Gastric bypass surgery refers to a surgical procedure in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different gastric bypass (GBP) procedures. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.

The operation is prescribed to treat morbid obesity (defined as a body mass index greater than 40), type 2 diabetes, hypertension, sleep apnea, and other comorbid conditions. Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity, not just gastric bypasses, which make up only one class of such operations. The resulting weight loss, typically dramatic, markedly reduces comorbidities. The long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40%. As with all surgery, complications may occur. A study from 2005 to 2006 revealed that 15% of patients experience complications as a result of gastric bypass, and 0.5% of patients died within six months of surgery due to complications.

Uses

Gastric bypass is indicated for the surgical treatment of morbid obesity, a diagnosis which is made when the patient is seriously obese, has been unable to achieve satisfactory and sustained weight loss by dietary efforts, and suffers from comorbid conditions which are either life-threatening or a serious impairment to the quality of life.

Prior to 1991, clinicians interpreted serious obesity as weighing at least 100 pounds (45 kg) more than the "ideal body weight", an actuarially-determined body-weight at which one was estimated to be likely to live the longest, as determined by the life-insurance industry. This criterion failed for persons of short stature.

In 1991, the National Institutes of Health (NIH) sponsored a consensus panel whose recommendations have set the current standard for consideration of surgical treatment, the body mass index (BMI). The BMI is defined as the body weight (in kilograms), divided by the square of the height (in meters). The result is expressed as a number - usually between 15 and 70 - in units of kilograms per square meter.

The Consensus Panel of the National Institutes of Health (NIH) recommended the following criteria for consideration of bariatric surgery, including gastric bypass procedures:

• people who have a BMI of 40 or higher
• people with a BMI of 35 or higher with one or more related comorbid conditions

The Consensus Panel also emphasized the necessity of multidisciplinary care of the bariatric surgical patient by a team of physicians and therapists to manage associated comorbidities and nutrition, physical activity, behavior, and psychological needs. The surgical procedure is best regarded as a tool which enables the patient to alter lifestyle and eating habits, and to achieve effective and permanent management of obesity and eating behavior.

Since 1991, major developments in the field of bariatric surgery, particularly laparoscopy, have outdated some of the conclusions of the NIH panel. In 2004 the American Society for Bariatric Surgery (ASBS) sponsored a consensus conference which updated the evidence and the conclusions of the NIH panel. This conference, composed of physicians and scientists of both surgical and non-surgical disciplines, reached several conclusions, including:

• bariatric surgery is the most effective treatment for morbid obesity
• gastric bypass is one of four types of operations for morbid obesity
• laparoscopic surgery is equally effective and as safe as open surgery
• patients should undergo comprehensive preoperative evaluation and have multi-disciplinary support for optimum outcome

Surgical techniques

The gastric bypass, in its various forms, accounts for a large majority of the bariatric surgical procedures performed. It is estimated that 200,000 such operations were performed in the United States in 2008. An increasing number of these operations are now performed by limited access techniques, termed "laparoscopy".

Laparoscopic surgery is performed using several small incisions, or ports: one to insert a surgical telescope connected to a video camera, and others to permit access of specialized operating instruments. The surgeon views his operation on a video screen. Laparoscopy is also called limited access surgery, reflecting the limitation on handling and feeling tissues and also the limited resolution and two-dimensionality of the video image. With experience, a skilled laparoscopic surgeon can perform most procedures as expeditiously as with an open incision--with the option of using an incision should the need arise.

The Roux-en-Y laparoscopic gastric bypass, first performed in 1993, is regarded as one of the most difficult procedures to perform by limited access techniques, but use of this method has greatly popularized the operation due to associated benefits such as a shortened hospital stay, reduced discomfort, shorter recovery time, less scarring, and minimal risk of incisional hernia.

