Surgical Treatment of Obesity:
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Surgical Treatment of Obesity:

Obesity is a chronic, relapsing medical condition for which there is no cure, only ongoing treatment and for certain obese patients, surgical intervention is an option and is frequently the treatment of choice; generally, the criteria includes one, or more, of the following:

1. To have a BMI of over 35 with obesity related medical complications, such as High Blood Pressure, Diabetes, Elevated Cholesterol or Sleep Apnea.
2. To have a BMI of over 40 without medical complications.
3. To have been unsuccessful after undergoing appropriate medical management.

The surgical methods have changed over the years, but can be divided into Gastric 'Stomach' Restrictive procedures, wherein the quantitiy of food is restricted and Combination Restrictive/Gastrointestinal Bypass procedures, wherein there is a restrictive component but also a component that leads to incomplete absorption of food.


Gastric 'Stomach' Restrictive Procedures (GRP) - Vertical Banded Gastroplasty (VBG):

In VBG, the stomach is Stapled to reduce its capacity to approximately 15 ml (1/2 oz.) and a silastic 'Plastic' ring is inserted to help prevent the stomach from stretching in size; what is formed is essentially a small stomach pouch that receives food from the esophagus and a much larger, unstapled stomach that receives small amounts of food from the proximal pouch.

When one eats, only a small amount of food can be consumed without the pouch becoming distended; this generally leads to an early feeling of satiation or fullness; if one continues to eat, one will develop nausea, vomiting, or pain, which generally results in the termination of eating; patients must adapt to their new, restricted stomach size and restrict their food intake to prevent vomiting and pain.

Possible Complications:

When VBG is performed by well trained physicians, the mortality, death rate, from the surgery is under 1%, but complications can include the risk of infection, an obstruction 'Blockage' of the outlet, necessitating surgical revision; the development of Blood Clots in the legs or lungs; Bleeding; Metabolic or Nutritional Deficiencies, including Protein Calorie Malnutrition and Recurrent Vomiting; although uncommon, it is also possible to slowly develop Vitamin, especially Vitamin B-12, and Mineral Deficiencies resulting in Anemia or Osteoporosis, the softening of the bones, after this surgery.


Post-operatively, the patient must be followed by physicians who are familiar with the long term complications and required long term treatment; the effectiveness of the surgery is fair, with loss of 40 to 50% of excess body weight with generally 50% of the weight loss being maintained after 5 years; though, it is common for the body weight to slowly increase after the first or second year.

The surgery requires a modified diet to prevent Nausea and Vomiting and to help prevent other long term side effects; additionally, one can partially bypass the restriction by eating calorie dense liquids such as ice cream or regular soda, but long term changes in eating habits must take place in order for the surgery to be successful.
Gastric 'Stomach' Restrictive Procedures (GRP) - Laparoscopic Gastric Banding (LGB):

Another restrictive gastric approach is LGB; this procedure, which was approved in the US in June 2001, is popular since it is high tech and utilises a Laparoscope, an instrument which is inserted into the abdominal cavity, and recovery time is only a few days; basically, an adjustable band is placed around the upper portion of the stomach, essentially resulting in a much smaller stomach; which restricts the amount of food that can be eaten, similar to the VBG.

Weight loss and complications are similar to that seen with VBG, but with added complications such as Band Slippage, Erosion of the Band into the stomach, Dilation of the Esophagus and Infections, many of which require removal of the device.

Combination Restrictive/Malabsorptive Procedures - Roux-en-Y Gastric Bypass:

The Roux-en-Y Gastric Bypass procedure involves both a Restrictive procedure by decreasing the size of the stomach by stapling across the top of it and a Malabsorptive component, achieved by bringing up and attaching a portion of the small intestine directly to the stomach, thus bypassing part of the small intestine; this surgery often results in significant long term Nutritional Deficiencis.

This procedure usually results in mild malabsorption of nutrients and causes Gastrointestinal Hormonal Changes, which result in decreased hunger and improved satiety or fullness; patients undergoing this surgery will lose significant amounts of weight, mainly body fat as opposed to lean body mass or muscle tissue; weight maintenance is generally excellent with small increases in weight occurring over subsequent years.

However, like any obesity surgery, the patient will require lifelong medical follow up and treatment of the medical complications that usually occur, like those listed earlier, especially the Vitamin B12 Deficiency and Anemia.

Sleeve Gastrectomy:

This Laparoscopic procedure, which is not reversible, reduces the stomach to about 25% of its original size, by the surgical removal of a large portion of the stomach, which follows the major curve; the open edges are automatically stapled together as the stomach is cut to form a sleeve or tube with a banana shape; the procedure permanently reduces the size of the stomach.

This surgery is a proven method of weight loss when combined with a supervised diet, increased activity and behaviour modifications; it can lead to long term weight loss and the associated health benefits; however, it results in a severe restriction of your capacity to eat solid food and the patient must remain under medical follow-up for the rest of their life, with several visits in the first year and at least an annual visit thereafter.

Biliopancreatic Bypass Procedures & Similar Extensive Intestinal Bypass Procedures:

In these procedures, the digestive juices from the liver and pancreas are diverted to the distal small intestine near the entrance to the large intestine; thus, food that enters the stomach, rapidly transverses the distal small intestine, where the absorption of nutrients primarily occurs, and is then delivered to the large intestine, where the excess water from the stool is removed.

This bypass results in a marked malabsorption of nutrients with a subsequent marked weight loss of up to 80% of excess body weight; since there is a marked malabsorption of essential nutrients, the probability of Vitamin, mineral, and protein-calorie malnutrition is significant; these procedures are generally best avoided since the marked nutrient malabsorption can result in severe long term complications.

These procedures are normally performed laparoscopically; Laparoscopic surgery, also called minimally invasive surgery, bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions, usually about 0.5 to 1.5 cms.


 

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