Surgery for obesity or bariatric surgery is being increasingly used for obese patients with associated diseases, with greater safety and less possibility of complications.
The advent of this type of treatment was due to the failure of nutritional, psychological, pharmacological and alternative therapies for the treatment of morbid obesity. In addition, the constant increase in the incidence of this disease worldwide with its high morbidity and mortality.
Surgical techniques for gastric bypass
Current surgical techniques for the treatment of obesity can be classified into 3 types:
1. Pure restrictive techniques:
· Ringed vertical gastroplasty.
· Adjustable gastric band.
2. Pure malabsorption technique:
· Colic jejunum bypass.
· Jejunum ileal bypass.
3. Mixed techniques (restrictive and malabsorptive):
· Gastric bypass.
· Bilio-pancreatic diversion with duodenal switch.
Different types of surgical treatment for obesity have been tried for a long time, the most common today are:
· Adjustable gastric band is the second most frequent bariatric surgery with 42%. It is used in Europe.
· Gastric bypass: it is the most frequent of all techniques, a frequency of 49% is reported worldwide. Being the preferred surgery in the United States.
How to choose the right type of surgery
In general, there are different factors that determine the choice of a type of surgery, between risks and benefits:
· It depends on the geographical area.
· Procedure is chosen depending on the BMI (Body Mass Index).
· Operative surgical risk.
· Previous metabolic disorders of the patient.
· Additional diseases.
· Surgeon skills and training.
· Preferences of the patient, the surgeon and the Institution.
The first gastric bypass performed in order to lose weight was performed by Mason, surgeons Aldet and Terry improved the technique, appearing the variety of open gastric bypass as at present.
The first gastric bypass performed laparoscopically was performed.
At present, gastric bypass is the most widespread and common standard surgical treatment for obesity worldwide. This is due to the simplification of its surgical technique, the mass training of surgeons and the obtaining of good results with little probability of complications.
Gastric Bypass is a surgery that aims to create a reservoir then the esophagus, the exclusion of the stomach from intestinal transit and the union of a portion of the stomach to a middle segment of the small intestine or gastro-jejunum-anastomosis.
It has 3 main characteristics
· Reservoir: which constitutes a small space created surgically in the manner of a small stomach, between the esophagus and the jejunum or small intestine. In such a way that food can accumulate in that small space before passing into the jejunum. The reserve capacity of ingested food is very limited. This drastically decreases the amount of food that can be eaten and there is a feeling of rapid fullness.
The original technique maintains that the reservoir should have about 30 cc of capacity. The current trend is to leave a 20cc reservoir.
In this technique, by separating the stomach from the reservoir, the passage of food through the stomach is prevented, which is excluded inside the abdominal cavity, this means that it has no participation in intestinal transit.
· The union that is made between the reservoir and the jejunum must be between 10 and 15 cm in diameter, in order to avoid strictures or stenosis in the future that require a new surgical intervention.
· Finally, the loop of the small intestine that connects to the reservoir should be between 75 and 150 cm long. It has been determined in numerous studies that the longer the loop, the greater the decrease in weight. The relationship between the length of the handle and subsequent weight gains has not been determined.
The challenge in these cases is that if the surgeon leaves a very long bowel loop, endoscopic access to the excluded stomach and duodenum becomes much more difficult, in case of the need for exploration of the bile and pancreatic ducts.
Criteria for gastric bypass surgery
The criteria for bariatric surgery are:
· BMI (body mass index) ≥ 40 (or ≥ 35 with associated complications).
· Obesity diagnosis time greater than 5 years.
· Absence of alcoholism, drug dependence or active consumption or serious or decompensated psychiatric illness.
· Age between 18 and 60 years.
· Patient acceptance and understanding of lifestyle changes and adherence to treatment and control after surgery.
There are institutions that have made the criteria for gastric bypass more flexible, in view of the fact that there are reports of performing the surgery in those over 60 years of age and in adolescents, without increased complications or risks.
Contraindications of gastric bypass surgery
There are some absolute contraindications to performing this surgical procedure,
· Mental / cognitive impairment.
· Pregnancy and breastfeeding.
· Active cancer or neoplasms. You can wait 4 to 5 years, after the cancer is cured, to consider gastric bypass again.
· Bulimia-type eating disorder.
· Hepatic cirrhosis-type liver diseases complicated with portal hypertension.
· Severe peripheral arterial disease.
Gastric bypass complications
30 years ago, complications were much more frequent, leading to very careful selection of candidates.
After the change in surgical techniques and the advent of laparoscopy in bariatric surgery, its use has spread worldwide and the statistics of complications and mortality have been improving.
Mortality in open surgeries is currently 0.12% and in laparoscopic surgeries 0.09%.
In general, the complication rate varies according to the study group that reports the statistics.
· The most common and most feared is leakage or leakage from the anastomosis or suture, which ranges from 0.6 to 4.4% of cases. It is the complication that is most related to mortality.
· Bleeding or hemorrhage between 0.4 and 5.5% of cases.
· Early intestinal obstruction is between 0.4 to 5.5% and occurs more frequently due to internal hernias.
· Long-term intestinal obstruction in approximately 5% of gastric bypass cases and not in gastric band or vertical gastroplasty.
· Pulmonary thromboembolism, which is a risk for any obese person in abdominal surgeries, with a mortality of 0.37% due to this cause.
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