Essential features

The gastric bypass procedure consists of:

• Creation of a small, (15-30 mL/1-2 tbsp) thumb-sized pouch from the upper stomach, accompanied by bypass of the remaining stomach (about 400 mL and variable). This restricts the volume of food which can be eaten. The stomach may simply be partitioned (like a wall between two rooms in a house or two office cubicles next to each other with a partition wall in between them - and typically by the use of surgical staples), or it may be totally divided into two separate/separated parts (also with staples). Total division (separate/separated parts) is usually advocated to reduce the possibility that the two parts of the stomach will heal back together ("fistulize") and negate the operation.
• Re-construction of the GI tract to enable drainage of both segments of the stomach. The particular technique used for this reconstruction produces several variants of the operation, differing in the lengths of small intestine used, the degree to which food absorption is affected, and the likelihood of adverse nutritional effects. Usually, a segment of the small bowel (called the alimentary limb) is brought up to the proximal remains of the stomach.

Variations of the gastric bypass

Gastric bypass, Roux en-Y (proximal)

This variant is the most commonly employed gastric bypass technique, and is by far the most commonly performed bariatric procedure in the United States. The small intestine is divided approximately 45 cm (18 in) below the lower stomach outlet and is re-arranged into a Y-configuration, enabling outflow of food from the small upper stomach pouch via a "Roux limb". In the proximal version, the Y-intersection is formed near the upper (proximal) end of the small intestine. The Roux limb is constructed using 80-150 cm (31-59 in) of the small intestine, preserving the rest (and the majority) of it for absorbing nutrients. The patient will experience very rapid onset of the stomach feeling full, followed by a growing satiety (or "indifference" to food) shortly after the start of a meal.

Gastric bypass, Roux en-Y (distal)

The small intestine is normally 6-10 m (20-33 ft) in length. As the Y-connection is moved further down the gastrointestinal tract, the amount available to fully absorb nutrients is progressively reduced, traded for greater effectiveness of the operation. The Y-connection is formed much closer to the lower (distal) end of the small intestine, usually 100-150 cm (39-59 in) from the lower end, causing reduced absorption (malabsorption) of food: primarily of fats and starches, but also of various minerals and the fat-soluble vitamins. The unabsorbed fats and starches pass into the large intestine, where bacterial actions may act on them to produce irritants and malodorous gases. These larger effects on nutrition are traded for a relatively modest increase in total weight loss.

"Mini-gastric bypass" (MGB)

The mini gastric bypass procedure was first developed by Dr Robert Rutledge from the USA in 1997, as a modification of the standard Billroth II procedure. A mini gastric bypass creates a long narrow tube of the stomach along its right border (the lesser curvature). A loop of the small gut is brought up and hooked to this tube at about 180 cm from the start of the intestine

Numerous studies show that the loop reconstruction (Billroth II gastrojejunostomy) works more safely when placed low on the stomach, but can be a disaster when placed adjacent to the esophagus. Today thousands of "loops" are used for surgical procedures to treat gastric problems such as ulcers, stomach cancer, and injury to the stomach. The mini gastric bypass uses the low set loop reconstruction and thus has rare chances of bile reflux.

The MGB has been suggested as an alternative to the Roux en-Y procedure due to the simplicity of its construction, and is becoming more and more popular because of low risk of complications and good sustained weight loss. It has been estimated that 15.4% of weight loss surgery in Asia is now performed via the MGB technique.

Physiology

The gastric bypass reduces the size of the stomach by well over 90%. A normal stomach can stretch, sometimes to over 1000 mL, while the pouch of the gastric bypass may be 15 mL in size. The gastric bypass pouch is usually formed from the part of the stomach which is least susceptible to stretching. That, and its small original size, prevents any significant long-term change in pouch volume. What does change, over time, is the size of the connection between the stomach and intestine and the ability of the small intestine to hold a greater volume of food. Over time, the functional capacity of the pouch increases; by that time, weight loss has occurred, and the increased capacity should serve to allow maintenance of a lower body weight.

When the patient ingests just a small amount of food, the first response is a stretching of the wall of the stomach pouch, stimulating nerves which tell the brain that the stomach is full. The patient feels a sensation of fullness, as if they had just eaten a large meal--but with just a thimble-full of food. Most people do not stop eating simply in response to a feeling of fullness, but the patient rapidly learns that subsequent bites must be eaten very slowly and carefully, to avoid increasing discomfort or vomiting.

