Introduction

" Laparoscopic techniques are now used in the treatment of severe obesity. Whether it be a gastric band, gastric bypass, or vertical gastrectomy (gastric sleeve), postoperative recovery is considerable different to the open procedures that we used to perform".

BELOW PLEASE FIND MORBID OBESITY SURGERY AND INFORMATION THAT YOU MAY FIND USEFUL.

Morbid Obesity is a disease and should be treated as seriously as any other medical problem. For each person the Body Mass Index (BMI) is calculated by dividing the body weight in kilograms between the height in square centimeters. For example, a person that weighs 75 kilograms with a height of 1.70 mts: 75 Kg ÷ (1.70 x 1.70) mts = 25 of BMI. Any score over 35 is considered morbid obesity. Those with BMI of 40 or with BMI ranging between 35 to 40 and suffering from a medical complication related to their overweight (hypertension, sleep apnea, arthritis, etc.) are candidates for surgery. It is estimated that one of every 5 people in Latin America is overweight. In the United States, 5% of the men (2.9 millions) and 7.2% of the women (4.5 millions) present morbid obesity. The exact cause is unknown but genetic, metabolic and psychological factors play an important role in the development of the disease. Obese patients have increased risk of having:

- depression
- coronary disease
- several joint arthritis
- sleep apnea
- hypertension
- diabetes mellitus
- premature death

Even though there are a certain number of patients that may loose weight in a transient manner with a combination of dietetic measures, medication and exercise, the incidence of gaining back lost weight is 95%.

While surgery is the last resort for those that have not been able to lose weight through diets and exercise, many clinical trials have demonstrated that when performed by good hands, it is a safe and effective method to loose weight.

Weight loss is achieved by reducing the functional size of the stomach and limiting its voiding. When this happens, it is simply impossible for the patient ingest sufficient calories to maintain its previous weight. This concept is valid for the Gastric Banding or the Vertical Gastrectomy, Sleeve type, as both of these are restrictive procedures. In other words, the amount of food entering the body is restricted. Gastric bypass combines the restrictive effect and malabsorptions since the amount of food entering the stomach is restricted and at the same time absorption is prevented. Results may vary from patient to patient but many reach close to 20% of their ideal weight, meaning they loose 80% of the body excess weight.

Gastric Banding

The gastric band (LAP-BAND Allergan, MR) is a device that is implanted, and adjusted which assists patients in the process of losing weight. Utilization of this method started in Europe, Israel and Australia more than 15 years ago. There are more than 100,000 patients in the world that have undergone this surgery. In 2001, the Food and Drug Administration Division approved its use in the United States. The only surgeons that can place the band are those that have completed authorized training.

See the following animations:

• La banda gástrica (ver animación)

Lap-Band system consists of an adjustable silastic band that is placed surgically around the stomach, usually via laparoscopy and under general anesthesia. A new “small stomach” is created over the band with the majority of the stomach underneath the band. This reduces the area of food deposit in the new stomach to a small area. The opening towards the rest of the stomach is limited by the band and it is adjustable. The patient will feel satisfied (“full”) promptly and the sensation will remain for a long period of time. The band is connected by a silastic tube to a reservoir that is placed under the skin during surgery. The band is adjusted by adding or eliminating liquid from the subcutaneous reservoir using a fine needle that is inserted through the skin. This procedure is almost painless, does not require general or local anesthesia and it is performed in the radiology section of a hospital or in the doctor’s office.

This surgery is scientifically proven; but the art is not only in placing the band but in accomplishing a good follow-up of the patient. That is why in some of the centers that train surgeons in the placement of bands a minimum of time that may range up to 2 weeks is being required to calibrate the band adequately.

This information is very important for the patient: If the band is too loose, weight loss will be minimal or nil. If the band is too tight, extraction of the liquid in the reservoir will be required. The ability to adjust the band is a unique feature that is not acquired with the performance of other surgeries. You must be willing to see your physician at least once per month after the surgery to evaluate your progress and determine if there is need to adjust your band. Your physician must be committed to solve your concerns in a timely manner and in a responsible way. Once that relationship is established, the likelihood of complications is minimal.

The majority of the patients are discharged 24 hours after surgery and generally get an x-ray evaluation before discharge. You will be placed on a restricted diet during the first days. Two weeks after, you will be placed on a soft diet. The band is adjusted 4 to 6 weeks after the surgery; future adjustments will depend on your weight loss and development. During the first two weeks we will try to prevent vomiting as much as possible. If there should be a problem, for example, the patient does not tolerate the food restriction or simply does not want to have the band anymore, it can be removed via laparoscopy. This is another feature that other surgeries do not posses.

