www.medodeal.com
Types of Bariatric Surgery - Full Comparison
The types of bariatric surgery you should consider depend on a number of factors, including how much weight you want to lose, which health problems you are looking to improve, risk level and cost.
There is no “one size fits all” procedure, so we’ll help you determine which ones best fit your goals.
The Fundamentals of All Types of Bariatric Surgery: Restriction Vs. Malabsorption
All types of bariatric surgery work in one of 3 ways…
- Restrictive surgeries shrink the size of the stomach which reduces the amount of food it can hold. This makes you feel full when eating much sooner than you did before surgery. The established restrictive procedures include…
- Adjustable gastric banding (lap band surgery)
- Gastric sleeve
- Malabsorptive surgeries rearrange and/or remove part your digestive system which then limits the amount of calories and nutrients that your body can absorb. Treatments with a large malabsorptive component result in the most weight loss but tend to have higher complication rates.
There are no longer any purely malabsorptive operations being performed. - Combination – When surgery combines both restrictive and malabsorptive techniques, it is know as a “combination” procedure (although some surgeons also refer to this type of surgery as malabsorptive). Most types of bariatric surgery carry at least a small element of both components, but the following established surgeries achieve a notable portion of weight loss from each…
- Gastric bypass (more malabsorption than the restrictive procedures listed above, but works primarily through restriction)
- Duodenal switch (more malabsorption - the sleeve stomach is the restrictive portion and the intestinal bypass (duodenal switch) is the malabsorptive component)
Complete List of Available Weight Loss Surgery Procedures by Category
Stomach Banding vs Stomach Staplingreading this page for more information about each procedure.
We recommend scrolling down to review this entire page, but you can also click the following links to jump further down the page to your Established Procedure of interest...
- Gastric Bypass Surgery (Roux-en-Y)
- Adjustable Gastric Banding (Lap Band Surgery)
- Gastric Sleeve Surgery (Vertical Sleeve Gastrectomy)
- Biliopancreatic Diversion with Duodenal Switch (Duodenal Switch or BPD/DS)
- Gastric Bypass Revision Surgeries (link will take you to a different page) - includes Sclerotherapy, the ROSE and StomaphyX procedures, addition of gastric band, lengthening of Roux limb and conversion to duodenal switch
Open vs Laparoscopic Types of Bariatric Surgery
Most bariatric procedures can be performed either open or laparoscopically. Open surgery may be required in rare cases (such as a build up of scar tissue from previous operations), although with a good surgeon laparoscopic surgery is usually a much better option. It results in shorter hospital stays, lower infection rates and smaller scars.
Open surgeries are performed by making a relatively large incision in the abdomen and carrying out the operation by direct observation through the open incision.
While many surgeons still perform open bariatric surgery successfully, these surgeries have a longer recovery time, a bigger risk of infection and a higher risk of adhesions (internal scarring that can lead to other problems). Obese patients’ bodies often have more difficulty healing which can complicate things further.
With open bariatric surgery, you should expect to be in the hospital for up to 5 days or more.
With laparoscopic weight loss surgery, the surgeon makes five or six small incisions that are just big enough to pass surgical instruments through. Smaller incisions mean less healing time, so you could leave the hospital in as soon as 2 days or less.
In addition to other medical instruments, the incisions are used to insert a special camera. The surgical camera projects the inside of the patient’s body onto a screen, and the surgeon uses that image to perform the surgery.
Experimental Types of Bariatric Surgery
The following experimental procedures seem the most promising based on the limited amount of published and peer-reviewed research (listed in alphabetical order)...
- EndoBarrier Gastrointestinal Liner
- Gastric Plication Surgery
- Implantable Maestro System
- Primary Obesity Surgery Endolumenal (POSETM) Procedure
- Transoral Gastric Volume Reduction (TGVR)
Established Types of Bariatric Surgery
Gastric Bypass Surgery (Roux-en-Y)
Gastric bypass, also called Roux-en-Y or RNY for short, is the most commonly performed bariatric surgery in the United States.
An entire section of our web site is dedicated to this popular and effective procedure, so we’ll save most of our discussion about it for those pages (link is below). The surgery is mainly restrictive in nature, but it also has elements of malabsorption.
From a very high level perspective, to perform gastric bypass surgery the surgeon...
