Surgical Innovations

Advances in Adult Obesity Surgery

After surgery for weight loss, 10–15% of patients may regain weight that they lost. To help such patients, the Center for Obesity Surgery at NewYork-Presbyterian Hospital/Columbia now performs several types of revisional, or secondary procedures.

If weight regain occurs after a Lap-Band® operation, surgeons at the Center leave the band in place and perform a gastric bypass, a technique the Center innovated about three years ago. This allows them to operate on a fresh portion of the stomach rather than a scarred area, and saves the adjustability of the band to enhance the overall results. For patients who experience weight regain after gastric bypass, the Center places a band on top of their bypass, another technique they developed. Such revisional procedures may have less risk than other revisional options, and they retain the option of band tightening to prevent weight regain in the future.

Marc Bessler, MD

"Not all places do revisional procedures," according to
Marc Bessler, MD, Director, Center for Obesity Surgery at NewYork-Presbyterian Hospital/Columbia. "These are complex procedures. But our experience and reputation bring many people here for this."

The Center for Obesity Surgery was designated a Center of Excellence in April 2006 by the American College of Surgeons. This designation entitles patients who are treated at the Center to be eligible for coverage by the Centers for Medicare and Medicaid Services (CMS). The only site in Manhattan to have received this designation, the Center performs the full range of laparoscopic procedures, including Lap-Band®, gastric bypass, sleeve, and biliopancreatic diversion procedures.

To develop further options for patients with weight regain, Dr. Bessler and colleagues conduct numerous studies of surgical technique, outcomes, and quality of life. One study investigated the addition of a ring of mesh around the stomach at the time of gastric bypass. In patients 200 pounds or more overweight, the mesh was shown to improve outcomes with 20% more weight loss by preventing the outlet from the stomach to the intestine from stretching. In light of these results, the Center is now beginning to use this technique in patients who are less than 200 pounds overweight.

A second study involves injections of sodium morrhuate, a sclerosing (scarring) agent, into the stomach pouch of patients who regain weight after gastric bypass. By causing scarring, the procedure narrows the exit from the stomach pouch, helping to restrict their food intake.

Pending approval by the FDA, a third study may evaluate yet another method: endoscopic insertion of a balloon-type device into the stomach, where it is filled with saline. During the six months it is in place, researchers believe the presence of the balloon may prevent patients from filling the stomach as fully with food, helping them to lose about 25% of their excess weight. Based on outcomes in Europe to date, Dr. Bessler expects that this trial could lead to FDA approval of the technique in the U.S.

The Center is also one of six institutions participating in a pivotal NIH-funded study evaluating the outcomes of obesity surgery. Known as the Longitudinal Assessment of Bariatric Surgery (LABS), this is the first cross-sectional NIH study examining obesity surgery. It involves a web of analyses of factors before and after various surgical procedures to assess risks, benefits, improvement in quality of life, and understanding of how these operations work.

Dr. Bessler has devoted his career to making procedures less invasive and easier for patients. Some of his newest clinical research focuses on the development of endolumenal surgery — going through the mouth endoscopically to operate within the space of the stomach, without creating any incisions for access. A major step beyond laparoscopic surgery, endolumenal surgery entails working within the space of the stomach without cutting it open. "This enables us to perform gastric bypass internally, either by inserting devices or suturing the stomach from the inside to cause weight loss," he says.

He has begun a clinical study to evaluate an endoluminal operation using FDA-approved instruments to revise roux en Y gastric bypass in patients who have experienced weight regain due to enlarging of the stomach pouch and stoma (opening between the stomach pouch and small intestines). The study is currently open for enrollment. "This new approach is helping us advance the goal of developing weight loss procedures that are less invasive," says Dr. Bessler.