BOTOX

BOTOX Cosmetic is a prescription medicine that is injected into muscles and used to improve the look of moderate-to-severe frown lines between the brows in people 18 to 65 years of age for a short period of time (temporary).

BOTOX Cosmetic is administered by a healthcare professional as a simple, nonsurgical treatment that is injected directly into the muscles between the brows. It works by blocking nerve impulses to the injected muscles. This reduces muscle activity that causes moderate to severe lines to form between the brows.

Facts about BOTOX Cosmetic:

• BOTOX Cosmetic, introduced in 2002, is the first botulinum toxin to be approved by the FDA to temporarily treat moderate to severe glabellar lines between the brows.

• With real, noticeable results, no surgery and no recovery time, there are many reasons why BOTOX Cosmetic has been chosen by millions of women and their doctors.

• Approximately 11.8 million BOTOX Cosmetic procedures have been administered in the United States since 2002.

• 92% of 303 patients surveyed were satisfied with the results of their BOTOX Cosmetic experience

What is the most important information I should know about BOTOX?
BOTOX cosmetic may cause serious side effects that can be life threatening. Call your doctor or get medical help right away if you have any of these problems after treatment with BOTOX:

• Problems swallowing, speaking, or breathing. These problems can happen hours to weeks after an injection of BOTOX usually because the muscles that you use to breathe and swallow can become weak after the injection. Death can happen as a complication if you have severe problems with swallowing or breathing after treatment with BOTOX.

• People with certain breathing problems may need to use muscles in their neck to help them breathe. These patients may be at greater risk for serious breathing problems with BOTOX.

• Swallowing problems may last for several months. People who cannot swallow well may need a feeding tube to receive food and water. If swallowing problems are severe, food or liquids may go into your lungs. People who already have swallowing or breathing problems before receiving BOTOX have the highest risk of getting these problems.

• Spread of toxin effects. In some cases, the effect of botulinum toxin may affect areas of the body away from the injection site and cause symptoms of a serious condition called botulism.

The symptoms of botulism include:

• loss of strength and muscle weakness all over the body
• double vision
• blurred vision and drooping eyelids
• hoarseness or change or loss of voice (dysphonia)
• trouble saying words clearly (dysarthria)
• loss of bladder control
• trouble breathing
• trouble swallowing

These symptoms can happen hours to weeks after you receive an injection of BOTOX.
These problems could make it unsafe for you to drive a car or do other dangerous activities.
There has not been a confirmed serious case of spread of toxin effect away from the injection site when BOTOX has been used at the recommended dose to treat severe underarm sweating, blepharospasm, or strabismus, or when BOTOX has been used at the recommended dose to treat frown lines.

Why Does Skin Age?

 

Aging skin and wrinkles result from a combination of many factors. It’s not just about cellular changes, collagen depletion, hormone loss, or damage caused by free radicals. The 11s – those vertical lines that appear between your brows – result from muscle contractions. When you concentrate, squint, or frown, the muscles between your brows contract, causing your skin to furrow and fold. After years of frequent contraction, those wrinkles can linger even after the muscles are at rest.

 

 

BOTOX Cosmetic for Men

• BOTOX Cosmetic is certainly not just for women. If you are a man and think it's time to do something about those moderate to severe glabellar lines between your brows, talk to your doctor about whether BOTOX® Cosmetic is right for you.
• 6% of total BOTOX Cosmetic procedures are performed on males (313,714 procedures)
• BOTOX Cosmetic is the most popular minimally invasive physician administered aesthetic procedure for males (314,000 procedures)

http://www.botoxcosmetic.com/

Gastric Band Patient Interview

http://www.bmihealthcare.co.uk/treatment/treatmentgroup/description?p_treatment_group_id=37&p_treatment_group_page_id=601&in_page=Susannah's%20story&p_parent_page_id=29

