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Fobi-Capella
Ring Variation
In this variation the new stomach or
upper gastric reservior is a little longer than in the
original GBP, but the RING makes
the food go more slowly to the intestine. |
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Bilio-pancreatic Diversion
(BPD-Scopinaro)
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Duodenal
switch variation
In this variation, although part of the
stomach is removed, the pilorus and the first portion
of the duodenum are preserved. The stomach is then
joined to the intestine, thus preventing the stomach
from emptying the food immediately towards the small
intestine. This helps to decrease the surgery´s
side effects. |
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GBP alters the absorption of:
It
is necessary that the patient takes calcium, iron and vitamins
for life.
BPD makes feces be soft and smelly,
and it alters the absorption of:
The diet must always include
calcium, vitamin D and iron.
Operated patients with GBP
and especially BDP must have a strict and medical
follow-up for life in order to detect possible defficiencies in the
level of those nutrients.
|
Laparoscopic surgery consists on entering the abdomen through
some tubes known as trocars; we usually use 5 tubes of about
10 mm of diameter. One of them is used to place an optic,
with which the abdomen insides can be seen on a monitor
or TV, and thus the surgery is led. The other tubes are
used to place the retractors, graspers and other especial
instruments needed for the surgery.
In order to visualise the operation
area, it is necessary to create an air chamber within the
abdomen so as to temporarily displace the rest of the viscera;
this is possible as long as CO2 (carbonic anhydride)
is injected. |
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The first laparoscopic surgeries were performed
in order to remove the gallblader. They were first performed in
1987 and the technique was rapidly perfected throughout the 90’s.
In 1993/94 Laparoscopic Bariatric Surgery is
launched world-wide. Our team in Argentina began to perform Laparoscopy
for Obesity Surgery in 1994.
-
Patients are able to walk immediately after
the surgery
In-hospital stay is shortened (less than 24
hs). The only difference between laparoscopic and open
surgery (laparotomy) lays in the way in which the abdomen is
approached, because what is performed within it, has to be exactly
the same in both ways.
Sometimes, and due to technical difficulties, laparoscopy
has to be converted to open surgery.
As more experience is gained, all obesity surgeries
are being performed via laparoscopy (learning curve).
It is vital that the surgeon is an expert in
2 areas: Obesity Surgery (bariatric surgeon) and Laparoscopy. Laparoscopic
approach is an advanced method; it means it is necessary that
the surgeon has a long expertise on this technique.
However, this approach may fail or be discredited if it is not performed
by a “bariatric surgeon”, i.e. an expert in obesity surgery techniques.
1 - Patient’s
position
The placement is done with the patient
laying on his back on the operation table.
Legs should be open, so as
to allow the surgeon a proper position.
Because the patient’s body lays
at a higher level than his legs, the abdominal fat descends
and surgical manoeuvres become easier. A padded device is
placed on the legs in order to compress them. This avoids
blood stasis and prevents thrombosis.
2 - Insuflation
In order to visualise the operation
area, it is necessary to create an air chamber within the
abdomen so as to temporarily displace the rest of the
viscera;
this is possible as long as CO2 (carbonic anhydride)
is injected .
3 - Placement of work ways
(trocars)
| Laparoscopic surgery consists on entering the abdomen
thruogh some tubes known as trocars; we usually use 5
tubes of about 10 mm. of diameter. One of them is used
to place an optic, with which the abdomen insides can
be seen on a monitor or tv, and thus the surgery is led.
The other tubes are used to place the graspers, the retractors
and the special instruments needed for the surgery. |
 |
4 - Dissection for the placement of the band
5 - Band pass and closure 
6 - Fixing of the band
7 - Placement of the valve
on the abdomen’s wall
After implating the band
around the stomach, the laparoscopic phase is over.
Through one of the abdominal incisions, the valve
is placed on the abdominal muscles and beneath its skin and fat. Thus
there is no need for the patient to be in hospital during the postoperative phase
and with radiological control, the band can be adjusted
with a very thin needle and through the valve, inflating
the ball and thus reducing the way out to the rest
of the stomach. The adjustment does not need a surgery.
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8 - Radiological view of the
Gastric Band
There are many kinds of gastric bands on the market,
which have been especially designed for this type of surgery (Bariatric
Surgery).
