Adjustable Gastric Band (Lap-Bandฎ)
How the Lap-Band works:
The Lap-Band is a procedure preformed through several small incisions with the aid of a fiber optic camera and other specialized instruments. During the surgery an adjustable band is placed around the top part of the stomach to create a small gastric pouch. A portion of the tube connects the band to the adjusting port that is placed under the skin in the abdominal wall allowing easy access for adjustments. The inner lining of the band is a balloon that is filled with saline to narrow the opening of the stomach, limiting the amount of food that is able to pass. Saline is either added or withdrawn through a needle and syringe placed in the port. Both the surgery and adjustments are minimally painful. The best part of the Lap-Band is that it is totally adjustable and reversible. So if for example a patient becomes pregnant the physician would simply drain the band for the duration of the pregnancy and then slowly refill it after the baby is born. Although it is not necessary to remove the band after one reaches the goal weight but it is possible to do so. This procedure requires the most effort of all of the procedures in order to be successful. Patient must be committed to good eating habits and exercise. The Lap-Band is most effective for patients that are more disciplined in following a strict diet and will commit to an exercise program. Provided patients follow the instruction by choosing the right foods and exercise after the procedure most patients will lose between 50 and 75% of the excess weight. Patients must eat 3 meals per day consisting of less than 1000 calories per day during weight loss. Patients will need to avoid certain foods that can become "stuck" such as bread, rice, nuts, dense meats that may cause pain and vomiting. Patients must not drink fluids with meals.
The Lap-Band is said to be much safer than other weight loss surgeries mainly because it is minimally invasive and the weight comes off at a much slower rate than with surgeries such as the gastric bypass.
Possible Side Effects: Slow weight loss
Port complications
Slippage
Erosion
Infection
Malfunction of Device
Inadequate weight loss
Roux-en-Y Gastric Bypass
Drs. Mason and Ito initially developed this procedure in the 1960s. The gastric bypass was based on the weight loss observed among patients undergoing partial stomach removal for ulcers. Over several decades, the gastric bypass has been modified into its current form, using a Roux-en-Y limb of intestine (RYGBP). The RYGBP is the most commonly performed operation for weight loss in the United States. In the U.S, approximately 140,000 gastric bypass procedures will be performed in 2005, far outnumbering the LAP-BANDฎ, duodenal switch, and vertical banded gastroplasty procedures.
Initially the operation was performed as a loop bypass with a much larger stomach. Because of bile reflux that occurred with the loop configuration, the operation is now performed as a Roux-en-Y with a limb of intestine connected to a very small stomach pouch which prevents the bile from entering the upper part of the stomach and esophagus.
The remaining stomach and first segment of small intestine are bypassed. In the standard RYGBP, the amount of intestine bypassed is not enough to create malabsorption of protein or other macronutrients. However, because the bypassed portion of intestine is where the majority of calcium and iron absorption takes place, anemia and osteoporosis are the most common long-term complications of the RYGBP. Therefore, lifelong mineral supplementation is mandatory.
The RYGBP has been proven in numerous studies to result in durable weight loss and an improvement in weight-related medical illnesses. Half of the weight loss often occurs during the first six months after surgery; weight loss usually peaks at 18-24 months. The obesity-related co morbidities that may be improved or cured with the RYGBP include diabetes mellitus of the adult onset type (so-called insulin resistant), hypertension, high cholesterol, arthritis, venous stasis disease, bladder incontinence, liver disease, certain types of headaches, heartburn, sleep apnea and many other disorders. Furthermore, the RYGBP has resulted in marked improvements in quality of life.
Small pouch (about 1 ounce/20-30cc) Pouch is connected to the small intestine where food and digestive juices are separated for the first 3 to 5 feet. The RnY significantly restricts the volume of food that can be eaten. Provides mild malabsorption of nutrients. Patients must eat 3 small meals a day. Patients must avoid sugar and fats to prevent "Dumping Syndrome" Patients must take vitamin and protein supplements to avoid deficiency. (Multivitamin, Calcium, Vitamin B12 and Iron for -menstruating women)
The Rny is effective for patients with a BMI of 35-55 and those with a "sweet-tooth". Patients can expect to lose 70% of excess weight.
Possible side effects: Dumping syndrome (from consuming sugar or fats).
Bowel obstruction
Stricture
Ulcers
Vitamin/mineral deficiencies
Leak
Anemia
Vertical Sleeve Gastrectomy (VSG)
This surgery is performed by creating a long narrow vertical pouch (about 2-3 oz or 60-100cc). Same shape as the duodenal switch pouch but smaller. However, there is no intestinal bypass. The VSG significantly restricts the volume of food that can be eaten. There is no malabsorption of nutrients or dumping.
This surgery was originally a staged procedure for patients who have extreme obesity or severe medical co-morbidities. A stage procedures decrease the complication rate in these high risk patients. This approach involves performing this less invasive procedure (VSG) that reduces weight to a safer lever and improves overall medical condition first; then a more complex, definitive procedure is performed (the Roux en Y or Duodenal Switch) once the operative risks of the patient decrease significantly due to the initial weight loss. However, it was discovered that some patients did well enough with the VSG alone that they did not require an additional procedure. Patients can expect to lose 60%-70% of excess weight loss at about 2 years. Long term results not available at this time. Patient should eat 3 meals a day containing 600-800 calories per day.
