BODY MASS INDEX
There is a possibility of weight gain in all of bariatric surgeries even though it is low. A second surgical procedure is applied to these patients, if they gain weight again, they can get rid of this weight, and if they stop losing weight, it is enables them to start losing weight again. All of these secondary procedures are called revision surgery.
All patients who have previously undergone bariatric surgery by any method and who gain weight again or cannot lose enough weight can be treated. However, the method to be applied to each patient is different. Therefore, each method cannot be applied to every patient. Also, all of these procedures can be done laparoscopically (closed).
Revision surgeries are surgeries that require considerable experience and skill. The treating physician and the unit should preferably have all of the following characteristics.
On the contrary, these are diseases caused and exacerbated by obesity. These diseases are not an obstacle for the surgery but they are the reason.
First of all, detailed information about the patient’s previous surgery should be obtained. First, epicrisis of the surgery and diseases should be found. Endoscopy should preferably be performed by the physician who will perform the surgery. In addition to endoscopy, barium scintigraphy, abdominal tomography with contrast matter, or Magnetic resonance imaging with contrast matter may be needed to better understand the anatomic changes associated with older surgery in these patients.
In addition to this, the following tests and examinations are applied before surgery as if it is the first time that every patient is operated;
After all these tests, necessary examinations are carried out by Anesthesia, Internal Medicine, Cardiology, Chest Diseases and Endocrine specialists. As a result of these examinations, firstly it is checked whether the patient has any other underlying disease that may cause weight gain. If there is no such disease, the patient will be examined for anesthesia like every patient who will be operated. Relevant specialists will make recommendations about pre-operative treatments if necessary. Thus, the problems that may arise during and after this significant surgery are reduced to the minimum.
Some procedures can be done by endoscopy without surgery. All procedures except this are done by laparoscopic (closed) operation method. The experience of the practicing physician here is much more important. Laparoscopic surgery is performed with a large number of small incisions. The ports placed from these incisions are used to reach the abdomen by the hand tools. One of these is a surgical telescope connected to a video camera and others are for the insertion of specialized surgical instruments. The surgeon monitors the operation from a video monitor. With experience, an experienced laparoscopic surgeon can perform many laparoscopic surgeries as in open surgery.
Patients with gastric banding:
In these patients first band is removed. This may be one session or different sessions. In some patients, the band enters the stomach, which may require endoscopic removal. Any surgical procedure can be performed as if the patient had never undergone surgery after the removal of the band.
Patient with gastric bypass:
First, if the transition between the stomach and the intestine is enlarged, the transition can be narrowed by sclerotherapy in three or four sessions with endoscopy. The food stays longer in the stomach, so the patient will feel satiety for a longer period of time.
Bowel loop combined to the stomach is separated and reassembled in forward. In this respect, the amount of calories taken is reduced because a smaller portion of the intestines is in contact with the food.
By bypassing the intestines, the interaction between the intestines and the food can be limited.
In patients with sleeve gastrectomy:
Firstly, if the first operation is not sufficient, or if the stomach is enlarged again, it can be re-sleeved.
Roux-en-Y (proximal) can be applied. This variant is the most commonly used gastric bypass technique and is the most applied bariatric procedure in the USA. This is the operation that leads to the minimum nutritional problems. A proximal gastric pouch smaller than 30 mL (at the entrance of the stomach) is formed at the entrance of the stomach. This new stomach pouch has a smaller volume than about 1 tea glass. By creating a stomach pouch, the existing stomach is disabled and the food is directed here. It is taken from the part of small intestine leading to the distal (large intestine), cut approximately 50-75 cm and is connected to the newly formed stomach pouch. The end of the small intestine that is left behind and through which the bile and pancreatic fluids come is re-associated to the intestine about 70-80 cm further.
Duodenal switch. In this process, duodenum is separated and connected to the small intestines from the part leading to distal (large intestine). In this case, the food contacts a smaller intestinal surface.
Transit bipartition. This helps to improve diabetes especially when you have diabetes. Anastomosis is performed near the stomach exit from the part of the small intestines towards the distal. On this count, half of the food goes directly to the end of the intestine, while half of the food gets around the entire intestine. This both reduces weight gain and controls the sugar, saving the patient from the use of insulin.
Gastric Bypass, Roux-en-Y (distal). The normal small intestine is between 600-1000 cm. At approximately 1 meter forward, one end of the intestine from which the bile comes is combined with the intestine from which the food comes. The association of bile with the food at the end of the small intestine is primarily responsible for malabsorption (reduced absorption) of fats and starches, but also of various mineral and fat-soluble vitamin vitamins. Unabsorbed fats and starch pass to large intestine. This can lead to faster weight loss. However, more serious nutritional problems (e.g. severe vitamin deficiency) can be observed. Moreover, the bacterial activity therein may lead to the production of irritants and the formation of malodorous gas.
There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health. Each product used has its own barcode with serial number. The barcode of each used material is placed in the patient file. Absolutely ask for the material used.
Leak test is performed during the revision surgery and then on the 2nd day. The purpose of the leak test in the operation is to determine if there is a problem with the staples, whether there is leakage at the suture line. If there is leakage, additional suture is added to prevent leakage. It is also possible to take the necessary measures on time and to intervene by conducting a leak test before starting the liquid nutrients after the operation.
