In some cases, bariatric surgery is used to treat obesity, a chronic endocrine and metabolic disorder of the body, and gastric bypass surgery is one of the most common types of surgery. In the course of this operation, surgeons reduce the volume of the stomach and reconstruct part of the small intestine adjacent to it.
Bariatric shunting of the stomach or bariatric gastroenterostomy can be used for pathological obesity that is not amenable to conservative treatment (with the help of a low-calorie diet and energy-consuming physical exertion), and one desire to "reduce" the stomach for weight reduction is not enough.
Indications for gastric bypass surgery include diagnosed grade 3 obesity (or morbid obesity) - when the BMI (body mass index) is equal to or greater than 40 (recall that the normal BMI is 18.5-25). That is, the weight of the body, according to Western experts, should be above the normal by 45-50 kg (in domestic bariatric surgery this figure is higher and averages about 80 kg).
The operation can be administered at a specified degree of obesity if the patient seriously suffers from concomitant diseases, in particular, if there is a history of severe arterial hypertension, type II diabetes, degenerative joint diseases (osteoarthrosis) or arthritis, cardiovascular diseases, chronic hypoventilation syndrome or sleep apnea.
Also in the medical history of candidates for this operation, unsuccessful attempts to get rid of excess weight through a controlled diet change should be recorded.
Where can I get a stomach shunt? This operation is performed in clinics of the gastroenterological profile, where there are specialists who know how to perform gastroenterostomy, or in specialized departments of endoscopic (laparoscopic) abdominal surgery. In this case, free gastric bypass surgery - as a bariatric surgery - is not provided.
Preparing for a gastric bypass surgery consists of the same comprehensive preoperative examination as that performed by patients before abdominal cavity operations. Anamnesis and physical examination are designed to identify in advance the concomitant diseases that can provoke complications.
Usually, a clinical and biochemical blood test is required (on the level of clotting, lipids, thyroid hormones, ferritin).
An ECG, chest X-ray, ultrasound of the stomach and intestines or gastroendoscopy (to determine possible gastric pathology) is done. The gallbladder, spleen and liver are also examined using ultrasound sonography.
In addition, the preparation includes a pre-operative liquid diet (for one to two weeks before the operation) - to reduce the amount of fat in the liver and spleen. The composition of the diet includes mashed soups-purees and vegetable purees; protein cocktails; rice broth; drinks without sugar, caffeine and carbon dioxide; vegetable juices. And drinks should be consumed half an hour after eating.
Also a week before the operation, some medications are stopped, including anticoagulants, steroids, NSAIDs, oral contraceptives, vitamin E.
If the patient smokes, then a few weeks before the surgery, he must give up this habit, as smoking slows recovery and increases the risks of complications.
Technique of the gastric bypass surgery
To date, the technique of gastric bypass surgery is to divide the stomach (by flashing with titanium clips) into two parts, with a volume of the upper part of no more than 30-50 ml. From the distal side of the smaller part (which will perform all the functions of the stomach), sew the axially dissected jejunum (the outflowing part), that is, form an anastomosis. The remaining (large by volume) part of the stomach is mechanically excluded from the digestive process.
Minimally invasive laparoscopic gastric bypass surgery is performed without laparotomy - limited access through 4-6 small incisions (ports): one is inserted through the endoscope connected to the camera, and others provide access to specialized surgical instruments. Surgical manipulations are visualized on the monitor.
By decreasing the volume of the stomach, the main goal of bariatric gastroenterostomy is to reduce the amount of food that can be consumed by the patient at one time, and therefore to be digested and absorbed (absorbed into the small intestine). Thus, the body will receive fewer calories from the food consumed.
In addition, the "change in the route" of food in the digestive tract - its entry into the primary parts of the jejunum, bypassing the stomach cavity (that is, bypassing it, through anastomosis) - leads to a feeling of satiety and a lack of appetite. Specialists attribute this to the fact that food falling directly into the proximal part of the jejunum reduces the production of ghrelin, which regulates the appetite of the peptide hormone.
Contraindications to the procedure
Since gastric bypass surgery refers to complex combined surgical interventions to create a gastrointestinal anastomosis, it is contraindicated with a BMI below 35.
Also, contraindications to gastric bypass surgery relate to patients older than 60 years; existing inflammation of the esophagus mucosa (esophagitis). This operation is not performed for mental disorders and in cases of alcohol or drug dependence of patients.
The gastric bypass is performed under general anesthesia, and the operation can last from two to four hours. Therefore, surgeons consider the presence of contraindications to general anesthesia: severe cardiac rhythm disturbances, post-infarction and post-stroke states, cerebral vascular pathologies, severe bronchial asthma and some others.
