Bariatric surgery

The bariatric surgery are a set of techniques and surgical procedures seeking changes in physiology to achieve weight loss maintained and durable over time. These are technically complex procedures that are not exempt from complications in the short or medium term, and that can also present mortality .

It is not cosmetic surgery , it is not without risks, it is not easy and it is not magic. Like other obesity treatments, it requires lifestyle changes and healthy diets to ensure successful medium and long-term results.

The surgeries that are carried out look for two types of objectives: Reduce the intake, or reduce the absorption capacity. This causes there to be restrictive, malabsorptive, or mixed techniques if they combine the two types of procedures.

Surgery is indicated only for those patients with morbid obesity with a BMI greater than 40kg / m2, or for those with severe obesity (BMI> •% kg / m2) and associated pathologies. Patients with a BMI less than 35kg / m2 have no indication for surgery, but may benefit from nonsurgical, pharmacological, and dietary- behavioral treatments. Medical professionals and nutrition and dietetics specialists can advise on the most appropriate treatment for each person.

Summary

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• 1 Etymology
• 2 Pathophysiological bases
• 3 Types of procedures
  • 1 Restrictive techniques
  • 2 Malabsorptive techniques
  • 3 Mixed (or restrictive / malabsorptive) techniques
• 4 Indications for bariatric surgery
• 5 Contraindications
• 6 Risks and complications
  • 1 Mortality
• 7 Sources

Etymology

The term “bariatric” derives from the Greek word βαρύς, “barýs”, which means “heavy” or “heaviness”; and “weight that overwhelms”, and from ἰατρικός, “iatrikós”, which means “related to medical treatment”. The term “bariatric” is associated with obesity. Despite the Greek etymology being recognized, various theories locate the origin of this word in the Hebrew language based on its use in the Ancient Scriptures.

Pathophysiological bases

The basic objective of bariatric surgery is to decrease energy intake and the formation of body fat and stimulate the consumption of already formed, under two principles: the restriction or reduction of food eaten (that is, regulating intake and appetite) and modifying its absorption.

Types of procedures

Due to the principles described above and their combination there are three categories: Each category and procedure has its own long-term results and its potential impact on nutrition. All of these alternatives can result in deficiencies of iron, vitamin B12 , folic acid, and calcium .

Restrictive techniques

They are procedures that induce weight loss by reducing gastric size or capacity, drastically limiting food intake.

• Vertical banded gastroplasty
• Vertical banded gastroplasty
• Adjustable gastric band
• Vertical reinforced gastroplasty
• Gastroplasty
• Vertical gastroplasty without ring
• Gastric sleeve or vertical gastrectomy
• Intragastric balloon or gastric balloon

Malabsorptive techniques

Exclusively malabsorptive procedures; These are rarely performed, due to the high risk of serious complications over time.

• Jejunoileal Bypass

Mixed (or restrictive / malabsorptive) techniques

Mixed restrictive-malabsorptive procedures that in addition to reducing gastric capacity, alter normal gastric continuity and interrupt the absorption of nutrients and ingested food.

• Gastric bypass : it is the most used procedure currently.
• Biliopancreatic diversion (Scopinaro, Marceau, Larrad)

A recent research and development technique that guides other types of bariatric surgery is the gastric pacemaker that regulates appetite by sending neuroelectric shocks to produce a feeling of satiety.

Bariatric Surgery Indications

The primary indication is in those cases in which medical treatment (which is the first line of choice) with diet, exercise and medications, and generally following a medical program that integrates behavioral changes, physical activities and psychological support, fails to achieve sustained weight loss, such as cases of class III (severe) obesity or morbid or class II obesity with a Body Mass Index (BMI) greater than 35 with the presence of complications or serious medical problems6 and also in case of pregnancy .7 The publications coincide in stating that, in these cases of morbid obesity, it has been established that the only really effective treatment for morbid obesity is bariatric surgery, as long as the treatment is carried out by a suitable team.In any case, the indications in each case must be established by medical professionals and for health reasons, taking into account the recommendations of the experts available in the scientific literature and which are generally based on the criteria published by the National Institutes of Health (NIH) of the USA in 1991 and widely accepted.

In general, the experts point out:

“The patient and / or their family members must know that the surgical procedures to which they are going to undergo are considered major and high-risk surgery techniques, among other reasons for the comorbidities that the disease itself entails” … “They must also know that It is a functional surgery that alters the anatomy of the digestive system, producing, in some cases, variable degrees of intestinal malabsorption and, sometimes, they are not reversible techniques.The patient must understand that although the aesthetic benefits are important, they are not the ultimate goal of surgery. Nor is the goal to reach the ideal weight, which on the other hand is only achieved in slightly more than half of the cases. Finally, due to the nutritional alterations derived from the different surgical techniques,long-term medical follow-up, probably for life, is necessary to detect and treat associated nutritional disorders ”

Contraindications

Among the relative contraindications are: age younger than 13 years and older than 65 years in adults, high anesthetic risk for cardiorespiratory problems and obesity of congenital or endocrine origin. Relative psychological contraindications for bariatric surgery are psychiatric illnesses such as major depression, bulimia nervosa; substance abuse such as cocaine, amphetamine, morphine, or alcohol. In these cases, it is recommended both for the success of the surgery (weight loss) and for the mental health of these patients, to receive prior treatment and strict follow-up in the postoperative period. In addition, various studies conclude that weight loss can lead to other risky behaviors such as the consumption of substances such as alcohol or smoking. Regarding absolute contraindications,

Risks and complications

In general, in addition to the risks and complications common to all highly complex surgical treatments, the most frequent of bariatric surgery are:

• Persistent vomiting (caused by overeating)
• Difficulty to swallow
• Staple line break (and possible gastric acid spillage)
• Suture dehiscence
• Ulcers
• Gastric pouch distention and painful abdominal distension
• Nutritional deficiencies that can cause anemia or osteoporosis.

Complications from surgery or surgical morbidity are found in around 10% .6

Mortality

Mortality varies depending on the publication: from 0.2% to 1.5%. Its most frequent cause is pulmonary embolism and multi-system failure. Mortality is higher in male patients, age over 65 years and depends on the experience of the surgical group that performs the procedure, which reinforces the importance of the learning curve; Mortality of 5% has been reported in groups that perform less than ten procedures per year and 0.3% in groups with large volumes of patients.