In bariatric surgery, additional suturing in addition to special materials called staples is controversial. Some surgeons think that suturing reduces the possibility of bleeding and leakage and that every patient should be sutured. Some surgeons say that suturing reduces the chance of bleeding to some extent but does not reduce the risk of leakage; in contrast, it may lead to more leaks and bleeding after vascular injury while suturing. We are among the two of them as a clinical approach. Although we do not use additional stitches to each patient, we will definitely add extra stitches if the stapler line is not safe enough for us. The fact that our results are much better than the average of the world suggests that our method is more successful. The most important point here is that the surgeon who performs the surgery must have the ability and experience to intervene and correct any problems.
During each surgery, there is a possibility of blocking blood vessels with intravascular blood clots. This can lead to serious problems when it is a vessel that feeds vital organs such as the heart, lungs and brain. As the weight of the patients increases, the risk of embolism increases. For this purpose, blood thinners are given to these patients regardless of the surgery. Although the risk of bleeding is slightly increased, the benefit is much higher. The use of blood thinners begins before surgery and continues for two weeks. The duration of use may be even longer in high-risk patients, such as those with cardiovascular disease or previous embolisms.
Since revision surgery is done laparoscopically (closed), by entering through millimetric holes, postoperative pain is much less than open surgery Still, the phrase “she/he had a surgery, of course there will be pain” is extremely wrong. No patient should feel pain in the 21st century. Pain is completely avoided by administering post-operative analgesic to each patient. The important point here is this: Pain threshold of each person is different. Again, drug tolerance and bioavailability from the drug are different. Therefore, treatment cannot be standard. The pain relief treatment should be regulated separately depending on the needs of each patient.
Since the incisions are very small, the aesthetic results are also fairly good. After a few months, these lines will become almost invisible. After the wound heals, you will be recommended a cream for less scar appearance. You will get much better aesthetic results if you use it for three months.
On the 2nd day of the surgery, you will start taking liquid food after the leak test. You will have soft (puree style) food for two weeks following the first two weeks of fluid feeding. You will be in constant communication with our dieticians throughout this entire process.
During the first 15 days, protein supplements are provided for the patients. Especially in the first year of the disease various vitamin and mineral supplements are provided. Protein and vitamin usage times differ according to the type of surgery. These are not standard for every patient but are determined according to what the patient needs and how much they need after the examinations performed on the routine controls.
Since surgery is done laparoscopically (closed), you can get up and walk after a couple of hours of surgery. Even during the period when you are in the hospital you will not be cared for, you will be able to do your own selfcare. Patients who work on desk and patients who do not require heavy effort can start back to work within a week. Patients who require heavy effort should stop working for at least one month. The resting report is given for as long as required to the patients after the surgery.
It is not necessary to take the stitches as dissolvable stitches are frequently used. If a non-dissolvable stitch is used for a different reason, the stitch is checked and removed when you arrive for a follow-up on the tenth day.
You can take a shower when you’re out of the hospital. There is no problem with the sutures getting open and wet. After showering, dry with a clean towel, apply batticon on the sutures and wait for them to dry. Batticon does not cause permanent stain in your clothes. There is no need to use batticon after the tenth day.
During the first month, do not use any medications except the ones we prescribe. If a medication is suggested by another physician, you should definitely consult us. You can use any medications after the first month. Nevertheless, try not to use too much painkiller and take plenty of fluid after taking the medication.
Although the mechanism differs according to the method used, it is essential to reduce the food intake and to ensure that the food taken is in contact with intestine less. In addition, the hormonal mechanism that varies between the stomach and intestines allows both the control of the sugar level and the quicker weight loss.
The risk of weight gain after a sleeve gastrectomy is very low. In order to maximize the benefits of this physiology, the patient only needs to eat at meals, take 2-3 meals a day, and avoid snacks between meals. This surgery requires changing the eating habits acquired over a long period of time. In almost all cases where weight gain was observed again in the late periods of surgery, there was no increase in the meal capacity. The reason why you gain weight again is especially high calorie snacks between meals. There is no known operation to overcome the side effects of this type of eating habit.
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The prices of bariatric surgery are slightly higher than other surgeries. However, a few titles are extremely important here.
The materials used are an important cost item. There are many different products in the market. The materials of the two leading American companies are the best quality products currently on the market and used all over the world. However, their costs are much higher than Chinese products used for the same purpose. Safety, not cost, is of first importance in health.
The operating room and the hospital where the surgery is performed must have certain equipments and standards. It is necessary to have sufficient number of intensive care beds and a full-time physician in all branches. All equipments from the operating table to the patient bed should be suitable for obese patients. Therefore, it is not appropriate to perform the procedure at every hospital.
Bariatric surgery is not completed only with the surgery; there should be a support team with specialist dieticians whom you can reach for 7 days 24 hours.
The cost of testing and preparation steps required for revision surgery is higher.
Meeting all these requirements increases the cost of surgery by a little more than other surgical procedures. Even if putting aside the quality of life, obesity is the actual cost considering in the long term. The amount of money to be spent on the treatment of health problems caused by obesity such as joint erosions, diabetes, asthma, sleep apnea and blood pressure is several times higher.
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