Sleeve, Bypass, Band or Duodenal Switch – How Do i Choose Which is The Right Procedure for Me?

Houston weight loss surgeryBarry Swartz, the author of The Paradox of Choice, points out that we live in a time of abundant choices, which often causes anxiety. He says one way to reduce anxiety is to have a clear picture of your goal and what you need to do in order to achieve your goal. He also says to be careful on choosing based on emotion.

I would add to also have a clear picture of the amount of risk you are willing to take to achieve your goal. First off, dieting has never been proven by any long-term study to help a person lose 50 or more pounds long-term. It’s clear that diets are not the path for almost everyone carrying that much or more excess weight.

So which is the right surgical procedure for you?

It is the procedure that will give you long-term weight loss success with the least possible risk. One must also consider the risk of failing to achieve success. In other words, all those serious medical problems and day-to-day difficulties will not go away if you fail. And that has serious consequences.

The gastric bypass and duodenal switch are complex operations. The sleeve gastrectomy and the lap band are much less complex. The more complex, the more risk of complications. This is true even among the greatest of surgeons.

I will share the pros and cons of each of these procedures, but first I would like to share my story of why I now only perform the sleeve gastrectomy. I had to revise this chapter because in the first edition of this book, I was still performing all three procedures. I would educate the patient and then ask them to choose. Now I can’t justify the extra risk, including the risk of failure, from the other procedures.

It’s my belief that everyone is a genius in some way. They have a particular skill set that makes them good at something. Laparoscopic surgery started big time in 1990 with gallbladder surgery. I quickly found that laparoscopy fit my skill set and began doing advanced procedures much earlier than most. I attended a live tel-seminar where Dr. Kelvin Higa did a laparoscopic gastric bypass. I knew immediately that this was for me.

It fit my skill set, background and educational, as well as my love for GI surgery. So I traveled to Dr. Higa to learn from the master. I also did a mini fellowship at Southwestern Medical School in Dallas, Texas. I performed my first laparoscopic gastric bypass in January 2000.

I was amazed that patients would come in with this huge list of medications and almost immediately after surgery would no longer need them. There were a few complications along the way and they were challenging to treat. Regardless, it was clear that the benefits of the gastric bypass tremendously outweighed the risk of complications. So, I became a big fan of the laparoscopic gastric bypass. Around the beginning of 2002, I attended a masters conference on weight loss surgery. The room was full of the most experienced surgeons. After going over the pros and cons of bypass versus lap band, a question was asked of the audience,“Which procedure would you choose for yourself if you were the patient?”

One after another approached the microphone and said they would choose the lap band for themselves because it was least likely to have a complication and they could not afford to have a complication. I was amazed. To me, the band was just another version of past procedures that had too high of a failure rate. However, during the conference a light bulb went off. Patients, like these surgeons, should have a choice of how much risk they are willing to take. So I immediately started the training process, and became one of the first five in Texas to be approved by the FDA for the procedure. I performed my first lap band procedure in November of 2002. I did my last lap band in 2012.

During this time there were many surgeons that only performed lap band surgeries.. I felt they did not offer the bypass because it was too technically difficult for them. Without doubt, the bypass was a superior operation. It did a much better job resolving diabetes and hypertension and these were issues for most of our patients.

Patients chose the band more than the bypass because it was a safer operation. So over time, I was doing 60% bands and 40% bypasses. The bypass patients rarely had a surgical complication and the office follow up was easy as well. Patients just seemed to lose weight effortlessly and rarely had issues.

When a complication did occur it was a big deal for the patient, the family and for me. I also found that many patients did not lock in the eating habits required for long-term success and over time re-gained some weight, usually about 20% of what they lost. They would tell me they were eating right, but their friends would tell a different story. In 2003, I attended a conference on laparoscopic revisional weight loss surgery- the first one ever done. Michael Gagner talked about the first ten laparoscopic gastric sleeves performed. This is the story of the beginning of the laparoscopic sleeve gastrectomy.

He was doing a duodenal switch (sleeve plus malabsorption procedure) when anesthesia asked if he find a way to end the operation early. They were having a difficult time ventilating the patient. The patient was super obese, and the breathing machine was having difficulty keeping the patient adequately oxygenated. So, he decided to do the sleeve part and come back later and do the malabsorption part. The patient lost weight very well, so he decided to start staging the operation. He would do the sleeve, and later come back to do the malabsorption part whenever they were not losing adequate weight. He found that many patients did not need the second part of the surgery and that the sleeve was adequate.

As he told the story I don’t think any of us thought this would eventually become the most commonly performed procedure. We just thought of it as another option. I started doing the sleeve in 2008. Very few knew how powerful this operation was at that time. From 2008 to 2009 very few patients chose the sleeve. First off, I did not know how powerful the operation was and many insurance companies did not approve it. By 2010, I had done enough of them that I could see the contrast between the sleeve, bypass and band.

The patients were losing weight and finding it easy to lock in and follow the eating rules required for long-term success. To this day, with more than 500 procedures performed, we have had no significant or serious complications. There are many chemicals and chemical pathways in our bodies that drive us towards bad food. It seems that once our body becomes obese, these chemicals work very hard to keep us from losing the weight and keeping it off.

Once we gain it, our body does not want to let it go. We knew that these chemicals were associated with the bypass procedure, but we had no idea that they effected the sleeve procedure as well. By 2010, we realized it. Research has shown it to be primarily related to changes in a chemical called Ghrelin, however there are many more than have yet to be discovered. The bottom line is that, by cutting out about two third of the stomach and leaving the upper third in a tube shape, our metabolism seems to normalize closer to what it was like before weight gain. We are able to get most patients off insulin and hypertensive medications the night of surgery, before weight loss has occurred due to these massive chemical changes.

I did many lap bands from 2002 to 2010 and it was like pulling teeth to get about 40% of those patients to follow the required eating rules. Subsequently, they would struggle with weight loss. Often they had mechanical issues with the band causing severe reflux esophagitis and vomiting. The typical patient that did well with the band was very good at following rules in their everyday life. They would learn the eating rules, get full on a small volume of food, and did great if no mechanical issues occurred. Because the lap band did not have the chemical changes like the sleeve and bypass, patients did not get off insulin and high blood pressure medications until they had lost significant weight.

Before the sleeve was an option, when patients were having problems, the only choice was the gastric bypass. Many patients did not want to take that risk. Now the patients can convert their band to a sleeve with relatively low risk. I quit offering the lap band and the bypass once I realized that the sleeve was low risk, had excellent weight loss, got most the patients off their medications the night of surgery, and the patients found it easy to lock in the important eating rules required for long-term success.

One of the hospitals that I use in Houston, Texas does more bariatric procedures per month than any other Houston hospital about 100 per month. Lap bands are no longer seen on the schedule at all. There are still bypasses, as some surgeons still feel that it is superior, and an occasional duodenal switch but mostly sleeves.

I think the story that I was a big fan of the bypass, did the band because it was safer, and now only do the sleeve is an important story that might help you understand why I think the sleeve is the right procedure for most patients. For those patients who do not achieve adequate weight loss with the sleeve, then the duodenal switch is a good option. The beauty is that half of the operation has already been done, and the next operation will be safer because of the weight loss achieved with the sleeve.

For most patients, the laparoscopic sleeve gastrectomy is the right choice.

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Disclaimer: Please note that there's no guarantee of getting the same results as each of these patients. Specific results vary by individual patient.