The original definition of morbid obesity was any individual who was greater than or equal to twice their ideal body weight, or greater than or equal to 100 pounds above their ideal body weight as determined by the 1983 Height and Weight Standards of the Metropolitan Life Insurance Company. Morbid obesity could also be defined by the amount of total body fat although this value is not easily obtained. Normally 20 to 25 percent of body weight is fat. If 40 percent or more of the body weight is fat, morbid obesity is present.

The modern definition of obesity is based on body mass index (BMI) as presented in the Practical Guide to the Identification, Evaluation and Treatment of Overweight and Obesity in Adults, a joint publication of the National Institutes of Health National Heart, Lung, and Blood Institute, and the North American Association for the Study of Obesity.¹ Body mass index compares body weight (in kilograms) to height (in meters) (BMI = weight/height²). "Normal" values are less than 24.9 kg/m², and "overweight" individuals have a BMI between 25 and 29.9 kg/m². "Obese" patients are placed in three classes: Class 1 = BMI 30 to 34.9 kg/m², Class 2 = BMI 35 to 39.9 kg/m², the "Morbidly Obese" Class 3 = BMI 40 to 49.9, and "Super Obese" BMI > 49.9 kg/m².

Click here to access a program to calculate BMI and interpret results.

Waist circumference is also an important consideration in determination of the risks of obesity. Men with a waist circumference > 40 inches and women with a waist circumference > 35 inches are at increased risk of complications of obesity. To reflect this increased risk, the classifications defined by BMI are increased one level.

Causes of Obesity

The biological basis for severe obesity remains unknown. Recent investigations, however, have identified multiple abnormal proteins present in the brain and peripheral blood of morbidly obese patients and experimental animals. These proteins, many of which are known to alter appetite, satiety, and energy conservation, are being associated with genetic abnormalities as well (see Leptin Story). Whatever the final pathogenesis is found to be, it is certain that morbid obesity is truly a disease -- not just a disorder of willpower -- and indeed a most complex disease. At a minimum, contributing causes are inheritance, environmental, cultural, socioeconomic and psychological.

Incidence of Obesity

Obesity is a world-wide problem with marked prevalence in Western societies. The Hanes II data collected between 1976 and 1980 suggested that 34 million Americans were overweight, representing approximately 26 percent of the population. Of these individuals, at least 3 million were felt to be morbidly obese. Over the past 10 years, the incidence of obesity has increased to epidemic proportions. The results of the most recent National Health and Nutrition Examination Survey indicate that 55 percent of Americans are overweight, with 22% being obese (BMI > 30 kg/m²). As many as 8 million Americans are now morbidly obese (BMI > 40 kg/m²). ^{2 3,4}

Some other interesting reported statistics follow:

1. As one's weight increases, so does the risk for many diseases linked to obesity: heart disease, pulmonary disease, diabetes, bone and joint pains, and certain types of cancer.
2. In 1990 the direct cost of obesity-associated disease in the U.S. was $45.8 billion, and the indirect cost of obesity was estimated to be $23 billion, a total of $68.8 billion. In 2003 the yearly cost has increased to over $75 billion (~5.5% of the total annual health care costs). In North Carolina alone, $2.1 billion was spent in 2003 (Report of the CDC, Obesity Research, Jan. 2004).

Obesity-Related Comorbidities

The seriousness of obesity as a public health problem has recently been addressed by the US Public Health Service’s health indicator list -- one of the top conditions leading to increased health problems is now obesity, ranking equal to or above tobacco use.

Mortality: Over 400,000 annual deaths are attributable to obesity in the United States. There is a direct association between the degree of obesity and medical problems, with an exponentially increased risk of death from comorbid conditions as the body mass index increases.^{5, 6,7, 8} A Veterans Administration study of 200 morbidly obese men found a twelve-fold increase in death in patients between the ages of 25 and 34, a fivefold increase between the ages of 35 and 44, a threefold increase between 45 and 54, and a twofold increase in those above 54 years of age, compared to men of normal weight. The Framingham Study related morbid obesity to a progressively higher incidence of sudden death. If a patient developed respiratory distress requiring supplemental oxygen or a tracheostomy, the mortality exceeded 30 per cent.

