الفهرس 
Prevalence of obesityOnly 14 pages are availabe for public view
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Abstract
Obesity is the most common form of malnutrition in developed countries. Prevalence of obesity is rising to an epidemic proportion around the world.
Obesity increases the risk of medical illness and premature death and thus imposes an enormous economic burden on the health care system.
Many morbidities are underlying causes for the earlier mortality associated with obesity including coronary artery disease, hypertension, impaired cardiac function, adult onset diabetes mellitus, venous stasis and hypercoagulability leading to an increased risk of pulmonary embolism.
The most widely accepted measure of obesity is the body mass index (BMI) which equals patient weight in kilograms divided by the square of his or her height in meters, a normal BMI ranges from 18.5-24.5 kg/m2 , overweight equals BMI between 25-29.5 kg/m2 , obesity equals BMI 30 kg/m2 or higher.
Treatment of morbid obesity should begin with simple lifestyle changes, including moderation of diet and initiation of regular exercise such as walking and pharmacological management.
However, because the only effective treatment for morbid obesity is bariatric surgery, these are the initial steps is to be taken in preparation for the more definitive, albeit invasive, treatment. Bariatric surgery offers the only means of delivering sustained weight loss.
Bariatric surgical techniques are divided into two groups: malabsorptive and restrictive procedures. In general, restrictive procedures are simpler to perform and are accompanied by less procedural complications than malabsorptive procedures.
The original purely malabsorptive procedures such as jejuno-ileal bypass are no longer performed due to their unacceptably high late complication rate. They have been replaced by restrictive or combined operations. Open surgery has largely been replaced by a laparoscopic approach.
The SG, also called greater-curvature, vertical, parietal as well as longitudinal gastrectomy is a new tool in the armamentarium of all bariatric surgeons.
Two predecessors of the sleeve gastrectomy had restriction of overall gastric volume as their goal: gastric plication, as described by Tretbar et al., and gastric wrapping, as described by Wilkinson and Peloso.
The use of SG extended worldwide due to its major potential benefits, including its technical simplicity and significant weight-loss outcomes with low rate of complications and mortality.
As patients experience excellent weight loss after SG alone so multiple recent reports have documented SG as single therapy in treatment of morbid obesity. It is also used as a revisional option for patients with failed bariatric procedures such as vertical banded gastroplasty, silastic ring vertical gastroplasty, laparoscopic adjustable gastric banding and previous sleeve Gastrectomy.
Laparoscopic sleeve gastrectomy (LSG), in creating a narrow tube-like stomach, is a restrictive procedure designed to decrease appetite by reducing the ability of the stomach to distend and producing the sensation of fullness with minimal oral intake.
As it consists of creating a maximal gastric reservoir or tube of 150 to 200 ml but, as an isolated procedure, the gastric pouch size usually varies from 60 to 120 ml.
By resecting 80-90% of the stomach and leaving behind only a sleeve restricts the amount of the food that can be ingested and gives the sensation of fullness with minimal oral intake.
The concept that the SG is a “purely” restrictive procedure is gradually changing. The significant reduction of large parts of the ghrelin-producing stomach mass and changes in gastric emptying may account for its superiority to other restrictive procedures in terms of weight loss and sustained decrease of hunger.
Complete removal of the greater curvature and fundus produces lower levels of ghrelin, which enhances the results on the control of food intake.
Following SG, gastric emptying is faster as compared to the preoperative state, and symptoms of vomiting after eating are either absent or very mild.
Surgeons should understand the complications associated with LSG and an approach for dealing with them. Early postoperative complications following LSG that need to be identified urgently include bleeding, staple line leak and development of an abscess. Delayed complications include strictures, nutritional deficiencies and gastroesophageal reflux disease.
The American Society for Metabolic and Bariatric Surgery (ASMBS) Clinical Issues Committee statement quotes an overall complication rate for LSG of 0–24 % and a mortality rate of 0.39 %.
Of the dreaded complications after LSG is a gastric leak, most commonly occurring at the upper staple line near the gastroesophageal junction. This complication may lead to abdominal sepsis, which might progress either to chronic gastric fistula or to multi-organ failure and patient demise.
Many surgeons have used different methods for staple line reinforcement in lapa¬roscopic sleeve gastrectomy operations. Although the importance of staple line reinforcement is described in literature, it is still controversial.
Many possibilities of leak treatment include oversewing, drainage (CT or open, two with NJ feeding and six with TPN), and endoscopic clippings. Persisting fistulas were treated with fibrin glue, five with stents, one with Roux loop, and one with total Gastrectomy.
Bleeding can occur from gastric blood vessels during dissection of the greater curve of the stomach. Most bleeding problems associated with LSG occur from the staple line after transection of the stomach.
Postoperative bleeding should only occur at the staple line or from divided short gastric vessels and other divided vessels.
About 40 % of bariatric patients have existing gastro-esophageal reflux disease (GERD), esophagitis, and/or hiatal hernias, and are at risk for an exacerbation of their reflux if it is not addressed at the time of surgery. SG may induce or exacerbate GERD in patients, requiring proton pump inhibitor (PPI) therapy. Coexisting hiatus hernia should be assessed and repaired during SG.
One of the infrequent complications of LSG is the stricture of the remnant stomach. Possible causes are ischemia of the pouch, retraction due to scarring, fistula, and inclusion of the esophago-gastric junction in the stapling line. Treatment options include endoscopic covered stent placement, laparoscopic seromyotomy, Roux -en -Y gastric bypass, resecting the remaining stomach and building the anastomosis.
SG may be effective treatment for morbid obesity up to 2 years after surgery; however it has been evident that a sub-group of patients regain weight. Dilatation may be the first cause of failure.
Nutritional deficits after LSG are rarely encountered. Regular determination of laboratory parameters should be performed 6 months after the operation and semiannually thereafter; if the patient’s weight stabilizes, laboratory parameters should be determined once a year.
The morbidly obese are at higher risk for development of deep venous thrombosis, and they have little cardiopulmonary reserve if a pulmonary embolus occurs. Pulmonary embolism is an established cause of mortality after bariatric surgery.
Perioperative subcutaneous heparin administration, early ambulation, graduated compression stockings (GCS), intermittent compression devices (ICDs) in combination with enoxaparin (LMWH) achieves a low incidence of venous thrombosis complications following LSG.
Then as more surgeons adopt the LSG as a primary procedure for weight loss, more cases of surgical management of failure will be reported, helping us understand the reasons and options for revisional or onversional surgery in this patient population.
The decision to proceed expeditiously to convert a sleeve gastrectomy to another operation must be tempered by evaluating patients’ adherence to post-operative follow up and expectations for weight loss.
When the issues of nutritional management have been adequately addressed and technical problems of inadequate fundal resection have been ruled out, the decision to revise to other options can be assessed. Revision options include Re-sleeve, RYGB, BPD-DS or the new technique; SADI-s.