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Bariatric surgery

A complete reference to a surgery that to be considered to treat obese Situations.

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Bariatric surgery

  1. 1. Bariatric surgery (weight loss surgery) includes a variety of procedures performed on people who have obesity. Weight loss is achieved by reducing the size of the stomach with a gastric band through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestine to a small stomach pouch (gastricbypasssurgery). Indications "Surgeryshouldbe consideredasatreatmentoptionforpatientswithaBMI of 40 kg/m2 or greater whoinstitutedbutfailedanadequate exercise anddietprogram(withorwithoutadjunctive drug therapy) andwhopresentwithobesity-relatedcomorbidconditions,suchashypertension,impaired glucose tolerance,diabetesmellitus,hyperlipidemia,andobstructive sleepapnea.A doctor–patient discussionof surgical optionsshouldinclude the long-termside effects,suchaspossibleneedfor reoperation,gallbladderdisease,andmalabsorption. Classifications of surgical Procedures Procedures can be grouped in three main categories 1. Predominantly malabsorptive procedures In predominantly malabsorptive procedures, although they also reduce stomach size, the effectiveness of these procedures is derived mainly from creating a physiological condition of malabsorption. 1.1 Biliopancreatic diversion Thiscomplex operationistermedbiliopancreaticdiversion(BPD) orthe Scopinaroprocedure.The original formof thisprocedure isnowrarelyperformedbecauseof problemswithmalnourishment. It has beenreplacedwithamodificationknownasduodenalswitch(BPD/DS).Partof the stomachis resected,creatingasmallerstomach(howeverthe patientcaneata free dietasthere isno restrictive component).The distal partof the small intestineisthenconnectedtothe pouch, bypassingthe duodenumandjejunum.
  2. 2. In around2% of patientsthere issevere malabsorptionand nutritional deficiencythatrequiresrestorationof the normal absorption.The malabsorptiveeffectof BPD isso potentthat those whoundergothe procedure musttake vitaminanddietaryminerals above andbeyondthat of the normal population.Withoutthesesupplements,there isriskof serious deficiencydiseasessuchasanemiaandosteoporosis. 1.2 Jejunoileal bypass Thisprocedure isno longerperformed.Itwasa surgical weight-lossprocedureperformedforthe relief of morbidobesityfromthe 1950s throughthe 1970s inwhichall but 30 cm (12 in) to 45 cm (18 in) of the small bowel wasdetachedandsettothe side. 1.3 Endoluminal sleeve A studyon humanswasdone inChile usingthe same technique howeverthe resultswere not conclusive andthe device hadissueswithmigrationandslipping.A studyrecentlydone inthe Netherlandsfoundadecrease of 5.5 BMI pointsin3 monthswithan endoluminal sleeve. 2. Predominantly restrictive procedures Procedures that are solely restrictive act to reduce oral intake by limiting gastric volume, produce early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications. 2.1 Vertical banded gastroplasty In the vertical bandedgastroplasty,alsocalledthe Masonprocedure orstomachstapling,apart of the stomach ispermanentlystapledtocreate asmallerpre-stomachpouch,whichservesasthe new stomach.
  3. 3. 2.2 Adjustable gastric band The restrictionof the stomachalso can be createdusinga silicone band,whichcanbe adjustedby additionorremoval of saline throughaport placedjustunderthe skin.Thisoperationcanbe performedlaparoscopically,andiscommonlyreferredtoasa "lap band".Weightlossis predominantlydue tothe restrictionof nutrientintakethatiscreatedbythe small gastric pouchand the narrow outlet.Itisconsideredone of the safestproceduresperformedtodaywithamortality rate of 0.05%. 2.3 Sleeve gastrectomy Sleeve gastrectomy,orgastricsleeve,isasurgical weight-lossprocedureinwhichthe stomachis reducedtoabout 15% of itsoriginal size,bysurgical removal of alarge portionof the stomach, followingthe majorcurve.The openedgesare thenattachedtogether(typicallywithsurgical staples,sutures,orboth) toleave the stomachshapedmore like atube,ora sleeve,withabanana shape.The procedure permanentlyreducesthe size of the stomach.The procedure isperformed laparoscopicallyandisnotreversible.Thiscombinedapproachhastremendouslydecreasedthe risk of weightlosssurgeryforspecificgroupsof patients,evenwhenthe riskof the twosurgeriesis added.Most patientscanexpecttolose 30 to 50% of theirexcessbodyweightovera6–12 month periodwiththe sleevegastrectomyalone.The timingof the secondprocedurewillvaryaccordingto the degree of weightloss,typically6– 18 months. 2.4 Intragastric balloon (gastric balloon)