At the 2004 American Surgical Association Meeting, investigators from McGill University presented results from a comparison of medical care of 5,746 morbidly obese patients matched 6:1 with 1,035 morbidly obese patients who underwent gastric bypass surgery. The matching was based on sex, age, and duration and degree of obesity. The average BMI for medically managed patients was 40 and for the surgical patients it was 50. Five-year mortality was reported as 6.17% in the medically managed group compared to only 0.68% in patients who underwent surgery. This ten-fold increased risk of dying without surgery was highly significant statistically with p<0.001. The different outcomes were even more startling when the health status of survivors was reviewed as the medically managed patients still were morbidly obese and suffered from the same medical problems, while the surgically managed group had lost over 100 pounds and were relieved of most of their obesity-related illnesses. The improved health status was reflected in the total healthcare costs for the two groups over the 5-year period. The total cost for medications, hospitalizations, and physician office visits was 34.5% lower in the surgical group. They concluded that not only were health care benefits remarkable, the cost of surgical intervention was recovered in just 3.5 years - thereafter the health care system SAVED money!

Hypertension and Cardiovascular Disease: There is a threefold increased incidence of high blood pressure in the morbidly obese patient with an increased incidence of heart disease and stroke.^{10,11,12,13,14} A weight reduction of as little as 4.5 kg has been shown to reduce blood pressure in most overweight persons with hypertension.¹⁵ Furthermore, small reductions in weight have demonstrated an improvement in ventricular function and oxygenation in patients with congestive heart failure,¹⁶ whereas larger weight losses, as those seen with gastrointestinal surgery for obesity, reduce cardiovascular mortality.¹⁷

Diabetes Mellitus: The Nurses' Health Study demonstrated a fourfold increased risk for type 2 diabetes mellitus in women with a BMI between 23.0 and 25.0 kg/m²compared with women with a normal BMI.¹⁸ Women with a BMI > 35.0 were over 93 times more at risk of developing the disease. The study also demonstrated that weight gain during adulthood increased the risk for type 2 diabetes mellitus and importantly, weight loss reduced this risk by an average of 50 percent in those who lose as little as 5.0 kg. For individuals who already have type 2 diabetes mellitus, weight loss improved the severity of the disease by reducing hyperglycemia and hyperinsulinemia.¹⁹

Obstructive Sleep Apnea: The incidence of sleep apnea in severely or morbidly obese patients that requires therapeutic intervention approaches 40 percent in men and 3 percent in women.²⁰ Strollo and Rogers documented a relationship between the presence of sleep apnea and hypertension, nocturnal dysrhythmias, pulmonary hypertension, right and left ventricular heart failure, myocardial infarction, and stroke.²¹ Weight reduction can significantly improve both the oxygen desaturation index and blood pressure and improve survival.²²

Gallstones: The risk of gallstones increases with increasing BMI. In women, the risk of either gallstones or cholecystectomy is about 20 per 1000 women per year for a BMI > 40 compared with 3 per 1000 in normal weight women.²³ Contrary to the other comorbid conditions, weight reduction in the morbidly obese patient increases the risk of gallstone formation, especially if the weight loss is rapid.²⁴

Cancer: The incidence of several cancers are now known to increase with increases in body mass index including breast cancer in postmenopausal women, endometrial cancer, prostate cancer in men, and colon cancer in both sexes.

Other Comorbidities: Crippling arthritis and aggravation of prior joint injuries is a common comorbid condition, sometimes restricting the ability to work. Additionally, morbidly obese patients suffer real psychological stresses with limited access to public conveniences, ridicule, prejudice on the job, and limitation of social activities. The suicide rate among these patients is greater than that of the normal population with nearly a tenfold incidence of depression.

Non-surgical Approaches to Morbid Obesity

Historical Care

Multiple attempts have been made to manage morbid obesity using various drug regimens. The amphetamine-like drugs did induce weight loss better than placebo in clinical trials. However, all studies were short-term and weight gain occurred after withdrawal of the drugs. The risk of drug abuse was relatively high, and long-term utilization was not recommended.

Thyroid hormone was evaluated in hopes that an increase in metabolic rate would result in weight loss. Long-term studies demonstrated no better results than simple dietary measures alone with only 20-30 pound weight loss and recovery of weight once the medication was discontinued. Weight loss occurring during thyroid hormone administration was due in part to breakdown of vital protein as well as unwanted fat. In addition, there was an increased stress on the heart due to the increased metabolic rate. As a result, use of thyroid hormone for weight reduction was abandoned.

