According to a consensus report by the National Institutes of Health, about 5 to 10 million Americans are morbidly obese—a condition linked to progressive, serious diseases. And that number is on the rise.
“We have become a nation of increased energy intake (high-calorie foods) and decreased energy output (more television and less physical education),” says Frederick N. Lukash, MD, FACS, who practices in New York City and Manhasset, NY. “The media promotes good health but also sells high-calorie, high-trans-fat foods.”
For morbidly obese patients, diets and exercise have only a limited ability to provide long-term weight loss. Therefore, patients increasingly are turning to surgery for long-term maintenance of weight loss.
The two types of bariatric surgeries performed today are (1) Lap-Band®, which is short for laparoscopic gastric banding; and (2) Roux-en-Y gastric bypass. Using staples or a band, Lap-Band reduces the size of the stomach, resulting in a drastic reduction in the quantity of food it can ingest. Roux-en-Y gastric bypass reduces stomach capacity and bypasses the upper part of the small intestine, causing a reduction in the number of calories and nutrients that the body absorbs.
What Is the Lap-Band Procedure?
The Lap-Band procedure was approved by the FDA in June 2001 as a method to reduce the health problems associated with obesity. Patients with a body mass index (BMI) of 40 or more, or a BMI of 35 or more with severe comorbid conditions, are candidates for the Lap-Band procedure.
During the procedure, a few small incisions are made in the abdominal wall. The Lap-Band is placed with the assistance of a laparoscope while the patient is under general anesthesia. A narrow camera is then inserted through one of the ports to allow the surgeon to view the site of the operation on a video monitor.
A small tunnel is created near the top of the stomach for the insertion of the band, which is then wrapped around the upper part of the stomach about 20 mm below the gastroesophageal junction. The silicone band contains an inner balloon and is connected by a tube to a subcutaneous access port in the abdominal wall during surgery. To inflate the band, saline solution is introduced to the inner balloon, which compresses the stomach into an hourglass shape. The balloon is not fully inflated until 4 to 6 weeks after the surgery.
The diameter of the channel or passageway (stoma) between the upper and lower stomach pouches can be reduced or enlarged by adding or removing saline solution. These adjustments determine the rate of weight loss. If the gastric band is not tight enough, the upper stomach will empty too quickly, inducing higher calorie intake. If the band is too tight, it can cause regurgitation and vomiting.
What Are the Postoperative Considerations?
After the surgery, adjustments to the Lap-Band are made either in a hospital or in a physician’s office. Sometimes, adjustments are performed in an outpatient clinic, and local anesthesia may or may not be required.
Adjustments are performed using a thin needle to inject or remove saline solution from the inner balloon. Only a small amount of solution is added or removed at each adjustment. An ideal “fit” of the band means that patients should be able to eat a sufficient amount of food to obtain the nutrients they require without veering from the restricted calorie regimen needed to lose weight.
After Lap-Band surgery, patients should expect to lose an average of two to three pounds per week during the first 12 months; weekly weight loss at 12 to 18 months after surgery is less. It is essential for patients to adhere to their postoperative eating and drinking regimen. Physicians warn that eating too much after surgery can cause vomiting, which can lead to stretching of the small stomach pouch.
What Is the Roux-en-Y Gastric Bypass Procedure?
Roux-en-Y is the most common bariatric surgery performed in the United States, and it demonstrates low postoperative complications and mortality rates.
During a Roux-en-Y bypass procedure, the plastic surgeon creates a smaller stomach (15 to 30 mL in size) to reduce the amount of food that the patient can consume. Most nutrient and caloric absorption occurs as the food passes along the small intestine, which means the longer the functional length of the small bowel, the more absorption.
Therefore, during Roux-en-Y surgery, the surgeon aims to bypass a significant section of this gastrointestinal tract, reducing the patient’s intake of nutrients and calories.
What Results Can Patients Expect?
After Roux-en-Y Bypass surgery, patients should expect to lose roughly 70% of their initial excess body weight during the first 24 months. Occasionally, patients may experience a weight regain of about 10% between the first 2 to 5 years.
For the first few days following surgery, patients should follow a clear liquid diet, advancing to a pureed diet. These foods are very soft and ensure problem-free passage through the small, newly formed pouch and stoma.
About 30 days after Roux-en-Y surgery, patients may begin eating solid foods, but should frequently revert to pureed foods. Typically, about 6 months after surgery, patients follow a long-term maintenance diet, which they will need to adhere to for the rest of their lives to help keep the weight off.
Where Does the Excess Skin Go?
What happens to the excess skin that is removed from a patient after bariatric surgery? According to the Musculoskeletal Tissue Foundation, a nonprofit, New Jersey-based tissue bank, more patients are donating their skin to help other patients who are in need of skin grafts.
Before the establishment of the Musculoskeletal Tissue Foundation 2 years ago, plastic surgeons relied on artificial skin from cadavers to cover burns or reconstruct breasts because it was thought that collecting skin from live donors would not provide the same-quality specimen. The foundation looked into the idea of collecting skin from live donors because physicians were in need of larger grafts that could not be collected from deceased donors. Furthermore, patients were interested in donating their excess skin after bariatric surgery.
Beverly Shafer, MD, a plastic and reconstructive surgeon practicing in Salem, Mass, uses reprocessed skin from live donors in reconstructive surgeries. “It’s wonderful,” she told the Gloucester Daily Times on July 27, 2007. “There are so many people who come into the office for this sort of surgery. People sort of askance say, ‘Can’t I give my skin to somebody, to the Shriners for burn surgery or something?’ “1
According to Cindy Gordon, a spokeswoman for the Foundation, the skin collected from live donors is different from the skin from cadavers—it is thicker, and the skin can be bunched up to fill in hollows, such as a deep indentation in a patient’s face or the gap left behind after a tumor is removed. Cadaver skin, on the other hand, is thinner and more appropriate for treating burn victims.
|See also “Not Without Its Risks” by Danielle Cohen in the December 2005 issue of PSP.|
Patients can be a live skin donor if they are having a surgery in which a large, continuous piece of skin will be removed (candidates are often patients who have lost 100 pounds or more and are undergoing surgery to remove excess skin), and if the plastic surgeon participates in a skin-donation program.
According to Gordon, to date, the Foundation has collected skin from more than 300 live donors, mostly through plastic surgeons on the West Coast. Skin donation is relatively new on the East Coast, so not all surgeons collect donations.
- Kirkwood J. Living skin donors expand options for reconstructive surgery. Gloucester Daily Times. July 27, 2007; Lifestyle section.