What Is The Term For A Group Of Procedures Used To Treat Morbid Obesity

Open access peer-reviewed chapter

Treatment Options in Morbid Obesity

Reviewed: July 25th, 2019 Published: October fourth, 2019

DOI: 10.5772/intechopen.88823

From the Edited Volume

Obesity

Edited by Hülya Çakmur

Abstract

Obesity has go the virtually common fatal and the second nigh common preventable epidemic disease later smoking in the world. Although it causes many morbidities, the psychosocial challenges it creates in the patients and the huge financial burden for its handling are the main problems. Medical handling for weight loss is usually inadequate, and surgery has become a major function of morbid obesity treatment. Roux-en-Y gastric featherbed (RYGB), sleeve gastrectomy (SG), adaptable gastric ring (AGB), and biliopancreatic diversion (BPD) are the most common current surgical procedures, and all can be performed laparoscopically. Eating less and early on satiety due to the reduction of gastric volume with surgery and the disruption of assimilation as a result of the bypass lead to significant weight loss.

Keywords

morbid obesity
surgical treatment
laparoscopy

Tülay Diken Allahverdi*
- University of Kafkas, School of Medicine, Section of General Surgery, Kars, Turkey

*Address all correspondence to: drtulaydiken@hotmail.com

1. Introduction

Obesity is a chronic disease and is the result of the energy obtained from food being higher than the energy consumed and is characterized by an increment in the torso's fat mass compared to the lean mass. Obesity is an important wellness problem that tin cause diverse issues and even death by affecting all organs and systems of the torso and especially the cardiovascular and endocrine systems. Obesity is accepted equally i of the ten most risky diseases by the Globe Health Organization (WHO), which has also found information technology to be closely associated with cancer in recent studies. The prevalence of obesity and being overweight has been increasing in many industrial countries and is now creating a hard problem for many populations [1]. There has been no other problem affecting humanity that is equally mutual as obesity. Obesity develops by a mechanism that depends on many factors such every bit eating habits, toxic chemicals, and lifestyle unlike diseases caused by an infectious agent such as the plague, tuberculosis, or AIDS. What this mechanism is or whether obesity is actually a disease is not yet clear.

The surgical treatment of obesity is named bariatric surgery. Long-term permanent weight loss is provided, many comorbid diseases are prevented, and survival is increased by decreasing the metabolic effects of obesity every bit a result of bariatric surgery. Sustainable weight loss tin can only exist achieved by bariatric surgery, and it decreases the excess weight past 50% [2]. Patients scheduled to undergo surgery should be clearly informed on the expected do good, risk and long-term outcomes of surgery, and the requirement for lifelong nutritional counseling and biochemical follow-upwardly.

ane.1 Bariatric surgery indications

BMI >twoscore kg/m² or the presence of additional disease (blazon 2 diabetes, hypertension, slumber apnea, hyperlipidemia) together with BMI >35 kg/m²
Acceptable surgical risk
Unsuccessful nonsurgical treatments
Being psychologically stable and lack of alcohol or drug addiction
The patient being well motivated and existence informed about the surgery and its sequelae
Lack of medical bug that will forestall the increased life expectation as a outcome of the surgery
Lack of uncontrolled psychotic and depressive disorders
Presence of full family and social back up

i.ii The about commonly performed bariatric surgical procedures

Restrictive procedures
Laparoscopic adjustable gastric band (LAGB)
Sleeve gastrectomy (SG)
Vertical banded gastroplasty (VBG)
Absorption-disrupting procedures
Biliopancreatic diversion (BPD)
Jejunoileal bypass (JIB)
Combined restrictive and assimilation-confusing procedures
Roux-en-Y gastric bypass (RYGB)
Duodenal switch (DS) forth with BPD

The machinery of activity of bariatric surgical procedures is related to the complex interactions between gastric resection and malabsorption as well as the hormonal and neural signals affecting hunger and satiety. Buchwald et al. [iii] reported the rate of improvement in diabetes with bariatric surgery every bit 56.seven, 79.7, 80.3, and 95.ane% following adjustable gastric band (AGB), Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch (BPD-DS), respectively, in a meta-analysis. Complete diabetes remission was observed in 78% of the patients. The lipid profile is also improved in 70% of the patients after bariatric surgery. The total cholesterol, LDL, and triglyceride levels are decreased, just no significant change has been reported for HDL levels.

Bloodshed rates in bariatric surgical procedures are equal to those observed with modest intra-abdominal operations such as laparoscopic cholecystectomy (0.3–0.6%) [4].