In 1992, a new era in weight reduction therapy began with combination medical therapy using the drug combination of phentermine and fenfluramine ("phen/fen") along with diet and exercise therapy.²⁵ The two drugs acted synergistically to produce more significant weight loss, with fewer side effects than when used alone. A third drug, dexfenfluramine, an isomer of fenfluramine, was approved by the FDA in 1996 and appeared to have similar good effects when used as a single agent along with exercise and diet programs. These drugs were heralded as the answer to the management of obesity until reports began appearing associating their use with cardiac valvulopathies and primary pulmonary hypertension.²⁶ These drugs have subsequently been withdrawn from the market.

Minimally invasive mechanical methods to limit dietary intake have likewise met with little success. In 1975, the first publication reporting use of acupuncture in the treatment of obesity appeared in the literature.²⁷ Several sites on the ear lobe were identified which reduced appetite when stimulated. No clinical benefit of weight loss has, however, been identified. In 1977, the concept of wiring the jaws together was introduced. Large clinical studies demonstrated a median weight loss of 55 pounds but after four months the weight loss reached a plateau.²⁸ When the wires were removed, patients regained 100 percent of the lost weight. Many patients failed to lose significant weight as they learned to sip high caloric fluids through straws, defeating the purpose of the wiring. In addition, jaw wiring was associated with aspiration if the patient vomited. In 1985, the Garren-Edwards gastric bubble was introduced. This was a balloon device placed inside the stomach which, when inflated, acted as artificial food with a sensation of fullness. The FDA initially approved its use as a temporary adjunct to diet and behavior modification for a maximum use of fourteen weeks. Subsequent complications with the device, including spontaneous deflation, passage into the small bowel with small bowel obstruction, and erosion through the stomach, and regain of lost weight upon removal of the bubble, led the FDA to withdraw its approval except for research purposes.²⁹

Current Medical Management

Current Pharmacotherapy: Pharmacotherapy is usually reserved for those patients with a BMI > 30, or >27 in those individuals with at least one comorbidity related to obesity. Several noradrenergic appetite suppressants continue to find use in weight reductions programs. They are usually used only for short-term results (up to 3 months): phentermine, mazindol, and diethylpropion. The most commonly prescribed of these has been Phentermine, which when used alone, has not been associated with cardiac valvular abnormalities or primary pulmonary hypertension.³⁰

Two new pharmacologic approaches, have had some limited success in the treatment of obesity: sibutramine and orlistat. Sibutramine is a serotonin-and norepinephrine-reuptake inhibitor. In recent studies it has been shown to result in a mean weight loss of approximately 4.8 kg at a dose of 10 mg and 6.1 kg at a 15 mg dose, with weight loss achieving a plateau at 6 months.³¹ Side effects include constipation, dry mouth, headache, insomnia, hypertension, and tachycardia. Relative contraindications for the drug include coronary artery disease, arrhythmias, congestive heart failure, and stroke.

Orlistat is a lipase inhibitor and inhibits absorption of dietary fat. Up to 30 percent of dietary fat absorption can be blocked with administration of 120 mg of orlistat with a meal. Unabsorbed fat is excreted in the stool representing the major side effect of the drug - diarrhea. Data from three randomized, prospective, placebo-controlled trials have been consistent, showing after 1 year of treatment, about 1/3 more patients treated with 120 mg of orlistat 3 times a day lost > 5 percent of the initial body weight than did those treated with placebo. Twice as many patients treated with orlistat lost > 10 percent of the initial body weight than placebo treated patients.³² In another study, patients who had lost weight over 6 months on a low-calorie diet were then treated with orlistat or placebo for one more year. Those who were given orlistat regained significantly less weight than those given placebo.³³

In summary, results of all drug trials have been disappointing. No successful studies have been reported in the morbidly obese patient population.

Dietary Measures: The rational of medical management of obese patients is to achieve weight loss through a twofold mechanism: a decrease in calories consumed and an increase in energy expended.

The cornerstone of dietary management is the low calorie diet (LCD), which usually restricts the diet to 800 to 1500 kcal/day. Average intake includes 250 gm or more of carbohydrates, 68 gm protein, and 60 gm or less from fat. Many commercial programs are available including: the Oprah diet, NutriSystem, Optifast, and Jenny Craig. Under special circumstances, a very-low-calorie diet (VLCD) is used providing 250 to 800 kcal/day, but special medical monitoring is required.³⁴ VLCD may be useful in special circumstances for rapid improvement of symptoms of sleep apnea, hypertension, or hyperglycemia, however clinical studies show that LCDs are just as effective as VLCDs in producing weight loss after 1 year. VanItallie reviewed results of LCDs and concluded they could produce a weight reduction of 8 to 10 percent over a 6 month period.³⁶ Long-term maintenance of weight loss has not been documented in any study.

