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<p>Malabsorptive surgeries such as gastric bypass have been shown to be the most successful type of weight loss surgery based on the amount of weight lost and are therefore suitable for those classed as super obese and above, with a BMI over 45. Despite this, there are obviously drawbacks in that the operations carry many more risks and complications than restrictive surgeries. Also, due to the nature of the operation, such procedures are not easily reversible.</p>
<p>As with the wholly restrictive procedures detailed above, the malabsorptive surgeries can also be carried out as an open operation or laparoscopically.</p>
<h4>Gastric Bypass</h4>
<p>After various technique modifications in the early years of gastric bypass surgery during the 1960s, the most common method used today is known as the <strong>Roux-en-Y</strong> (RNY) gastric bypass, (pronounced Roo-in-Why). It is named after the French surgeon Dr Phillibart Roux who pioneered the original technique in the 19th Century, which was later perfected for gastric bypass surgery by Dr. Ward Griffin in the late 1970s. The Y refers to the shape created with the rerouting of the small intestine following surgery. The laparoscopic version of RNY gastric bypass was first performed in 1993.</p>
<p>According to The American Society of Metabolic and Bariatric Surgery, the RNY gastric bypass is the most commonly performed operation for weight loss in the United States.</p>
<p><img style="border: 1px solid currentColor; margin-top: 5px; margin-bottom: 5px; margin-left: 10px;" alt="Roux-en-Y Gastric Bypass Operation" align="right" src="https://www.consultingroom.com/uploads/Image_Directory/Treatment_FAQs/gastricbypass.gif" width="340" height="219" /></p>
<p>A small pouch is made at the top of the stomach using a line of staples, effectively separating it completely from the lower section of the stomach. A new opening is then made in this stomach pouch and the small intestine cut into two halves, with the lower portion being brought up and attached to the opening in the new stomach pouch (this is known as the Roux limb section), and the upper portion of intestine which carries digestive juices from the bypassed remainder of the stomach and duodenum (first section of small intestine where digestive juices from the pancreas, liver and gallbladder empty into to break down food) is joined to the Roux limb.</p>
<p>Therefore the small stomach pouch means that the intake of food is reduced and this food now leaves the stomach pouch through the new opening and bypasses the rest of the stomach and some of the small intestine, resulting in fewer calories being absorbed as the food passes through the digestive process. This malabsorption of food doesn’t affect the amount of protein absorbed, but does bypass the area where most calcium, iron and B vitamin absorption takes place so lifelong vitamin and mineral supplements will be recommended to avoid such conditions as anaemia and osteoporosis.</p>
<p>Technically this procedure can be considered as both restrictive and malabsorptive as the size of the stomach pouch is reduced, but as the primary function is to limit food absorption by the digestive system, it is often only referred to as simply a malabsorptive technique. Average weight loss is typically 30-50% of original weight.</p>
<h4>Sleeve Gastrectomy</h4>
<p><img style="border: 1px solid currentColor; margin-top: 5px; margin-right: 10px; margin-bottom: 5px;" alt="Sleeve Gastrectomy Operation" align="left" src="https://www.consultingroom.com/uploads/Image_Directory/Treatment_FAQs/sleeve_gastrectomy.jpg" width="200" height="221" /></p>
<p>For those classed as super obese or above, the risks involved in surgery are much higher so in order to reduce the amount of time spent under anaesthetic some surgeons choose to do gastric bypass surgeries effectively in two stages.</p>
<p>This is done by initially performing a sleeve gastrectomy, which involves reducing the size of the stomach by about 60-75% by dividing it from top to bottom, vertically, using staples (the excess stomach is then removed) to create a smaller banana or sleeve shaped stomach, which functions exactly as the full stomach did, but is much smaller so restricting food intake. </p>
<p>At a later date (and when the patient has lost some weight which reduces their surgery risk) this can then be modified with further surgery into an RNY gastric bypass or a duodenal switch (see below). In some cases a person will lose enough weight from the sleeve gastrectomy alone to not need further bypass surgery.</p>
<h4>Biliopancreatic diversion</h4>
<p><img style="border: 1px solid currentColor; margin-top: 5px; margin-bottom: 5px; margin-left: 10px;" alt="Biliopancreatic Diversion Operation" align="right" src="https://www.consultingroom.com/uploads/Image_Directory/Treatment_FAQs/BPD_web.jpg" width="235" height="286" />A biliopancreatic diversion (BPD), now superseded by the duodenal switch operation (see below), includes a gastrectomy procedure and the bypassing of most of the small intestines, thus combining restrictive and malabsorptive methods for weight loss.</p>
<p>First a large section of the stomach is removed via a horizontal gastrectomy, to leave a small remaining top pouch and a sealed duodenum; the small intestine is then cut in two, in much the same way as with an RNY procedure, but much further down. This end section of small intestine is then connected directly to the base of the remaining stomach pouch, thus bypassing the now sealed duodenum, which forms the beginning of the small intestine where bile and digestive juices are mixed with the food. This biliopancreatic loop of intestine which starts with the duodenum is then attached to the small intestine again at a point close to where it meets the large intestine, thus diverting it.</p>
<h4>Duodenal Switch (biliopancreatic diversion with duodenal switch)</h4>
<p><img style="border: 1px solid currentColor; margin-top: 5px; margin-right: 10px; margin-bottom: 5px;" alt="Duodenal Switch Operation" align="left" src="https://www.consultingroom.com/uploads/Image_Directory/Treatment_FAQs/duo_switch.gif" width="245" height="328" />A duodenal switch operation is based on and includes the biliopancreatic diversion procedure and works primarily by malabsorption, in conjunction with the inherent restrictiveness of removing part of the stomach. This procedure is not widely performed in the UK.</p>
<p>First a large section of the stomach is removed using the sleeve gastrectomy procedure described above, so that a small vertical section remains. This means that the stomach maintains most of its normal functions; unlike with the original biliopancreatic diversion procedure. At the base of the stomach where the small intestine starts, known as the duodenum, a cut is made in the intestine and another is made about half way along it. This lower section of intestine is then brought up to meet the cut end at the duodenum to form the new route for food leaving the stomach – hence the name duodenal switch. The bile and digestive juices in the upper part of the intestine now separated from the stomach and rest of the intestine is known as the biliopancreatic loop and is then sealed off at the top (old duodenum end) and joined to the base on the small intestine just before it meets the large intestine in what’s called the biliopancreatic diversion.<br /> <br />The digestion and absorption of fat depends on it mixing with bile from the liver when it enters the duodenum. After a duodenal switch this mixing doesn’t happen until much further on in the intestine, where the biliopancreatic loop joins back again, so the body's ability to digest and absorb calories from fat is very much reduced (even when eating normally). Those who have a duodenal switch operation may therefore be less restricted in what they can eat than a gastric bypass recipient, however this malabsorption of fat does also prevent proper absorption of protein, iron, zinc and vitamins A, D, E and K, hence a very high protein diet and supplements are required ongoing for life. Average weight loss is typically 40-45% of original weight.<br /></p>

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