The most commonly used ones are:
Lap Band®, (USA)
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It is made of a 13 mm – wide silicone elastomer
(bio-compatible) which forms a circular ring when closed,
of 9.75 or 11 cm (the larger has a ball with more capacity),
according to model.
-
The band’s tube and valve are radio-opaque,
i.e. they can be seen through x-ray, even when they have
no fluid within.
-
The band’s closure during the surgery does
not need to be sutured because a taut instrument is used.
-
The fluid (saline solution) inflation system
is a high-pressure one. The injected quantity depends on
the patient’s need as well as on the band’s model.
More than 100.000 bands have been implanted
world-wide (2002).
-
It has been approved by the American Food
and Drug Administration (FDA), on June,5th 2001.
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Obtech®, Sweeden
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There is one available model and 2 prototypes to be launched
in 2004/5.
It is a low-pressure system,
with a great ball capacity. The ball is softer, more flexible
and bigger than the American band, and it is filled with
a contrasting fluid (visible in x-ray), because neither the
band (except part of it), nor the tube are radio-opaque.
|
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Two prototypes have been designed in order to avoid using
a needle through the valve when doing the adjustments (2004/5).
|
| PROTOTYPE
I
The
adjustment is made through the fluid contained in a compartment,
which is a prolongation of the band’s tube.
A
flow of electromagnetic energy moves the fluid (inflates
or deflates the band). That energy originates in an external
unity, which lays on the skin through a transmitter, and
it is caught by a receiver that is placed beneath the
skin and that moves the fluid.
|
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PROTOTYPE
II
The band is made of a very soft material;
the adjustment and disadjustments are not turned on by
a filling hydraulic mechanism. The latter is merely mechanic
and it also originates in electromagnetic waves.
|
The
implants, results, weight loss and complications of these 2 bands
(Lap Band ® and Obtech ®) are similar.
|
7 Risks and complications |
We should bear in mind the fact that we are operating on a high-risk
patient (because of severe obesity and its co-morbidities).
General complications are
those caused by any major surgery involving general anaesthesia.
Specific complications caused
by LAGB are:
During the surgery, complications
are almost null, as long as it is performed by a well trained
surgical team, one with a long expertise on the subject.
Postoperative complications
are few, and we should pay special attention to:
1 - Slippage:
The gastric reservoir increases
its size (upper-gastric pouch dilatation). This is due to a slippage
of the gastric ball that lays beneath the band. It happens
in a 2 to 15 % of the surgeries, but larger,individual
and co-operative series have placed that percentage in a
range from 2 to 9. It occurs more often during the 1st
postoperative year.
Its symptoms are: gastric intolerance,
pain in the upper abdomen, vomits,reflux esophagitis, weight loss
interruption, absolute and irreversible
food intolerance due to the obstruction of the orifice
that links the
upper pouch (enlarged and inclined) with the rest of the
stomach.
It can be acute or chronic.
It is necessary to detect it on time, especially the first
one, so as to treat it early.
-
Excessive and frequent vomits
-
-
Esophagus contractions alterations
-
The treatment can include:
-
Total or partial deflation of the band
-
Relaparoscopy, in which case the stomach and
the same or a new band
are replaced in their original position
2 - Valve complication:
The small reservoir used for making
the adjustments and which is
placed on the abdomen’s wall on the muscle.
It happens in 0,5 to 10,4 % of the
cases, and it consists in rotation, liquid filtration or infection.
Its treatment usually consists in
minor surgery. The valve can be removed, replaced either in its
original position or by a new one, depending on the case.
Relaparoscopy is needed sometimes
as an alternative, in order to fix the band’s tube as well as
the valve in another part of the stomach. This applies when an
infection of the valve reservoir occurs (0,3-3%).
3 - Erosion
or penetration:
The band may incorporate itself
to the stomach wall and thus be partially seen in the
lumen of this organ.
This is the most serious complication,
but its occurrence is rare (1%). Only a few series
have shown a slightly higher percentage. The causes are still
unclear. This complication does not put the patient’s life at
risk, and the band can be removed through relaparoscopy or endoscopy,
or it can be controlled periodically if it still produces weight
loss.