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two. Laparoscopic Roux-en-Y gastric bypass (LRYGB)

LRYGB is the near commonly used restrictive method. It is reported to exist the gold standard in the surgical treatment of morbid obesity as it provides long-term weight loss and has acceptable morbidity and mortality [five]. The gastric featherbed method in bariatric surgery was first suggested by Edward E. Mason [vi]. While 90% of the stomach volume is reduced, malabsorption is ensured past bypassing the duodenum in this method. The main aim is to create a proximal small-scale-volume (<20 ml) gastric pouch that is completely detached from the breadbasket (Figure 1). The Roux limb can exist pulled upward from the front of the colon and stomach, from the front of the colon and the back of the breadbasket, or from the dorsum of the colon and stomach for gastrojejunostomy. Transoral round stapling, linear stapling, manual suturing, or transgastric circular stapling can exist used for gastrojejunostomy. The biliopancreatic limb is prepared at a length of l cm and the Roux limb at a length of 100–150 cm distal to the Treitz ligament. Once the breadbasket is cut perpendicularly to the modest curvature and iii–5 cm distal to the esophagogastric junction with a linear stapler (sixty mm long and 3.8 mm thick), the pouch is formed by completing the cut activity toward the angle of His. Postoperative fluid support and ensuring adequate urine output are very important. The results and whatever nutritional deficiency should exist checked at the postoperative third week, the third and sixth months, and the commencement year [7]. These patients lose threescore–lxxx% of their extra weight within 1 yr afterwards the surgery. Consequently, a significant comeback is seen in the comorbid diseases. Bloodshed is <1% and morbidity is xv%. Complications such every bit postoperative leakage (1–two%), stenosis (1–19%), small-scale bowel obstacle-internal hernia (7%), and marginal ulcer (three–15%) tin be seen. Urgent surgical intervention is required when intestinal obstacle is suspected equally it may crusade long segment necrosis. Roux-en-Y gastric bypass is more than effective than a laparoscopic adjustable gastric band peculiarly in the treatment of blazon 2 DM and gastroesophageal reflux disease (GERD) symptoms.

3. Sleeve gastrectomy (vertical gastrectomy)

Sleeve gastrectomy was first introduced equally a restrictive component of duodenal switch surgery. Adequate weight loss at an early flow is seen with sleeve gastrectomy lone in patients who are very obese and at adventure with duodenal switch (DS) surgery [viii, 9]. This method has been put into exercise every bit a risk-reducing method in patients who cannot tolerate high-risk and long-term procedures [9]. Laparoscopic sleeve gastrectomy (LSG) has become a safe and efficient principal bariatric surgical method with increasing frequency of use and high popularity for both surgeons and patients [two]. Laparoscopic sleeve gastrectomy constitutes v% of all bariatric surgical procedures, and the number of patients is increasing quickly [10]. A narrow tubular stomach is created with this method (Effigy two). Stomach resection is performed after releasing the big curvatura pylori 2–3 cm proximal to His angle. A tissue stapler 4.v mm in size (thick) is used in the antrum and 3.8 mm in size (medium) for the other parts of the breadbasket. To avert leaving a large fundus pouch, meticulous posterior autopsy should be performed so that the His angle is visible. If the lateral traction of the stomach is not good, a spiral-shaped resection line may develop. To decrease the take a chance of leakage, 1 cm of gastric serosa should be seen on the left side of the stapler cartridge before firing the final stapler. After resection, leakage and hemorrhage in the stapler line is checked with the endoscope. In the instance of possible leakage, the omentum is sutured to the suture line in order to create a potential barrier. The sleeve tube is fixed and angle of the stomach from the incisura angularis is prevented by suturing the omentum or gastrocolic fat [11, 12, xiii]. Laparoscopic sleeve gastrectomy is preferred in the super obese and in patients who take a BMI of <fifty kg/m² and want to undergo surgery with this method. Mean loss in excess weight was reported equally 55% with a complication rate of 8% and mortality rate of 0.19% in the review of 2500 patients (mean BMI: 51.two kg/thou²) where this method had been preferred [9]. While the diabetes remission rate post-obit laparoscopic sleeve gastrectomy is reported to exist 66.2%, a new bariatric procedure may be required later on on in 15% of the patients [9]. Laparoscopic sleeve gastrectomy has become a usually preferred method by itself or combined with other methods in the treatment of morbid obesity [14]. The most of import complexity is leakage (ii%) and is often seen nearly the bending of His. Placing the stop of the stapler line close to the esophagus, stenosis of the incisura angularis and bending of the tubular stomach are among the causes of leakage. Gastroesophageal reflux occurs in 26% of the patients after laparoscopic sleeve gastrectomy [7]. Revision surgery should be performed in the case of treatment-resistant gastroesophageal reflux.