Susannah's story

Every year thousands and thousands of women start a new diet determined that this time they will slim down and stay slim! Susannah before (left) and after the procedure (right) But for many it all ends in tears as weeks, sometimes months, of determined dieting ends in yet another failure and the pounds steadily pile back on. Susannah before the gastric band procedure “Some people just need more help than others,” says Nottinghamshire financial adviser Susannah Martin. “In the end I decided that the only way I was going to succeed was by having surgery. I knew that a gastric band was my last chance of winning my battle against my weight. Now, after shedding an amazing 10 stone, after having a gastric band fitted at BMI Park Hospital in Arnold, Susannah is determined that women choosing the surgery option are not seen as ‘taking the easy way out’. “This was not the easy option,” said 39-year-old Susannah. “There can’t be a diet anywhere that I haven’t tried and, when I say tried, I mean really tried. “I would lose a couple of stone but then I would just put it back on again. It was heart-breaking. It is only people who have never had weight problems who don’t see how hard it is for people who really try to lose weight and simply continue to fail. “I needed to stop the vicious circle and take control over food and the hold it had over my life. I’m not sure which the turning point was - not fitting in an aeroplane seat, ordering a take away and pretending it was to feed a family, not being able to walk up one set of stairs without resting or just not wanting to feel invisible anymore.” Susannah after the gastric band procedure But whatever pressure she had put on herself to lose weight, Susannah still didn’t rush her decision. Following some internet research, she arranged to meet Marc Abraham, a dietician who works with bariatric consultant Ian Beckingham at BMI Park Hospital. “It was a very important meeting. Marc also made it very clear that the band is a tool to aid weight loss – not a miracle cure! The band doesn’t stop you craving or even eating chocolate or drinking wine but it does restrict the amount of food you can to eat by making you feel fuller quicker and for longer. “That was perfect for me as it was snacks and savouries that had been my main problem. I feel a little embarrassed about it now but at one stage I could easily eat a full French stick with cheese in one sitting,” she explained. Susannah then had several meetings with both Marc and Mr Beckingham to take her though how she could make the gastric band really work for her. “Once I got the hang of eating the right foods I found that I was actually eating a much healthier diet and certainly didn’t feel I was depriving myself. “I ate what I wanted but kept my portion size smaller and bulked up on vegetables – and I always served my meals on a small plate,” she explained. Susannah’s success also received praise from surgeon Mr Beckingham. He said: “Having the band fitted is only the beginning. In some ways the hard work starts after the operation. “Susannah has had to totally change her diet and her relationship with food. For someone who has struggled with their weight for so many years this is no easy thing.” And as she starts planning her next holiday on the beach, Susannah, who lives in Arnold with husband Jim, a company director, explains how her new look has changed her life. “The days of sitting in the car before a social gathering worrying if I’m going to be the fattest person there or whether I’ll fit in the chairs or make it up the stairs are gone – I now get out there and get on with all the great things life has to offer.” “I also have a personal trainer twice a week and I’m healthier than I have ever been.” “And it isn’t just me that’s a lot lighter – my bank balance has taken a bit of a battering as I am now enjoying shopping for clothes! Don’t tell anyone but on my last holiday I had a different bikini for every day at the beach!” As for husband Jim, he is delighted with Susannah’s success and has supported her every step of the way. “Jim never put pressure on me to lose weight but he did worry about my health. When I decided on a gastric band he was fully behind my decision and has been there for me every step of the way,” she said. “I can’t thank Mr Beckingham, Marc and their team enough. I honestly feel they have given me my life back. Neither said that a gastric band was an easy fix but with their support and my determination it has been a tremendous success.”

Skin Scarring

Each year in the developed world 100 million patients acquire scars, some of which cause considerable problems, as a result of 55 million elective operations and 25 million operations after trauma. There are an estimated 11 million keloid scars and four million burn scars, 70% of which occur in children. Global figures are unknown but doubtless much higher. People with abnormal skin scarring may face physical, aesthetic, psychological, and social consequences that may be associated with substantial emotional and financial costs. This article reviews the spectrum of abnormal scar types, a range of problems associated with scarring, and provides advice on assessment, treatment, and new therapeutic developments.

Method

This article is based on our scientific and clinical experiences in dermal scarring and on selected articles in recent issues of journals on plastic and reconstructive surgery, dermatology, and wound healing. Key terms included keloid disease, hypertrophic scars, and contractures, plus diagnosis, prevention, and treatment.

Why do we scar?

Scars are the end point of the normal continuum of mammalian tissue repair. The ideal end point would be total regeneration, with the new tissue having the same structural, aesthetic, and functional attributes as the original uninjured skin. Scarless skin healing occurs in early mammalian embryos, and complete regeneration occurs in lower vertebrates, such as salamanders, and invertebrates.

What, if any, are the advantages of scarring, and why do we scar? We hypothesise that wound healing is evolutionarily optimised for speed of healing under dirty conditions, where a multiply redundant, compensating, rapid inflammatory response with overlapping cytokine and inflammatory cascades allows the wound to heal quickly to prevent infection and future wound breakdown. A scar may therefore be the price we pay for evolutionary survival after wounding.

Skin scarring: the clinical problem

Scars arise after almost every dermal injury— rare exceptions include tattoos, superficial scratches, and hopefully venepunctures. Scars are often considered trivial, but they can be disfiguring and aesthetically unpleasant and cause severe itching, tenderness, pain, sleep disturbance, anxiety, depression, and disruption of daily activities. Other psychosocial sequelae include development of post-traumatic stress reactions, loss of self esteem, and stigmatisation, leading to diminished quality of life. Physical deformity as a result of skin scar contractures can be disabling. Many scars take two to three years to pale and mature.

In spite of media suggestions to the contrary, scars cannot yet be made to disappear. Many patients arrive at plastic surgery clinics with unrealistic expectations. Clinical judgment is required when considering treatment, balancing the potential benefits of the various treatments available against the likelihood of a poor response and possible iatrogenic complications. The evidence base for the use of many current treatments is poor, and some may have only placebo benefit.