The band can remain within the patient’s
stomach for life. It might be removed due to complications; however,
if that is not the case, then up to this day there exists no reason,
nor is it advisable to remove it, because it secures the patient
against eating too much, as long as the proper adjustments are made when necessary. If the band is removed,
the patient is at risk of regaining weight, unless a radical change
and a constant psychological follow-up of the patient´s eating behaviour
are made.
Gastric Banding is a simple technique.
It is implanted through laparoscopy,
it preserves the stomach’s integrity, it is reversible, safe (with
a minimum of complications) and effective, with a good weight
loss.
Patients we operate on are complex: their co-morbidities put them at risk.
Why should we increase
the risks with a complex surgery that increases both the complications
rate and mortality?
Why would we use a technique which
might add other diseases, such as anemia, osteoporosis and malnutrition
(alterations in iron, calcium and proteins absorption)?
Why would patients take supplements
or other medication for life to avoid the complications the surgery
might cause, and have a strict follow up in order to detect those
deficiencies (which are many times serious ones) on time?
All obesity surgeries are risky; however, in the case of Gastric Banding (GB), the
risks are reduced to the minimum. The complications that
may occur are not serious. Besides, neither
the stomach nor intestine anatomy nor their physiology are
altered, and mortality is almost non-existent.
During the patients’ evaluation,
it is necessary to know which are the results of their weight
loss in the long term.
Our series have shown that with Laparoscopic
Adjustable Gastric Banding the results are good in a 68 % of
the patients, and that weight loss is higher than a 50
% of the overweight.
Then why should we perform a complex
surgery on that 68 % of the patients if it causes a higher mortality
and more co-morbidities, when we know that with a simple one (GB)
we get “Good” or “Excellent” results?
The rest of the patients (32 %) does
not have such satisfactory results (“Fair” or “Failure”), and
cannot lose more than a 50 % of their overweight; however, they
certainly improve their quality of life
and many co-morbidities. That group of operated
patients (32 %) is given the chance of undergoing a second surgery
(GBP-BPD), which is more complex.
It is better to perform an undertreatment
surgery on that 32 %, than to perform an overtreatment
one on the 68 % of the patients.
After 36 months of the Laparoscopic
Adjustable GB, our patients’ evaluation shows an Average Percentage
of Excess Weight Loss (EWL%) of 61% for all categories.
If we consider the categories separately,
then different EWL% are shown:
-
Severe
Obese
73%
-
Morbidly Obese
61%
- Superobese
59%
- Supersuperobese
59%
- Triple Obese 60%
Patients
with a pre-surgical BMI>60 will take more time to arrive to
the same percent weight lost .
The
other two complex surgeries (GBP-BPD) increase mortality
and complications even more when they are performed on patients
who have a high BMI (more than 60), such as supersuper and
triple obese ones.
Because
of all these reasons, we choose a simple, safe and
effective surgery for high-risk patients.
“The
patient is difficult, the procedure must be simple”
When evaluating the results, we should
consider weight loss in proportion to time; a surgery is successful, if a 40 or 50 % of overweight is lost.
The latter is determined in terms of
the ideal weight, according to the American Insurance Companies’
tables, which relate weight, height and body structure, thus looking
for the weight in which mortality is less probable and life span
is longer. This is the “ideal” weight, although many times is not
the real one; therefore, we choose to refer to it as the “desired”
weight. These tables have their limitations, but they are only used
to learn the patients’ overweight.
When evaluating a surgery, we need
to consider two very important factors that occur with weight loss:
-
A change in the patients’ quality
of life, as well as a feeling of satisfaction, which
relates to their self esteem, and physical, professional, social,
work and sexual activities.
A scoring table is established
(B.A.R.O.S – Bariatric Analysis and Reporting Outcome System),
adding the above mentioned criteria to weight loss, in order to
define whether a surgery has been successful or not. Complications
and reoperations are also added, and the results are classified
in: Failure, Fair, Good, Very Good and Excellent.
A long-term follow-up
is necessary, in order to evaluate the results correctly.
| 10
Which
medical examinations are required before the surgery? |
Patients’ clinical medical history must include the
following information:
How was their obesity onset (Infancy
Type or Reactive Type) and which dietary regimes and eating
behaviour have they led
Co-morbidities (Hypertension, diabetes)
Physical examination
Discussion and explanation of the
surgical techniques
The surgical risks are evaluated
afterwards.
