Metabolic Syndrome
The coexistence of various risk factors that play ...
Laparoscopic obesity is used in people with extremely high body weight. Laparoscopy involves using a special telescope (laparoscope) to make small incisions on the abdomen to view the stomach.
This brochure will explain:
Severe obesity, also known as “morbid obesity”, is defined as a body weight approximately 45.5 kg above the ideal body weight (BMI-body mass index >40). Approximately 3-5% of the adult population in the United States has severe obesity. This disorder is associated with the development of life-threatening complications such as hypertension, diabetes and coronary artery disease, for example.
Numerous treatment approaches have been supported for this problem, including low-calorie diet, medication, behavior modification and exercise therapy. However, the only approach proven to be effective in the long-term treatment of morbid obesity is surgical intervention.
The cause of severe obesity is poorly understood. There are probably many factors involved in the process. In obese individuals, the energy storage point is often high. This different threshold may result from slow metabolism combined with low energy consumption, excessive caloric intake, or a combination of these. There is scientific data suggesting that obesity is a hereditary feature.
Advanced obesity is most likely the result of a combination of genetic, psychosocial, environmental, social, and cultural influences that interact to result in complex impairment of both appetite regulation and energy metabolism. Advanced obesity appears simply as the patient's inability to control himself.
In 1991, the International Conference of Institutes of Health concluded that, with rare exceptions, non-surgical weight loss methods are not effective in the long term in severely obese patients. Almost all individuals who participated in any non-surgical weight loss program due to severe obesity regained the body weight they lost within 5 years. Although prescribed and over-the-counter medications are used to promote weight loss, they do not appear to play a long-term medical role in the management of morbid obesity. Appetite-suppressing medications can result in a 5 to 10 kilogram reduction in body weight. However, weight is gained rapidly after the medication is stopped. Various professional weight loss programs use behavior modification techniques along with low-calorie diets and increased physical activity. A decrease in body weight of 1/2 to 1 kilogram per week has been reported; However, almost all of the weight lost is regained after 5 years.
A number of weight loss surgeries have been designed over the past 40-50 years. Surgeries accepted by the majority of surgeons include: vertical banding gastroplasty, gastric banding (adjustable or non-adjustable), Roux-en-Y gastric bypass and malabsorption surgeries (biliopancreatic diversion, duodenal replacement).
Gastric bypass surgery involves dividing the stomach and creating a small stomach pouch. This new stomach pouch is connected to your small intestine of various lengths shaped like a Y (Roux-en-Y gastric bypass) (Figure 1).
Laparoscopic gastric banding involves placing a 1.5 cm thick belt or clamp around the upper part of the stomach. This method creates a small pouch and a fixed outlet in the lower part of the stomach. The adjustable band, approved by the PDA in June 2001, is filled with sterile saline. When physiological saline is added, the stomach outlet is reduced, further restricting the exit of food from the pouch (Figure 2).
Vertical banded gastroplasty involves creating a pouch that restricts exit to the lower part of the stomach. This outlet is supported by a piece of mesh to prevent disruption and dilatation. Malabsorption surgeries cause weight loss by reducing the absorption of calories in the small intestine. These surgeries involve reducing the size of the stomach and bypassing most of the intestines (Figures 3 and 4).
Choosing one of the different surgeries depends on the surgeon's preference and the patient's eating habits.
Advantages of the laparoscopic approach include:
Below are patient selection guidelines for bariatric surgery established by the National Institutes of Health:
In some cases, a patient whose ideal body weight is not exactly 44.5 kg or who has a body weight 0 above the ideal body weight may be a candidate for surgical intervention. This patient must have a significant health problem(s) that would benefit from weight loss.
In the laparoscopic procedure, surgeons make small incisions (5 mm to 10 mm) to reach the abdominal cavity through trocars (small surgical instruments similar to tubes). The laparoscope, connected to a small video camera, is inserted into a small trocar. The resulting image is projected onto a TV screen, providing the surgeon with a magnified view of the stomach and other internal organs. To perform the surgery, 5 to 6 small incisions are made and trocars are inserted to use special surgical instruments.
The entire surgery is performed inside the abdomen after inflating the abdominal cavity with carbon dioxide (CO2) gas. When the surgery is completed, the gas is removed.
Laparoscopic method cannot be performed in a small number of patients. Factors that may increase the likelihood of choosing or converting to “open” surgery include a history of previous abdominal surgery that caused adhesions, inability to visualize organs, or bleeding problems during surgery.
The decision to perform open surgery is a decision that must be made by your surgeon before or during the surgery. If the surgeon feels that it is safer to convert the laparoscopic procedure to open surgery, this is not a complication but rather a purely surgical decision. The decision to return to open surgery is based entirely on the safety of the patient.
