Bariatric Surgery: A Review of Procedures and Outcomes Katherine A. Elder, Bruce M. Wolfe  Gastroenterology  Volume 132, Issue 6, Pages 2253-2271 (May 2007) DOI: 10.1053/j.gastro.2007.03.057 Copyright © 2007 AGA Institute Terms and Conditions

Figure 1 Jejunoileal bypass. A surgical short bowel syndrome was created by bypassing >90% of the functioning small intestine, creating a long blind loop. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 2 Vertical banded gastroplasty. The stomach was partitioned with staples. The “stoma” between the gastric pouch and body of the stomach was reinforced with prosthetic material to prevent dilation of this opening. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 3 Gastric bypass partitioned. In this version of gastric bypass, the stomach is partitioned rather than divided. A Roux-en-Y gastrojejunostomy is done with variable lengths. The alimentary limb refers to the jejunal Roux-en-Y limb anastomosed to the stomach. The biliopancreatic limb transmits bile and pancreatic secretions to the jejunojejunostomy where the ingested nutrients and digestive juices first mix. The common channel refers to the distance from the enteroenterostomy to the ileocecal valve. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 4 Gastric bypass loop. In this example, the stomach has been divided rather than partitioned. Rather than a Roux-en-Y limb, a loop gastrojejunostomy is done. Bile reflux gastritis and esophagitis are problematic with this procedure. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 5 Retrocolic Roux-en-Y gastric bypass. This diagram depicts the anatomic details for the most common gastric bypass. The Roux-en-Y limb may be transmitted to the small gastric pouch either anterior or posterior to the colon and stomach. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 6 Long-limb Roux-en-Y gastric bypass. Variable lengths for the alimentary and biliopancreatic limbs and the common channel have been used in an effort to achieve maximum outcomes. If the Roux-en-Y or alimentary limb is >150 cm in length, the procedure is generally termed a long-limb Roux-en-Y gastric bypass. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 7 Banded gastric bypass. In this operation, the features of constriction of the gastric pouch by prosthetic material applied in a similar manner to that done in vertical banded gastroplasty are combined with gastric bypass. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 8 Adjustable gastric band. In this procedure a collar constricting the cardia of the stomach is placed and imbricated to prevent slippage of stomach in a retrograde manner through the band. These bands are generally placed by a laparoscopic technique (laparoscopic adjustable gastric band, LAGB). Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 9 Biliopancreatic diversion. In this original description, an approximate 50%–80% gastrectomy is done. Limb lengths vary from a gastric bypass in that the enteroenterostomy is very distal, creating a common channel from 50–100 cm in length. The forward flow of bile and pancreatic juice in the biliopancreatic limb is believed to reduce complications of bacterial statis that were associated with the long blind loop of intestinal bypass. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 10 Biliopancreatic diversion with duodenal switch. In this procedure a gastric sleeve is created by vertical resection of the greater curvature of the stomach creating a long tubular stomach along the lesser curvature. A duodenoileostomy is done either end-to-end or end-to-side fashion, thereby preserving the pylorus. The intestinal lengths are similar to those described for biliopancreatic diversion. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Figure 11 Gastric stimulation. A gastric pacemaker of similar design to cardiac pacemakers is connected to the stomach by leads that are sutured in place. The gastric stimulation can be controlled externally. Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions

Bruce M. Wolfe, MD Gastroenterology 2007 132, 2253-2271DOI: (10.1053/j.gastro.2007.03.057) Copyright © 2007 AGA Institute Terms and Conditions