Possible Side Effects: Nausea and vomiting
Heartburn
Leak
Weight regain
Inadequate weight loss
Additional procedure may be needed to obtain adequate weight loss
Duodenal Switch (DS)
The duodenal switch (DS) is a modification of the BPD designed to prevent ulcers, increase the amount of gastric restriction, minimize the incidence of dumping syndrome, and reduce the severity of protein-calorie malnutrition. However, the dumping syndrome is also believed by many to be a benefit, rather than a detriment, in that it helps patients avoid eating sugary and high fat foods which would adversely affect weight loss. The DS was first reported by Dr. Doug Hess in 1986.
The DS works through an element of gastric restriction as well as malabsorption. The stomach is fashioned into a small tube, preserving the pylorus, transecting the duodenum and connecting the intestine to the duodenum above where digestive juices enter the intestine. Compared to the BPD, the DS leaves a much smaller stomach that creates a feeling of restriction much like that of a RYGBP. Anatomically, the main difference between the DS and the BPD is the shape of the stomach the malabsorptive component is essentially identical to that of the BPD. Instead of cutting the stomach horizontally and removing the lower half (such as with the BPD), the DS cuts the stomach vertically and leaves a tube of stomach that empties into a very short (2-4 cm) segment of duodenum.
The duodenum is tolerant of stomach acid and therefore is much more resistant to ulceration compared to the small intestine. Removing part of the stomach also decreases the amount of acid present. Whereas the BPD involves an anastomosis (connection) between the stomach and the intestine, the DS involves an anastomosis between the duodenum and the intestine. The duodenum is cut about 2-4 cm from the stomach (measured from the pyloric valve). The intestine is sewn to the end of the duodenum which remains in continuity with the stomach. The other side of the duodenum will carry all the bile and pancreatic secretions. A theoretical (but clinically unproven) benefit of the DS is an improvement in absorption of iron and calcium in comparison to the BPD. The disadvantage of transecting the duodenum is the large number of vital structures immediately adjacent to the duodenum. Several large blood vessels and the major bile duct are located here. Injury to these structures can be life-threatening.
This procedure has some of the highest reported weight loss in long-term studies, but also has the highest rate of nutritional complications compared to the RYGBP and the purely restrictive procedures. These operations are some of the most complex in bariatric surgery. However, as with most studies of weight loss surgery, there is wide variability in long-term results between different centers. Only multi-center comparative studies can establish definitively the true differences between all these operations.
Patients can expect to lose 75% - 80% of excess weight. Some patients can lose too much weight. Patients should eat 3 meals a day and must strictly adhere to protein and vitamin supplements to avoid deficiencies. (Multivitamins, ADEK vitamins, Calcium and Iron for menstruating women)
The DS is effective for patients with a BMI of > 50 kg/m2. Those with BMI of < 45 kg/m2 may lose too much weight. The DS has a higher incidence of complications than other procedures.
Possible Side Effects: Nausea and vomiting
Severe foul smelling diarrhea
Ulcers
Kidney stones
Heartburn
Bowel obstruction
Stricture
Leak
Nutritional deficiencies (Vitamin A,D,E,K)
Loss of too much weight requiring re-operation
Plastic Surgery Procedures
Plastic Surgery, also referred to as Cosmetic Surgery, encompasses many different procedures all designed to enhance the beauty of the patients face or body. Additionally, due to the increase of bariatric surgeries, there has been an influx of patients seeking plastic surgery after massive weight loss. Many patients find that after losing a massive amount of weight, they are left with excess skin which has lost its elasticity and cannot retract to the new leaner body. The only way to correct this is through Cosmetic Surgery. Below is a list of commonly performed procedures.
• Abdominoplasty also referred to as a Tummy Tuck, removes excess skin from abdomen and tightens the underlying muscles.• Body Lift removes excess skin from the abdomen buttocks, and outer thighs and tightens the underlying muscles.
• Thigh Lift removes excess skin from the inner thighs
• Brachioplasty, commonly referred to as an Arm Lift removes the excess skin on the upper arms
• Mastopexy or, Breast Lift removes excess skin and lifts the breasts
• Breast Augmentation enlarges the breast and can also help to fill out excess skin in the breasts after weight loss
• Breast Reduction reduces breast size by removing some of the breast tissue and tightening the skin
• Liposuction removes fat from certain areas of the body and can be used for contouring the body after weight loss
• Face Lift removes wrinkles, excess skin and tightens the underlying muscles of the face
• Buttock Lift tightens and lifts the buttocks
• Rhinoplasty, often referred to as a nose job, reshapes the nose.
• Chin Augmentation, or chin implant, enlarges the chin to give the face a more symmetrical appearance
• Botox is an injectable substance which paralyzes certain muscles which temporally removes wrinkles
• Mesotherapy is injections to dissolve fat
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