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home - Stomach - Obesity Surgery - Gastric Surgery Restrictive Type Written by Dr Sebastian Zeki
Knowledge


Describes the risks associated with obesity
Describes the dietary, pharmacological and surgical techniques
(including anatomical re-configuration) for managing obesity and their
associated medical and nutritional complications

Skills
Takes a relevant history and perform an appropriate examination in
order to be able to define level of obesity, identify potential
complications and arrange relevant investigations before referral to
an obesity service

Investigates and appropriately manages (in conjunction with surgical
and dietetic colleagues) patients admitted with complications from
bariatric surgery

Behaviours
Recognises obesity as an illness and will evaluate and treat the
patient in a sympathetic manner

Gastric Surgery Restrictive Type

Vertical banded gastroplasty Restrictive ProceduresRestrictive procedures limit caloric intake by downsizing the stomach's reservoir capacity.Vertical banded gastroplasty (VBG) and laparoscopic adjustable gastric banding (LAGB) are purely restrictive procedures and share similar anatomical configurations.Both limit solid food intake by restriction of stomach size as the only mechanism of action, leaving the absorptive function of the small intestine intact.Although these procedures are simpler in comparison to malabsorptive procedures, they tend to produce more gradual weight loss. Complications:Not useful if have high calorie liquid meals/ sweet eaters.The majority of revisions are required for staple line disruption band disruption, pouch dilatation.-GORD (usually after stomal stenosis and pouch dilation).-Disruption of staple line- can occur in 30%.-Vomiting in 15%(etiology is multifactorial, including maladaptive dietary patterns (such as eating too quickly or not chewing properly) as well as functional problems such as stomal stenosis, pouch dilation, staple line disruption, or GERD.).-Stomal stenosis occurs in 30%.-Band erosion in 5%. Laparoscopic adjustable gastric bandingThis compartmentalizes the upper stomach by placing a tight, adjustable prosthetic band (locking silicone ring connected to an infusion port placed in the subcutaneous tissue.) around the entrance to the stomach.A saline infusion into the port tightens the ring.Contraindications include PHTN, connective tissue disorders with esophageal dysmotility, or chronic steroid use (relative contraindication).Outcomes show a 58 % EWL at 2 yrs. Advantages:Safer than gastric bypass.Technically easier.Avoids multiple anastomoses.Reduces postoperative risk of internal herniation.Protein and mineral malabsorption. Complications of Restrictive Procedures:Acute stomal obstruction in 6%- this occurs early.Acute stomal obstruction is due to inclusion of excess tissue (perigastric fat) or tissue oedema. Operation: Laparoscopic partial gastrectomy with greater curvature of the stomach removedThe tubular stomach is small in its capacity (restriction), resistant to stretching due to absence of fundus, and devoid of ghrelin producing cells (a gut hormone involved in regulating food intake) Band erosion (through stomach wall)- 7%Occurs late (mean of 22 months after surgery.)Aetiology: Gastric wall ischemia from an excessively tight band or mechanical trauma related to the band buckleTreatment: Band removal Band slippage/prolapse 10%Treatment: Usually surgery to replace the band Port/tubing malfunction 5%Usually need hardware replacement Pouch/esophageal dilation (pseudoachalasia syndrome)- 10%Related to excess food intake or overtight bandUsually responds to loosening the band Infection 0.3-9%Remove infected port and investigate for band erosion with OGD EsophagitisRare and usually responds to loosening the band Operation: Upper part of the stomach is partitioned by a vertical staple line with a tight outlet wrapped by a prosthetic mesh or band.The small upper stomach pouch gets filled quickly by solid food and prevents consumption of a large meal. Outcome: EWL of up to 66 % at 2y.Revision required in up to 56%. Complications of LABG:Most common restrcitive bariatric surgeryLowest mortality rate (0 to 0.5 %) among all bariatric procedures as no staple lines to break down and no stomal mesh causing stenosisAnatomy can be restored by loosening the band Intragastric balloonProcedureThis is a saline-filled balloon placed endoscopically.It is indicated before a definitive weight loss procedure.Complications include nausea, vomiting, abdominal pain, ulceration, and balloon migration.Outcome have shown EWL 45% and 26% maintained at 1 year. Removed part of stomach Sleeve Oesophagus Staples Small stomach pouch Band Stomach Duodenum Treatment: Surgical correction if persistent obstruction Outcomes: 33 % EWL at 1yr.Better weight loss and hunger control at one and three years after surgery compared to adjustable gastric band.Better suppression of ghrelin compared with gastric bypass. Sleeve gastrectomy Vertical banded gastroplasty Written by Dr Sebastian Zeki

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