  4. 4. Intragastricballooninvolvesplacingadeflatedballoonintothe stomach,andthenfillingitto decrease the amountof gastric space.The ballooncanbe leftinthe stomachfor a maximumof 6 monthsand resultsinanaverage weightlossof 5–9 BMI overhalf a year.The intragastricballoonis approvedinAustralia,Canada,Mexico,India,UnitedStates(receivedFDA approval in2015) and several EuropeanandSouthAmericancountries.The intragastricballoonmaybe usedpriorto anotherbariatricsurgeryin order to assistthe patienttoreach a weightwhichissuitable forsurgery, furtheritcan alsobe usedon several occasionsif necessary. 2.5 Gastric placation Basically,the procedure canbestbe understoodasa versionof the more populargastricsleeve or gastrectomysurgerywhere asleeve iscreatedbysuturingratherthanremovingstomachtissue thus preservingitsnatural nutrientabsorptioncapabilities.Gastricplicationsignificantlyreducesthe volume of the patient'sstomach,sosmalleramountsof foodprovide afeelingof satiety.The procedure isproducingsome significantresultsthatwere publishedinarecentstudyinBariatric Timesandare basedon post-operative outcomesfor66 patients(44 female) whohadthe gastric sleeve plicationprocedure betweenJanuary2007 and March 2010. Mean patientage was34, witha meanBMI of 35. Follow-upvisitsforthe assessmentof safetyandweightlosswere scheduledat regularintervalsinthe postoperative period.Nomajorcomplicationswere reportedamongthe 66 patients.Weightlossoutcomesare comparable togastricbypass. The study describesgastricsleeve plication(alsoreferredtoasgastricimbricationorlaparoscopic greatercurvature plication) asa restrictive techniquethateliminatesthe complicationsassociated withadjustable gastricbandingandvertical sleevegastrectomy—itdoesthisbycreatingrestriction withoutthe use of implantsandwithoutgastricresection(cutting) andstaples. 3. Mixed procedures Mixed procedures apply both techniques simultaneously. 3.1 Gastric bypass surgery A commonformof gastricbypasssurgeryis the Roux-en-Ygastricbypass,whereasmall stomach pouchis createdwitha staplerdevice andconnectedtothe distal small intestine.The upperpartof the small intestineisthenreattachedinaY-shapedconfiguration.Thegastricbypasshadbeenthe mostcommonlyperformedoperationforweightlossinthe UnitedStates,andapproximately 140,000 gastricbypassprocedureswere performedin2005. Its marketshare has decreasedsince thenand by2011, the frequency of gastricbypasswasthoughtto be lessthan50% of the weightloss surgerymarket.A factorinthe successof any bariatricsurgeryisstrict post-surgical adherence toa healthypatternof eating.Thereare certainpatientswhocannottolerate the malabsorptionand dumpingsyndrome associatedwithgastricbypass.Insuchpatients,althoughearlierconsideredto
  5. 5. be an irreversibleprocedure,there are instanceswhere gastricbypassprocedurecanbe partially reversed. 3.2 Sleeve gastrectomy with duodenal switch A variationof the biliopancreaticdiversionincludesaduodenal switch.The partof the stomach alongitsgreatercurve isresected.The stomachis"tubulized"witharesidual volumeof about150 ml.Thisvolume reductionprovidesthe foodintake restrictioncomponentof thisoperation.This type of gastric resectionisanatomicallyandfunctionallyirreversible.The stomachisthen disconnectedfromthe duodenumandconnectedtothe distal partof the small intestine.The duodenumandthe upperpart of the small intestine are reattachedtothe restat about75–100 cm fromthe colon. 3.3 Implantable gastric stimulation Thisprocedure where adevice similartoa heart pacemakerisimplantedbyasurgeon,withthe electrical leadsstimulatingthe external surface of the stomach,isbeingstudiedinthe USA.Electrical
  6. 6. stimulationisthoughttomodifythe activityof the entericnervoussystemof the stomach,whichis interpretedbythe braintogive a sense of satiety,orfullness.Earlyevidence suggeststhatitisless effectivethanotherformsof bariatricsurgery. Eating after bariatric surgery Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free drinks and gelatin desserts. This diet is continued until the gastrointestinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of high protein, liquid or soft foods such as protein shakes, soft meats, and dairy products. Foods high in carbohydrates are usually avoided when possible during the initial weight loss period. It is very common, within the first month post-surgery, for a patient to undergo volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are all factors that have a significant contribution to dehydration. In order to prevent fluid volume depletion and dehydration, a