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Kind of Surgery
All patients that have to be submitted to surgery need to exactly know all the possible alternatives and all the risks related to the operation. Patients need to be informed that the operation will always be performed under general anesthesia, and that this carries a definite risk. The surgical procedure itself and the morbid obesity of the patient enhaces this risk of possible complications. Anyway, these complications will be more frequent after a traditional open surgical approach than after a laparoscopic one. Currently, surgery for morbid obesity can be classified as it follows: open surgery and laparoscopic surgery. A) Open surgery During the open surgical approach two different operations can be performed: one based on the malabsorption of food and one based on section and reduction of the gastric volume in order to reduce the amount of food ingested. 1) Malabsorption technique The most representative one is the bilio-pancreatic by-pass. It is based on the resection of the distal part of the stomach and in the reduction of the length of the small intestine (where bile and pancreatic juice act to prepare the food for absorption). The ingested food pass from the stomach to the small bowel (50 cm) and from there to the large bowel, where theoretically most of the absorption should happen. In such way, absorption of food is largely incomplete and altered. This technique determines severe enzimatic, electrolytic and vitaminic deficiencies and imbalances, that require a strict postoperative medical control. If such a control fails, serious and severe problems to the health of the patient can arise. 2) Gastric restriction technique The most commonly performed is the vertical rin ged gastroplasty that is based on performing a hole in the middle of the stoma ch and suturing and/or sectioning with the aid of mechanical staplers the gast ric wall, thus determining a small gastric conduit for the passage of food, that is reinforced with a prosthetic ring and that determines a reduction of gastric volume to one tenth of its original one. Such a reduction is responsible for a strong reduction of hunger, food intake and body weight. These two techniques are performed through an open surgical approach, and carry a definite risk of infections, incisional hernias, respiratory tract complications, aesthetic problems (scars) and the risk that the sutures or staples placed on the stomach could disrupt, thereby leading to a leakage of gastrointestinal contents with the acute onset of peritonitis, intra-abdominal abscesses and ultimately death of the patient. The series published in the medical literature carry a mortality rate of 1%. Larger series dealing with bilio-pancreatic by-pass reach a 6-8% mortality rate. B) Laparoscopic surgery We perform this surgery in the "Centro Médico Teknon" in Barcelona, requiring specific electronic equipment and instrumentation and experienced personnel. It needs the insufflation of the peritoneal cavity with CO2, thereby creating a cavity in which we introduce a miniaturized camera that transmits the images to a TV monitor. In order to introduce the camera and the instruments we place five ports (cannulas), 3 of 5 mm and 2 of 10 mm in diameter. Our technique is based on the basic concepts of obesity surgery and works through the functional reduction of gastric volume through the placement of a PTFE (polytetrafluorethylene) band at the level of the upper stomach, creating an upoper gastric pouch of approximately 50 ml. This band is stitched to the gastric walls by means of sutures and special staplers. With this techniques we are able to achieve the same reduction of gastric volume offered by a vertical banded gastroplasty, without dividing nor suturing the gastric walls. Weight loss is comparable to the one offered by vertical banded gastroplasty, but our technique offers the advantages of the laparoscopic approach. 1º: We do not open the abdomen, therefore scarring is absent or minimal, and this can be very important for young patients, there is no risk of incisional hernias and infections, postoperative pain is not a problem, and the patient leaves the hospital between 24 and 48 hours after the procedure. 2º: There is no gastric division and/or suturing, thereby leaving the stomach as it was before the procedure and eliminating the risk of suture line breakdown and peritonitis. Even more important is to notice that the procedure is totally and always reversible, and if the patient desires it, he can return to the status prior to the operation. Comparing the techniques In the inmediate postoperative period the patient will face symptoms directly related to the type of surgery performed. Open surgery allows the patient to leave the hospital 7-10 days after the procedure, and needs 1 to 3 months for a complete recovery of a full physical activity. Moreover, it is necessary to keep in place a nasogastric tube and a urinary catheter in the postoperative period. With laparoscopic surgery the patient is discharge 24 to 72 hours after the operation, and return to a full physical activity is generally achieved within 1 to 2 weeks, although some highly motivated patients have returned to work after only 48 hours. There is no need to keep tubes or catheter in place. After open surgery there is respiratory distress, pain due to the incision, risk of infections, abscesses, peritonitis and of incisional hernias. This leads to the routine use of tubes and parenteral (i.v.) infusions during the first 4-5 days after the operation. After laparoscopic surgery there are no or minimal respiratory problems, infections, abscesses, peritonitis and incisional hernias are virtually absent. The patient comes out from the operating theatre without tubes and resumes oral ingestion of fluids within 12 hours. Usually, one to three dosis of pain-killer are necessary in the postoperative period. Symptoms arising after laparoscopic surgery are pain in the right or left shoulder (due to the insufflation and distention of the abdominal cavity) and in the anterior abdominal muscles, similar to that experienced by women after delivery. When starting the oral diet the patient notices a sensation of early fullness and satiety due to the reduction of stomach volume. If he tries to force the ingestion of further liquids he can experience a retrogastric pain. In order to avoid such symptoms it is important to slow down food ingestion and to stop it when he feels full. When starting the oral diet the patient notices a sensation of early fullness and satiety due to the reduction of stomach volume. If he tries to force the ingestion of further liquids he can experience a retrogastric pain. In order to avoid such symptoms it is important to slow down food ingestion and to stop it when he feels full. After surgery From the discharge to the loss of excess weight the patient needs to be controlled by a specialized endocrinologist that should control his diet. Postoperative food intake will be hypocaloric and vitaminic, in order to let the patient loose weight leading a normal life-style. The great advantage of gastric volume reduction is that the patient does no more experience the sensation of hunger that he had before (bulimia). The endocrinologist maintains the hypocaloric regimen until the patient has reached a satisfactory weight loss. In a first period the patient will be allowed only a liquid diet of very low caloric content, and will be gradually re-educated to a normal diet. Time necessary to loose the excess weight depends upon the amount of weight excess, and varies within 6 to 12 months. During this period the patient is controlled by the endocrinologist at 3, 6 and 12 months. The results are considered good when the weight lost in the first year is more than 25% of the excess weight. As an example, if the patient had 100 Kg excess weight, when he has lost more than 25 Kg during the first year after the operation. In our experience patients loose between 10 and 20 Kg during the first month, reaching 25 Kg at 3-4 months, depending on age and excess weight. Nevertheless, weight loss need to be controlled and contained in a range leaving the patient confortable with himself and free of psychological consequences. Before surgery all patients need to be submitted to the following workup, after excluding any metabolic and/or endocrinologic disorder (especially thyroideal):
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