La manga gástrica o gastrectomía vertical es la intervención de cirugía bariátrica que se está imponiendo en todo el mundo.
Vertical gastrectomy is a relatively new intervention first described in 2000 and has become the most commonly performed intervention in most parts of the world. In the United States it already constitutes more than 60% of all surgeries
Estimate of Bariatric Surgery Numbers USA 2011-2018
Published June 2018
| 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018* | |
| Total | 158,000 | 173,000 | 179,000 | 193,000 | 196,000 | 216,000 | 228,000 | 252,000 |
| Manga | 17.8% | 33.0% | 42.1% | 51.7% | 53.6% | 58.1% | 59.4% | 61.4% |
| By-pass | 36.7% | 37.5% | 34.2% | 26.8% | 23.0% | 18.7% | 17.8% | 17.0% |
| Banda Gástrica | 35.4% | 20.2% | 14.0% | 9.5% | 5.7% | 3.4% | 2.7% | 1.1% |
| Derivación bilio-pancreática | 0.9% | 1.0% | 1.0% | 0.4% | 0.6% | 0.6% | 0.7% | 0.8% |
| Cirugía de revisión | 6.0% | 6.0% | 6.0% | 11.5% | 13.6% | 14.0% | 14.1% | 15.4% |
| Otros | 3.2% | 2.3% | 2.7% | 0.1% | 3.2% | 2.6% | 2.5% | 2.3% |
| Balón intra-gástrico | — | — | — | — | 0.3% | 2.6% | 2.8% | 2.0% |
It consists of cutting the stomach from being bagpipe-shaped to banana-shaped. It is a much simpler technique than other interventions such as gastric bypass or bilio-pancreatic diversion, but in reality its working is complex through physiological, hormonal and metabolic mechanisms.
IS THE GASTRIC SLEEVE A RESTRICTIVE SURGERY?
Traditionally and in a simplistic way, obesity surgeries have been considered as either “restrictive”, “derivative” or a mixture of both.
Restrictive surgeries limit the space to house food and derivatives or malabsorptives produce a reduction in the absorption of nutrients.
The gastric sleeve is not simply restrictive because although it reduces the capacity of the stomach by approximately 80%, it still leaves a capacity of about 250 cc, which supposes a volume much higher than the restriction produced for example by a by-pass in which reduces the stomach to just over 3% of its volume, that is, 20-60 cc (less than the volume of an egg)
In the gastric sleeve, by removing the gastric fundus, the hormonal mechanisms of hunger are modified and it is possible to reduce appetite, making hunger coincide with the capacity of the stomach and with the patient’s real feeding needs.
The gastric sleeve through complex hormonal and metabolic mechanisms achieves results equivalent to those of the by-pass, with a much greater gastric capacity and without the malabsorptive component. The stomach, although limited in volume, maintains its function like the rest of the intestine, which maintains its absorption capacity of all nutrients.
INDICATIONS GASTRIC SLEEVE
The gastric sleeve is indicated for patients with a BMI of more than 40 (morbid obesity) or patients with a BMI> 35 (obesity grade II) with some comorbidity such as diabetes, hypertension, etc … although in certain cases it can even be considered from BMI of 30 (obesity grade I)
NTERVENTION TIME HOSPITALIZATION AND RECOVERY
Average intervention time: 1.5 hours.
Hospitalization time: 24 hours.
Postoperative duration: 5 -7 days.
WHY CHOOSE THIS TREATMENT?
It is the intervention with the best relationship between safety and efficacy.
Provides excellent results and minimal complications.
The capacity of the stomach is reduced without altering the absorption of nutrients, so it is not essential that the patient take vitamins for life as it happens with other techniques.
Weight loss is easier than with other procedures, since the patient will notice a greatly reduced feeling of hunger.
It is technically much simpler than traditional stomach reduction surgery.
Avoid long-term complications such as the formation of internal hernias that are common after undergoing other techniques to treat obesity.
PARTICULARS OF THE SURGICAL TECHNIQUE CARRIED OUT BY DR. CARLOS MOLINA:
The technique that Dr. Molina uses offers more safety than the standard technique, and is only performed by expert surgeons due to its complexity.
It is performed by laparoscopy and in most cases through only 3 small incisions when 5 incisions are used in most centers.
A double safety suture is performed, after performing the first suture with the latest generation stapler, a second manual suture of the staple line is performed.
This increases the safety and probably the durability of the intervention.
Thanks to his technique, the time of hospital admission and postoperative period is minimized.
The risk of possible bleeding or fistula is decreased.
Greater therapeutic efficacy is achieved.
The frequency of future dilations can be reduced.
DISADVANTAGES OF THE GASTRIC SLEEVE
Irreversible surgery.
Although it is usually mentioned as a drawback of the gastric sleeve I do not fully understand how this is a drawback and rather I see it as an advantage.