Protein Sparing Modified Fast: A special weight loss program called Protein Sparing Modified Fast was introduced in the late 1970's by Dr. George Blackburn and co-workers at the New England Deaconess Hospital in Boston.³⁷ This program consists of a special low carbohydrate, low fat, high protein diet designed to protect body protein mass while selectively using body fat as an energy source. It is supplemented with extra vitamins, minerals, and electrolytes. A weight loss of between 2 and 3 pounds a week has been observed. Compliance with the diet is problematic due to the unpalatability of the restricted diet. Regaining weight is the rule if the diet is discontinued.

High-Protein, Low-Carbohydrate Diet: Commercial variants of the protein sparing modified fast diet program have become quite popular. It has gone under such names as Dr. Stillmans' Quick Weight Loss Diet, The Scarsdale Medical Diet, Dr. Atkins' Weight Loss Revolution, and the more recent Sugar Busters, Enter the Zone, Dr. Atkins' New Diet Revolution, and Protein Power diets. These diets fall into two main groups: very-low-carbohydrate (10 to 15 percent of calories from carbohydrates), or moderate-carbohydrate diets (40 percent of calories as carbohydrates). The Atkins' Diet and Protein Power are examples of the very-low-carbohydrate diets. Average daily caloric intake is about 1200 kcal and contains 30 to 45 gm carbohydrates, 90 gm of protein, and 70-80 gm fat. The Zone and Sugar Busters diets follow the moderate-carbohydrate diets. Average daily caloric intake is also about 1200 kcal but they contains 120 gm carbohydrates, 90 gm of protein, and 40 gm fat. With proper supervision and appropriate transition to "standard" diet programs, these diets can be safe and moderately effective, although no long-term study has been conducted documenting maintenance of weight loss. Serious metabolic deficiencies and complications can occur if proper monitoring is not performed.

Exercise Programs: An increase in physical activity is recommended for any weight reduction program. Exercise increases energy expenditure, improves comorbid conditions, combats depression, and helps maintain weight loss. Generally, up to 30 minutes of moderate-intensity physical activity is recommended 5 to 6 days a week. In a study of women who had regained lost weight compared to those who maintained their weight loss, Kayman et al. found 90 percent of maintainers engaged in vigorous exercise at least three times per week for at least 30 minutes, whereas only 34 percent of the regainers reported this level of activity.⁴²

Surgical Approaches to Morbid Obesity

Candidates for surgical intervention include those patients with a BMI > 40 or with a BMI > 35 with obesity-related comorbidities. Traditionally, surgery was restricted to patients who were older than 18 and less than 50 years old. Improved perioperative care has enabled the procedure to be extended to patients up to 65 years old. Medicare is currently considering coverage of weight loss surgery to their enrollees. Only rarely is the procedure offered to anyone below 18 years of age due to concern over whether they have the level of maturity necessary to succeed with the drastic life changes.

The objectives of surgery in the treatment of morbid obesity to serve as an aid in weight management. Surgery is not a cure for obesity but can be an effective adjunct to sound medical management.

History of Obesity Surgery: The history of weight loss surgery has been one of trial and error. To the credit and expertise of many dedicated surgeons, anesthesiologists, nurses, and nutritionists, we have learned from prior mistakes and now can provide safe and effective operative procedures. A snapshot of this evolution is described below.

Intestinal Bypass:

The concept of intestinal bypass in the treatment of morbid obesity was first proposed by Kremen and Lineer in 1954.⁴⁴ They described dramatic weight loss in patients who had undergone extensive small bowel resection due to poor blood supply to the intestines. The first operation done intentionally to induce weight loss for obesity was by Payne in 1963.⁴⁵ A near complete bypass of the small bowel was performed in ten morbidly obese patients. All patients developed marked diarrhea and lost a dramatic amount of weight. Multiple metabolic, fluid, and electrolyte problems were encountered. This led to early reversal of the bypass. Following reestablishment of normal anatomy, all ten patients rapidly regained weight to their preoperative level. With this poor experience, the procedure was abandoned.