The following areas are explored:
Cardiopulmonary system
- Chest
x-ray - front and
profile
-
Functional pulmonary tests
-
Electrocardiogram and surgical risk
Gastrointestinal system
-
G-I x-ray (esophagus-gastro-duodenal-double contrast)
Hepatobiliary system
-
Sonogram of liver, pancreas and bile ducts
- Liver function tests
- Electroforetic Proteinogram
-
Antib. HIV
- Atg.
HBs
-
Antib. HBs
-
Antib. HBc
- Antib. HCV
Endocrine – Metabolic system
- Basal serum glucose
and post intake 75grs. glucose (2hs)
- Basal serum insuline
and post intake 75grs. glucose (2hs)
- Glycosilated
hemoglobin (HbA1c)
- Free
Thyroxine (FT4) - TSH
- Anti-Thyroperoxidase
Antibody (TPO-Ab)
-
Thyroid Microsomal Fraction Antibody
-
Total Lipids
-
Triglycerids
-
Total Cholesterol
-
Cholesterol HDL
-
Cholesterol LDL
- Free fat acids
Renal
-
In blood ionogram (Na Cl K)
- Blood Urea
- Blood Creatine
- Urine Creatine
- Urinary
free cortisol (24hs)
- Uric acid
- Urine uric acid
-
Calcium
-
Magnesium
-
Potassium
-
Complete Urine
Hematolgic
- Blood group
- Hemogram
- Prothrombin time
- K.P.T.T.
-
Coagulation time
-
Bleeding time
The patient is evaluated through
psychological tests and through interviews in the psychological
area, as well as in nutritional and endocrinology areas.
Finally, the patient is evaluated by
the anaesthesiologist team.
1) TREATMENT
STAGES
a. Transition
stage
This stage begins immediately after
the surgery and ends in the 4th post-surgical week.
Food consistency is the most important indication to be complied
with, not because you are on a diet and you want to lose weight,
but to protect the band, that is to say, the surgery.
It is very important to follow feeding
instructions as much as possible to secure the position, stability
and good function of the band. If you do not follow
these instructions you could endanger the band, feel abdominal nuisances,
pain and vomits.
b. Restriction
stage
This stage begins with the first adjustment
which aims to reduce the diameter of the band in order
to further restrict the entrance of food into the stomach. The number of adjustments varies according to the person (generally
2 / 4). They start during the first post-surgical month. The more adapted to the treatment you are, the less adjustments
will be necessary.
It is important to feel the effect
of the band and not to fight against it, insisting on overeating
foods that "pass" easily. Insisting on eating
when you already are satiated causes a lot of pressure on the band
and it will provoke vomit.
In this restriction stage, you should
not drink liquids when you are eating solids, nor push the food
with liquids because you will thus increase the pressure in the
upper part of the stomach and you may vomit. In the
long run, increasing pressure on the band and the stomach can cause
the enlargement of the upper part of the stomach and the effect
of the band will be lost.
This stage finishes when you reach the
desired weight.
c. Maintenance
stage
This stage begins once you have reached
the desired weight. The band can keep the diameter of
the last adjustment, or be opened up a little, in order to eat more
food and to stabilise the weight.
The ideal situation occurs when you
can maintain your own weight on your own, and order your feeding
– this will help you to feel well for the rest of your
life.
The patient that does not consciously
eat in an orderly way will take more time to reach the ideal
weight and will depend longer on the band.
2)
DURING THE 24-HOUR HOSPITAL STAY
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Patients start taking chopped ice, water, and
they can walk 2 or 3 hours after the surgery, once the anesthetic
effects have completely worn out.
3)
POST-SURGICAL FEEDING PROGRAM
Post-surgical feeding should
be very carefully planned, because it is fundamental in order to
get the expected results.
After surgery you will take
a new road:
A NEW BEHAVIOUR IN YOUR EATING
HABITS
Important
points:
I) Quantity
II) Consistency
III) Quality
IV) Frequency
I) Quantity
You will start eating 12 to 24 hours after the operation.
You should be especially careful with the quantities, because
the amounts indicated in the plan are estimated. Do
not force the tolerance, it can make you vomit, and it can
be dangerous for the position of the band, especially at the transition
stage.
