Bariatric surgery

Bariatric surgery is a branch of medicine that studies the causes, treatment, and prevention of obesity.

The term "bariatrics" comes from the Greek words "baros" - weight and "iatrics" - treatment. This term has been used since 1965. Bariatrics includes both drug treatment and surgery.

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Bariatric surgeries

The "gold standard" in bariatric surgery is three types of operations:

1. insertion of an intragastric balloon (which, strictly speaking, is not an operation - it is an outpatient endoscopic procedure)
2. gastric banding surgery
3. gastric bypass surgery

According to modern requirements, all bariatric surgeries must be performed exclusively laparoscopically - i.e. without wide surgical incisions. This technology allows to significantly ease the postoperative period and reduce the risk of postoperative complications.

Intragastric silicone balloon

The installation of an intragastric balloon is classified as a group of gastrorestrictive interventions. These balloons are intended to reduce body weight, the mechanism of their action is based on the reduction of the volume of the stomach cavity when it is inserted into the latter, which leads to a faster formation of a feeling of satiety due to partial (reduced) filling of the stomach with food.

The balloon is filled with a physiological solution, due to which it takes a spherical shape. The balloon moves freely in the stomach cavity. The balloon filling can be adjusted within the range of 400 - 800 cm ³. The self-closing valve allows isolating the balloon from external catheters. The balloon is placed inside the catheter block, designed for insertion of the balloon itself. The catheter block consists of a silicone tube with a diameter of 6.5 mm, one end of which is connected to the shell containing the deflated balloon. The other end of the tube fits a special Luer-Lock cone connected to the balloon filling system. The catheter tube has marks to control the length of the inserted part of the catheter. To increase rigidity, a conductor is placed inside the hollow tube. The filling system in turn consists of a T-shaped tip. A filling tube and a filling valve.

According to literature, different authors give different indications for the installation of an intragastric balloon to correct obesity and excess weight. We consider it appropriate to treat with this method whenever there are no contraindications.

Contraindications to the use of an intragastric balloon

• diseases of the gastrointestinal tract;
• severe cardiovascular and pulmonary diseases;
• alcoholism, drug addiction;
• age under 18 years;
• the presence of chronic foci of infection;
• unwillingness or inability of the patient to comply with the diet;
• emotional instability or any psychological qualities of the patient that, in the opinion of the surgeon, make the use of the indicated method of treatment undesirable.

With a BMI (body mass index) of less than 35, an intragastric balloon is used as an independent treatment method; with a BMI of more than 45 (super obesity), an intragastric balloon is used as preparation for subsequent surgery.

The intragastric silicone balloon is intended for temporary use in the treatment of patients suffering from excess weight and obesity. The maximum period during which the system can be in the stomach is 6 months. After this period, the system must be removed. If the balloon is in the stomach for a longer period, the gastric juice, acting on the balloon wall, destroys the latter, the filler leaks, the balloon decreases in size, as a result of which the balloon may migrate into the intestine with the occurrence of acute intestinal obstruction.

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Cylinder installation technique

After standard premedication, the patient is placed on his left side in the endoscopy room. A sedative (Relanium) is administered intravenously. A probe with a balloon attached to it is inserted into the esophagus. Then a fibrogastroscope is inserted into the stomach and the presence of the balloon in its cavity is visually confirmed, the guide is removed from the probe and the balloon is filled with a sterile physiological solution of sodium chloride.

The liquid should be injected slowly and evenly to avoid rupture of the balloon. On average, the volume filled should be 600 ml, leaving the stomach cavity free. After filling the balloon, the fibrogastroscope is inserted into the esophagus to the level of the cardiac sphincter, the balloon is pulled to the cardia, and the probe is removed from the nipple valve. In this case, the fibrogastroscope creates traction on the balloon in the opposite direction, which facilitates removal of the conductor.

After the probe itself is removed, the balloon is inspected for leaks. The balloon can be installed on an outpatient basis in an endoscopic room, without hospitalizing the patient.

Balloon Removal Technique

The balloon is removed when the fluid has been completely evacuated from it. A special instrument is used for this, consisting of a 1.2 mm diameter needle attached to a long rigid conductor - a string. This perforator is inserted through the fibrogastroscope channel into the stomach at an angle of 90 degrees to the balloon. The balloon is then displaced toward the antral part of the stomach and becomes more accessible for manipulation. Then the balloon wall is perforated. The conductor with the needle is removed, the fluid is removed with an electric suction. With a two-channel fibrogastroscope, forceps can be inserted through the second channel, with which the balloon is removed from the stomach cavity.

Before installing the balloon, it should be taken into account that this procedure itself does not guarantee significant weight loss. The intragastric balloon helps reduce the feeling of hunger that plagues patients during diets. Over the next 6 months, the patient will need to follow a low-calorie diet, consuming no more than 1200 kcal per day, and also increase their physical activity (from simple walks to regular exercise, the best of which are water sports).

Since the patient has time to form and consolidate a new conditioned-unconditioned food reflex, patients continue to adhere to the diet that was in place during the time they had the intragastric balloon without any harm to themselves. Usually, body weight increases by 2-3 kg after the balloon is removed. Repeated installation of the intragastric balloon is performed provided that the first one is effective. The minimum period before installing the second balloon is 1 month.