There is considerable quantitative and qualitative variation in scarring potential between individuals and even within the same individual: scars are normally worst in the deltoid and sternal regions and best in intraoral tissues, reflecting biological and mechanical differences between such sites. Injury in adolescents and young adults normally results in worse scarring than does similar injury in elderly people, reflecting the altered inflammatory and cytokine profile of old wounds, which in many respects resemble those of the early embryo. Individuals with pigmented skin are more prone to severe skin scarring than white people.

Responses

5 June 2003: Preventation of scarring

Retired Registered Nurse

The following method reduces the incidence of unsightly scarring, especially on the face.
I have had numerous skin cancers removed from my face by curretting, liquid nitrogen and plastic surgery. My skin is prone to scarring even from mosquito bites or minor abrasions. This method has left me with little or no scarring on my face.

1. Clean the wound gently with witch hazel; never use soap or alcohol. Soap is alkaline and destroys the natural acid mantle of the skin. Alcohol toughens the skin. Use a facial tissue, clean cotton cloth or gauze; avoid anything with the potential to leave lint in the wound. Blot, don't wipe.

2. Apply Polysporin or Bacitracin ointment to the pad of a bandaid before applying to affected area. Once daily treatment is sufficient as long as there is no sign of infection.

3. As soon as the raw wound has filled in with normal skin tissue, apply Vitamin E 400 IU to the area once or twice a day and cover with a bandaid to avoid accidental scratching. Use a sterilized, glass-headed pin to poke a hole in the Vitamin E capsule, squeeze a little Vitamin E on the wound and replace the pin in the hole in the capsule.

13th January 2003: IS BOTULINUM TOXIN [BOTOX] OUR NEXT WEAPON TO COMBAT FACIAL SCARRING?

Surgeon

The excellent review by Bayat et al has once again highlighted the many variables which can affect the severity of scarring, including the size, depth, and location of the wound, the blood supply to the area, the thickness and colour of the skin, and the direction of the scar.

Recently, there are several reports in the literature to suggest that immediate injection of botulinum toxin into the muscles underlying a wound can improve the cosmetic outcome of cutaneous scar. This is because one of the major factors in determining the final cosmetic appearance of a cutaneous scar is the tension acting on the wound edges during the healing phase. By injecting through the skin into the underlying muscle, botulinum toxin paralyzes the muscles and relieves the tension. As a result of the chemo-denervation, more aesthetic scar can thus be achieved. Using primate models, Gassner et al. at the Mayo Clinic has shown that surgical wounds that had been immobilized with botulinum toxin were rated as significantly better in appearance than the control wounds.

This adds to the list of wide variety of clinical applications of botulinum toxin, and may be our next weapon in combating facial scarring.

References

1. Bayat A, McGrouther DA, Ferguson MWJ. Skin scarring. BMJ 2003; 326: 88-92 ( 11 January ).
2. Sherris DA, Gassner HG. Botulinum toxin to minimize facial scarring. Facial Plast Surg 2002; 18: 35-39.
3. Wieder JM, Moy RL. Understanding botulinum toxin. Surgical anatomy of the frown, forehead, and periocular region. Dermatol Surg 1998; 24: 1172-1174.
4. Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds with botulinum toxin A improves cosmetic outcome in primates. Plast Reconstr Surg 2000; 105: 1948-1953; discussion 1954-1955.

Weight Loss Surgery

http://www.bmj.com/content/339/bmj.b3402

Clinical Review

Surgery for obesity in adulthood

BMJ2009;339doi: http://dx.doi.org/10.1136/bmj.b3402(Published 22 September 2009)

Cite this as:BMJ2009;339:b3402

 

 

The relation between morbid obesity, serious morbidity, and early mortality is well known (fig 1⇓ and table 1⇓). A recent systematic review of over 890 000 participants found that each 5 point increase in body mass index (kg/m²) over 25 was associated with a 30% increase in overall mortality. Conservative approaches to managing obesity (dieting, exercise, and cognitive behavioural therapy) achieve long term weight loss in only a small minority of highly motivated individuals. Weight loss drugs such as orlistat and sibutramine produce modest weight loss and can be prescribed only for a short time. Bariatric (weight loss) surgery is the only treatment that randomised controlled trials have shown to produce effective long term weight loss.This review provides an overview of surgical procedures for adult obesity, including results, follow-up, and complications of surgery. It focuses mainly on practice in the United Kingdom.

 

 

Fig 1 Proportion of people with a major comorbidity, by degree of obesity.

 

  

 Table 1 : Risk of developing diseases associated with obesity. Data adapted from guidance from the National Institute for Health and Clinical Excellence

Who should be considered for weight loss surgery?

Categories of obesity are classified according to body mass index (weight(kg)/(height (m)²)) (table 2⇓). Recommendations on the management of obesity in adults are provided in guidelines published by the National Institute for Health and Clinical Excellence (NICE).