Since 2002, Dr.Chitrit has been performing gastric sleeve surgeries in the Republic of Panama. During this time, he has operated hundreds of patients with excellent results. Until today, we haven't had a case of infected reservoir, band penetration or any serious complication. Our mortality rate during this surgery is 0%. Three bands have been realized late (more than 2 years after the surgery) because of sliding of the band or severe expansion of gastric pouch. This patients have been operated again performing a bypass or a gastric sleeve evolving perfectly.

Gastric Bypass

Gastric Banding consists of a procedure that removes the upper portion of the stomach leaving a small reservoir with a 25 ml capacity and at the same time, the reservoir is connected to a segment of the small intestine that has a length of approximately 1.5 meters. This intestine will only serve to transport the food to a place where digestion will initiate when food is combined with pancreatic juices (See figure). The gastric bypass combines the restrictive effects with the malabsorption producing a large weight loss in a short period of time. This is the ideal procedure for patients with severe obesity and that have to loose a great amount of weight to attain their ideal weight. The rate of weight loss has been reported to be greater in patients that have undergone gastric bypass than those with gastric banding or vertical gastrectomy but all the procedures have demonstrated good results. The majority of the researches show a reduction of 40-50% of the excess weight in patients with gastric banding versus a 66-70% of weight loss with the gastric bypass after a year. Weight loss continues in all the procedures for 18 to 24 months after the surgery is performed.

Alter the bypass surgery, there may be nutritional deficiencies of Vitamin B-12, folic acid and iron. If you take the necessary vitamins and supplements, these may be prevented. Another potential effect of the gastric bypass is the Dumping Syndrome which consists of abdominal pain, colic, sweating, and diarrhea that typically happen after the patient ingests foods that are rich in sugars. Dumping Syndrome can be prevented by avoiding sugar ingestion.

See the following animations:

• El bypass gástrico (ver animación)

Watch the following videos of the surgery:

• Bypass Gastricos - Dr Moises Chitrit
• Bypass Gastricos 2

Vertical Gastrectomy Sleeve Type or Gastric Sleeve

Vertical gastrectomy Sleeve type is a relatively new procedure that consists of removing 66% of the stomach decreasing considerably its capacity. Obese patients need to fill their stomach in order to create a stimulus or message indicating that enough food had been ingested. When two thirds of the stomach are cut out, the patient will have the same feeling of satiety with a small amount of food. This procedure is being recommended to patients that are extremely obese (BMI greater than 50 kg/mt²) and that perhaps might not resist a prolonged surgery. Weight reduction is seen during 12 to 18 months. If after this time, the patient has lost weight notably but not sufficiently, the patient may be taken back to the operation room and complete a gastric banding procedure with an improved health condition and with the capacity to resist a longer surgical procedure. On the other hand, if the patient has lost enough weight and is close to the ideal weight, no other procedures are added and in these cases this procedure would compete with gastric banding in the sense that it is a pure restrictive procedure but without foreign bodies, without calibrations and without the control and follow-up by the physician that is required for other surgeries. It is usually performed using instruments with linear cutters that shoot three lines of staples on each side to guarantee an impermeable seal. In 2005, Dr. Chitrit performed the first gastric sleeve in the Republic of Panama. Since then, he has realized this procedure succesfully in more than 180 patients with a weight loss of more than 70% of the excess weight, with minimum complications and no mortality at all. Without a doubt, he is the best panamanian surgeon with more experience in this field in Panama. In the year 2006 he realized a course of Gastric Sleeve Surgery in New York, along with Dr. Michel Gagner, considered the world pioneer in the gastric sleeve developtment and surgery. Usually patientes have to say at the hospital for 2 nights. Then they are sent home with oral analgesics and liquid diet for 2 weeks. The weight loss during the first month is between 15 and 25 pounds (7 to 11.5 Kg.) and usually after 6 months, the patients have loss more than half the excess weight they had. At the end of the first year, you will be in your ideal weight and enjoying the benefits of a new and healty life.

Watch the following animation:

• La manga gástrica (ver animación)

Watch the following video of the surgery:

• Manga gastrica Laparoscopica - Dr. Moises Chitrit