The operation will begin to regulate the quantity of what you
can eat. Although this regulation begins immediately
after surgery, it becomes evident after the first adjustment.
The mouthfuls should be small (30% of the usual).
You should stop eating when you begin to feel a full stomach or
satiated, or even before this sensation appears.
The maximum size of the portion to be eaten
corresponds approximately to that of a “tennis ball".
II) Consistency
During the 1st. month the consistency of the
food will have to be liquid, semi-liquid and semi-solid.
The “puree” consistency type, favours the stabilisation
of the band at the transition stage.
The restriction stage begins as from the first month,
after the 1st. adjustment, with normal consistency feeding, and
following the recommended instructions.
Liquids should not be drunk with solid food, but
30 minutes before or after. You will have to wait
enough time so that the superior bag evacuates to the rest of
the stomach.
Food should be very well chewed. You
should not swallow pieces of food. It is advisable
to chew between 20 and 30 times before swallowing. Food should be soft. This takes time;
it is
necessary to diminish the speed at which you eat, enjoying your
food more.
The surgery cannot discriminate the quality of the food you eat,
therefore it depends on you.
The provided nutritional plan is varied, in order to have a balance
and avoid nutritional deficiencies.
You should get used to diet beverages, diet food, to sweeten
with a sweetener ("Nutrasweet ®" or " saccharin
"). You can only add a teaspoon of oil, preferably sunflower
or olive oil.
You should avoid hyper-caloric liquids or foods,
i.e., alcoholic beverages such as whisky (a measure: 245
calories), gin tonic (1 glass: 180 calories), beer (1 glass: 150
calories), wines (1 glass: 150 calories), cola-type beverages
(1 glass: 105 calories), chocolate (1 glass of milkshake: 450
calories; a chocolate bar, 30 gr.: 150 calories), ice creams (1
cup: 270 calories), creams (1 cup: 400 calories). Although they
“pass easily” through the stomach –narrowed by the calibration
of the band–, their ingest will result in an important limitation
of weight loss. It is advisable not to drink sparkling
soft drinks, and to reduce the ingest of fatty foods. The ideal consumption of fat is less than 30
g a day.
Feeding should be ordered and scheduled. The 1st and 2nd weeks, you should have 6 daily meals, and
as from the third week, only 4 meals a day (breakfast, lunch, snack
and dinner).
You should avoid eating between meals and nibbling,
because you will lose less weight.
4) PHYSICAL ACTIVITIES PROGRAM
You should work out at least 45 minutes a
day, 4 to 5 times per week as from the second week after surgery. We highly recommend walking (4 cal / min), and also bicycling (6.5
cal / min), walking on a tape, swimming (8 cal / min), working out
on a climbing machine, doing aerobics, etc. The distance you walk should be gradually increased. You should reach 2
km in 6 weeks. You can drive and climb stairways. Workout will make your skin and muscles firmer, improve your cardiopulmonary
condition and increase calory consumption.
REMEMBER:
In order to get good results with the treatment
of severe obesity, we should pay attention to the following items:
• Gastric band surgery corresponds to approximately
60 % of the entire treatment and it only limits the food quantity.
• A 30% depends on the new habit or eating
behaviour (that needs to be changed) with control of the food quality,
frequency and consistency. A psycho-social
harmony must as well be reached
in order to improve your quality of life. This 30% only depends on you, on our
support and help.
• A 10% of the improvement in weight loss
is due to physical excersise and
it also
depends on you.
Your
co-operation is vital to get the best results
THE BASIC POINTS FOR THE SUCCESS OF THE TREATMENT
ARE:
2. Chew the foods very well.
3. Take small mouthfuls (30% of the usual ones).
4. Stop eating when you feel
full or satiated, or even before. Remember the
maximum quantity you eat should be the size of a “tennis ball”.
5. Liquids should be drunk
before or after solids, never together (just small sips so
as to wet the food).
6. Eat no more than 4 times a
day after the second post-surgical week.
7. Avoid eating between meals or nibbling.
8. Take strict care of the quality of the food
you eat.
9.Work out 45 minutes a day (4 to 5 times
a week) .
95% of the post-surgical vomits
are due to the fact that the first 5 points above are not
strictly complied with.
With the correct adjustment of the
band, 95% of the reasons for not loosing weight or doing so
very slowly, are due to failure to comply with points 6, 7,
8 and 9.