 

 

Table 2 : Classification of obesity based on body mass index thresholds

 

The NICE guidance states that surgical treatment is beneficial for people with obesity if they have a body mass index of ≥40, or between 35 and 40 if they have a coexisting disease that could be improved by weight loss (such as type 2 diabetes, high blood pressure, or sleep apnoea). All non-surgical methods should have failed to achieve or maintain clinically beneficial weight loss for at least six months. Surgery is appropriate only if the patient will receive specialist management, is fit for general anaesthesia, and is committed to long term follow-up.1 Surgery can be considered as a first line option in patients with a body mass index >50. Evidence from the United States and Australia shows the benefit of bariatric surgery in patients with lower body mass indices (30 to 35). The NICE criteria do not specify an age limit for surgery, although general fitness for surgery is likely to play a major part in the selection of older patients.

What procedure should I follow when referring a patient for surgery?

In our own bariatric surgery practice we recommend that certain steps be taken as part of the assessment process, as illustrated in the treatment algorithm (fig 2⇓).

 

 

 

In the United Kingdom, funding for bariatric surgery must be applied for on an individual patient basis from the primary care trust, which must apply the NICE guidelines in its selection process. Thus it is important to ensure that patients meet the criteria for surgical intervention, not only in terms of their body mass index and associated comorbidities but also in terms of previous efforts at losing weight through dieting, exercise, and medical treatment. The exact process for applying for funding and the particular information required by the primary care trust will vary between trusts. Some trusts allocate funding before surgical referral, whereas in others funding can only be applied for by the surgical service after the cycle of assessment of the patient has been completed. The primary care trust should be informed that the patient is being referred for consideration of surgery.

Helpful referral information from the general practitioner includes:

• The patient’s weight and body mass index (and trends in these two variables), as well as weight loss achieved through non-surgical means (for most patients this means dieting, exercise, and medical treatment)
• Presence or absence of associated comorbidities that could be improved by surgery or affect the patient’s fitness for a particular surgical procedure
• Details of psychiatric, psychological, and social history, including any history of eating disorders and their treatment.

Some patients can find the changes in diet and lifestyle after surgery difficult to come to terms with and require a degree of psychological self reliance and resilience, in addition to support from professionals and family. A history of psychiatric illness is not a contraindication to surgery. Although not essential, it is helpful to record any potential causes for obesity as well as dietary habits and a history of physical exercise and to identify reasons for failure of conservative measures to control weight. The patient must be committed to lifelong follow-up. Bariatric surgery is a tertiary referral practice involving a multidisciplinary team approach (box 1).

 

 

What surgical procedures are available?

The most commonly performed procedures are gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion (table 3⇓). Vertical banded gastroplasty (stomach stapling) is rarely, if ever, performed now because of its high long term failure rate.

 

 

Data for mortality and weight loss for gastric banding and Roux-en-Y gastric bypass were derived from a systematic review on outcomes after bariatric surgery.Mortality and morbidity data for sleeve gastrectomy was obtained from a combination of Spanish and German National Registries.

 

 

In gastric banding (fig 3⇓) a band is placed around the upper part of the stomach. It is connected to a port under the skin into which saline can be injected or withdrawn. This allows the band to be inflated and deflated. The aim of increasing restriction is to reduce hunger and provide a feeling of satiety after eating a small meal.

 

 

Fig 3 : Gastric banding. Top: Gastric band around the upper stomach. Bottom: The relative positions of the gastric band and port. The port is attached to the anterior abdominal wall and accessed percutaneously with a special (Huber) needle, which has its lumen placed on the side to avoid coring out the silastic seal of the port and thus avoids a leak

 

In sleeve gastrectomy (fig 4 ⇓) most of the body and all of the fundus of the stomach are resected to leave a long narrow tube of stomach.

 

 

Fig 4 Sleeve gastrectomy, showing the portion of stomach removed (light blue shading)

 

In a Roux-en-Y gastric bypass a small gastric pouch is formed by division of the upper stomach, on to which the jejunum is joined, so that food bypasses the stomach and upper small bowel (fig 5⇓).

 

 

Fig 5 Laparoscopic Roux-en-Y gastric bypass. Top: The gastric pouch is made from the upper stomach. The upper small bowel is divided 80 cm below the duodenojejunal flexure. The small bowel below this (blue) will become the alimentary limb and the small bowel above this will become the biliopancreatic limb (purple). Bottom: The bowel has been rejoined

 

Two surgical procedures (Scopinaro biliopancreatic diversion and biliopancreatic diversion with duodenal switch) function by bypassing most of the small bowel, leaving a small segment through which nutrients can be absorbed. Operative details for these two procedures differ but the common themes are that food passes through a segment of small bowel about 250 cm long and that a shorter segment of this (50-150 cm) receives both food and digestive juices (fig 6⇓).

 

 

Fig 6 Laparoscopic biliopancreatic diversion with duodenal switch. Left: A sleeve gastrectomy has already been performed. The small bowel has been divided just beyond the pyloris (at A) and 250 cm from the ileocaecal valve (between B and C). Right: The configuration once the bowel is rejoined

How effective is weight loss surgery?