minimum of 48–64 fl oz should be consumed by repetitive small sips all day. Effectiveness of surgery WeightLoss - The maximum weight loss occurs in the first 10 months after surgery. More recent studies have demonstrated that the medium (3–8 years) and long term (> 10 years) weight loss results for RYGB and LAGB become very similar.However, the range of excess weight loss for LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data (beyond 5 years) for sleeve gastrectomy indicates weight loss statistics similar to RYGB. Reduced mortality and morbidity In the short term, weight loss from bariatric surgeries is associated with reductions in some comorbidities of obesity, such as diabetes, metabolic syndrome and sleep apnea, but the benefit for hypertension is uncertain. It is uncertain whether any given bariatric procedure is more effective than another in controlling comorbidities. There is no high quality evidence concerning longer-term effects compared with conventional treatment on comorbidities Psychiatric/Psychological Some studies have suggested that psychological health can improve after bariatric surgery.
  7. 7. Costs of Surgery The costs of bariatric surgery depend on the type of procedure performed and method of payment along with location-specific factors including geographical region, surgical practice and hospital in which the surgery is performed. The four established procedure types, Roux-en-Y gastric bypass, gastric banding, vertical sleeve gastrectomy (gastric sleeve) and duodenal switch, carry an average cost in India of Rs 15 lakhs, Rs 9 Lakhs , Rs 12 Lakhs and Rs 16 lakhs approximately respectively. However, location- specific costs can vary significantly. Quoted costs generally include day-of-surgery fees for the hospital, surgeon, surgical assistant, anesthesia and implanted devices (if applicable). Depending on the surgical practice, quoted costs may or may not include pre-op, post-op or longer-term follow-up office visits. Adverse effects Complicationsfromweightlosssurgeryare frequent.A studyof insurance claimsof 2522 whohad undergone bariatricsurgeryshowed21.9% complicationsduringthe initial hospital stayanda total of 40% riskof complicationsinthe subsequentsix months.Thiswasmore commoninthose over40 and ledtoan increasedhealthcare expenditure.Commonproblemswere gastricdumpingsyndrome inabout 20% (bloatinganddiarrheaaftereating,necessitatingsmall mealsormedication),leaksat the surgical site (12%),incisional hernia(7%),infections(6%) andpneumonia(4%) where the mortalitywas0.2%. Asthe rate of complicationsappearstobe reducedwhenthe procedure is performedbyanexperiencedsurgeon,guidelinesrecommendthatsurgerybe performedin dedicatedorexperiencedunits.Ithasbeenobservedthatthe rate of leakswasgreaterinlow volume centreswhereashighvolumecentresshowedalesserleakrate.Leakrateshave now globally decreasedtoa meanof 1-5%. Metabolicbone disease manifestingas osteopeniaandsecondaryhyperparathyroidismhave been reportedafterRoux-en-Ygastricbypasssurgerydue toreducedcalciumabsorption.The highest concentrationof calciumtransportersisinthe duodenum.Since the ingestedfoodwillnotpass throughthe duodenumafterabypassprocedure,calciumlevelsinthe bloodmaydecrease,causing secondaryhyperparathyroidism,increase inbone turnover,andadecrease inbone mass.Increased riskof fracture has alsobeenlinkedtobariatricsurgery. Rapidweightlossafterobesitysurgerycancontribute tothe developmentof gallstonesaswell by increasingthe lithogenicityof bile.Adverse effectsonthe kidneyshave beenstudied.Hyperoxaluria that can potentiallyleadtooxalate nephropathyandirreversiblerenal failure isthe mostsignificant abnormalityseenonurine chemistrystudies.Rhabdomyolysisleadingtoacute kidneyinjury,and impairedrenal handlingof acidandbase has beenreportedafterbypasssurgery.
  8. 8. Nutritional derangementsdue todeficienciesof micronutrientslike iron,vitaminB12,fatsoluble vitamins,thiamine,andfolateare especiallycommonaftermalabsorptive bariatricprocedures. Seizuresdue tohyperinsulinemichypoglycemiahave beenreported.Inappropriateinsulinsecretion secondarytoisletcell hyperplasia,calledpancreaticnesidioblastosis,mightexplainthissyndrome. Thiswill helpyoutoknowaboutthe surgerythatcan be possible consideredagainstObese Situation. ReadMore At www.healthKumbh.com To Promote HealthyLifestyle. To Promote Healthysociety. JoinHealthKumbh Here.

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A complete reference to a surgery that to be considered to treat obese Situations.

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