Laparoscopic horizontal gastroplasty using silicone bandage

This operation is the most common worldwide for the treatment of overweight and obese patients.

Indications

• Obesity.

Contraindications to bandaging

• Diseases of the gastrointestinal tract.
• Severe cardiovascular and pulmonary diseases.
• Alcoholism, drug addiction.
• Age under 18 years.
• Presence of chronic foci of infection.
• Frequent or constant use of NSAIDs (including aspirin) by patients.
• The patient's unwillingness or inability to adhere to a diet.
• Allergic reactions to the composition of the system.
• Emotional instability or any psychological qualities of the patient that, in the opinion of the surgeon, make the use of the indicated method of treatment undesirable.

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Technique of implementation

The adjustable silicone band is used in the same cases as the intragastric silicone balloon. The band is a 13 mm wide retainer, which when fastened is a ring with an internal circumference of 11 cm. A flexible tube 50 cm long is connected to the retainer. An inflatable cuff is placed over the retainer, which provides an adjustable inflation zone on the internal surface of the cuff-retainer assembly.

After applying the bandage, a flexible tube is attached to the reservoir from which the fluid is injected and which, in turn, is implanted under the aponeurosis in the tissue of the anterior abdominal wall. It is also possible to implant in the subcutaneous tissue in the projection of the anterior abdominal wall and under the xiphoid process, however, with the latter methods, with weight loss and a decrease in subcutaneous fat, these implants begin to contour, which causes cosmetic problems for patients. With the help of a cuff, the size of the anastomosis is reduced or increased. This is achieved by changing the inflatable cuff. Using a special needle (5 cm or 9 cm) through the skin, you can adjust the volume of fluid in the reservoir by adding or removing it.

The mechanism of action is based on the creation of a so-called "small stomach" with a volume of 25 ml by means of a cuff. The "small stomach" is connected to the rest of the stomach, which is larger in volume, by a narrow passage. As a result, when food enters the "small stomach" and the baroreceptors are irritated, a feeling of satiety is formed with a smaller volume of food consumed, which leads to a restriction of food consumption and, as a consequence, weight loss.

The first injection of fluid into the cuff is performed no earlier than 6 weeks after the operation. The diameter of the anastomosis between the "small" and "large" ventricles is easily adjusted by introducing different volumes of fluid.

The peculiarities of this operation are its organ-preserving nature, i.e. during this operation no organs or parts of organs are removed, less trauma and greater safety compared to other surgical methods of treating obesity. It should be noted that this technique is usually performed laparoscopically.

Gastric bypass surgery

The operation is used in people with severe forms of obesity and can be performed both by open and laparoscopic access. This method refers to combined operations that combine a restrictive component (reducing the volume of the stomach) and a bypass (reducing the area of intestinal absorption). As a result of the first component, there is a rapid saturation effect due to irritation of the stomach receptors by a smaller volume of consumed food. The second ensures the limitation of absorption of food components.

The "small stomach" is formed in the upper part of the stomach with a volume of 20-30 ml, which is connected directly to the small intestine. The remaining large part of the stomach is not removed, but simply excluded from the passage of food. Thus, the passage of food occurs along the following path: esophagus - "small stomach" - small intestine (alimentary loop, see the figure below). Gastric juice, bile and pancreatic juice enter the small intestine through another loop (biliopancreatic loop) and mix with food here.

It is known that the feeling of satiety is formed, among other things, from the impulses of the stomach receptors, which are activated by mechanical irritation of food entering the stomach. Thus, by reducing the size of the stomach (which is involved in the digestion process), the feeling of satiety is formed faster and, as a result, the patient consumes less food.

The period of weight loss is from 16 to 24 months, and the weight loss reaches 65 - 75% of the initial excess body weight. Another advantage of the operation is its effective effect on type 2 diabetes and a positive effect on the lipid composition of the blood, which reduces the risk of developing cardiovascular diseases.

The main complications after gastric bypass in the early postoperative period are:

• anastomotic failure;
• acute dilation of the small ventricle;
• obstruction in the area of Roux-Y anastomosis;
• development of seroma and suppuration in the area of the postoperative wound.

In the late postoperative period, it should be noted that there is a possibility of developing complications associated with the exclusion of part of the stomach and duodenum from the digestive process:

• anemia;
• vitamin B 12 deficiency;
• calcium deficiency with the development of osteoporosis;
• polyneuropathy, encephalopathy.

In addition, dumping syndrome may occur, especially when consuming large amounts of sweet foods.

For prophylactic purposes in the postoperative period, it is necessary to take multivitamins, vitamin B 12 twice a month in the form of injections, calcium preparations at a dose of 1000 mg per day, iron preparations for women with preserved menstrual function to prevent the development of anemia associated with the exclusion of part of the stomach and duodenum from digestion. To prevent the development of peptic ulcer, it is recommended to take omeprazole for 1-3 months, 1 capsule per day.

Some authors believe that gastric bypass surgery is contraindicated in the first 18 to 24 weeks of pregnancy.