For the undecided

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For those of you still deciding you might find this article I just

read interesting...

Excerpt from:

North American Association for the Study of Obesity (NAASO) 2000

Annual Meeting

Surgical Management of Obesity

Author: K. Buffington, PhD

Reviewer: S. M. Cowan, Jr, MD

Distal RYGB

The anatomic configuration of the distal RYGB, is designed to limit

nutrient absorption by effectively shortening the bowel available for

the absorption of nutrients. The intestinal limb connects proximally

to the gastric pouch and distally to the end-to-side

enteroenterostomy, where it joins with the bypassed biliopancreatic

limb (also known as the afferent limb) to form the common limb,

which, in turn, empties into the colon. In contrast, with the

standard RYGB, the short limb measures less than 100 centimeters in

length.

For patients with BMI in the range of 35 to 50, results following the

distal RYGB are excellent (93% reported as successful and only 7% as

failures). However, for individuals who have a BMI greater than 50,

the distal RYGB may not be as effective, with a lower reported

success rate of 57%.[10]

Biliopancreatic Diversion (Scopinaro Procedure)

The biliopancreatic diversion was first performed in Italy in 1976 by

Scopinaro and colleagues.[11] The procedure involves gastric

resection leaving a 200- to 500-mL gastric pouch. Malabsorption

results from bypassing all small intestine except 250 cm -- 200 cm

located between the gastric pouch and the end-to-side

enteroenterostomy and the remaining 50 cm consisting of bypassed

small intestines (the biliopancreatic, or afferent, limb). In follow-

up studies, Scopinaro and colleagues reported a 75% excellent weight

loss up to 22 years postoperatively. Patients experience 2 to 4 bowel

movements per day, which are usually malodorous. The authors noted no

long-term difference in success rates between the morbidly obese and

the supermorbidly obese. Therefore, this procedure appears to be

superior to the distal RYGB for the supermorbidly obese.

Duodenal Switch This procedure was developed by Hess and colleagues

in 1987.[12] It is designed to avoid the dumping syndrome and prevent

peptic ulcers. The gastric pouch is formed by resecting the fundus

and leaving the pylorus intact, approximating an 80% gastrectomy.

Distal to the pylorus, the Roux-en-Y small intestinal limb is

attached, with the small intestine divided in half -- half for food

and half bypassed and carrying juices toward the enteroenterostomy.

The duodenal switch combines the restrictive gastric pouch with the

malabsorptive components of the Scopinaro procedure. The benefit

claimed is that the retention of the pylorus results in fewer

problems with bowel movements, including dumping syndrome, marginal

ulcers, anemia, and other complications. Most malabsorptive surgeries

are open abdominal surgeries and not usually performed

laparoscopically. The procedure results in an excess weight loss of

70% to 80%, with good-to-excellent success rate of 93% and no

differences between patients with BMI scores above or below 50.[12]

The results are reproducible.

Open vs Laparoscopic Bariatric Procedures

Gastroplasty and other surgeries require a large abdominal incision,

which increases stress hormones, energy expenditure, oxygen demand,

and pulmonary function. All of the organ systems are affected

adversely to some degree by such a major incision, including the

immune system, heart, lungs, and kidneys. By contrast, laparoscopic

bariatric surgery reduces the catecholaminergic central nervous

system stress responses both during and after surgery. Additionally,

patient pulmonary function is less affected compared with open

surgery, the immune system is improved, and fewer adhesions are

formed; wound healing has obvious benefits in the absence of a large

midline upper abdominal scar.

In clinical studies, the advantages of laparoscopic over open surgery

have been well documented. For example, mortality rates for

gallbladder surgery in land have dropped 28% since laparoscopic

cholecystectomy became available.[14] Numerous studies have

demonstrated the clear advantages to less invasive surgery, including

reductions in postoperative recovery time, overall wound healing

time, overall morbidity and mortality, wound complication rate,

perioperative complications, and postoperative complications.

All bariatric surgical procedures can be done laparoscopically. As

Dr. Schauer described, open RYGB generally requires 2 to 4 hours to

perform, 4 to 8 days for inpatient hospital stay, 6 to 12 weeks for

recovery, 2.5% to 10% major complications, up to 15% wound

infections, 17% to 23% hernias, up to 1% mortality, and 65% to 72%

weight loss. By contrast, closed laparoscopic RYGB procedures

generally use 5 access ports, the surgery lasts for approximately 2

hours, and the patient is discharged from the hospital 2 days

postoperatively. For well-experienced, skilled, laparoscopic

bariatric surgeons, the major complications of laparoscopic RYGB are

similar to those of open RYGB, such as peritonitis, abscess, and

small-bowel obstruction, but there is a lesser (3.3%) incidence and

recovery sufficient to return to work occurs after 2 weeks. Minor

complications and the amount of excess weight loss are also similar

to open surgery.[15]

In a follow-up discussion, concern was expressed that the skills

required for open bariatric surgery and for laparoscopic surgery were

different. In support of this contention, it was stated that recovery

and complications following laparoscopic bariatric surgery may

approximate those of the open procedure unless the surgeon possesses

sufficient skills and experience. It was agreed that the benefits of

laparoscopic surgery improve as the surgical laparoscopic techniques

of the surgeon improve.

http://www.medscape.com/medscape/CNO/2001/NAASO/NAASO-02.html

mary bmi 68

corona, ca

pre op 6/27/01 dr rabkin

cigna ppo