Bariatric surgery is the only adequate method that provides the possibility of achieving not only pronounced, but also a persistent reduction in body mass index (BMI) in patients aged 18-60 years. In some cases, it can be applied to people from 15 years of age.
Surgical treatment can be carried out with morbid obesity and the ineffectiveness of previously held conservative measures in individuals:
- BMI> 40 kg / m 2 (regardless of the presence of concomitant diseases);
- BMI> 35 kg / m 2 and the presence of serious diseases, for which you can influence by reducing body weight.
- III and IV functional classes of chronic heart failure, renal or hepatic failure, other changes of vital systems and organs that are irreversible;
- aggravation of peptic ulcer and duodenal ulcer;
- mental disorders in the form of severe depressive states and certain types of psychopathy; bulimia nervosa; alcohol, drug or other psychotropic addiction;
- the presence of a malignant neoplasm.
The decision on the necessity and possibility of performing surgical treatment, the choice of methodology and risk assessment is carried out by a commission composed of a surgeon, an endocrinologist, a therapist or cardiologist, a dietician and a psychiatrist with the participation of the patient himself. Bariatric surgeries are performed by the laparoscopic (mostly) method. According to the mechanism of action, they are combined into 4 groups:
- Installation of intragastric balloon.
- Malabsorption, aimed at reducing the absorption of nutrients in the small intestine.
- Restrictive, narrowing the upper sections of the stomach.
Installation of intragastric balloon
This is a surgical manipulation of the introduction into the cavity of the stomach of a balloon of 0.4-0.7 liters, after which it is filled with saline. The balloon fills most of the stomach, which promotes rapid saturation, and also has a stimulating effect on saturation receptors. These factors contribute to the achievement of the goal of the method - the formation of a feeling of rapid saturation with a reduced amount of food. The cylinder is installed for a period of six months, after which it is removed. The technique is applied for:
- weight loss with a BMI of 35-40 kg / m 2 ;
- preparing the patient for radical surgery.
The advantages of installing an intragastric balloon are the simplicity of the method (the operation of installing the balloon occurs without a single incision), a small risk of side effects, and the effectiveness of the method (during therapy, along with the recommendations of the doctor, reduces overweight to 30%).
They are aimed at reducing the absorbability of nutrients in the small intestine. Of the entire group, only biliopancreatic shunting (BPS) is sometimes used at present. The technique of operation consists in flashing the stomach with the formation of two sections:
- proximal volume of about 100 ml (normal - 2000 ml), which connect the small intestine;
- distal stomach with duodenum 12, which receives bile and pancreatic juice.
As a result, incoming food "meets" with bile and enzymes only in the final sections (50-100 cm) of the small intestine, where it undergoes splitting into its constituent components and partial absorption into the blood.
Thus, the small intestine consists of two long and one short loops: the alimentary loop is for hummus, the biliopancreatic loop is for bile and pancreatic juice, common (Fig. 1).
This has two goals:
- reducing the amount of food consumed;
- a significant reduction in the degree of cleavage and entry into the blood due to the reduction of the cleavage time and suction area .
Such a technique, in its type, refers to restrictive and malabsorptive variants with the predominant effect of the second. It allows you to reduce overweight by 70-75%, but is dangerous due to complications, due to the development of severe hypoproteinemia (low protein content in the blood) and painful chronic diarrhea. This explains the extremely rare use of BPP in its “pure form”. If necessary, it is used in a smaller volume and in combination with other techniques.
- Adjustable bandage gastroplasty , allowing to reduce overweight by 50%. It is a superposition on the stomach of a silicone cuff with a lock, the port of which is displayed under the skin of the anterior abdominal wall. This is achieved by dividing the stomach into 2 parts (the volume of the upper - 10-20 ml), connected by a lumen. The diameter of the latter is gradually regulated by injecting fluid through the port so that the monthly weight loss does not exceed 7 kg.
- Vertical resection of the stomach, or sleeve gastroplasty (reduces overweight by 50-60%) - longitudinal resection with removal of the greater curvature and the bottom of the stomach while maintaining the pyloric. A “tube” of up to 200 ml is formed from the remaining part.
- Gastroplication is a technique fundamentally very similar to the previous version. The difference is that the formation of the “sleeve” is performed not by resection, but by stitching and screwing part of the stomach inside (like a surgical purse string suture).
These mainly include:
- Gastric bypass surgery (gastroshuntirovanie). It consists in the complete isolation of the upper parts of the stomach with a volume of 20 to 30 ml from the lower ones by means of staplers. After that, an anastomosis (connection) is formed between the upper sections of the stomach and the small intestine below the duodenum (in the region of the middle sections of the jejunum). This is achieved by limiting the amount of food intake and a moderate malabsorptive effect. The operation allows you to reduce overweight by 70%.
- The combination of sleeve gastroplasty with gastroshuntirovaniem.
Fig. 1 - The most popular bariatric surgery
Tubular gastroplasty is the most popular: in terms of the complexity of technical implementation and the number of complications, it occupies an intermediate position between the bandaging technique and gastroshunt bypass.