Bariatric Procedures

 
Panama

Available and most common procedures  

                    LAP-BAND adjustable gastric banding (LAGB). The surgeon uses an inflatable band to partition the stomach into two parts by wrapping the band around the upper part of your stomach. Pulling it tight like a belt, the surgeon creates a tiny channel between the two pouches. The band keeps the opening from expanding and is designed to stay in place indefinitely. It can be adjusted or surgically removed if necessary. LAGB is gaining popularity because it's a simpler procedure and has a lower complication rate when compared with more-involved procedures. However, LAGB causes less weight loss and a slower rate of weight loss than does the Roux-en-Y gastric bypass. This surgery isn't recommended for people who have certain medical conditions, such as Crohn's disease, large hiatal hernias or a history of gastric ulcers.

§                  Vertical banded gastroplasty. This operation, also referred to as stomach stapling, divides the stomach into two parts — limiting space for food and forcing you to eat less. There is no bypass. Using a surgical stapler, the surgeon divides your stomach into upper and lower sections. The upper pouch is small and empties into the lower pouch — the rest of your stomach. Partly because it doesn't lead to adequate long-term weight loss, this weight-loss surgery has fallen out of favor.

§                  Biliopancreatic diversion with duodenal switch. This can be a full or partial bypass, determined by your physician/surgeon. In this procedure, the surgeon removes up to 80 percent of the stomach. The valve that releases food to the small intestine is left along with a limited portion of the small intestine that normally connects to the stomach (duodenum). The surgery bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach. This weight-loss surgery offers sustained weight loss, but it presents a greater risk of malnutrition and vitamin deficiencies and requires close monitoring. It's generally used for people who have a body mass index greater than 50.

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Gastric bypass surgery: You need to explore ALL of the facts...
Information provided by: The Mayo Clinic

Weight-loss (bariatric) surgery changes the anatomy of your digestive system to limit the amount of food you can eat and digest. The surgery aids in weight loss and lowers your risk of medical problems associated with obesity.

Gastric bypass is the favored bariatric surgery in the United States. Surgeons prefer this surgery because it's safer and has fewer complications than other available weight-loss surgeries. It can provide long-term, consistent weight loss if accompanied with ongoing behavior changes.

Gastric bypass isn't for everyone with obesity, however. It's a major procedure that poses significant risks and side effects and requires permanent changes in your lifestyle. Before deciding to go forward with the surgery, it's important to understand what's involved and what lifestyle changes you must make. In large part, the success of the surgery is up to you.

How is gastric bypass surgery done?

In gastric bypass (Roux-en-Y gastric bypass) the surgeon creates a small pouch at the top of your stomach and adds a bypass around a segment of your stomach and small intestine.

The surgeon staples your stomach across the top, sealing it off from the rest of your stomach. The resulting pouch is about the size of a walnut and can hold only about an ounce of food. The pouch is physically separated from the rest of the stomach. Then, the surgeon cuts the small intestine and sews part of it directly onto the pouch.

This connection redirects the food, bypassing most of your stomach and the first section of your small intestine, the duodenum (doo-o-DEE-num). Food enters directly into the second section of your small intestine, the jejunum (jay-JOO-num), limiting your ability to absorb calories. Even though food never enters the lower part of your stomach, the stomach stays healthy and continues to secrete digestive juices to mix with food in your small intestine.

Some surgeons perform this operation by using a laparoscope — a small, tubular instrument with a camera attached — through short incisions in the abdomen (laparoscopic gastric bypass). The tiny camera on the tip of the scope allows the surgeon to see inside your abdomen.

Compared with traditional "open" gastric bypass, the laparoscopic technique usually shortens your hospital stay and leads to a quicker recovery. Fewer wound-related problems also occur. Not everyone is a candidate for laparoscopic gastric bypass, however. Talk to your doctor about whether this approach is appropriate for you.

What can you expect during the surgery?

Gastric bypass surgery is performed under general anesthesia. This means you inhale analgesics as a gas or receive the anesthetic agent through an intravenous (IV) line so that you're asleep during the surgery.

During surgery, a tube is passed through your nose into the upper stomach pouch. Occasionally, this tube stays in overnight. The tube is connected to a suction machine after surgery to keep the small stomach pouch empty so that the staple line can heal.

You may have another tube in the bypassed stomach. This tube comes out the side of your abdomen and is removed four to six weeks after surgery. Some skin irritation may develop around this tube.