Surgery versus conventional treatment

Results of surgery are evaluated by change in weight or body mass index, or percentage loss of excess body weight and by resolution or improvement in comorbidities. Excess body weight is calculated by subtracting the ideal weight of a patient, assuming a body mass index of 25, from his or her actual weight.

Surgery is more effective at ensuring weight loss and controlling comorbidities than medical treatment. Published data from the prospective, randomised controlled Swedish Obese Subjects Study, show the benefits of gastric surgery in moderately obese and morbidly obese patients compared with conventional treatment. Greater weight loss occurred after gastric surgery (gastric bypass 32%, vertical banded gastroplasty 25%, and gastric banding 20%) than with conventional treatment (2%). These findings accord with an Australian prospective randomised study of gastric banding versus conventional treatment in patients with mild to moderate obesity. At two years, the surgical group had greater weight loss, with a mean of 21.6% of initial weight lost and 87.2% of excess weight lost, whereas the non-surgical group had a loss of 5.5% of initial weight and 21.8% of excess weight.

Results of surgery

A systematic review of bariatric surgery published in 2006 examined 43 studies. The mean percentage excess weight loss for Roux-en-Y gastric bypass was higher than for laparoscopic adjustable gastric banding at one and two years (67% v 42% and 67% v 53% respectively). The excess weight loss for laparoscopic adjustable gastric banding at 8 years was 59% and for Roux-en-Y gastric bypass at 10 years was 52%. These differences were not statistically significant.

A recent series involving 1140 patients undergoing gastric banding showed an excess weight loss of 59% at 36 months, and a further series involving 591 patients, with a 10 year follow-up period, showed a loss of excess body weight of 83% at 10 years. However, in some series, gastric banding is also associated with high long term complication and failure rates. In one report 128 (34%) of 380 patients had their bands removed and only 25% (63) of the remaining 252 patients achieved >50% excess weight loss. In another report 105 (33%) of 317 patients developed late complications and 22% (69) required major revision surgery. At seven years the band failure rate was 37%. In the patients who still had the band in place, the mean excess weight loss at five years (58.5%) was consistent with findings in other series. When these data were analysed on the basis of “intention to treat” and the results of failed band surgeries included, the percentage excess weight loss at five years was reduced to about 42%. The disparity in outcomes form laparoscopic adjustable banding has been apportioned to surgical technique, although older age, binge eating disorder, and sweet-eating behaviour also predict a poor outcome.

A large prospective study involving 1500 patients having a Roux-en-Y gastric bypass reported an excess body weight loss of 69% at one and two years and 62% at three years. Compared with gastric banding, Roux-en-Y gastric bypass surgery provides greater and more consistent weight loss, and fewer patients require repeat surgery for complications. A prospective randomised trial comparing sleeve gastrectomy with gastric banding found that three years after surgery a greater reduction in body mass index was achieved with sleeve gastrectomy (median reduction in body mass index 27.7 (range 0-39) versus 18 (range 0-48). The long term results of sleeve gastrectomy are not yet available.

Weight loss is greater after biliopancreatic diversion with duodenal switch than after other bariatric procedures. However, it is a more complex procedure with significantly greater risks of protein energy malnutrition; micronutrient, mineral, and vitamin deficiencies; anaemia; osteopenia; and intractable diarrhoea. Despite its effectiveness in promoting weight loss and its ability to prevent the regain in weight seen four years after Roux-en-Y gastric bypass surgery, it is the least commonly performed bariatric procedure in the United Kingdom. This is possibly because it is only slightly better in promoting weight loss than Roux-en-Y gastric bypass, and protein energy malnutrition and vitamin and micronutrient deficiencies are common and can appear insidiously, making close follow-up essential.

Quality of life and resolution of comorbidities after surgery

A large cohort study showed that surgical intervention leads to considerable improvements in the management of obesity related comorbidities and heath related quality of life when compared to patients treated with diet alone. At two years, the incidence of hypertension is lower in patients who have had surgery (3%) than those receiving conventional treatment (10%). A systematic review and meta-analysis of the resolution of type 2 diabetes after bariatric surgery found a total remission rate of diabetes in 78% (associated with 55% excess weight loss) of patients and improvement in 87%. The relative effectiveness in resolving type 2 diabetes for gastric banding, gastroplasty, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch was 56.7% (excess weight loss 46.2%), 79.7% (55.5%), 80.3% (59.7%), and 95.1% (63.6%) respectively. The resolution of type 2 diabetes occurs immediately after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch, whereas with gastric banding resolution is dependent on weight loss. This may take several years, and diabetes will not resolve if the patient fails to lose weight. Resolution of type 2 diabetes after sleeve gastrectomy occurs immediately in some patients but does not occur for some time in others.