Food is first churned in the stomach before passing into the small intestine. When the lumen of the small intestine comes into contact with nutrients, a number of hormones are released, including cholecystokinin from the duodenum and PYY and GLP-1 from the ileum. These hormones inhibit further food intake and have thus been dubbed "satiety factors". Ghrelin is a hormone that is released in the stomach that stimulates hunger and food intake. Changes in circulating hormone levels after gastric bypass have been hypothesized to produce reductions in food intake and body weight in obese patients. However, these findings remain controversial, and the exact mechanisms by which gastric bypass surgery reduces food intake and body weight have yet to be elucidated.

For example, it is still widely perceived that gastric bypass works by mechanical means, i.e. food restriction and/or malabsorption. Recent clinical and animal studies, however, have indicated that these long-held inferences about the mechanisms of Roux en-Y gastric bypass (RYGB) may not be correct. A growing body of evidence suggests that profound changes in body weight and metabolism resulting from RYGB cannot be explained by simple mechanical restriction or malabsorption. One study in rats found that RYGB induced a 19% increase in total and a 31% increase in resting energy expenditure, an effect not exhibited in vertical sleeve gastrectomy rats. In addition, pair-fed rats lost only 47% as much weight as their RYGB counterparts. Changes in food intake after RYGB only partially account for the RYGB-induced weight loss, and there is no evidence of clinically significant malabsorption of calories contributing to weight loss. Thus, it appears RYGB affects weight loss by altering the physiology of weight regulation and eating behavior rather than by simple mechanical restriction or malabsorption.

To gain the maximum benefit from this physiology, it is important that the patient eat only at mealtimes, 5 to 6 small meals daily, and not graze between meals, which can effectively "bypass the bypass". Concentration on obtaining 80-100 g of daily protein is necessary. Meals after surgery are 1/4-1/2 cup, slowly getting to 1 cup by one year. This requires a change in eating behavior and alteration of long-acquired habits for finding food. In almost every case where weight gain occurs late after surgery, capacity for a meal has not greatly increased. Some assume the cause of regaining weight must be the patient's fault, e.g. eating between meals with high-caloric snack foods, though this has been debated. Others believe it is an unpredictable failure or limitation of the surgery for certain patients (e.g. reactive hypoglycemia). Of course, there may be no operation which can completely counteract the adverse effects of destructive eating behavior. This surgery is only a tool and as with most tools, if not used correctly, it can be of no use.

Complications

Any major surgery involves the potential for complications--adverse events which increase risk, hospital stay, and mortality. Some complications are common to all abdominal operations, while some are specific to bariatric surgery.

Mortality and complication rates

The overall rate of complications during the 30 days following surgery ranges from 7% for laparoscopic procedures to 14.5% for operations through open incisions. One study on mortality revealed a 0% mortality rate out of 401 laparoscopic cases, and 0.6% out of 955 open procedures (6 Deaths). Similar mortality rates--30-day mortality of 0.11% (364 deaths), and 90-day mortality of 0.3%--have been recorded in the U.S. Centers of Excellence program, the results being from 33,117 operations at 106 centers.

Mortality and complications are affected by pre-existing risk factors such as degree of obesity, heart disease, obstructive sleep apnea, diabetes mellitus, and history of prior pulmonary embolism. It is also affected by the experience of the operating surgeon: the learning curve for laparoscopic bariatric surgery is estimated to be about 100 cases. Supervision and experience is important when selecting a surgeon, as the way a surgeon becomes experienced in dealing with problems is by encountering and solving them.

Complications of abdominal surgery

Infection

Infection of the incisions or of the inside of the abdomen (peritonitis, abscess) may occur due to release of bacteria from the bowel during the operation. Nosocomial infections, such as pneumonia, bladder or kidney infections, and sepsis (blood-borne infection) are also possible. Effective short-term use of antibiotics, diligent respiratory therapy, and encouragement of activity within a few hours after surgery can reduce the risks of infections.

Venous thromboembolism

Any injury, such as a surgical operation, causes the body to increase the coagulation of the blood. Simultaneously, activity may be reduced. There is an increased probability of formation of clots in the veins of the legs, or sometimes the pelvis, particularly in the morbidly obese patient. A clot which breaks free and floats to the lungs is called a pulmonary embolus, a very dangerous occurrence. Blood thinners are commonly administered before surgery to reduce the probability of this type of complication.