Gastric bypass surgery takes about four hours. After surgery, you wake up in a recovery room, where medical staff will monitor you for any complications. Your hospital stay may last from three to five days.

What can you expect after gastric bypass surgery?

You won't be allowed to eat for one to three days after the surgery so that your stomach can heal. Then, you'll follow a specific progression of your diet for about 12 weeks. The progression begins with liquids only, proceeds to pureed and soft foods, and finally to regular foods.

With your stomach pouch reduced to the size of a walnut, you'll need to eat very small meals during the day. In the first six months after surgery, eating too much or too fast may cause vomiting or an intense pain under your breastbone. The amount you can eat gradually increases, but you won't be able to return to your old eating habits.

You may experience one or more of the following changes as your body reacts to the rapid weight loss in the first three to six months:

What are the benefits of gastric bypass surgery?

Within the first two years of surgery, you can expect to lose 50 percent to 60 percent of your excess weight. If you closely follow dietary and exercise recommendations, you can keep most of that weight off long term.

In addition to dramatic weight loss, gastric bypass surgery may improve or resolve the following conditions associated with obesity:

The improvements observed in type 2 diabetes, high blood pressure and high blood triglycerides may significantly decrease the risk of cardiovascular events in people who have undergone gastric bypass surgery compared with those people who did not have surgery. Also, gastric bypass surgery may reduce the risk of dying of diabetes, heart disease and cancer. The surgery has also shown to improve mobility and quality of life for people who are severely overweight.

What are the risks of gastric bypass surgery?

As with any major surgery, gastric bypass carries risks such as bleeding, infection and an adverse reaction to the anesthesia. Possible risks specific to this surgery include:

§                  Death. A risk of death has been associated with gastric bypass surgery. It has generally been reported to be one death per 200 to 300 surgeries. Higher risks have been reported amongst Medicare recipients. The risk varies depending on age, general health and other medical conditions. Talk to your doctor about the exact level of risk gastric bypass surgery may pose for you.

§                  Blood clots in the legs. Blood clots in the legs are more likely to occur in very overweight people. Blood clots can be dangerous. In some cases, they travel to the lungs and lodge in the lungs' arteries causing a pulmonary embolism — a serious condition that damages lung tissue and can lead to death. Walking and using leg wraps that apply intermittent pressure to the leg can help reduce this risk of blood clots in the legs. Smoking has been shown to increase the risk of clotting in people undergoing gastric bypass surgery. Quitting smoking is strongly recommended.

§                  Leaking at one of the staple lines in the stomach. This severe postoperative problem is treated with antibiotics. Many cases heal with time. Often, however, the leak can be serious enough to require emergency surgery.

§                  Incision hernia. An incision hernia is a weakness in the incision. This is more likely to occur if you have an open procedure and a large abdominal incision. This usually requires surgical repair, depending on the symptoms and the extent of the hernia.

§                  Narrowing of the opening between the stomach and small intestine. This rare complication may require either an outpatient procedure — in which a tube is passed through your mouth to widen (dilate) the narrowed opening — or a corrective surgery.

§                  Dumping syndrome. This is a condition where stomach contents move too quickly through the small intestine, causing nausea, vomiting, diarrhea, dizziness and sweating. It's frequently experienced after eating sweets or high-fat foods.

 Questions and Answers about Bariatric Surgery

How Does Bariatric Surgery Affect The Digestive Process?

Before Surgery
Food is chewed in the mouth, then swallowed, passing through the esophagus to the stomach, (roughly the size of a melon) where stomach acids dissolve it into smaller particles. The liquid (chyme) then passes into the small intestine where enzymes and bile continue the digestive process. The first section is the duodenum, the shortest section. Here, calcium, iron and a few vitamins are absorbed. The second and third sections are the jejunum and ileum, both about ten feet in length. Here, the bulk of food nutrients (vitamins and minerals) and calories are absorbed.

After Surgery
During both main types of obesity surgery, the size of the stomach is reduced by up to 90 percent, to the size of an egg or even the size of a thumb. Typically, its capacity is 3-4 tablespoons of food. This stomach reduction drastically reduces the quantity of food which can be consumed in one sitting and speeds up satiety. During bypass surgery, the digestive tract below the stomach is also altered. After leaving the small stomach pouch, food is re-routed to bypass most of the duodenum and is directed into the final part of the jejunum. Because the food passes along a much reduced length of small intestine, and comes into contact with smaller amounts of digestive enzymes, fewer calories and nutrients are absorbed.