Bariatric surgery reduces mortality in patients with a body mass index >35. A recent longitudinal study found that the overall mortality of obese patients was 0.68% in the surgically treated group (vertical banded gastroplasty and Roux-en-Y gastric bypass) and 6.17% in obese patients who had not had bariatric surgery. The Swedish Obese Subjects Study found fewer deaths related to myocardial infarction and cancer in the surgically treated group, and Adams et al found a 40% reduction in mortality in surgically treated obese patients. Even when the risks of death associated with surgery are taken into account, the patients who have surgery are more likely to be alive one year after surgery than the patients who choose conservative treatment. The risk of death from all types of bariatric surgery is very low (0.28%; adjustable banding 0.05%, gastric bypass 0.5%).

What dietary guidelines should patients follow after surgery?

A detailed review of all aspects of bariatric surgery, including dietary requirements and deficiency states, has been compiled by the American Association for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and the Obesity Society. A more accessible document, written specifically for general practitioners can be found on the UK’s National Obesity Forum’s website (www.nationalobesityforum.org.uk/images/stories/documents/NOF-Medical-management.pdf). Box 2 outlines the principles of dietary advice after bariatric surgery.

 

 

 

The Roux-en-Y gastric bypass bypasses the upper small bowel and leads to the relative malabsorbtion of nutrients normally absorbed at this site. These nutrients are iron, calcium, and fat soluble vitamins (A, D, E, and K) as well as some micronutrients such as copper and zinc. In addition, vitamin B-12 does not mix with intrinsic factor as it normally would in the stomach and so its absorbtion in the terminal ileum is reduced. All patients should have regular blood tests to detect deficiency states and be given additional supplementation as indicated.

What complications of surgery might the generalist encounter in the medium to long term?

Mechanical problems with a gastric band include slippage, erosion of the band into the stomach, symmetrical dilatation of the gastric pouch, and fracture or disconnection of the tubing or displacement of the port.

Erosion of the band into the stomach often presents with a loss of restriction and weight regain but may present with mild to moderate pain. Slippage and symmetrical dilatation present with dysphagia. The diagnosis of erosion can be made on upper gastrointestinal endoscopy, and the eroded band can often be removed endoscopically. Slippage and symmetrical dilatation of the gastric pouch present with increased restriction and dysphagia, which may also be a feature of the band being too tight after inflation. The diagnosis of slippage or symmetrical dilatation can be made on a plain abdominal radiograph where the band can be seen to be lying horizontally and confirmed on a contrast swallow. The band should be deflated. If symptoms fail to resolve or recur after deflation or after reinflation then the gastric band should be removed or replaced. Occasionally, patients with slippage of the gastric band will present with acute, severe dysphagia and pain. These patients should be referred to the hospital as an emergency since gastric perforation and peritonitis may result.

Long term complications after gastric bypass are less frequent. Ulceration at the gastrojejunal anastomosis may lead to upper abdominal pain, and strictures may develop at this site. Fortunately, seven out of 10 strictures are amenable to dilatation. Occasionally, internal hernias, presenting as small bowel obstruction, may occur. Diagnosing the cause of small bowel obstruction can be difficult, and in contrast with the normal practice of watching and waiting, early laparoscopy is necessary for patients with such features. Other problems include dumping syndrome, which is best avoided by separating eating and drinking at meal times and by avoiding drinks with high sugar load. Protein energy malnutrition is uncommon.

The insidious development of malnutrition and deficiency states is a particular problem with biliopancreatic diversion. Sleeve gastrectomy may produce anaemia if there is ulceration of the stomach. Stenosis and substantial weight regain after dilatation of the sleeve may also occur.

 

Is weight loss surgery cost effective?

In 2002, data from a report prepared for a House of Commons select committee estimated that the direct costs of treating obesity within the National Health Service were between £45.8m (€52.1m; $74.5m) and £49m. The costs of treating the consequences of obesity were thought to amount to nearly £1075m a year. In 2005 over 871 000 prescription items were dispensed for the treatment of obesity compared with 127 000 in 1999.

The costs of bariatric surgery must be balanced against the cost of continuing medication, hospital visits, and treatment that would be required if the patient did not have surgery. A study from the United States estimated the investment in a bariatric procedure of between $17 000 and $26 000 could be recouped within 25 months if the procedures were laparoscopic and 53 months if open. Examination of the cost per quality adjusted life year (QALY) for bariatric surgery has shown that bariatric surgery is more cost effective than conservative treatment. Studies from European countries also suggest that bariatric surgery is more cost effective than conventional treatment.

A study of working practices found that significantly more patients worked after surgery than worked before (76% v 58%); significantly more patients worked longer hours than they did before (35.8 h v 30.1 h); and fewer patients claimed welfare benefits (19 respondents claimed 32 benefits before surgery and six claimed eight benefits after surgery). Additional benefits included the fact that patients felt less limited in the kind of work they could do and had less difficulty in performing tasks.

What are the possibilities for the future ?

