Cirugía de la Obesidad - Dr. Alberto Daccach Plaza - Guayaquil

PERSPECTIVE:

General perspective of the alternative obesity surgical treatments

Gastric Restriction Procedure. Vertical Gastroplasty with the band.

Vertical gastroplasty with the band is a completely restrictive procedure. In this operation, the upper part of the stomach, proximate with the esophagus, is stapled in a vertical extension of approximately 2 ½ inches (6 cm) to create a smaller gastric bag. The bags exit orifice is reduced with a band or a ring that slows down the draining of food and generates a satiety sensation.

Advantages

The main advantage of this restrictive procedure is the reduced amount of well-chewed food that enters and goes through the digestive tract in its habitual form. This allows all the nutrients and vitamins (as well as the calories) to be totally absorbed by the body. After ten years, studies reveal that in these cases 50% of the patients can maintain their desired weight loss.

Risks

After the operation, the stapling of the stomach takes along with it the risk or rupture that can produce a leak or a serious infection. This may require a long hospitalization, accompanied by a antibiotic treatment or an additional operation. The rupture of the stapling line can also, on a long run, cause weight gain. For these reasons some surgeons divide the wall of the stapling line from the rest of the stomach to lower the risk of rupture as time passes. The application of the band or ring can lead to obstruction or piercing complications that may require surgical intervention. Although these procedures are known to create a satiety sensation, they don't leave you with the necessary sensation that you have eaten enough. Given that the restrictive procedures depend only on a small gastric bag to reduce the ingestion of food, there is a risk that the bag will widen or that the restrictive band or ring can break, permitting the patients to eat more than they have to.

Illustration 4

Around 40% of the patients that submit themselves to these procedures have lost more than half of their body weight. Like in any weight reduction surgery, hospitalization to replace fluids or dietary support can be required if too much vomiting occurs and if the patient can't maintain regular food ingestion.

Combination of bad absorption and restrictive procedure. Gastric derivation or gastric bypass with ROUX.

Over the recent years, the best clinical understandings of the combined restrictive procedures and of bad absorption have increased the successful alternative weight loss surgeries for thousands of patients. By adding the bad absorption method, the mixing of the food with the bile and pancreatic juices slows down, which helps the nutrients to be absorbed. The result is a quick sensation of satiety combined with satisfaction that diminishes the anxiety to eat. According to the United States Bariatric Surgery Society and the Health National Institutes, nowadays the gastric derivation or gastric bypass with y Roux is the model procedure in weight reduction surgery. It's one of the most frequent weight loss surgeries done in The United States. In this procedure the stapling creates a small bag (15 to 20cc) in the stomach. The remaining stomach is not extracted but it remains complete closed by the staples and separated from the gastric bag. The exit orifice of the recently formed bag evacuates directly to the lower part of the jejunum, eluding this way the absorption of calories. This is done dividing the small intestine just after the duodenum, with the purpose to lift and form a union with the recently formed gastric bag. The other extreme is put together to the lateral ramification of the Roux (look at the 3er illustration) intestine, which creates a "y" which gives it its technical name. The length of any of the 2 segments of the intestine can grow with the objective of producing inferior or superior levels of bad absorption.

Advantages

· The average of weight reduction after the Roux "y" procedure is in general higher in a collaborating patient than in a patient with purely restrictive procedures.

· A year after the surgery, the weight reduction can range from 77% of the body's overweight.

Illustration 5

· There are studies that reveal that after 10 to 14 years some of the patients maintain from 50% to 60% of the weight reduction.

· In the year 2000 a study of 500 patients showed that 96% of certain health conditions associated with obesity (back aches, sleep apnea, high blood pressure, diabetes and depression) improved or totally healed.

Risks

Given that the food digestion is omitted by the duodenum, the absorption of calcium and iron, which can produce a lowering of the iron level in the body and an anemic predisposal caused by a deficiency of this element. This constitutes a particular concern for the patients experimenting chronic reduction of blood through their menstrual cycles or bleeding hemorrhoids. Women should be conscious of the elevated potential loss of calcium in their bones, being inherent with the risk of osteoporosis appearing after menopause. The omission of the food transit through the duodenum ha causes osseous metabolic diseases in some patients and has produced pain in the bones, reduction in height, lordosis, rib and hip fractures. Never the less, all the recently described deficiencies can be managed with a appropriate diet and vitamin supplements. Chronic anemia can be caused by the lack of vitamin B12. Regularly this problem can be handled with pills and injections of this vitamin. One condition known as "evacuation syndrome" can occur as a result of fast evacuation of the stomachs volume toward the small intestine. This sometimes occurs when too much sugar or a great deal of food is consumed. Although, its not considered a serious health risk the results can be extremely nasty and may include nausea, sweat debility, fainting feelings, and in some cases diarrhea after eating. Some patients are incapable of eating any kind of sweet foods after de surgery In some cases the effectiveness of the procedure can be affected if the gastric bag widens or if it lodges a volume higher than 15-20 cc. If problems like ulcers, bleeding or malignity occur the abandoned portion of the stomach, the duodenum and segments of the small intestines will not be easily visualized when x-rays or endoscopies are being done.