Is Bariatric Surgery An Easy Solution for Weight Loss?

No. According to the American Society For Bariatric Surgery, gastric reduction surgery is not an easy option for obesity sufferers. It is a drastic step, and carries the usual pain and risks of any major gastrointestinal surgical operation.

Does Bariatric Surgery Involve New Eating Habits?

Yes. All types of gastrointestinal obesity surgery compel patients to change their eating habits radically, and make them very ill if they overeat. And after bariatric surgery is performed, patients remain at a lifelong risk of nutritional deficiencies.

Does Bariatric Surgery Typically Lead to Major Weight Loss?

Yes and No. Some patients who undergo bariatric gastrointestinal surgery lose more than 100 pounds in weight - some lose as much as 200 pounds weight. Typically, patients who undergo adjustable gastric banding procedures, such as Lap-Band lose less weight than those who have gastric bypass like Biliopancreatic Diversion (BPD) or Duodenal Switch (BPD-DS). Some patients reach a normal weight, while others remain overweight, although less overweight than before. However, in order to maintain this type of weight reduction, patients must follow carefully the post-operative guidelines relating to diet and exercise.

Who Is A Candidate for Bariatric Weight Loss Surgery?

Some bariatric surgeons accept patients in their 60's, and some even operate on teenagers. But because bariatric surgery is a last-gasp treatment solution for obesity, to be used when conventional weight loss programs have been tried and failed, candidates must have severe obesity-related health problems.

• Typically, to qualify for bariatric surgery you must be 'morbidly obese', which usually means being overweight by 100 pounds (man) or 80 pounds (woman) with a Body Mass Index (BMI) of 40+.
• Alternatively, bariatric surgery may be appropriate if you are 80 pounds overweight (BMI 35+) and have a serious obesity-related condition like type 2 diabetes or life-threatening cardio-pulmonary problems such as severe sleep apnea or obesity-related heart diseas

Is Hospitalization Necessary Before Undergoing Bariatric Surgery?

Not usually, although patients with extremely severe obesity (End Stage obesity syndrome) may n

eed to be hospitalized before undergoing weight loss surgery in order to lower the health risks of surgery.

Is Obesity Surgery Dangerous?

Yes. Both types of bariatric surgery (gastric banding and gastric bypass) involve major operations lasting one to two hours (longer if performed laparoscopically) and patients typically need three to five nights in hospital. The first night following the operation is usually spent in a high dependency unit or intensive care environment. (Note: After laparoscopic bariatric surgery, patients typically remain in hospital for 2-3 days, rather than the 4-5 days after open surgery. Patients typically return to work after 2-3 weeks, compared to 4-6 weeks after open surgery.) The level of health risk varies according to patient condition, type of procedure and the experience of the surgeon. (Patients are five times more likely to die if the surgeon has less experience, per University of Washington Study.) But in general, bariatric surgeries carry all the possible health risks of any major medical operation.

Do Bariatric Patients Regularly Suffer From Health Complications?

Typically, it depends upon patient-condition, the complexity of the specific operation and the skill and experience of the surgeon. Recent research suggests that 4 out of 10 patients suffer complications within six months of surgery. Of these patients, up to 20 percent required re-hospitalization to treat specific problems relating to their stomach bypass or gastric banding procedure. As well as perioperative and post-

operative health problems, patients should expect to face a number of longer term physical and emotional problems. To begin with, the recommended post-operative diet regime requires an immediate and drastic change of eating habits. Gastric bypass also necessitates nutritional supplementation for life. Secondly, after losing a significant amount of weight, patients typically experience a distressing amount of loose skin. Removal will require cosmetic/plastic surgery. Your surgeon and/or the staff at your obesity clinic will advise you about the specific weight-related health issues you are likely to face.

Are The Health Risks Of Bariatric Surgery Greater Than The Risks Of Obesity?

For most patients suffering from morbid obesity (BMI 40+), super-obesity (50+) or end stage obesity syndrome (BMI 60+), the big question is, do the benefits of bariatric surgery outweigh its risks? The answer is Yes. Severe obesity is a chronic, frequently progressive, life threatening disease, and the known health risks associated with morbid obesity far outweigh the risks associated with surgery. Published studies indicate that someone who is 100 percent above his/her ideal weight has a risk of mortality ten times higher that of a person of normal weight. By comparison, the mortality rate for both vertical banded gastroplasty, adjustable gastric banding and roux-en-y gastric bypass is less than one percent. Morbidity (ie. rate of disease) in the immediate post-operative period is roughly ten percent or more, although the combined risk of the most serious complications is less than three percent. In the later postoperative period, other health complications can and do arise, and may require corrective surgical treatment. Also, some patients are unable to comply with post-operative eating and exercise guidelines over the long term. But in general the overriding health benefit of bariatric treatment is now well established.

