The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered one of the ‘gold standard’ operations of weight loss surgery.

The Procedure
There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.
Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Advantages
1. Produces significant long-term weight loss (60 to 80 percent excess weight loss)
2. Restricts the amount of food that can be consumed
2. May lead to conditions that increase energy expenditure
4. Produces favorable changes in gut hormones that reduce appetite and enhance satiety
5. Typical maintenance of >50% excess weight loss

Disadvantages
1. Is technically a more complex operation than the AGB or LSG and potentially could result in greater complication rates
2. Can lead to long-term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron, calcium, and folate
3. Changes in anatomy may result in internal hernias

Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance 

The Laparoscopic Sleeve Gastrectomy – often called the sleeve – is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.
This operation has gained tremendous popularity to become the most performed bariatric operation worldwide as of 2016.

The Procedure
This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.
Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

Advantages
1. Restricts the amount of food the stomach can hold
2. Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%
3. Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
4. Involves a relatively short hospital stay of approximately 2 days
5. Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety

Disadvantages
1. Is a non-reversible procedure
2. Has the potential for long-term vitamin deficiencies
3. May cause an increase in acid reflux

Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance 

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band. This operation’s popularity is decreasing due to the long-term complications and results, see below.

The Procedure
The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin.
Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band. What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally.
The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

Advantages
1. Reduces the amount of food the stomach can hold
2. Induces excess weight loss of approximately 40 – 50 percent
3. Involves no cutting of the stomach or rerouting of the intestines
4. Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
5. Is reversible and adjustable
6. Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
7. Has the lowest risk for vitamin/mineral deficiencies

Disadvantages
1. Slower and less early weight loss than other surgical procedures
2. Greater percentage of patients failing to lose at least 50 percent of excess body weight compared to the other surgeries commonly performed
3. Requires a foreign device to remain in the body
4. Can result in possible band slippage or band erosion into the stomach in a small percentage of patients
5. Can have mechanical problems with the band, tube or port in a small percentage of patients
6. Can result in dilation of the esophagus if the patient overeats
7. Requires strict adherence to the postoperative diet and to postoperative follow-up visits
8. Highest rate of re-operation

The one-anastomosis gastric bypass (OAGB), previously referred to as the “mini” gastric bypass or the single-anastomosis gastric bypass, is a modification of the original “loop” bypass described in 1967.

The Procedure
The OAGB consists of a long narrow gastric pouch created by dividing the stomach, and a loop gastrojejunostomy (connection between the stomach and intestine) at the lower end of the pouch. OAGB has been promoted as a technically easier alternative to the Roux-en-Y gastric bypass (RYGB), as the RYGB requires an additional gastrointestinal anastomosis involving the small bowel (see gastric bypass above). That gained the OAGB the common name of ‘mini’ gastric bypass. The operation actually relies more on malabsorption than RYGB and therefore has significant weight loss and potential for vitamin deficiencies.
In 2011, OAGB represented approximately 1.5% of bariatric surgeries worldwide.

Advantages
1. One anastomosis (connection)
2. Shorter operative tie as a result
3. Excellent weight loss results in short term

Disadvantages
1. Lack of long-term data
2. Potential for bile reflux, a carcinogenic condition
3. Potential for significant malnutrition

Requires adherence to dietary recommendations, life-long vitamin/mineral supplementation, and follow-up compliance

Single incision surgery refers to performing laparoscopic surgery through one single small incision as opposed to the usual 4-5 small incisions required for laparoscope surgery. The main benefit of single incision surgery is cosmetic. For that reason, typically these operations are performed through an incision hidden in the belly button, that on the long run, does not show/scar. Dr. Alami routinely performs Single Incision Sleeve Gastrectomy and colon resections on patients who are deemed appropriate and request this approach.

As part of his fellowship training, Dr. Alami trained under the mentorship of Dr. Myriam Curet at Stanford University. Being one of the pioneers of robotic bariatric surgery, Dr. Curet trained Dr. Alami on the performance of complex robotic bariatric procedures to the point where he was certified as a robotic surgeon and was involved in teaching robotic surgery to other surgeons in the USA. Dr. Alami is the robotic general surgery champion at AUBMC. In addition to performing robotic operations on some of his patients, he supports or trains other surgeons at AUBMC in robotic surgery. In addition to his expertise in Robotic Roux en Y Gastric Bypass, Dr. Alami uses the available Da Vinci Si robot at AUBMC for select general surgical procedures. The main uses of robotic surgery in the field of general surgery are in colorectal operations, operations on the Gastro-esophageal junction and Complex abdominal wall hernias.