Consequences after the procedure
This surgical intervention can accompany both complications after the procedure, and numerous long-term negative consequences of gastric bypass surgery.
Among the main postoperative gastro-shunting complications that occur in almost a quarter of cases, an early occurrence of anastomotic leakage (in 2% of cases), intra-abdominal infections (about 3% of cases), gastrointestinal hemorrhage (1.9%) and pulmonary embolism 0.4%). The possibility of damage to the stomach, intestines or other organs during surgery is not excluded. According to some estimates, mortality in the first month after the operation varies from 2.5 to 5% of cases, and within six months after surgery - 0.5%.
And over time, the effects of gastric bypass surgery can manifest in the form of a hernia (in 0.5% operated), the appearance of gall stones in the gall bladder (in 6-15% of patients), stenosis (4.7% of cases), intestinal obstruction due to formation adhesions (1.7%). Deficiency of vitamins B12 and D, folic acid, calcium and iron can lead to the development of secondary hyperparathyroidism, bone resorption and iron deficiency anemia. There are also cases of gastritis and gastric ulcer.
For this reason, it is recommended to visit the doctor quarterly within the first year after the gastric bypass; during the second year - twice a year, and then annually (with the delivery of a detailed biochemical blood test).
Care after the procedure
Most patients are in the clinic for three to four days after the operation, but to sit in bed and gradually walk the doctors recommend as early as the first day.
Care after the procedure includes ensuring the sterility of the postoperative wound, catheter (it must be installed with laparotomy shunting), drug prevention of blood clots, anesthesia, etc.
The medical staff tracks blood pressure, the state of gas exchange in the lungs and the total metabolism after surgery (complete blood count, with prothrombin time and electrolyte level, kidney and liver function).
For prophylaxis of deep vein thrombosis after bariatric surgery, their condition is assessed on the basis of ultrasound or angiography. Patients are advised to use compression knitwear on their legs.
Immediately after the operation - the first two days - eating anything from food or drinks is strictly prohibited.
Diet and nutrition after gastric bypass surgery
Diet after gastric bypass during the first week (minus the first postoperative days) allows only clear liquids (no more than 30-45 mg per hour); it can be water (without gas), skim milk or broth, juice without sugar.
The next two weeks the patient eats only liquid food, consisting of protein cocktails, grated with skim milk or broth of low-fat soft cheese, cottage cheese or boiled white meat (65 grams of protein a day). In addition, you should drink at least 1.5-1.6 liters of water per day: in small portions, slowly, about half an hour before meals and every hour after eating.
Necessarily daily accepted polyvitamins and iron preparations, as well as calcium citrate (0.4 g twice a day) are prescribed.
Diet and nutrition after gastric bypass surgery for 4-5 weeks include the gradual introduction of soft food - chopped boiled meat (lean chicken, turkey), fish (also boiled) and boiled vegetables. Recommendations for drinking water are the same. To already taken vitamins and minerals, vitamin D3 (1000 ME per day) is added.
On the sixth week, patients begin to eat solid food. But this does not mean that you can eat everything. The diet limits the total daily intake to 800-1200 kcal during the first year and up to 1500 kcal, after 1.5 years the gastric bypass field. Also, avoid foods that are poorly digested (beef, pork, whole grains, mushrooms, grapes, corn, legumes), whole milk, canned food, fatty and spicy foods, sweets.
Experts in the field of bariatrics warn: gluttony after gastric bypass surgery is excluded. At the physiological level, overeating is prevented by the so-called dumping syndrome, which occurs due to too rapid or excessive absorption of food (especially sweet and fatty). The stomach, reduced by surgery, simply "drops" food into the small intestine, which causes vomiting, diarrhea, bloating, weakness, muscle cramps, hyperhidrosis, palpitations (this usually lasts for one or two hours). So patients after gastric bypass surgery, who tried a couple of times to return to the habit of "eat tightly", simply stop doing "experiments" on their stomach.
The portion size at each meal intake should not be more than your fist.
Reviews and results
According to the experts of the American Society for Metabolic and Bariatric Surgery (ASMBS), the prognostic results of bariatric gastric bypass surgery - getting rid of 50-60% of extra pounds during the first 12 months after the operation: an average of 5-7 kg per month.
It is important to understand that over time, weight loss will decrease and in the long run, to a large extent, everything will depend on the lifestyle: healthy eating and physical activity.
Feedback from some patients suggests that the greatest weight loss bypass stomach was given in the first 6-8 months after it was carried out. Many emphasize the fact of lowering blood pressure, normalizing the level of glucose and lowering the level of cholesterol in the blood.
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