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OBESITY SURGERY: INDICATIONS, TECHNIQUES, WEIGHTLOSS and POSSIBLE COMPLICATIONS - Review Article

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OBESITY SURGERY: INDICATIONS, TECHNIQUES, WEIGHTLOSS and POSSIBLE COMPLICATIONS - Review Article REFERENCES: 1. Makauchi M, Mori T, Gunven P, et 3. Belghiti J, Noun R, Malafosse R, et T, Sauvanet A. Portal triad clamping or al. Safety of hemihepatic vascular occlusion al. Continuous versus intermittent portal hepatic vascular exclusion for major liver during resection of the liver. Surg Gynecol triad clamping for liver resection. A resection. A controlled study. Ann Surg. Obstet 1989; 130:824–831. controlled study. Ann Surg 1999; 229:369 1996 Aug; 224(2):155-61 2. Wobbes T, Bemelmans BLH, –375. 6. PE Clavien, S Yadav, d. Syndram, R. Kuypers JHC, et al. Risk of postoperative 4. J.R. Hiatt J.Gabbay,R W. Busuttil. Bently. Protective Effects of Ischemic septic complications after abdominal Surgical Anatomy of the Hepatic Arteries Preconditioning for Liver Resection surgery treatment in relation to in 1000 Cases. Ann Surg.1994 Vol. 220, Performed Under Inflow Occlusion in preoperative blood transfusion. Surg No. 1, 50-52 Humans. Ann Surg Vol. 232, No. 2, 155– Gynecol Obstet 1990; 171: 5. Belghiti J, Noun R, Zante E, Ballet 162 Corresponding author: Ludmil Marinov Veltchev, MD PhD Mobile: +359 876 259 685 E-mail: [email protected] Journal of IMAB - Annual Proceeding (Scientific Papers) 2009, book 1 OBESITY SURGERY: INDICATIONS, TECHNIQUES, WEIGHTLOSS AND POSSIBLE COMPLICATIONS - Review article Ludmil M. Veltchev Fellow, Master’s Program in Hepatobiliary Pancreatic Surgery, Henri Bismuth Hepatobiliary Institute, 12-14, avenue Paul Vaillant-Couturier, 94804 Villejuif Cedex SUMMARY type of treatment is the only one leading to a lasting effect. In long-term perspective, the conservative treatment Basically, two mechanisms allow the unification of all of obesity is always doomed to failure and only the surgical known methods into three categories: method allows reducing obesity. At this stage, the surgery - restrictive operations (gastric band and vertical of choice remains the gastric bypass, which is reduces on gastroplastica) average 60-70% of the overweight and which is effective in - low absorbing operations (jejuno-ileal bypass, 80% of the operated patients. Preoperative preparation, biliopancreatic derivation) surgical interventions and postoperative monitoring of the - mixed operations (gastric bypass) patients are crucial to its effectiveness. Description of techniques: a) Roux-en-Y Gastric Bypass (RYGB) works by Key words: obesity, surgical techniques, restricting food intake and by decreasing the absorption of complications food. Food intake is limited by a small pouch that is similar in size to the adjustable gastric band (3, 4). In addition, INTRODUCTION absorption of food in the digestive tract is reduced by The significant percentage increase of the population excluding most of the stomach, duodenum, and upper with overweight and the ineffectiveness of the medication intestine from contact with food by routing food directly treatment (diet, drugs) allow bariatric surgery to take an from the pouch into the small intestine. (fig. 1.) important place in the treatment (1, 2). At this point this b) Vertical Sleeve Gastrectomy (VSG) historically had 74 been performed only as the first stage of BPD-DS (see removing a large portion of the stomach, a more tubular above) in patients who may be at high risk for complications “gastric sleeve” (also known as a vertical sleeve from more extensive types of surgery. These patients’ high gastrectomy or VSG) is created. The smaller stomach risk levels are due to body weight or medical conditions. sleeve remains connected to a very short segment of the However, more recent information indicates that some duodenum, which is then directly connected to a lower patients who undergo a VSG can actually lose significant part of the small intestine. This operation leaves a small weight with VSG alone and avoid a second procedure. It is portion of the duodenum available for food and the not yet known how many patients who undergo VSG alone absorption of some vitamins and minerals. However, food will need a second stage procedure. A VSG operation that is eaten by the patient bypasses the majority of the restricts food intake and does not lead to decreased duodenum. The distance between the stomach and colon absorption of food. However, most of the stomach is is made much shorter after this operation, thus promoting removed, which may decrease production of a hormone malabsorption. BPD-DS produces significant weight loss. called ghrelin. A decreased amount of ghrelin may reduce However, there is greater risk of long-term complications hunger more than other purely restrictive operations, such because of decreased absorption of food, vitamins, and as gastric