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Bariatric Surgery
Introduction
Obesity has reached epidemic proportions
globally, with more than 1.7 billion people falling
in the overweight/obese category (as per WHO). Weight
loss can range from being relatively simple to being
almost unattainable, depending on several factors
such as type and severity of obesity, the age and
lifestyle of the individual and the psychological
mindset. It is often seen that in the few spurts of
knowledge dispersed on weight loss, people across
resort to dieting, exercising and a host of other
methods, though not always intelligently. Some in
spite of balancing these are unable to shed and/or
maintain their weight. These treatment options may
prove to be beneficial for overweight people, however,
incase of morbid obesity, which is estimated to afflict
20% of the obese population, there exists a 98% recidivism
rate with such weight loss methods.
A viable treatment option for such
people is Bariatric surgery. The word ‘bari’ is the
plural of ‘baros’. In Greek, “baros” means burden
or load. From this stems “Baris” referring to the
obese or overweight people. With the help of this
surgery, these candidates also can take care of the
myriad of comorbidities like diabetes, hypertension,
hyperlipidemia, asthma, stroke, cancer and depression
to name a few. Bariatric surgery should not be mistaken
as a cosmetic procedure. It is a life saving alternate
for obese people who fail to show weight loss by the
age old conventional methods.
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Lap. Gastric Banding
Restrictive weight loss surgery
works by reducing the amount of food consumed at one
time. The theory is simple; due to the restriction
created, you feel satiated with small amounts of food
and because of a smaller outlet, food stays in the
stomach for a longer time. The net result is - a reduction
in daily caloric intake without a feeling of deprivation.
Procedure
Entails laparoscopic implantation
of a Silastic band around the stomach just below the
gastro-esophageal junction to section off a small
portion called as stomach pouch creating an hour-glass
effect. A small outlet, about the size of a pencil
eraser, is left at the bottom of the stomach pouch.
Effects
The hour glass configuration only
constricts the upper stomach thus acting as a pure
restrictive operation. Since the outlet is small,
food stays in the pouch longer and one also feels
satiated for a longer time.
In a cooperative and compliant patient,
the reduced stomach capacity, along with behavioral
changes, can result in consistently lower caloric
intake and consistent weight loss. Patients who see
the best results from a restrictive procedure are
those who learn to eat slowly, eat less, and avoid
drinking too many caloric fluids, particularly carbonated
beverages. If the patient fails to follow these guidelines,
they can stretch the stomach pouch and/or the stoma
outlet and defeat the purpose of the surgery. The
effectiveness of a restrictive procedure is reduced
by constant snacking or by drinking high-calorie,
high-fat liquids.
Possible Complications
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Lap. Gastric Bypass
Procedures that alter digestion are
known as malabsorptive procedures. Malabsorptive techniques
reduce the length of intestine that comes in contact
with food so that the body absorbs fewer calories.
According to the American Society for Bariatric Surgery
and the National Institutes of Health, Roux-en-Y gastric
bypass is the current gold standard procedure for
weight loss surgery. In this procedure, stapling creates
a small (15 to 20cc) stomach pouch. The remainder
of the stomach is completely stapled shut and divided
from the stomach pouch. It is not completely removed.
The outlet from this newly formed pouch empties directly
into the lower portion of the jejunum, called the
Roux limb, thus eliminating the duodenum and a small
portion of the jejunum from the absorptive circuit.
The omitted segment is connected into the side of
the Roux limb of the intestine creating the "Y"
shape that gives the technique its name. The length
of either segment of the intestine can be adjusted
to produce lower or higher levels of malabsorption.
Risks
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The duodenum being bypassed, poor absorption of iron and calcium
can result in the lowering of total body iron and a predisposition
to iron deficiency anemia.
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A chronic anemia due to Vitamin B12 deficiency may occur. The
problem can usually be managed with Vitamin B12 pills or
injections.
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A condition known as "dumping syndrome" can occur as the result of
rapid emptying of stomach contents into the small intestine. This
is sometimes triggered when too much sugar or large amounts of
food are consumed. While generally not considered to be a serious
risk to your health, the results can be extremely unpleasant and
can include nausea, weakness, sweating, faintness and, on
occasion, diarrhea after eating. Some patients are unable to eat
any form of sweets after surgery.
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Metabolic bone disease in some patients, resulting in bone pain,
loss of height, humped back and fractures of the ribs and hip
bones.
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All the above listed deficiencies can be easily managed through a
proper diet and vitamin and calcium supplements. It is mandatory
for patients undergoing gastric bypass to consume a multivitamin
and calcium supplement daily.
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Sleeve Resection
This is the latest procedure in the
Bariatric surgery group. It is performed
laparoscopically (keyhole surgery). It involves
removing the lateral 2/3rds of the stomach with a
stapling device. It basically leaves a small stomach
tube instead of a big stomach sack. The residual
stomach capacity is about 150mls so a generous
entry should be possible. Grehlin, which is an
enzyme produced in the fundus of stomach, is
responsible for hunger and craving for food. In this
operation, Grehlin producing area of stomach is also
removed, with the result that patient has satiety
even after eating little bit of food and the person
does not crave for food in between meals.
The greatest advantage of the procedure is that the anatomy and physiology of the intestinal tract is not altered, because of which patient does not need long term replacement of nutrients, minerals or vitamins. It gives excellent results in the form of weight loss as seen in numerous scientific studies performed over last five years, where the average weight loss is shown to be 60 to 70% of excess weight in the first year. However since it is a relatively newer procedure and long term results are awaited. This procedure is also offered to patients as part one of a two stage Bypass operation particularly if they are super obese ( BMI>60) because it allows good weight loss until the patient gets down to a safe weight and the more radical bypass can then be offered laparoscopically, when they are at a safer weight. It was seen in different studies that most of such super obese patients, in whom it was offered as stage one of two stage procedure, lost adequate weight and did not require second stage procedure. This procedure is not reversible.
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