The stomach that remains with a gastric sleeve is enough for normal nutrition and in fact one of the problems is that if the intake is forced, the stomach can give up.
“Any part of the human body can be stretched with time and patience”
Gastroesophageal reflux.
Gastro-esophageal reflux may be the Achilles heel of the gastric sleeve and presents as heartburn.
The scientific evidence in relation to this point is conflicting, there are studies that show worsening and others show improvement in GE reflux, but as longer term studies are published, both worsening of patients who already had reflux and the appearance of new reflux seems to be more frequent.
In my experience, if the patient has symptoms before the intervention, it is mandatory to perform a gastroscopy before the operation and a methodical repair of the hiatus hernia is mandatory. Of those patients who have their hiatus hernia repaired during the procedure two thirds will improve their symptoms, the rest may need to take omeprazole long term.
Meticulous dissection of the hiatus region is essential and part of my technique to identify hidden hiatus hernias and to properly mobilize the stomach.
It is important to note that in many cases reflux is not symptomatic before or after surgery, so it is recommended to perform follow-up gastroscopies after the intervention.
GASTRIC BYPASS
It is a surgical technique considered by many to be the “gold standard” of bariatric surgery.
Gastric bypass consists of reducing gastric capacity to its minimum expression (volume of a small egg) by sectioning the stomach into two parts and connecting the smallest part directly to the small intestine. In this way, it is possible to decrease caloric and nutrient absorption and therefore weight loss.
Average intervention time: 2-3 hours.
Hospitalization time: 3 –5 days.
Postoperative duration: 8 –10 days.
What type of patients is indicated for: people with BMI> 40
ADVANTAGE:
- Proven technique with good results in terms of weight loss and resolution of comorbidities in the short and long term.
DISADVANTAGES:
- More complex intervention than the gastric sleeve.
- Longer and uncomfortable postoperative, drains are usually placed, the admission time is usually 2-5 days
- The anatomy of the digestive system is substantially altered, and although no part is removed, it is practically impossible to return it to its previous state.
- The patient must take vitamins for life after the intervention.
- It can cause complications such as dumping syndrome.
- The patient has to radically change his eating habits.
- Most of the stomach is excluded and can no longer be reviewed with an endoscopic technique, making the diagnosis of possible gastric pathologies practically impossible after the intervention.
- In a recent study in the USA on 129,432 patients who underwent gastric bypass, it has been calculated that a third of the patients present at least one complication in the 10 years after the intervention, with a total mortality of 2.2% in the first year, 4.4% at 5 years and 8.1% at 10 years. It is not surprising that many patients reject this intervention. “The best is the enemy of the good”
GASTRIC BAND
Adjustable and reversible laparoscopic technique
Using this technique, a silicone band that compresses the upper part of the stomach is inserted laparoscopically. The purpose of this device is to limit the amount of food and the speed with which it passes through it. Once in place, the specialist can regulate the elastic band so that it exerts more or less pressure depending on the patient’s needs.
Intervention time: 45 min.
Hospitalization time: Outpatient intervention, does not require hospital admission.
Postoperative duration: 5 –7 days.
What type of patients is indicated for: people with BMI> 30
ADVANTAGE
-
The anatomy of the stomach and the rest of the digestive system are not modified.
- It is a quick and easy intervention.
-
• It is completely reversible
DISADVANTAGES
- If the band is not perfectly adjusted it does not work. Sometimes it is not possible to reach the midpoint. Either it is too loose and therefore does not produce any results, or it is too tight and causes difficulty in swallowing and regurgitation.
- It produces less and slower weight loss than other techniques such as bypass or gastric sleeve.
- Requires a high rate of patient collaboration and lifelong monitoring for band adjustment
BALÓN INTRAGÁSTRICO
Tratamiento endoscópico para la reducción de peso
El balón intragástrico consiste en la introducción de un globo de silicona en el estómago mediante una técnica endoscópica (por la boca). Este globo se infla con suero salino hasta alcanzar un volumen de 400 –700 cc.
Tiempo medio de intervención: 15 minutos.
Se realiza con sedación.
Tiempo de hospitalización: ambulatorio.
Duración del “postoperatorio”: 1 –3 días.
Para qué tipo de pacientes se indica: personas con IMC >28.
VENTAJAS:
- No es necesaria la cirugía.
- Más probabilidad de éxito que con una dieta.
- Se realiza seguimiento durante un año para intentar corregir los malos hábitos.
- La reeducación es la base del éxito a largo plazo.
- No es necesario el uso de medicamentos.
- Puede repetirse varias veces.
INCONVENIENTES:
- El balón solo puede permanecer 6 meses en el estómago.
- Provoca náuseas las primeras horas.
- Si no se consigue modificar los hábitos, el paciente puede recuperar el peso perdido con facilidad.