- Cuts and staples the top portion of the stomach to create a small pouch at the end of the esophagus
- Leaves the remainder of the stomach attached to the top of the small intestines
- Goes further down the small intestine, cuts it, and attaches it to the pouch
- Takes the end of the small intestine that is still connected with the non-pouch portion of the stomach and attaches it to the bottom of the “Roux limb.” This allows the digestive juices produced by the stomach to meet up with the food in the intestines.
It’s much more easily understood by watching a video…
Most patients have successful long term weight loss with minimal weight regain. However, over time some patients' stomach pouch or stoma (the opening between the stomach and small intestines) can stretch causing significant weight regain.
In these cases, gastric bypass revision surgery may be appropriate.
Adjustable Gastric Banding (Lap Band Surgery)
This is the second most popular U.S. bariatric surgery procedure and is restrictive in nature. It’s been used in Europe since the 90’s, but wasn’t approved by the FDA in the States until 2001.
The lap band surgery procedure involves the sewing of a silicone and Silastic band around the top of the stomach. A balloon around the inner surface of the band (imagine the inside of a bicycle tire) is connected to a tube that leads to a half-dollar-sized port above the abdominal muscles but below the skin.
During follow up visits, your doctor will add or remove saline solution (salt water) to make it tighter or looser. The tighter it is, the less hungry you feel and vice-versa.
Here’s the procedure…
Gastric Sleeve Surgery (Vertical Sleeve Gastrectomy)
The Vertical Sleeve Gastrectomy (VSG), also called gastric sleeve surgery, is the newest addition to the short list of Established & Generally Accepted Types of Weight Loss Surgery.
It extremely effective and safe as compared with the other procedures. As a result, the popularity of VSG has skyrocketed in recent years, to the point that it appears to be overtaking gastric bypass as the new "gold standard" procedure.
The procedure is performed by dividing the stomach to create a long pouch that connects the esophagus to the small intestine. The pouch is stapled and the rest of the stomach is removed…
Biliopancreatic Diversion with Duodenal Switch (BPD/DS) (Duodenal Switch)
More simply referred to as a Duodenal Switch, this procedure could be classified as a Gastric Bypass/Gastric Sleeve combination with a twist….
- A large portion of the stomach is removed to create a cylinder-shaped pouch connecting the esophagus to the top of the small intestine.
- The top of the small intestine is cut, but the surgeon leaves part of the duodenum, or the top part of the small intestine where most chemical digestion occurs, attached to the stomach.
- The surgeon then cuts the small intestine several feet down. The part that is still attached to the large intestine (or colon) is connected to the duodenum.
- The loose part of the small intestine (the part that wasn’t just attached to the stomach) is then attached to the small intestine so the digestive juices it creates can mix with the food coming from the stomach.
Since the stomach is shrunk and only a small portion of the intestine has a chance to digest food before it enters the colon, the duodenal switch procedure is both restrictive and malabsorptive. But this surgery is effective mainly because of malabsorption.
**We developed the Research Ranking scores using a combination of factors including supporting research for short- and long-term weight loss, complication rates, risk factors and insurance coverage. Percentages listed for the above types of bariatric surgery are meant to provide a rough idea for each procedure. No studies are available that directly compare all types of bariatric surgery, so we have combined the results of many studies. | |||||
| Gastric Bypass (Roux-en-Y) | Combination (primarily restrictive) | 50 to 70% | Up to 15% | $24k | A |
| Gastric sleeve surgery (Vertical Sleeve Gastrectomy) | Restrictive | 65% to 75% | Up to 10% | $19k |
A
|
| Biliopancreatic Diversion with Duodenal Switch (BPD/DS) | Mal-absorptive | 65% to 75% | Up to 24% | $27k |
A
|
| Gastric Banding (i.e. Lap Band) | Restrictive | Extremely variable – average is about 50%, but ranges from 25% to 80% | Up to 33% | $15k |
C
|
Summary of Positives & Negatives of Established Weight Loss Surgery Procedures
Following is a comparison of the established types of bariatric surgery...
Roux-en-Y Gastric Bypass
Patients typically don’t lose as much weight after laparoscopic gastric bypass surgery as they do after the more complicated duodenal switch, but 60 to 70% of excess weight lost after gastric bypass is substantially better (and more consistent among patients) than what is expected following gastric banding.
The presence of dumping syndrome is a significant difference versus other procedures. While the symptoms are extremely uncomfortable, many patients feel that they help to keep their diet and long-term weight loss on track.