Six years later, Payne revised his operation to an end-to-side jejunoileostomy beginning the new era of intestinal bypass procedures.⁴⁶ Over the next 20 to 25 years, multiple modifications of this procedure were published in the literature with good success in overall weight loss and maintenance of weight loss. Up to 90 percent of the small intestine was routinely bypassed. The weight loss occurred because of poor food absorption and diarrhea. Severe complications of fluid and electrolyte imbalances (in particular potassium, calcium, and magnesium), vitamin deficiencies (especially vitamin B-12, vitamin A, and vitamin E) and fatty infiltration of the liver, some with cirrhosis and liver failure were encountered. Low blood proteins, kidney stones, polyarthritis, bone demineralization, and migratory arthralgia were also diagnosed. Due to these severe complications, most of the early intestinal bypass procedures have been reversed in recent years and today the procedure is no longer performed.

Current Operative Procedures

Gastric Restrictive Procedures:

The disappointing clinical experience with intestinal bypass surgery led to consideration of gastric restrictive or bypass procedures. The mechanism of weight loss would be decreased dietary intake and delayed gastric emptying rather than malabsorption and diarrhea. In 1967, Mason and Ito published results of a gastric bypass procedure whereby a loop of small bowel was sewn to the side of a small gastric pouch.⁴⁷ This procedure was revised by Pories and Flinkinger into what is now called a Roux-en-Y Gastric Bypass Procedure (see right).⁴⁹ In 1982, Mason proposed a Vertical Banded Gastroplasty using again a small stomach pouch with a circumferential Marlex band around the outlet (see right).⁵⁰ The latter two procedures have been, until recent years, the standard surgical approaches.

An extensive outcome literature has been collected since 1982 utilizing the Roux-en-Y Gastric Bypass (RYGBP), and the Vertical Banded Gastroplasty (VBG), relevant to actual weight loss. A review of the published literature suggests that approximately 85 percent of patients achieve a satisfactory result with loss of at least 40 to 50 percent of their excess weight following VBG. Of some recent concern, however, is the report by Balsinger of 10 or more years follow up after VBG.⁷³ They found only 26% of 71 patients maintained a weight loss of at least 50% of their excess weight and 17% required reoperation with conversion to a roux-en-Y gastric bypass. They felt this Mayo Clinic experience demonstrated the VBG to not be an effective, durable bariatric operation and discouraged it use. On the other hand, approximately 60 to 70 percent of excess weight loss has been reported following RYGBP. Long-term maintenance of that weight loss has been observed to extend to over 14 years by several investigators. Morbidly obese patients with this degree of weight loss are therefore converted from morbid obesity to just being overweight. They no longer are greater than twice their ideal body weight or 100 pounds over their ideal body weight. Associated illnesses improve rapidly after bypass including high blood pressure (drugs to lower blood pressure can usually be discontinued), sleep apnea and shortness of breath (CPAP can usually be discontinued), and diabetes mellitus (insulin therapy can be reduced or discontinued). Arthritis, however, shows less dramatic improvement. It is postulated that this degree of weight loss and improvement in associated diseases will result in improved survival and decreased morbidity. No long-term studies have been completed, however, to document such a beneficial clinical effect. Many patients return to some form of employment. Both operative procedures can occasionally be complicated by suture breakdown, anastomotic leaks, scaring and narrowing of the stomas, bezoar formation, indigestion, esophagitis, gastritis, occasional nutrient deficiencies, and failure - either with excessive or, more commonly, inadequate weight loss.

Recently, the most successful weight loss outcomes have been obtained by combining the gastric restrictive procedure with a very limited intestinal bypass - so called "Gastric Restrictive Procedure with Gastric Bypass for Morbid Obesity; with Short Limb (75 to 150 cm) Roux-en-Y Gastroenterostomy" (more commonly referred to as simply the Roux-en-Y Gastric Bypass Procedure). This procedure currently is giving the best short- and long-term results and is the preferred operative procedure.⁶⁶ Operative mortality has been reported to range from 0.3 to 1.6 percent.^67,68 Stenosis of the gastrojejunal anastomosis has been reported to occur in between 5 and 7 percent of patients within the first three months. Usually one to three balloon dilatations are sufficient for long term correction of the stenosis. The average excess weight loss is expected to be 15 percent at 1 month, 31 percent at 3 months, 47 percent at 6 months, and 60 percent at 9 months with maintenance of this weight loss documented over 14 years of follow up. The hospital stay following the operation ranges from 2 to 3 days. Usually a 75 to 100 cm Roux-en-Y limb is created, Weight loss has been greater than 50 percent of excess weight in 75 to 80 percent of patients.⁶⁹

The Roux-en-Y Gastric Bypass, has been associated with very few long-term complications. Reported complications include iron deficiency anemia, vitamin and mineral deficiencies, dehydration, persistent vomiting, and a dumping syndrome.

