الفهرس 
ANATOMY OF THE STOMACHOnly 14 pages are availabe for public view
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Abstract
CONCLUSION
Surgical treatment of morbid obesity is no longer considered out of the main stream of general surgery. It is now a component of most surgical residents‘ training programs and currently represents the fastest Growing area of general surgery. Patient demand for the procedure has vastly increased at present, surgeons Operate annually on less than 2% of eligible patients who would benefit from Bariatric surgery. This Research has discussed all aspects of the performance of bariatric surgery in current surgical practice, including the most commonly performed current procedures. The disease process of morbid obesity is, unfortunately, incompletely understood but rapidly increasing in prevalence. At present, surgical therapy is the only effective treatment of morbid obesity. Obesity has become major health problem in both developed and developing nations, because of its high prevalence and causal relation- ship with serious medical and psychological complications (Sugerman, 2001).
Little is known about the etiology of obesity. There are probably spectrum of different kinds of disorders as genetic, environmental or both which increase intake, decrease expenditure of an obese individual (Pi-Sunyer, 1996). Obesity may be defined as increase number and size of fat cells which lead to excess of body fat that frequently results in significant impairment of health (Myers, 1995). Physical examination including measurement of weight and height is usually sufficient to diagnose obesity.The earlier method, involved tables of desirable weights at various heights. These tables based on illness and health rates. But currently, body mass index (BMI) is preferred formula that more closely correlates with body fat and metabolic complications of obesity. BMI is
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calculated as weight (W) in kg divided the square height (H) in meters = W/H2.According to BMI morbid obesity is approximately equivalent to > 40kg/m2 or 45kg above desirable weight (Gazet, 1996). The risk of metabolic complications and comorbid factors is related to both BMI and waist circumference specifically the risks of hypertension (3.0 times higher) and risks of diabetes mellitus (2.9 Times higher) and risk of atherosclerosis (1.5 times higher) (Warner and Garret, 1999).
Reduction body weight can be achieved through medical treatment and/or surgical treatment. Medical treatment including therapeutic management and conservative management which including behavioral modification, dietary modification, exercise programs and appetite suppressant. All of these measures have not been effective in patient with marked obesity. Published scientific reports document that non operative methods are rarely successful especially in long term weight loss in severely obese adult only about 10% weight loss. It has been shown that majority of patients regain all weight loss over next 5 years (American society for Bariatric Surgery, 2001).
Surgical treatment is only proven method to achieve long term weight control for morbid obesity about 30%. (Sugerman, 2001).
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There are 2 types of surgical management of obesity:
Restrictive, to reduce food intake (e.g. vertical banded gastroplasty, gastric banding, and laparoscopic gastric banding (Lap. Band))
Combined restrictive and malabsorptive to reduce food absorption by gastric bypass in which stomach is connected to jejunum or ileum of small intestine bypassing the duodenum e.g. (jejunal bypass & biliary diversion) (Bethesda, 2005).
The surgical modalities used in bariatric surgery, initially used in treating other condition, and these modalities were found to cause weight loss postoperatively as a side effect Trzebicky was the first to note nutritional in-balances in dogs following proximal and distal small bowel resection. Von Eiselberg reported weight loss in humans after gastric or small intestinal resection in 1895. Kremen demonstrated a decade later that resection of 50% of the distal small intestine produced a profound interference with fat absorption and weight loss, whereas resection of 50% to 70% of proximal small intestine resulted in normal nutritional balance. The first clinical trial of obesity surgery was performed by Payne and Dewind in 1955, but their end-to-side jejunal -transverse colon intestinal bypass procedure was restricted because of severe metabolic disturbances, liver failure, and protein-calorie malnutrition (Brunicardi et al, 2001).
In the late 1960s, a gastric bypass procedure was introduced by Mason and Ito that achieved weight loss through the production of a small gastric pouch that empties into a loop gastro-jejunostomy. Later, the transverse pouch was changed to a vertical lesser curvature pouch. Gastric pouch problems such as marginal ulcers and staple-line
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disruption led to the development of a transected gastric pouch (Schauer and Schirmer, 2005).
In 1981, Scopinaro and coworkers reported initial results with bilio-pancreatic bypass, which combines a subtotal gastrectormy with a Roux-en-Y gastro-ileal anastomosis and a jejuno-ileal anastomosis 50 cm proximal to the ileo-cecal valve to allow absorption of nutrients in the distal 50-cm common channel. Results reported by Scopinaro and coworkers have been excellent, with reduction in excess weight of nearly 75%. Marcean and associates modified the technique of Scopinaro and developed the bilio-pancreatic diversion with a duodenal switch (Brunicardi et al, 2001).
In the late 1970s, gastric banding was also introduced which used various banding materials to create a small upper gastric pouch. This is the least invasive bariatric procedure though complications like band migration and slippage (Schauer ad Schirmer, 2005).
In an attempt to restrict food intake, horizontal gastroplasty was developed. Its failure was due to proximal fundal pouch dilatation, outlet dilatation and staple - line breakdown. In 1980, Mason began performing the vertical banded gastroplasty (VBG). It consists of a stapled vertical gastric channel along the lesser curvature, extending to the angle of His. Sufficient weight loss has been generally achieved (Schauer and Schirmer, 2005).
Following the introduction and rapid acceptance of laparoscopic cholecystectomy, surgeons began performing laparoscopic bariatric procedures. Chelala and Belachew and their colleagues reported performing laparoscopic adjustable gastric banding in 1992. Laparoscopic Roux-en-Y gastric bypass and laparoscopic vertical banded
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gastroplasty were reported in 1993 by Witt grove (Brunicardi et al, 2001).
In the late 1960s, a gastric bypass procedure was introduced by Mason and Ito .In this procedure, the jejunal loop was brought up to the proximal stomach often under tension which increased the likelihood of an anastomotic leak, which would be catastrophic because of agrees of copious caustic gastro-duodeno-bilio-pancreatic secretions .Thus, the configuration was changed to a Roux-en-Y (which decreased the stretch on the mesentery and eliminated bile reflux (Deitel, 2002).
With the availability of surgical staples, the ability to create a partition across the upper stomach using staples was increased without the need to remove any part of the stomach (Sugerman, 1997).
Some workers partitioned the stomach by application of a linear stapler. But staple-line disruption and development of an ulcer on the jejunal side of the anastomosis (marginal ulcer) (Sugerman and De Maria, 2003).
Thus, many surgeons divide the stomach, leaving an upper tiny pouch and the large lower gastric segment. Patients generally maintain a long-term loss of 50% of excess body weight. In order to increase the rapidity of weight loss, the bilio-pancratic or Roux limbs were moved more distally (Deitel, 2002).
But with the far distal Roux-en-Y configuration, excess protein malabsorption and hypo-albuminemia may be a complication (Rhode and Mac Lean, 2000).
Complications of Bariatric surgeries, the procedures described are associated with complications that can occur with any intra-abdominal operation, such as pulmonary embolism. However, each operation has
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unique complications and different rates of Occurrence of some common complications seen after any abdominal operation (Sugerman and De Maria, 2003).
A number of reports have shown laparoscopic procedures to be associated with less respiratory, surgical wound, and thrombotic complications. The benefits promoted for Laparoscopic surgeries go beyond the cosmetic effects and actually influence postoperative complication rates, which makes the laparoscopic technique my preferred approach for almost every patient, including remedial operations (Rhode and Mac Lean, 2000).