In addition, the malabsorptive component of gastric bypass can lead to malnutrition issues, so careful and ongoing attention should be paid to diet supplementation. However, malnutrition risks are much less after gastric bypass than after the duodenal switch.
Adjustable Gastric Banding (Lap band Surgery)
Lap band surgery has an impressively low rate of serious complications and is the only well-researched surgery that is completely reversible (note: we're keeping an eye on the investigational gastric plication surgery).
While the average 50% of excess weight lost is a decent percentage, the amount each patient could lose ranges from below 25% to over 80%. It also has a much higher rate of minor complications and reoperations than any other procedure.
The number of doctor visits after surgery is another consideration. Patients see their surgeon up to 10 times or more in the two to three years following surgery for band adjustments.
Concerningly, longer-term research is showing an alarmingly high rate of lap band failures and required reoperations - as many as one in three patients. For these reasons, some surgeons are choosing to no longer perform adjustable gastric banding surgery.
However, Lap Band surgery still has many champions due to the fact that it's (a) reversible and (b) much less invasive than the other established procedures.
See our Lap Band vs Gastric Bypass page for a full comparison of these two popular types of bariatric surgery.
Duodenal Switch
The Biliopancreatic Diversion with Duodenal Switch, or “Duodenal Switch” for short, deserves more credit and attention than it’s been given by those seeking bariatric treatment. On average, it results in more weight loss than any other procedure.
And although it carries the highest risk of complications, it's mortality risks are on par with other procedures and it may be the best procedure for those with a body mass index of 50 or over (“super-obese”) in terms of average weight loss and elimination of obesity health problems. (See our How to Calculate BMI page for more about body mass index.)
However, its higher rate of serious complications and the amount of malabsorption that it causes command careful consideration by the patient and surgeon before moving forward.
Gastric Sleeve (Vertical Sleeve Gastrectomy)
Gastric sleeve surgery has recently caught up with gastric bypass in terms of popularity and adoption by surgeons; it carries the low risks of gastric banding with the higher weight loss associated with gastric bypass.
Compared with gastric bypass, it appears to carry a lower rate of complications and reoperation. But recent research shows that it may not be as effective at resolving obesity-related health problems such as resolving type 2 diabetes mellitus, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and arthritis.4
The main concern is that the pouch could stretch over time, although there are several minimally invasive options available for reducing the pouch size down the road if necessary.
Summary
Your individual situation will determine which types of bariatric surgery are right for you, but following is a general summary…
Roux-en-Y Gastric bypass has a relatively low complication rate compared with its high levels of excess weight loss and significant improvement in co-morbidities. Its popularity also means that there are more surgeons out there with enough procedures under their belt to improve your chances for a good outcome.
However, lap band surgery is a better option for some mentalities. It has a lower risk of serious complications, and for those who are not 100% sure that they’re ready to permanently change their body, it is the only established procedure that is completely reversible; it can be relatively easily converted into a more elaborate procedure at a later date.
Unfortunately, lap band surgery has a very high variability in weight loss from patient to patient, and is associated with more minor and annoying complications. Most concerningly, lap band surgery is much more likely to require reoperation over the long-term as a result of permanent failure.
The duodenal switch is probably the most effective procedure for the super-obese. It has been proven to be successful (result in at least 50% of excess weight loss) for about 85% of patients after 3 years.2
It may also be the most effective procedure for treating obesity-related health problems. For example, in one study duodenal switch surgery cured 100% of diabetic patients (Alverdy and Prachand, University of Chicago).
The amount of weight loss long-term also appears to be better than any other procedure, but it has the highest rate of serious complications and the most intensive bariatric vitamin adherence requirements due to the level of malabsorption.
Gastric sleeve surgery is the newest addition to many bariatric surgeons' list of available surgeries. It is less complicated than gastric bypass and duodenal switch and leads to similar weight loss.
While not reversible or easily adjustable like the lap band, it carries a much higher weight loss and much lower risk of reoperation.
Gastric sleeve surgery appears to be a bit safer than gastric bypass in terms of reoperation and complications, but gastric bypass seems to have a better effect on many obesity-related health problems.
During our Annual Weight Loss Surgery Cost Survey, when we speak directly with literally hundreds of surgical practices all over the world, we discovered that the majority of practicing surgeons are now recommending gastric sleeve surgery more often than any of the other more established procedures.