Hemorrhage

Many blood vessels must be cut in order to divide the stomach and to move the bowel. Any of these may later begin bleeding, either into the abdomen (intra-abdominal hemorrhage), or into the bowel itself (gastrointestinal hemorrhage). Transfusions may be needed, and re-operation is sometimes necessary. Use of blood thinners to prevent venous thromboembolic disease may actually increase the risk of hemorrhage slightly.

Hernia

A hernia is an abnormal opening, either within the abdomen or through the abdominal wall muscles. An internal hernia may result from surgery and re-arrangement of the bowel, and is a cause of bowel obstruction. Antecolic antegastric Roux-en-Y gastric bypass surgery has been estimated to result in internal hernia in 0.2% of cases, mainly through Petersen's defect. An incisional hernia occurs when a surgical incision does not heal well; the muscles of the abdomen separate and allow protrusion of a sac-like membrane, which may contain bowel or other abdominal contents, and which can be painful and unsightly. The risk of abdominal-wall hernia is markedly decreased in laparoscopic surgery.

Bowel obstruction

Abdominal surgery always results in some scarring of the bowel, called adhesions. A hernia, either internal or through the abdominal wall, may also result. When bowel becomes trapped by adhesions or a hernia, it may become kinked and obstructed, sometimes many years after the original procedure. An operation is usually necessary to correct this problem.

Complications of gastric bypass

Anastomotic leakage

An anastomosis is a surgical connection between the stomach and bowel, or between two parts of the bowel. The surgeon attempts to create a water-tight connection by connecting the two organs with either staples or sutures, either of which actually makes a hole in the bowel wall. The surgeon will rely on the body's natural healing abilities and its ability to create a seal, like a self-sealing tire, to succeed with the surgery. If that seal fails to form for any reason, fluid from within the gastrointestinal tract can leak into the sterile abdominal cavity and give rise to infection and abscess formation. Leakage of an anastomosis can occur in about 2% of Roux-en-Y gastric bypass and less than 1% in mini gastric bypass. Leaks usually occur at the stomach-intestine connection (gastro-jejunostomy). There is a change in the drain fluid contents from serous (before the leak) to fecal/bilious (after the leak). Usually significant leaks need urgent re-operation. Sometimes a minor leakage can be treated with antibiotics only. It is usually safer to re-operate if an infection cannot be definitely controlled immediately.

Anastomotic stricture

As the anastomosis heals, it forms scar tissue, which naturally tends to shrink ("contract") over time, making the opening smaller. This is called a "stricture". Usually, the passage of food through an anastomosis will keep it stretched open, but if the inflammation and healing process outpaces the stretching process, scarring may make the opening so small that even liquids can no longer pass through it. The solution is a procedure called gastroendoscopy, and stretching of the connection by inflating a balloon inside it. Sometimes this manipulation may have to be performed more than once to achieve lasting correction.

Anastomotic ulcer

Ulceration of the anastomosis occurs in 1-16% of patients. Possible causes of such ulcers are:

• Restricted blood supply to the anastomosis (compared to the blood supply available to the original stomach)
• Anastomosis tension
• Gastric acid
• The bacteria Helicobacter pylori
• Smoking
• Use of non-steroidal anti-inflammatory drugs

This condition can be treated with:

• Proton pump inhibitors, e.g. esomeprazole
• A cytoprotectant and acid buffering agent, e.g. sucralfate
• Temporary restriction of the consumption of solid foods

Dumping syndrome

Normally, the pyloric valve at the lower end of the stomach regulates the release of food into the bowel. When the gastric bypass patient eats a sugary food, the sugar passes rapidly into the intestine, where it gives rise to a physiological reaction called dumping syndrome. The body will flood the intestines in an attempt to dilute the sugars. An affected person may feel their heart beating rapidly and forcefully, break into a cold sweat, get a feeling of butterflies in the stomach, and may have an anxiety attack. The person usually has to lie down, and could be very uncomfortable for 30-45 minutes. Diarrhea may then follow.

