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Surgical Therapy
There are a number of surgical procedures that have
been devised as a means of producing and maintaining
weight reduction. The fall into three broad categories:-
Restrictive operations:- in which the size of the stomach
is restricted so that people feel full after only a
small amount of food. This can be achieved by placing
a band around the upper stomach or by stapling or dividing
the stomach.
Malabsorbtive operations:- in which part of the bowel
is bypassed leading to a reduction in the amount of
food absorbed.
Combination operations:- which have a restrictive and
malabsorbtive component, such as gastric bypass.
Gastric Band (restrictive
operation)
The gastric band is an adjustable device made from silastic
which is placed around the upper
stomach. On its inner surface {next to the stomach)
there is a balloon which can be inflated and deflated
via a port placed under
the skin of the upper abdomen. Above the band is
a small gastric pouch
which is capable of holding only a mouthful of food
and below the main part of the stomach. During a meal,
food enters the small gastric pouch and then passes
through the channel guarded by the gastric band into
the main part of the stomach. The rate at which food
passes through depends on the size of the channel and
this in turn depends upon the degree of inflation of
the balloon. The more inflated the balloon the narrower
the channel and the more slowly food passes through.
Whilst food remains in the pouch it produces distension
of the pouch with an accompanying feeling of fullness
and satiety.
On removal of a gastric band the stomach is returned
to a normal or near normal state.
However, the gastric band is inserted with the intention
that they should remain in place permanently. * If it
needs to be removed for any reason then the weight lost
will be regained.
The operation
The operation to insert the gastric band can usually
be completed laparoscopically in less than an hour through
five small cuts in the
abdominal wall, the largest of which is about 4cm in
size. The port used to inflate and deflate the balloon
is placed under the largest of these and can usually
be felt under the skin after the operation. The balloon
is left uninflated at the end of the operation.
Whilst the operation is not completely painless there
is less pain following a laparoscopic procedure than
one involving a large cut in the abdomen. Most patients
are able to go home within 48 hours.
The postoperative
period
After the operation it is important to reintroduce liquids
and solids gradually during the period the stomach is
getting used to the band.
Post-operative fluid
and diet:
Day of surgery:
Drink water as tolerated with most of the fluid being
provided
via a drip.
1 –3 days:
Drink increasing amounts of fluids and yoghurt
2 - 3 weeks:
During this period thickened fluids such strained soup
and
pureed fruits can be introduced,
4 - 8 Weeks:
In this period more solid food should be started. All
food should
be chewed well and only small mouthfuls swallowed at
one
time. Vegetables which contain a lot of fibre and meat
are
most likely to cause difficulties at this stage.
Some foods
may stick or be regurgitated or vomited back.
8 Weeks onwards: Most solid
food should be tolerated: patients may avoid certain
foodstuffs which stick or are regurgitated.
Band adjustment
By 6 to 8 weeks the stomach swelling that occurs following
surgery will have settled and the band can be inflated.
Some weight loss will have occurred during the first
few weeks but injecting fluid into the band to narrow
the opening between the pouch and the stomach can further
increase this. This process is carried out in the x-ray
department where the size of the opening between the
pouch and the stomach can be watched on the x-ray screen
as the adjustment is made. Adjustments may need to be
carried out a number of times in order to get the desired
degree of weight loss. The best way of judging whether
further inflation is needed is to look at how much weight
has been lost in the proceeding weeks and months. Occasionally,
if the band is too tight {patients complain of having
difficulty swallowing solid food} it will be necessary
to remove some fluid. There is no need for sedation
or anaesthesia during band adjustment; the only discomfort
experienced being the passage of a fine needle through
the skin into the reservoir.
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