Iron deficiency anemia: Iron deficiency anemia develops partly due to decreased nutrient intake and partly due to malabsorption of iron. Iron absorption is facilitated by gastric acid and the small pouch produces little acid. Furthermore, iron is predominantly absorbed in the duodenum and proximal jejunum and these areas are bypassed by the surgery. Usual supplementation is 325 mg/day of FeSO₄ and patients must be monitored for a microcytic anemia and decreasing serum iron concentrations.

Vitamin deficiencies: Most vitamin deficiencies can be avoided with daily oral supplementation. However, vitamin B-12 must be supplemented with intramuscular injections every 6 months. For this vitamin to be absorbed from oral intake, it must combine with a protein secreted by the stomach called intrinsic factor. This protein is produced mainly in the bypassed portion of the stomach and therefore will no longer mix with any oral intake. Without intramuscular injections, Vitamin B-12 deficiency has been reported in from 25 to 70 percent of patients following gastric bypass. To avoid catastrophic complications of B-12 deficiency, 1000 units IM vitamin B-12 should be given every 6 months.

Mineral abnormalities: Hypocalcemia will occur in all patients without proper supplementation. To be absorbed from dietary intake, calcium must be modified by the action of acid in the stomach. As the small gastric pouch makes little if any acid, dietary calcium will not be absorbed and a calcium deficiency will develop leading to bone demineralization and potential bone fractures. Supplementation with oral calcium as calcium citrate, which does not require acidification for absorption, is completely effective. Usual daily recommendations are from 800 to 1200 mg calcium.

Dehydration: Dehydration can occur, especially with exposure to dry hot days. Once dehydrated, patients have a significant difficulty catching up and intravenous supplementation is occasionally necessary. Patients should be encouraged to travel with bottles of water and drink throughout the day during hot summer days.

Laparoscopic Roux-en-Y Gastric Bypass:

Since first described by Wittgrove et al. in 1994,⁷¹ the laparoscopic approach to Roux-en-Y Gastric Bypass has rapidly become the procedure of choice. When compared to an open procedure, where an upper midline incision is made, the laparoscopic approach avoids potential serious wound complications, shortens hospital stay, and results in a more rapid recovery of normal function and return to work. Click HERE for a step-by-step video of the procedure.

Conversion rates to an open procedure reported in the literature range from 0 to 10.3 percent and anastomotic leak rates range from 1.2 to 6.9 percent. The average excess weight loss is identical to the open procedure. The average hospital length of stay following the operation ranges from 2 to 3 days. Usually a 75 to 100 cm Roux-en-Y limb is created, however for the very obese patients, up to 200 cm may be bypassed to increase malabsorption and enhance total weight loss.

Bilopancreatic Bypass or Duodenal Switch Procedure::

A Biliopancreatic bypass duodenal switch has been proposed by some as another possible approach to the surgical management of super obesity.⁷⁰ Reported weight loss has been slightly greater than for the average weight loss following Roux-en-Y Gastric Bypass, however metabolic and nutritional disturbances have been seen with this procedure and there is little long-term results available. If it is indicated in any patient, it would be one who is markedly overweight.

LapBand Procedure::

Considerable experience has been obtained, mainly in Australia and Europe, with placement of an inflatable Silastic band around the top part of the stomach to create a small gastric pouch, without the need for any bowel anastomosis. This procedure is performed laparoscopically and is called the LapBand Procedure. The surgical incisions for the needed laparoscopic ports are as shown.

Results so far have been very encouraging, however weight loss is less than for the Roux-en-Y Gastric Bypass (about 10 to 20 percent less) and management requires more frequent clinic visits to adjust the band inflation.

The device consists of a band, connection tubing, and a plastic access port. The band has a plastic ring lining the inside that can be filled with water to narrow the stomach opening, thus limiting the amount of food that can pass over time. The access port is used to add or remove water from the band, here shown with a needle and syringe placed for an adjustment.

An area is cleared at the top of the stomach for passage of the band and the band is secured about the stomach by an interlocking mechanism. After placement of the band, all instruments are removed from the abdomen and a small plastic access port is implanted just under the skin. The band has a plastic ring lining the inside that can be filled with water to narrow the stomach opening, thus limiting the amount of food that can pass over time. The amount of water in the plastic ring is adjusted by placing a needle into the plastic access port and adding or withdrawing fluid. Placement of the needle is minimally painful.