band. (fig. 2.) minerals. (fig. 3.) c) Biliopancreatic Bypass (BPD) et Biliopancreatic d) Adjustable Gastric Band (AGB) works primarily by Bypass with duodenal switch (BPD-DS) Scopinaro (5,6), decreasing food intake. It was developed by Morina at the usually referred to as a “duodenal switch,” is a complex end the 80s. Food intake is limited by placing a small bariatric operation that principally includes 1) removing a bracelet-like band around the top of the stomach to produce large portion of the stomach to promote smaller meal sizes, a small pouch about the size of a thumb. The outlet size is 2) re-routing of food away from much of the small intestine controlled by a circular balloon inside the band that can be to partially prevent absorption of food, and 3) re-routing of inflated or deflated with saline solution to meet the needs bile and other digestive juices which impair digestion. By of the patient. (fig. 4.) Fig. 1. Roux-en-Y Gastric Fig. 2. Vertical Sleeve Fig. 3. Biliopancreatic Fig. 4. Adjustable Gastric Bypass Gastrectomy Diversion with Duodenal Band Switch INDICATION or renal failure, inflammatory diseases of the gastro enteric Regardless of the anesthesiology progress, surgery tract, neoplastic diseases and inherited coagulation on patients with overweight always represents a risk. disorders (7, 8). According to the formulated criteria, surgery is indicated in patients who have an index of total weight more or equal to EFFECT OF SURGERY 40 kg / m², as well as in those patients with more than 35 kg The biliopancreatic derivation (DBP) shows best / m² and one or more concomitant diseases caused by the effectiveness, followed by the gastric encircling obesity syndrome or taking a turn for the worse because of anastomosis (BPG), the vertical calibrated gastroplastica it. The obesity must date back to 5 years. There must be no (GVC) and the gastric adjusting band (CGA). The weight effect of the conservative treatment. And no loss depending on the applied technique is shown in contraindications must be present, such as narcotic Table 1.: dependence, psychiatric disorders, chronic infections, liver 75 Table 1. Method Roux-en-Y Gastric Vertical Sleeve Adjustable Biliopancreatic Bypass Bypass Gastrectomy Gastric Band With a Duodenal Switch Median weigh loss 60-70% 50-60% 50-60% 70-80% COMPLICATIONS Early complications of these operations can include regain much of the weight that they lost. Some behaviors bleeding, infection, leaks from the site where the intestines such as frequent snacking on high-calorie foods or lack of are sewn together, and blood clots in the legs that can exercise can contribute to inadequate weight loss. Technical progress to the lungs and heart. Examples of complications problems that may occur with the operation, like a stretched that may occur later include malnutrition, especially in pouch or separated stitches, may also contribute to patients who do not take their prescribed vitamins and inadequate weight loss. Some patients may also require minerals. In some cases, if the malnutrition is not addressed emotional support to help them through the postoperative promptly, diseases such as pellagra, beri beri, and changes in body image and personal relationships. The kwashiorkor may occur along with permanent damage to the bariatric surgery remains an aggressive treatment with risky nervous system. Other late complications include strictures complications and unpleasant sensations in the early period. (narrowing of the sites where the intestine is joined) and In Roux-en-Y Gastric Bypass the intra operative mortality hernias (9, 10). Two kinds of hernias may occur after a patient is around 0.5% in larger series and morbidity between 10% has bariatric surgery. An incisional hernia is a weakness that and 20 %, as the most common causes are anastomotic leaks sticks out from the abdominal wall’s fascia (connective due to a fistula, hemorrhage, intestinal occlusion and tissue) and may cause a blockage in the bowel. An internal mechanical ileus, severe wound infections and less often hernia occurs when the small bowel is displaced into pockets thromboembolism despite the anticoagulant prophylaxis. In in the lining of the abdomen. These pockets are created a longer period of time, the observed disorders are when the intestines are sewn together. Internal hernias are malabsorpion of metals, mostly iron and vitamins of B group considered more dangerous than incisional ones and need (B12, B1), folic acid and calcium with a risk of secondary prompt attention to avoid serious complications. Research hiperparatiroidizam. Other complications are structure of the indicates that about 10 percent of patients who undergo anastomosis (5%), sore of the anastomosis (2-3%), bariatric surgery may have unsatisfactory weight loss or mechanical ileus and internal hernia (3-5%). Table 2. Roux-en-Y Gastric Vertical Sleeve Adjustable
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