BARIATRIC SURGERY

Gastric Sleeve Surgery:

It is a relatively new surgery for the treatment of morbid obesity, but its use has been increasing significantly in the last ten years. It is a procedure that we perform laparoscopically, this is done through five small wounds in the abdomen, three of 5mm and two of 12mm. The fundamental objective is to reduce gastric capacity, removing around 85% of the stomach.

Once the patient is anesthetized, we pass a candle or probe through the mouth to the stomach and using this as a mold, we cut the stomach with a sharp linear stapler (Echelon Flex 60 mm from Ethicon Endosurgery J & J) starting 6 cm from the pylorus (where the stomach ends, and the duodenum begins) to the Angle of His (union of the esophagus with the stomach).

Then we make a second line of suture manually, reinforcing the first one. We do not leave any type of drains, because we do not consider them useful and on the contrary, they are very annoying for the patient.

Why it is recommended:

In my experience, the Gastric Sleeve has become the surgery that I perform the most, basically because:

• Weight loss is not different from that achieved with Gastric Bypass in patients with a Body Mass Index (BMI) less than 40.
• The quality of life is very good, without some annoying side effects from other operations such as flatulence, diarrhea, feeling of abdominal distention, colicky pain, among others.
• It is an operation that produces a feeling of immediate fullness, without the frustration of wanting to continue eating and not being able to do so.
• Patients report a significant decrease in appetite.
• Deficiency states (malnutrition) are rare after this surgery as it practically does not produce poor absorption.
• The need to take supplements is minor and in many cases is temporary.
• Women who want to get pregnant can do so sooner.
• It is a very safe operation, in our hands it has low mortality rates, even lower than gallbladder surgery.
• It is an excellent option for young people and elderly patients.
• Women with obstetric interest (having children) can do so from the second semester or the first year after the operation.
• I think it is a good option for teenagers and young people as well as for obese seniors.
• It is a comfortable surgery for people who have difficulty attending regular medical check-ups, people with jobs such as chefs, pilots, people in close contact with people, as some side effects of other surgeries can be very annoying: very bad bowel movements and flatulence.
• The studies published to date continue to support this surgery as an excellent option for the treatment of obesity.
• Finally, and although it is not desired, this operation leaves the option of being converted to others, for example, to a Gastric Bypass, in case of failure.

Gastric Bypass Surgery:

Laparoscopic Gastric Bypass is considered the “gold standard” of bariatric surgery, it serves as a reference to determine the effectiveness of other bariatric procedures. It is a “mature” surgery, tested over time, with more than 40 years of experience, with thousands of patients with it, with its benefits and problems well known today. For our group, it is one of the surgeries we have performed the most, with more than three thousand patients.

It is a procedure that we call Mixed, it has a Restrictive component and a Malabsorptive component. The restrictive part seeks to reduce the amounts of food that the patient can consume, and the poor absorptive part seeks to alter the absorption of food in a portion of the small intestine.

Why it is recommended:

It is also an operation that we call Metabolic, as it produces very positive changes in the metabolism of sugar and fats (cholesterol and triglycerides). It is our preferred surgery to treat obese diabetics, since in general the improvement of this disease exceeds 80% of cases. We make five small wounds in the abdomen, three of 11mm and two of 5mm and first we carry out the restrictive part: we make a gastric bag or “pouch” of approximately 80 ml capacity. The rest of the stomach remains intact, “alive” and functional, but food does not enter it. We call it an “abandoned” stomach.

Then we begin the poorly absorptive part, we measure 100 to 200 cm of intestine (depending on the degree of obesity) from the origin of the intestine (Treitz angle). At this point we section the intestine and the part that continues distally we anastomose (“glue”) to the gastric pouch. We count 100 to 200 cm of the intestine that we put into the pouch and anastomose it with the initial section point of the intestine. This bypass ensures that food does not encounter digestive juices, a mixture necessary for the absorption of nutrients, in 200 or 400 cm of intestine (depending on the degree of obesity).

Gastric Bypass is the surgery I choose for my heavier patients, with BMI of 45 and more, with type II diabetes mellitus, with severe lipid disease (dyslipidemia) and for patients with severe Gastroesophageal Reflux disease (Barrett’s Esophagus) It is also the first choice for patients with other failed surgeries (adjustable gastric band and gastric sleeve). This operation requires regular medical check-ups and the taking of permanent vitamin and mineral supplements.

SADI-S:

By its acronym in English, it means Gastric Sleeve with duodenal-ileal diversion of a single anastomosis. In other words, it is a surgery that combines a Gastric Sleeve with an intestinal bypass, with poor absorption.

It is a relatively new procedure, 2007, designed for patients with severe obesity (BMI greater than 45-50), with histories of obesity since childhood and relatively young people where other surgeries such as Gastric Sleeve and Gastric Bypass have high probabilities of failure over time. The SADI-S is the surgery with the lowest probability of failure in terms of weight re-gain when compared to the Bypass and the Sleeve in these patients. It has similar results to surgeries such as Biliopancreatic Diversion and Duodenal Switch with a lower incidence of side effects that mean that these 2 surgeries are rarely done today.

Why it is recommended:

SADI-S is also a very effective procedure to combat diseases such as Type 2 Diabetes Mellitus, Dyslipidemia, High Blood Pressure, Sleep Apnea Syndrome, etc.

This surgery can be done in a single stage or in two stages. We decided to do it in two stages when patients are severely obese and/or very sick. We first do a gastric sleeve and after 6 to 10 months, once you have lost weight and your condition has improved, we perform the second part, the intestinal bypass, achieving very low complication rates.

It is a very effective surgery for weight control and associated diseases, but it must be said, it requires long-term follow-up with control examinations to evaluate nutritional condition and forces patients to take vitamin and mineral supplements for life.

Metabolic Surgery:

Metabolic surgery refers to the surgical treatment of diseases that are associated with Obesity from its early stages, that is, from Grade I Obesity. The most important is Diabetes Mellitus type 2, representing a new treatment option for this disease, previously considered only medical treatment. The rates of improvement and even suspension of insulin and oral medications reach up to 75-85% of operated patients.

The shorter the duration of diabetes, the better the result. Other diseases that improve with surgery in the early stages of Obesity are High Blood Pressure, Hyperlipidemia (High Cholesterol and/or Triglycerides), and Sleep Apnea. Some patients with serious injuries to large joints (hips, knees) also benefit from surgery in the early stages of Obesity.

Why it is recommended:

Metabolic surgery in well-chosen cases allows improving the quality of life and life expectancy in patients with mild obesity.

Metabolic Surgery derives from bariatric surgery or surgery for Morbid obesity. The metabolic surgery par excellence is the Laparoscopic Gastric Bypass, especially for the control and improvement of Type 2 Diabetes Mellitus. In some cases, a Gastric Sleeve could be performed and is determined with a complete evaluation of the patient.

Revisional Surgery:

Revisional surgery is indicated for patients with previous bariatric surgeries and who have any of the following conditions:

• Insufficient weight loss.
• Weight gain.
• Side effects of previous bariatric surgery, which impair quality of life: for example, intractable Gastroesophageal reflux, diarrhea, malabsorption, etc.
• Excess weight loss with malnutrition symptoms.

Why it is recommended:

Revisional surgery will always be more difficult than the original procedure and the results are actually less predictable, mainly as far as patients with weight gain or insufficient weight loss are concerned.

The procedures to be performed are highly variable and depend on the findings found during the evaluation of the previous surgery.

When a patient decides to review their surgery due to weight gain, that is, they lost the desired weight and regained it, it is very important to evaluate lifestyle habits and have the patient’s commitment to adherence to the program.