How Important Is Patient Attitude For The Success Of Bariatric Surgery?

Very important! The higher the motivation of patients to lose weight and manage the post-operative requirements of dietary modification and behavioral therapy, the more successful surgery is likely to be, in solving their obesity and weight problems. The pre-op screening process adopted by obesity clinics to identify good candidates for bariatric surgery, is strongly influenced by patient attitude.

What Is The Cost of Bariatric Weight Loss Surgery?

Bariatric gastrointestinal surgical operations cost about $25,000 or more, depending on the experience of the surgeon, the medical team, the surgical procedure and the level of post-op services chosen.

Is Bariatric Surgery Covered By Health Insurance?

Health insurers are slowly beginning to accept that obesity surgery can deliver powerful medical benefits that will save them money in the long run, especially where convention weight loss remedies have consistently failed to reduce obesity. Therefore in several states, obesity surgeries like gastric bypass and lap band are covered by most medical insurance plans. However, patients may need to work closely with their surgeon or clinic to submit the necessary forms to the health insurance company in order to receive authorization for weight loss surgery. This includes a Letter of Medical Necessity which typically (a) Patient's weight (BMI 40+ or 35+ with health complications), (b) List of obesity-related medical symptoms (eg. type 2 diabetes, sleep apnea, raised blood pressure, high blood fats, insulin problems), (c) How long patient has been overweight (at least five years), (d) History of failed weight-loss programs, with details of type of program, whether or not medically supervised, amount of weight lost

Are Cosmetic or Plastic Surgery Operations Covered By Health Insurance?

No. Post-op plastic surgery procedures (like abdominoplasty, tummy tuck etc.) to remove loose skin caused by massive weight loss, are deemed to be 'cosmetic' rather than health related operations. As a result they are not usually covered by medical insurance plans.

What Do Doctors Think About Surgical Treatment For Obesity?

Many of the current standards and guidelines for performing bariatric surgery were set in 1991, by a Consensus Panel of physicians, sponsored by the National Institutes of Health (NIH). In particular, they established the body mass index (BMI) as the basis for selecting candidates for surgical treatment, to which was added the presence of severe comorbid conditions. The panel also stated the necessity for patients to receive multidisciplinary care by a team of doctors and therapists, to handle their weight-related co-morbidities, and emotional needs. Bariatric operations were viewed as a means of enabling patients to change their lifestyle and eating habits, in order to reduce and manage their obesity. Since 1991, there have been significant developments in the field of gastric reduction surgery, especially laparoscopy. As a result, a new Consensus Conference, sponsored by the American Society for Bariatric Surgery (ASBS), was held in 2004, which updated the evidence and the conclusions of the NIH consensus panel. They concluded that: (1) Bariatric surgery is the most effective treatment for severe clinical obesity. (2) Stomach bypass is one of four types of surgical treatment for morbid obesity. (3) Laparoscopic surgery is as effective and as safe as traditional open surgery. (4) Bariatric patients should receive comprehensive pre-op assessment, and multi-disciplinary post-op support, in order to achieve the best weight loss results.

Should You Have Bariatric Surgery?

The health dangers of severe obesity are well documented. Words like globesity and diabesity are evidence of the growing impact of this body-fat disease. Also, statistics show that severely obese patients have little chance of losing weight using conventional diets. However, this does not mean that bariatric surgery is a guaranteed solution for obesity. Long term studies of bariatric patients suggest that 1 in 2 fail to maintain any significant weight loss, and many patients regain all the weight they lose. Patients who have realistic expectations, a positive attitude and, above all, a genuine commitment to making lifelong changes in their attitude to food and exercise, typically achieve much better results.

Inform Yourself About Bariatric Surgery

Do not believe everything you read about bariatric surgery. Before taking any decisions, talk with patients who have undergone this form of weight loss surgery. Find out about the problems, issues and health risks involved. Listen carefully to the advice offered by your obesity clinic. When choosing a clinic, always inquire about what post-op support services they offer, such as counseling, email or forum support

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