Bariatric and metabolic surgery

Metabolic surgery
La cirugía metabólica se refiere al tratamiento quirúrgico de la Diabetes Mellitus tipo 2, representando una nueva opción de tratamiento para esta enfermedad hasta hoy día considerada sólo de tratamiento médico.

La cirugía metabólica deriva de la cirugía bariátrica o cirugía para la Obesidad Mórbida.

Bariatric surgery
La cirugía bariátrica es el conjunto de procedimientos quirúrgicos usados para tratar la obesidad, buscando disminución del peso corporal y como alternativa al tratamiento con otros medios no quirúrgicos. Actualmente se considera el único tratamiento efectivo para perder el exceso de peso y mantener los resultados con excelente calidad de vida.

Techniques
Básicamente consiste en reducir, mediante distintas técnicas (gastroplastia, bypass gástrico, banda ajustable, etc.), la capacidad del estómago y alterar el recorrido intestinal para evitar la absorción de las grasas durante el proceso digestivo.

Indications
Se aplica en aquellos casos en que el tratamiento médico con dieta, ejercicio y medicamentos fracasa, tras haber seguido un programa médico que integra cambios de conducta, actividades físicas y apoyo psicológico. Se ha establecido que el único tratamiento realmente efectivo para la obesidad mórbida es la cirugía bariátrica, siempre y cuando el tratamiento sea realizado por un equipo idóneo.

By laparoscopy
El paciente es intervenido por vía laparoscópica y a través de pequeñas incisiones (menos de 6mm) por donde se inserta todo el instrumental, como son la cámara y luces, que permiten al cirujano operar con alta precisión en el interior de la cavidad abdominal. Mediante la laparoscopia el paciente experimenta una recuperación más rápida, mínimo dolor postquirúrgico y escaso daño sobre la pared abdominal.

Gastric sleeve

The gastric sleeve is a procedure that consists in converting the stomach in a tube surgically removing a substantial part of it in order to reduce its capacity. Its mechanism of action is: it is based on causing satiety by reducing the gastric capacity. It also causes a lack of appetite by eliminating the ghrelin secretion, which in turn will improve blood glucose levels.

Gastric sleeve advantages
The weight loss is produced reducing the intake. The food progresses as usual through the intestine and the need of taking supplementary medication is minimized. If the progression in the diet is not adjusted to the recommendations there may be postprandial discomfort and vomiting.

What are the results of the gastric sleeve?
The gastric sleeve achieves losses from 40% to 60% of the excess weight during more than 2 years. The effects on comorbidities are also positives, especially on diabetes, with an improvement up to the 85% of patients.

Gastric band

The gastric band is a silicone ring that does not need to be moved away and is placed in the upper stomach tightening the intake of food.

How does it work?
The gastric Bolson induces early satiety and reduces the amount of intake that can be taken in each meal.

Gastric band advantages
Advantages and disadvantages: there is no alteration of digestive anatomy and the surgery recovery is very quickly. The intake type and its limited amount enable the achievement of the desired weight loss. Among the disadvantages, we find the presence of odd material within the organism and the erosion that may produce on the gastric wall. It is not a decisive technique for diabetes, so its application must be very strict.

What are the results?
The weight loss achieved with this technique is between a 30% and a 50% of the excess weight according to the revised series. This is also associated with a discreet control of metabolic comorbidities. According to the American Society for Metabolic and Bariatric Surgery, diabetes resolution only occurs in 47% of cases.

Gastric bypass

Such interventions outperform diabetes, as they achieve a greater weight loss in the long term. The gastric bypass consists in placing a very small pouch in the stomach and changing the food transit through the insertion of an intestine. Its mechanism of action is partly restrictive, as it reduces the amount of food that can be ingested. By bridging a section of the intestine, there is a reduction in the absorption of the ingested food.

Gastric bypass advantages
It achieves a great weight loss by reducing the food intake and causing a slight malabsorption. Among the disadvantages, we find the presence of vomits and the need for taking supplements, such as calcium and iron. The patient may need clinical and analytical supervision.

What are the gastric bypass results?
According to the American Society for Metabolic and Bariatric Surgery, diabetes resolution occurs in 83% of cases. It has been observed that it also improves other metabolic syndrome parameters. The weight loss achieved with the gastric bypass is between a 60% and a 70%.

Biliopancreatic diversion

The biliopancreatic diversion consists in keeping a small stomach, with a wide exit for the food that bridge a great part of the intestine as it mixes with intestinal juices and the food consumed in the last 60 cm of the small intestine. The results are obtained in a very common short handle. Its mechanism of action is mainly a reduction of the fat food absorption, by bridging a great part of the small intestine. In an initial phase, there is a decrease of the food intake capacity, but the amount that can be eaten is much higher than the produced in the gastric bypass.

Biliopancreatic diversion advantages
The weight loss is maintained in the long term, by avoiding the absorption of foods high in calories. It causes an appearance of doughy stools facing the fat food intake. Usually, several fragrant stools are made a day. There is a need for clinical and analytic supervision to adjust the supplementary mineral and vitamin needs.

What are the biliopancreatic diversion results?
According to the American Society for Metabolic and Bariatric Surgery, it is the best technique for the diabetes resolution with an improvement or cure of 97,9% of the cases. This technique has proved an excellent weight control with loses higher to the 65% of the weight excess in the medium and long term. It has also proved an excellent control of the metabolic comorbidities, especially with diabetes, with resolution rates above the 90%. It has also proved to have beneficial effects for the non-alcoholic fatty liver disease associated with obesity.

Asociación Española de Cirujanos (AEC)
Sociedad Española de Cirugía de la Obesidad (SECO)
Sociedad de Cirugía Laparoscópica y Robótica (SECLA)
Sociedad Española para el Estudio de la Obesidad (SEEDO)
Centro Integral de Nutrición Islas Baleares (CINIB)
Acadèmia Mèdica Balear
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