-
After surgery, you will have to
change your eating habits.
-
The changes that you should learn will alter
your social diet habits.
-
Experience has shown that patients
who have followed indications and advice have had less post-surgical
problems and their loss of weight has also been more satisfactory.
-
The changes that we recommend are
necessary and depend on you.
-
Use small plates, cups and glasses (dessert
and coffee ones), as well as teaspoons.
-
When you begin to chew something, leave the
fork or spoon on the plate. Start eating the
second mouthful once you have finished eating the first one.
-
Make pauses between mouthfuls.
-
Eat very slowly, do not hurry, take 30 to
40 minutes per meal. Enjoy each mouthful.
-
You should use small quantities of salt,
and avoid foods that contain high levels of this minerals: ham,
olives, pickles, etc.
-
Food with high content of fibre like fresh
fruits, vegetables and whole grains (wheat,bran, oats, rye,
bran rice) are very important for the diet. Vitamins
and mineral are also included in them. They will
help you to feel satisfied and regularise the functioning
of your bowels.
-
Tolerance to some food varies from one individual
to another, therefore, the best way to find which food
you will accept better, will be through a system of trial and
error.
-
The following is a list of foods (fibrous
and sticky) that some people find it difficult to tolerate:
-
Hard meats (especially
beef).
-
Very dry meats (certain birds).
-
Fatty meat (e.g.
sausages, etc.).
-
Fried and very seasoned
food.
-
Dried fruits (nuts, almonds)
and oranges (can get stuck in the new opening of the
stomach).
-
Very fibrous vegetables
(celery - asparagus - broccoli). Popcorn, peanuts,
bran rice and some type of pasta.
-
Be careful with small cores,
seeds or the skin of some fruits and vegetables.
-
Remember that the pills with
covering or hard consistency are difficult to digest.
- We believe that through the changes you will start feel
and enjoying the change in your
body image. At this stage, we require the highest possible
co-operation from you, in order to achieve the
best results. The gastric band has not
been designed to prevent the patient from eating, but only to
limit his or her feeding (it is a restrictive operation). The band is adjusted to reach a balance between a reasonable
tolerance to the food and a good loss of weight. Our nutritional medical support team will assist you
with any problem or difficulty that you may encounter.
Should you have any doubt,
do not hesitate to get in touch with the Centre
Your questions are welcome
Not all of the patients who have lost weight after the obesity
surgery need an operation the remaining or “hanging” skin.
It depends on many factors, such as age, skin elasticity
and muscular tone, and on whether the patient has been working
out or not after the surgery.
Physical exercise is very important, because not
only does it contribute to weight loss, but also it improves muscles
and the body frame.
As a general rule, plastic or aesthetic corrective
surgeries must not be performed before 12 months have passed,
because weight loss may continue to occur. It is necessary to
wait until the patient’s weight is stable.
If a patient is in need of this kind of surgery,
then it means that he or she has lost a significant amount of
weight.
Other important factors that requires surgical prescription
are:
Functional limitations, because skin excess
may in some cases make it difficult to walk, work out, have sexual
activity or improve one’s personal hygiene.
Psychological aspects: due to their body frame
improvement and the consequent raise in their self-esteem, patients
would feel the need of making their “new body” look more beautiful.
Only with an aesthetic aim
The most frequently affected parts of
the body due to weight loss, are:
-
Abdomen
-
Thighs and buttocks
-
Arms
-
Back
-
Breasts
It is not necessary to enter the abdominal cavity if a plastic
surgery is to be performed on the abdomen. The skin and fat
excess is removed, the abdominal walls’ muscles are reinforced
in order to avoid flabbiness. Pre-surgical wall hernias may be
corrected after this reconstructive plastic surgery. The umbilicus
may or may not slip back to its original position.
Not only does tights and/or buttocks plastic surgery
remove the excess within both thighs and/or buttocks, but it
also lifts and fixes their structures, thus shaping the body.
Through arms and back surgery there exist two possibilities:
a resection of the skin excess or a lipoaspiration, according
to the degree of what hangs.
Breast plastic surgery is performed in order to correct
them, so as not to leave them pendulous or hanging. Breasts can
be lifted, reduced in size or enlarged, according to each patient’s
needs.
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