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The chat of this month :
Do you know about \"sleeve gastrectomy\" and what do, you think of it?
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Digestive surgery |
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There are several procedures that have been
developed for more than 30 years. Some are much more frequently performed
according to certain countries, or different habits from physicians and
surgeons. Trends are coming up, sometimes with discrepancies. In the United
States, complex procedures are currently ahead, while in Europe laparoscopic
procedures using adjustable bands are leading for a few years.
At a first look, we can distinguish two types of
procedures:
restrictive and malabsorbtive
operations. The first ones aim to restrict the capacity of the
stomach, thus creating satiety in a simple way. But they elicit discomfort and
vomiting at first. Then over the time patients will cope with it and therefore
results are less interesting in the long run. That is the reason why in the US,
where the population of obese people having poor food-habits is very large, more
aggressive procedures are done, using malabsorbtion, i.e. a decreased absorption
of food by the alimentory tract. Different procedures are used, mainly employing
a bypass between the stomach and the small bowel. These techniques are more
complex than the restrictive ones, and the consequences are more serious,
demanding a careful attention in the follow-up. But long-term effectiveness is
obviously better in terms of weight-control. Our purpose is to describe herewith
only the three major procedures : the adjustable band, the gastric stapling and
the gastric-bypass. | | | |  | Laparoscopic adjustable gastric banding |
| The procedure is simple in
its principle. A band is placed around the superior part of the stomach, thus
creating a tiny pouch through which food will pass in a small but sufficient
amount.
If the volume of absorbed food exceeds the size of the pouch,
either in quantity or in quality (non masticated pieces), there will be a
painful stop or a vomiting. | | |
|  One can see on this picture
that the ring is placed 2 cm below the oesophagus. It has two parts: an outer silicone rigid part, and an inner inflatable part.
The latter is connected to a small subcutaneous port,
allowing injection or deflation of saline serum.
There are
currently two available bands, one is inflated with saline, the other with X-ray
contrast. They vary according to their size, shape and capacity. There is no
current evidence for a sheer superiority of either one. |
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The inner diameter of the band can thus vary
according to the patient's needs : less if he vomits to often or looses too much
or too rapidly weight, more if alimentation remains unrestricted without a
satisfactory weight-loss. The port is placed for instance below the costal
margin, on the left side, deep enough to prevent irritation. However it can harm
moderately for a while. The band is not inflated at first, then, one month
after, 1 to 3 cm3 can be inflated under radioscopy, by a simple
puncture with a small needle. This does not request any anesthesiology.
The adjustment is the core of the method, because
it makes it possible to obtain a fine regulation of weight-loss, depending of
the patient's will and abilities. Besides, this procedure can almost always be
performed through laparoscopy. | | | | | | Stapling gastroplasty |
| The
most classical restrictive operation is the vertical banded gastroplasty, that
exists for more than 30 years. It is usually performed through laparotomy, that
is through an opening of the abdominal wall from the xyphoid to the umbilicus. A
small upper gastric pouch is also created in this procedure, using a small ring
(or a mesh) and a staple line.
This operation is still largely performed worldwide, although surgeons know from the follow-up that it has many disadvantages. Among them is the alimentory discomfort, which is not likely to disappear since there is no possibility for adjustment. | | |
| | | | Bypass procedures |
| | Gastric bypass operations
are more complex procedures. They entail an anastomosis (ie a suture) between
the stomach and the small bowel. They are very common in the United States,
because long- term outcomes are deemed much better. In Europe, they are mostly
replaced by simpler operations, because of their seriousness, the
non-reversibility, and the possibility of nutritional deficiencies.
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