction in hunger due to removing the portion of the stomach that over produces Ghrelin
3) No maintenance, no aftercare

Three disadvantages of this surgery:

1) Not reversible
2) Less than 1% additional *surgical* risk over the Adjustable Band
3) Risk of B12 deficiency


Gastric Bypass is considered the Gold Standard for WLS in the US. Many believe the Adjustable Band and Gastric Bypass will be considered "yesterday's procedures" and the VSG and DS will be tomorrow's procedures due to better weight loss and improved resolution of comorbidities. This topic is under debate by both surgeons and patients. But the fact remains that the Gastric Bypass procedure is probably the most common surgery performed today in the US.

This is the preferred method of performing gastric bypass surgery. In Roux-en-Y, your stomach is stapled to create a small pouch and a passage for food to go around (bypass) a section of your small intestine.

A gastric bypass first divides the stomach into a small upper pouch and a much larger, lower "remnant" pouch and then re-arranges the small intestine to allow both pouches to stay connected to it. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different GBP names. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and psychological response to food. The long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40%; however, complications are common and surgery-related death occurs within one month in 2% of patients depending on the target group being studies. Bottom line is the larger the patient and the more illnesses (comorbidities such as high blood pressure, diabetes, etc.) the higher the risk due to the invasive nature and length of the surgery.

This surgery type is ideal especially for Type II diabetics and those with uncontrolled reflux (GERD) not caused by a hiatal hernia or obesity.

The problem with this surgery type is that the stoma (pass through from pouch to small intestine) can dilate in as much as 1 in 5 patients. This causes a complete lack of restriction 2+ years post op. The stoma is designed to keep food in the pouch to provide satiety for several hours after eating. If the stoma dilates, or stretches, there is nothing holding food in the pouch and the patient tends to feel hunger all the time. Since Bypass folks only malabsorb calories for 6-24 months, if their stoma dilates they are hungry all the time and 3 years post op they are no longer malabsorbing calories... the regain starts.

Many believe that Gastric Bypass is not reversible. Theoretically it is totally reversible. This does not mean you should go into this thinking if it does not work you can always have it reversed. It is a huge and major surgery to try to reverse and it cannot always be done. Many believe the surgery is not reversible because intestine is removed. Intestine is not removed in this procedure, it is bypassed thus the name, Gastric Bypass.

For every 120cm of small intestine bypassed people tend to malabsorb about 33% of calories. This is not a permanent feature. We all have something in our intestines called villi. Villi are responsible for absorbing fat, calories, and nutrients. The body has an amazing way of compensating for alterations we choose to make. Within about 2 years the body creates more villi to absorb fat and calories and the patient will never absorb nutrition properly again. Nutrients are absorbed in very specific parts of the intestine, for example iron is absorbed directly under the pyloric valve (the part of the stomach that controls how fast the stomach is emptied to the small intestine, this is bypassed in RNY folks, btw) and this part of the intestine is bypassed so you will need to take supplements for the rest of your life to make up for this. If you cannot or will not take supplemental protein, vitamins, and minerals and if you will not agree to have vitamin labs done at least annually you should NOT have this procedure.

A Welsh study recently announced that 85% of the time within 10 days of surgery patients are in full remission of Type II diabetes. This is significant in the sense that it is changing the way science is approaching diabetes in prevention as well as treatment.

Three advantages of this surgery:

1) Ideal for Type II Diabetics and those with uncontrolled reflux not caused by a hiatal hernia or obesity
2) Fast weight loss the first year especially for insulin resistant people such as PCOS patients
3) Dumping - some consider this to be an advantage, some consider it a disadvantage. For about 1/3 of bypass patients if they consume high sugar or high fat foods they "dump" and for many this keeps them on the straight and narrow, it keeps them from eating foods that are not ideal for weight loss.

Three disadvantages of this surgery:

1) Significant morbidity rate for very high risk patients
2) Ability for the stoma to dilate causing increasing hunger and weight regain
3) Side effects such as reactive hypoglycemia, possible seizure disorder, vitamin deficiencies, and necessity for labs annually for a lifetime. When this surgery works well it works very well. When complications happen they can be quite serious.


In this procedure, the surgeon removes about 80 percent of the stomach, forming a thin sleeve-like stomach. The valve that releases food to the small intestine remains (duodenal switch) along with a limited portion of the small intestine that normally connects to the stomach (duodenum). The surgery bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach (biliopancreatic diversion). This weight-loss surgery is effective but has more risks, such as malnutrition and vitamin deficiencies, and requires close monitoring.