Recent evidence from an unblinded randomised controlled trial suggests that weight loss surgery (adjustable band) may be more effective in treating type 2 diabetes than conventional treatment. Rather more controversial is the possibility that surgical intervention has similar benefits in type 2 diabetic patients with a body mass index <35. Future studies will aim to clarify the role of surgery in managing these patients. Similarly, further work is required to establish the benefits of bariatric procedures in those with mild to moderate obesity (body mass index 30-35), although an initial study suggests an advantage for surgery over conventional treatments.

A recent innovation is the management of obesity and type 2 diabetes is the Endobarrier. It is a device composed of a 60 cm impermeable sleeve which is placed endoscopically in the pylorus and which deploys into the duodenum and upper jejunum, excluding food from coming into contact with the mucosa. This produces a non surgical duodenojejunal bypass. In an initial study involving 12 patients who had the device in place for 12 weeks there was an average weight loss of 23.6% of excess weight with resolution of diabetes in all four diabetic patients. The Endobarrier is still undergoing clinical trials and not yet commercially available, so it remains to be seen what its role and efficacy will be in managing obesity and type 2 diabetes.

Ileal interposition grafting, in which a segment of terminal ileum is moved to a position in the upper jejunum, mimics the effects of diverting the flow of intestinal contents away from the upper small bowel and towards the distal small bowel, as seen in Roux-en-Y gastric bypass or biliopancreatic diversion. It may be combined with a sleeve gastrectomy. It may prove effective in managing type 2 diabetes, mild to moderate obesity, and hypercholesterolaemia.

 

 

 

Sources and selection criteria

We conducted a literature review using Medline and Embase databases and the Cochrane Library using the following headings: “Obesity”, “Bariatric”, and “Surgery”. Most studies were of class II-IV evidence, being derived from case series. We included randomised controlled trials where available and have identified them in the text. We also reviewed epidemiological data from the World Health Organization, hospital episode statistics, and the International Association for the Study of Obesity. We refer to our own experience from a UK specialist practice

 

 

A patient’s perspective

• As a child I was always bigger than other children but was crazy about swimming. As a teenager I loved walking. When I started nursing at age 18, I was a size 14.

• I soon put on weight. I had poor eating habits and had given up swimming and walking. Over the years as my weight gradually increased, I tried various diets and pills. I would lose 3-4 stone (19-25 kg) over several months then put it all back on and more. I knew about the health risks associated with morbid obesity, but the amount I needed to lose seemed insurmountable. When I reflected on my weight, I would feel quite low.

• While pregnant with my daughter, Grace, I was about 20 stone, and I was aware that any number of emergencies could occur because of my weight. But after Grace’s birth I ate whatever I liked because I was breast feeding. Soon the weight piled on again.

• I was determined that Grace would not miss out on life and forced myself to take her to mother and toddler groups and swimming. I became increasingly tired. At this point I was 24 stone. I became more desperate, more aware of how much I had to lose: a loving partner and a baby. I was aware that my life expectancy was going to be short. I researched laparoscopic gastric bypass surgery and spoke to a colleague who had had the procedure.

• At my initial consultation for surgery I weighed 150 kg and was a size 34. I was breathless and tired. Walking was difficult, and I was getting back and knee pain. After surgery, early in 2007, the first few months were difficult as I had to relearn how to eat and listen to my body.

• Life is completely different now. I am 12st 7lb and size 14. I no longer have breathing problems, tiredness, or pain. Friends and family have difficulty keeping up with me. As a family we are more active and health conscious. Our portion sizes are much smaller. I enjoy going into shops to buy clothes, and I love my partner telling me I look great

Questions for future research

• What is the role of bariatric surgery in managing patients with type 2 diabetes who have a body mass index <35?
• What is the role of bariatric surgery in treating obese patients with a body mass index 30-35?
• What is the role and efficacy of the Endobarrier device, an endoscopically inserted 60 cm impermeable sleeve that produces a non-surgical duodenojejunal bypass?
• What is the role of ileal interposition grafting in metabolic and bariatric surgery?

Additional educational resources

Resources for healthcare professionals

• The American Society for Metabolic and Bariatric Surgery (www.asmbs.org/)—For overview of weight loss surgery and history of bariatric surgery
• International Federation for the Surgery of Obesity and Metabolic Disorders (www.ifso.com/)—Access to journals and information on obesity related conferences
• International Association for the Study of Obesity (www.iaso.org/index.asp)—Access to new data and approaches to management and prevention of obesity
• National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006. Clinical guideline 43. www.nice.org.uk/CG43
• National Obesity Forum (www.nationalobesityforum.org.uk/)—An independent charity working to improve the prevention and management of obesity
• World Health Organization (www.who.int/topics/obesity/en/)—For facts and figures on the scale of obesity as an international problem

Resources for patients

• British Obesity Surgery Patient Association (www.bospa.org)—Provides information and support to patients who are considering or have had bariatric surgery
• WLSinfo (www.wlsinfo.org.uk)—A UK charity providing information and support to patients who are considering or have had bariatric surgery
• North London Obesity Surgery Service (www.whittington.nhs.uk/default.asp?c=6160)—The website of the North London Obesity Surgery Service offers advice and help to patients and professionals. It is available to all patients referred to the service for bariatric surgery, which includes patients from outside London

Notes

Cite this as: BMJ 2009;339:b3402

Footnotes

• Contributors: Both authors set out the topics to be covered in the review, did the literature search, and read articles. DRL wrote the first draft, which was rewritten by DH. Both authors prepared the final draft. DH is the guarantor.
• Competing interests: None declared.
• Provenance and peer review: Not commissioned; externally peer reviewed.
• Patient consent obtained.