Nutritional deficiencies

Nutritional deficiencies are common after gastric bypass surgery, and are often not recognized. They include:

• Secondary hyperparathyroidism due to inadequate absorption of calcium may occur for GBP patients. Calcium is primarily absorbed in the duodenum, which is bypassed by the surgery. Most patients can achieve adequate calcium absorption by supplementation with vitamin D and calcium citrate (carbonate may not be absorbed--it requires an acidic stomach, which is bypassed).
• Iron frequently is seriously deficient, particularly in menstruating females, and must be supplemented. Again, it is normally absorbed in the duodenum. Ferrous sulfate can cause considerable GI distress in normal doses; alternatives include ferrous fumarate, or a chelated form of iron. Occasionally, a female patient develops severe anemia, even with supplements, and must be treated with parenteral iron. The signs of iron deficiency include: brittle nails, an inflamed tongue, constipation, depression, headaches, fatigue, and mouth lesions.
• Signs and symptoms of zinc deficiency may also occur such as: acne, eczema, white spots on the nails, hair loss, depression, amnesia, and lethargy.
• Deficiency of thiamine (also known as vitamin B₁) brings the risk of permanent neurological damage (i.e. Wernicke's encephalopathy or polyneuropathy). Signs of thiamin deficiency are heart failure, memory loss, numbness of the hands, constipation, and loss of appetite.
• Vitamin B₁₂ requires intrinsic factor from the gastric mucosa to be absorbed. In patients with a small gastric pouch, it may not be absorbed, even if supplemented orally, and deficiencies can result in pernicious anemia and neuropathies. Vitamin B₁₂ deficiency is quite common after gastric bypass surgery with reported rates of 30% in some clinical trials. Sublingual B₁₂ (cyanocobalamin) appears to be adequately absorbed. In cases where sublingual B₁₂ does not provide sufficient amounts, injections may be needed.
• Protein malnutrition is a real risk. Some patients suffer troublesome vomiting after surgery, until their GI tract adjusts to the changes, and cannot eat adequate amounts even with 6 meals a day. Many patients require protein supplementation during the early phases of rapid weight loss to prevent excessive loss of muscle mass. Hair loss is also a risk of protein malnutrition.
• Vitamin A deficiencies generally occur as a result of fat-soluble vitamins deficiencies. This often comes after intestinal bypass procedures such as jejunoileal bypass (no longer performed) or biliopancreatic diversion/duodenal switch procedures. In these procedures, fat absorption is markedly impaired. There is also the possibility of a vitamin A deficiency with use of the weight-loss medication orlistat (marketed as Xenical and Alli).
• Folate deficiency is also a common occurrence in gastric bypass surgery patients.

Nutritional effects

After surgery, patients feel fullness after ingesting only a small volume of food, followed soon thereafter by a sense of satiety and loss of appetite. Total food intake is markedly reduced. Due to the reduced size of the newly created stomach pouch, and reduced food intake, adequate nutrition demands that the patient follow the surgeon's instructions for food consumption, including the number of meals to be taken daily, adequate protein intake, and the use of vitamin and mineral supplements. Calcium supplements, iron supplements, protein supplements, multi-vitamins (sometimes pre-natal vitamins are best), and vitamin B₁₂ (cyanocobalamin) supplements are all very important to the post-operative bypass patient.

Total food intake and absorbance rate of food will rapidly decline after gastric bypass surgery, and the number of acid-producing cells lining the stomach increases. Doctors often prescribe acid-lowering medications to counteract the high acidity levels. Many patients then experience a condition known as achlorhydria, where there is not enough acid in stomach. As a result of the low acidity levels, patients can develop an overgrowth of bacteria. A study conducted on 43 post-operative patients revealed that almost all of the patients tested positive for a hydrogen breath test, which indicated an overgrowth of bacteria in the small intestine. Bacterial overgrowth causes the gut ecology to change and induces nausea and vomiting. Recurring nausea and vomiting eventually change the absorbance rate of food, contributing to the vitamin and nutrition deficiencies common in post-operative gastric bypass patients.

Protein nutrition

Proteins are essential food substances, contained in foods such as meat, fish and poultry, dairy products, soy, nuts, and eggs. With reduced ability to eat a large volume of food, gastric bypass patients must focus on eating their protein requirements first, and with each meal. In some cases, surgeons may recommend use of a liquid protein supplement. Powdered protein supplements added to smoothies or any food can be an important part of the post-op diet.