This is a procedure that is nice in the sense that the first half of the surgery is a Vertical Sleeve Gastrectomy and the second half is the DS, or bypassing of intestine. There is no concern for dilating a stoma as in Gastric Bypass and the long term weight loss is the best of all surgical procedures. But as explained earlier, the thing about WLS is that the less the risk, the less the weight loss. The greater the risk in surgery the greater the weight loss. This is the greatest risk of all surgery types for malnutrition and various vitamin deficiencies yet it provides the best long term weight loss stats. It does not have "more" complications than Gastric Bypass but if complications occur, the complications are greater in nature.

By the time you have this procedure you will not absorb 80% of fat, 50% of protein, and a handful of complex carbs. A high fat diet is not only permissible with this surgery type, it is necessary.

One down side to this surgery types more-so than other surgery types is that if you consume a great deal of white carbs such as flour, sugar, rice, or pasta you will have gas that is not pleasant to the nose. This happens with RNY as well but not to the same degree.

Not all surgeons can do this surgery type. It requires a skill as well as an art, much experience is necessary to perform this particular surgery safely and effectively. For detailed information please see the following website:

They can do this surgery type far more justice than I can.

Three advantages of this surgery:

1) Best weight loss and best long term weight loss stats of all surgery types
2) Not only the ability but the necessity for the patient to consume a very high fat, high protein, low carb diet
3) A more normal stomach than bypass, there is no pouch and no stoma

Three disadvantages of this surgery:

1) Highest risk surgery type
2) Highest risk for vitamin and mineral deficiencies
3) Not appropriate for vegetarians or vegans or those unable to comply with a high fat diet

There is another procedure type, it is one I cannot suggest to anyone for any reason:


This was the original bypass procedure and due to bile leaking into the stomach and esophagus (causing SEVERE burns) ALL the better surgeons stopped doing it in the 1970s. It is merely dangerous and only the bottom-feeder surgeons even do this procedure. It is technically easier to do than RNY or full gastric bypass but due to the danger to the patient none of the skilled doctors with good reputations will do it.


This is a new procedure, as of this writing the best long term stats are only 18 months old. It is similar to a sleeve but instead of stapling and removing tissue it requires sutures instead to create a sleeve shape. No part of the fundus is removed.

It is restrictive only and not malabsorptive.

Three advantages of this surgery:

1) No risk of a staple line leak however, there can still be a leak from perforating the stomach.

2) There is no tissue removed (This creeps out some people who are considering the sleeve.)

3) It is done by lap instead of full open incision surgery.

Three disadvantages:

1) It will be extremely difficult to revise to anything else but DS if it does not work and it is unknown if it will work because there are no long term stats available.

2) Reflux is much more significant for this surgery type vs. the sleeve. Unfortunately, there is little to do to resolve this if meds (PPIs) do not help.

3) The sutures can give way over time and the stomach would be larger thus the person could eat more. Speaking of sutures one of the dangerous aspects of this surgery is the blood supply in the stomach. The stomach has a rich blood supply and many large blood vessels on the left side of the stomach. When the plicated stomach is folded in and sutured it can potentially cut off the blood supply and the stomach tissue will die and become necrotic. This can happen immediately post op or months down the road.



As of this writing the doctor who originally created this surgical procedure was at a Germany Bariatric Conference within the last week and he strongly advises physicians to explain this procedure is a temporary weight loss procedure that is not expected to give long term results. It is sill investigational and his own 3 year stats show significant regain at the 3 year point post op. The creator of this surgical type does not suggest this surgery for long term weight loss.


More info and animation coming soon. If you want to see an animation of the procedure please visit Dr. Husted's website, he is the only surgeon in the US that does this procedure:

Now it is your job to determine which surgery type is right for you. First you consider if you want restrictive only (Bands/Sleeves) or if you want Restriction AND malabsorption (Bypass/DS). The greater the risk the better the weight loss and long term regain stats. It's a trade off, whatever you think is right for you.

Remember, if a doctor can only afford to advertise on, it might behoove you to look elsewhere for a more skilled surgeon.


Anonymous said...

Have you heard of the Mini Gastric Bypass? This is a surgery that I am very interested in! It is reviseable and reversable!

WASaBubbleButt said...

MGB is only done by bottom-feeder surgeons. No good surgeon with a positive rep really does that surgery. Please feel free to email me at

Anonymous said...

Love this post it put a lot of thoughts in my head I am on OH