Weight loss: The success rate in weight loss is reported to be slightly higher with gastric bypass surgery than with gastroplasty or gastric banding; however, all techniques showed good to excellent results. Many reports report weight loss rates after 1 year of 40-50% for gastric banding and vertical banded gastroplasty and 65-70% for gastric bypass. Malabsorption surgeries generally achieve an average weight loss of 70-80% after 1 year. Weight reduction generally continues for 18-24 months after surgery in all surgeries. Some weight gain is common for about 2 to 5 years after surgery. Effect of surgery on associated medical conditions: weight loss surgery has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure and high cholesterol levels. Many patients report improvements in mood and other aspects of psychosocial functioning after surgery. Since the laparoscopic approach is performed similarly to open surgery, its long-term results appear to be similarly good.
Although the surgery is considered safe, as with all major surgery, complications can occur.
In reported case series, the sudden death rate after laparoscopic obesity interventions is quite low (below 2%). On the other hand, complications such as wound infections, wound opening, abscess, stapler opening and leakage, intestinal rupture, intestinal obstruction, large ulcers, pulmonary problems and blood clots in the legs may occur at or above levels. Other problems may occur in the postoperative period that may require additional surgical interventions. These problems include enlargement of the bladder, constant vomiting, stomach pain or inability to lose weight.
Gallstones are a common finding in obese patients. These gallstone-related symptoms are a common consequence of weight loss. Many physicians treat their patients with drugs that reduce bile secretion (Actigall or URSO) or recommend removal of the gallbladder during surgery. These options should be discussed with your surgeon or physician.
Deficiencies of nutrients such as Vitamin B12, folate and iron may occur after gastric bypass. Taking necessary vitamins and nutritional supplements usually prevents these. Another potential consequence of gastric bypass is “dumping” syndrome. Dumping syndrome is characterized by abdominal pain, cramps, sweating and diarrhea after eating foods and drinking beverages high in sugar. Avoiding foods with high sugar content prevents these symptoms. After malabsorption surgeries, nutrient deficiencies and protein deficiency similar to those seen after gastric bypass are observed. Diarrhea or loose “stools” are also common after malabsorption surgeries, depending on the amount of fat intake.
Doctors and clinical care staff need to pay special attention to women who become pregnant after any surgical procedure. Generally, complication rates for the laparoscopic approach are equal to or below those of traditional open surgery. After obesity surgery, the patient must get used to the effect of the changing body image.
As with all surgeries, there is a risk of complications. However, the risk of one of these complications occurring is not higher than the risk if open surgery was performed.
Most often, you will stay in the hospital for 1 to 3 days after a laparoscopic surgery. A tube may be inserted through your nose and you may not be allowed to eat or drink anything until it is removed. On the night of the surgery, you should not lie in your bed but sit in a chair and start walking the following day. You will need to participate in breathing exercises. You will be given painkillers when you need them.
An X-ray of your stomach will be taken on the first or second day after surgery. X-rays are a way for the surgeon to see if the stitches in your stomach are OK before allowing you to eat. If a leak or blockage is not visible (mostly invisible), you will be allowed to have 30 grams of liquid food every hour. The volume of liquid you drink will be gradually increased. Some surgeons will allow you to have baby formula or “puréed” food. You will continue to take a liquid or pureed diet until your doctor re-evaluates you approximately 1-2 weeks after you return home.
It is strongly recommended that patients walk and engage in light activities. It is important to continue breathing exercises when you return home after surgery. Pain after laparoscopic surgery is usually mild; However, some patients may need painkillers. At the first follow-up visit, your doctor will discuss possible dietary changes with you.
After surgery, it is important to follow your doctor's instructions. Although people often feel better within a few days, remember that your body needs time to heal. You will most likely be able to return to most of your normal activities in 1 to 2 weeks. These activities include showering, driving, climbing stairs, work and light exercise.
You should call your doctor to make a follow-up appointment within 2 weeks after surgery.
Call your physician or surgeon immediately if any of the following develop:
In this surgery, the stomach is divided into two parts, proximal and distal, with a band placed on the proximal part of the stomach. The volume of the proximal part is adjusted to 25-30 cc.
The patient is discharged after the surgery by encouraging oral fluid intake on the 2nd day and on the 3rd day with a liquid diet and warning to use only a liquid diet for 1 month. At the end of the first month, the patient's diet is changed to solid while the band is adjusted. The patient is called for control at the 3rd, 6th, 9th and 12th months.
Laparoscopic Roux-En-Y Gastric Bypass (Lrygb)
Gastric bypass surgery, which creates a small-volume pouch in the proximal part of the stomach and disables its distal part, was first performed by Mason and Ito in 1966. In this surgery, the proximal pouch is obtained by dividing the stomach into two with a stapler line, and the passage is provided by anastomosis between the proximal stomach pouch and the jejunum. Gastric bypass intervention not only limits stomach capacity but also causes mild malabsorption.
Laparoscopic Gastric Sleeve Resection (LGSR)-
Linear Gastrectomy
Biliopancreatic Diversion - With Duedonal Switch