iv. Laparoscopic adjustable gastric band

The laparoscopic adjustable gastric band method has been available in the Usa since 2001 [15]. This method decreases the nutrient intake with its complete restrictive effect and results in loss of weight. An inflatable silicone band is wrapped around the stomach three cm below the esophagogastric junction, and a reservoir of 25–30 cm long is formed at the proximal section. At the other end of the ring, there is a subcutaneously placed port (Effigy iii). The calibration of the gastric opening can be changed by fluoroscopy-guided filling and elimination of the silicone band. The band is initially inserted in completely deflated form. The pars flaccida technique has become the standard since band prolapse and erosion are less common in this way. The laparoscopic adjustable gastric ring method requires frequent follow-up and should therefore merely be performed in patients who live in close proximity to the infirmary. Simply multivitamins are recommended after the surgery. Adjustment of the band is as important every bit the surgery itself, and weight loss of 0.5 kg per week is ideal with this method [16]. Patients lose 58–lx% of their extra weight in 7–viii years after the surgery. The complication and mortality rate are less than the absorption-disrupting techniques [7]. Prolapse (3%), displacement (<iii%), band erosion (1–2%), and port and tube complications (5%) can be seen. Although a loftier reoperation ratio is the major disadvantage, the technique is still popular in the Us [17].

Figure 3.

Laparoscopic adjustable gastric ring.

5. Biliopancreatic diversion with duodenal switch

The biliopancreatic diversion with duodenal switch (BPDDS) procedure is frequently referred to as DS surgery. This technique is a modification of the original biliopancreatic diversion defined past Scapinaro et al. [xviii, 19] in 1979. The three main components of this technique are pylor-protected gastric tube formation, distal ileoileal anastomosis, and proximal duodenoileal anastomosis (Effigy 4). Iii intestinal limbs are formed in this method. Food passes through ane limb (Roux limb), the fluid of the digestive organs (bile) from 1 limb (biliopancreatic limb), and food and digestive fluids from the mutual limb. While the pocket-sized curvature of the breadbasket is removed and the pylor is preserved in biliopancreatic diversion with duodenal switch surgery, the pylor was also removed by distal gastric resection in the original surgery of Scapinaro. The gastric pouch is 250 ml in size, and malabsorption is created past Roux-en-Y reconstruction of the distal intestines in both techniques. The master limb length is l–100 cm and the alimentary limb 250 cm, and the biliopancreatic limb is connected to a location 100 cm proximal to the ileocecal valve. Since the pylor is preserved in the biliopancreatic diversion with duodenal switch technique, complications such every bit loop formation, dumping, and marginal ulcers are less common. The method can also be performed in stages to reduce complications. If adequate weight loss cannot be provided with laparoscopic sleeve gastrectomy, the biliopancreatic diversion with duodenal switch procedure is performed vi–12 months later. Glucose command in severely obese patients with type 2 diabetes is better with biliopancreatic diversion with duodenal switch surgery than medical treatment. Although the technique is well described and provides constructive weight loss, biliopancreatic diversion with duodenal switch process is not normally used. While early weight loss is provided by the sleeve gastrectomy, dumb fatty assimilation is responsible for the long-term weight loss. The decrease in ghrelin and increment in peptide YY after the biliopancreatic diversion with duodenal switch procedure as well increment weight loss. Mechanical changes also every bit hormonal changes may therefore be responsible for the weight loss in this technique [20]. The surgical mortality charge per unit is around 1%. The patients require high doses of vitamin and mineral supplementation after the surgery. There is meaning comeback in the comorbid conditions later on biliopancreatic diversion with duodenal switch. While 92% of diabetics and 90% of those with sleep apnea show full resolution, 80% of asthmatics decrease the dose of their medication [21, 22]. Close follow-upwards and vitamin supplements are necessary to prevent postoperative malnutrition. This method tin can be recommended every bit a revision method for severely obese patients, those who cannot exercise and stick to a nutrition afterwards restrictive methods, and after any previous unsuccessful surgeries. This method should not be performed in those who cannot be monitored closely, who practise not accept adequate income for vitamin support, and previously suffered from calcium, iron, vitamin, and mineral deficiencies.

Figure 4.

Biliopancreatic diversion and duodenal switch.

Vertical banded gastroplasty, laparoscopic mini-gastric bypass (LMGB), and laparoscopic large curvature plication (LLCP) are methods that are rarely used in morbid obesity surgery.

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Written By

Tülay Diken Allahverdi

Reviewed: July 25th, 2019 Published: October fourth, 2019

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed nether the terms of the Creative Commons Attribution three.0 License, which permits unrestricted use, distribution, and reproduction in whatever medium, provided the original piece of work is properly cited.