Calorie nutrition

The profound weight loss which occurs after bariatric surgery is due to taking in much less energy (calories) than the body needs to use every day. Fat tissue must be burned to offset the deficit, and weight loss results. Eventually, as the body becomes smaller, its energy requirements are decreased, while the patient simultaneously finds it possible to eat somewhat more food. When the energy consumed is equal to the calories eaten, weight loss will stop. Proximal GBP typically results in loss of 60-80% of excess body weight, and very rarely leads to excessive weight loss. The risk of excessive weight loss is slightly greater with distal GBP.

Vitamins

Vitamins are normally contained in foods and supplements. The amount of food eaten after GBP is severely reduced, and vitamin content is correspondingly lowered. Supplements should therefore be taken to complete minimum daily requirements of all vitamins and minerals. Pre-natal vitamins are sometimes suggested by doctors, as they contain more of certain vitamins than most multi-vitamins. Absorption of most vitamins is not seriously affected after proximal GBP, although vitamin B₁₂ may not be well-absorbed in some persons: sublingual preparations of B₁₂ provide adequate absorption. Some studies suggest that GBP patients who took probiotics after surgery are able to absorb and retain higher amounts of B₁₂ than patients who did not take probiotics after surgery. After a distal GBP, fat-soluble vitamins A, D, and E may not be well-absorbed, particularly if fat intake is large. Water-dispersed forms of these vitamins may be indicated on specific physician recommendation. For some patients, sublingual B₁₂ is not enough, and patients may require B₁₂ injections.

Minerals

All versions of the GBP bypass the duodenum, which is the primary site of absorption of both iron and calcium. Iron replacement is essential in menstruating females, and supplementation of iron and calcium is preferable in all patients. Ferrous sulfate is poorly tolerated. Alternative forms of iron (fumarate, gluconate, chelates) are less irritating and probably better absorbed. Calcium carbonate preparations should also be avoided; calcium as citrate or gluconate (with 1200 mg as calcium) has greater bioavailability independent of acid in the stomach, and will likely be better absorbed. Chewable calcium supplements that include vitamin K are sometimes recommended by doctors as a good way to get calcium.

Alcohol metabolism

Post-operative gastric bypass patients develop a lowered tolerance for alcoholic beverages because their altered digestive tract absorbs alcohol at a faster rate than people who have not undergone the surgery. It also takes a post-operative patient longer to reach sober levels after consuming alcohol. In a study conducted on 36 post-operative patients and a control group of 36 subjects (who had not undergone surgery), each subject drank a 5 oz. glass of red wine and had the alcohol in their breath measured to evaluate alcohol metabolism. The gastric bypass group had an average peak alcohol breath level at 0.08%, whereas the control group had an average peak alcohol breath level of 0.05%. It took on average 108 minutes for the gastric bypass patients group to return to an alcohol breath of zero, while it took the control group an average of 72 minutes.

Pica

There have been reported cases in which pica recurs after gastric bypass in patients with a pre-operative history of the disorder, which are possibly due to iron deficiency. Pica is a compulsive tendency to eat substances other than normal food. Some examples would be people eating paper, clay, plaster, ashes, or ice. Low levels of iron and hemoglobin are common in patients who have undergone gastric bypass. One study reported on a female post-operative gastric bypass patient who was consuming eight to ten 32 oz. glasses of ice a day. The patient's blood test revealed iron levels of 2.3 mmol/L and hemoglobin level of 5.83 mmol/L. Normal iron blood levels of adult women are 30 to 126 µg/dL and normal hemoglobin levels are 12.1 to 15.1 g/dl. This deficiency in the patient's iron levels may have led to the increase Pica activity. The patient was then given iron supplements that brought her hemoglobin and iron blood levels to normal levels. After one month, the patient's eating diminished to two to three glasses of ice per day. After one year of taking iron supplements the patient's iron and hemoglobin levels remained in a normal range and the patient reported that she did not have any further cravings for ice.