 

 

 

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What war is good for

What war is good for

Cite this as:BMJ2011;342:d2416

Wendy Moore, freelance writer and author, London

“War—what is it good for?” asks the old protest song. Advances in surgery, if nothing else, might be the answer. The patients of the French surgeon Ambroise Paré (1510–90) certainly benefited from his long experience treating the casualties of muskets and cannons in the conflicts that ravaged Renaissance Europe.

From humble origins, Paré was apprenticed to a barber before he enrolled as a trainee surgeon at the Hôtel-Dieu, Paris. After joining his first military campaign at the age of 27, he spent almost 30 years amputating limbs and excising musket balls on European battlefields, and applied the lessons he learnt to improving surgery for all. Despite his rise to the rank of royal surgeon to three French kings, Paré wrote his many books on surgery in French rather than the customary Latin and remained humble and open minded about his craft.

Decades of wading through blood did not inure Paré to the horrors of warfare. Musing on the inventor of the gun, he concluded, “I think the deviser of this deadly Engine hath this for recompense that his name should be hidden by the darkness of perpetual ignorance.”

Paré made his most famous discovery on his first outing as a rookie army surgeon during an expedition to Italy in 1536. Following standard practice, he was cauterising gunshot wounds with scalding oil, based on the common belief that this neutralised the supposed poison in gunpowder. When he ran out of oil, in desperation Paré applied a salve of egg yolk, rose oil, and turpentine to the wounds. Unable to sleep that night from guilt, he rose early the next day to discover those soldiers treated with the salve were healing while their fellows scalded with oil still writhed in feverish pain.

Importantly, Paré resolved to apply the results of his unintentional randomised controlled trial to future practice, deciding that “neither I nor any other should ever cauterise any wounded with gun-shot.”

Paré popularised his finding in the first of many medical texts, his Treatise on Gunshot Wounds, published in 1545. He applied the same scientific method to test a folk remedy of raw onions on a boy who fell into a cauldron of scalding oil. Paré coated some injured areas with onion salve and others with orthodox remedies, and found that the folk remedy reduced blistering. Always mindful to reduce pain and diminish suffering, Paré also pioneered ligatures in amputations, designed prosthetic limbs, and championed podalic version in obstetrics.

With a wit as sharp as his amputation knife, his works were dedicated to promoting rational medicine and dispelling superstition. His “rules of chirurgy” were simple and logical, beginning with the sage observation, “Health is not received by words, but by remedies fitly used.” Poignantly, Paré countered criticism from snobbish physicians in his Apologia, published when he was 75 years old, detailing his vast battlefield experience with clinical precision. Addressed to Étienne Gourmelen, dean of the faculty of physicians, Paré wrote, “My little master, I wish you had been there.”

 

Notes

 

Cite this as: BMJ 2011;342:d2416

 

Footnotes

• Source: Paré, Ambroise. The Collected Works of Ambroise Paré, translated out of the Latin by Thomas Johnson. London, 1634 (first published 1575).

http://www.bmj.com/content/342/bmj.d2416

Ambroise Paré Research

 

Ambroise Paré was an innovative French surgeon who served as royal surgeon for a number of French kings, including Henri II. Having been apprenticed to a barber, Paré joined the army in 1536, and spent much of the next 30 years as a military surgeon. He improved or invented many techniques, especially in the treatment of war wounds.

Many surgeons gained experience as a result of war, and Paré was no exception. It was common practice at the time for surgeons to seal wounds by the use of cauterisation but, in his first job as a war surgeon in 1536, Paré ran out of the boiling oil which was used to seal the soldier's wounds in this way. Instead, he made a tincture of egg yolk, turpentine and oil of roses. The following morning, and to his amazement, the soldiers who had been treated with the tincture were in a much better condition than those who had been treated with boiling oil.

Paré also rejected cautery to seal wounds after amputation. Instead, he used ligatures to tie off the blood vessels. While this was less painful for the patient, the ligatures could cause infection, complications and death, so were not adopted as readily by other surgeons.

He was also interested in the application of new anatomical ideas - such as those of Andreas Vesalius - developed a number of instruments and artificial limbs, and introduced new ideas in obstetrics.

His famed work as a war surgeon, and afterward as a surgeon in Paris, together with the publication of his book Les Oeuvres in 1575, ensured that Ambroise Paré’s techniques and ideas spread across Europe. His success was also influential in beginning to raise the status of barber-surgeons.


http://www.sciencemuseum.org.uk/broughttolife/people/ambroisepare.aspx