Results and health benefits of gastric bypass

Weight loss of 65-80% of excess body weight is typical of most large series of gastric bypass operations reported. The medically more significant effects include a dramatic reduction in comorbid conditions:

• Hyperlipidemia is corrected in over 70% of patients.
• Essential hypertension is relieved in over 70% of patients, and medication requirements are usually reduced in the remainder.
• Obstructive sleep apnea improves markedly with weight loss and bariatric surgery may be curative for sleep apnea. Snoring also reduces in most patients.
• Type 2 diabetes is reversed in up to 90% of patients usually leading to a normal blood-sugar level without medication, sometimes within days of surgery. Furthermore, Type 2 diabetes is prevented by more than 30-fold in patients with pre-diabetes. All these findings were first reported by Walter Pories and Jose F. Caro.
• Gastroesophageal reflux disease is relieved in almost all patients.
• Venous thromboembolic disease signs such as leg swelling are typically alleviated.
• Lower-back pain and joint pain are typically relieved or improved in nearly all patients.

A study in a large comparative series of patients showed an 89% reduction in mortality over the five years following surgery, compared to a non-surgically treated group of patients.

Concurrently, most patients are able to enjoy greater participation in family and social activities.

Cost of gastric bypass

The patient's out of pocket cost for Roux-en-Y gastric bypass surgery varies widely depending on method of payment, region, surgical practice and hospital in which the procedure is performed.

Methods of payment in the United States include private insurance (Individual & Family coverage, Small Group coverage through an employer (Under 50 full-time employees) and Large Group coverage through an employer (50 or more full-time employees), public insurance (Medicare and Medicaid) and self-pay. Out of pocket costs for a patient with private or public insurance that specifically list bariatric surgery as a covered benefit include several insurance-policy-specific parameters such as deductible levels, coinsurance percentages, copay amounts and out of pocket limits.

Patients without insurance must pay for surgery directly (or through a third party lender), and total out of pocket costs will depend on the surgical practice they choose and the hospital in which the surgical practice performs the procedure. On average, the total cost of gastric bypass surgery is about $24,000 in the United States, although on a state-specific level it ranges from an average of $15,000 (Arkansas) to an average of $57,000 (Alaska).

Living with gastric bypass

Gastric bypass surgery has an emotional and physiological impact on the individual. Many who have undergone the surgery suffer from depression in the following months as a result of a change in the role food plays in their emotional well-being. Strict limitations on the diet can place great emotional strain on the patient. Energy levels in the period following the surgery can be low, both due to the restriction of food intake and negative changes in emotional state. It may take as long as three months for emotional levels to rebound. Muscular weakness in the months following surgery is also common. This is caused by a number of factors, including a restriction on protein intake, a resulting loss in muscle mass and decline in energy levels. Muscle weakness may result in balance problems, difficulty climbing stairs or lifting heavy objects, and increased fatigue following simple physical tasks. Many of these issues pass over time as food intake gradually increases. However, the first months following the surgery can be very difficult, an issue not often mentioned by physicians suggesting the surgery. The benefits and risks of this surgery are well established; however, the psychological effects are not well understood.

Even if physical activity is increased patients may still harbor long term psychological effects due to excess skin and fat. Often bypass surgery is followed up with "body lifts" of skin and liposuction of fatty deposits. These extra surgeries have their own inherent risks but are even more dangerous when coupled with the typical nutritional deficiences that accompany convalescing gastric bypass patients.

Surgeon accreditation

The American Society for Metabolic & Bariatric Surgery lists bariatric programs and surgeons in its "Centers of Excellence" network, while the American College of Surgeons accredits providers through its Bariatric Surgery Center Network. For listings of surgeons and centers in other countries, the International Federation for the Surgery of Obesity and Metabolic Disorders lists medical associations by country.

See also

• Adjustable gastric banding surgery
• Duodenal Switch surgery
• Vagotomy--Cutting of the vagus nerve to reduce the feeling of hunger
• StomaphyX--Revisional, natural orifice procedure for patients that have regained weight after gastric bypass
• American Society for Bariatric Surgery

References

• Buchwald, H; Cowan, GSM; Pories, WJ (2007), Surgical Management of Obesity, Saunders Elsevier, ISBN 978-1-4160-0089-1 
• Buchwald, H; Consensus Conference, Panel (2005), "Bariatric surgery for morbid obesity: health implications for patients, health professionals, and third-party payers", J Am Coll Surg 200 (4): 593-604, doi:10.1016/j.jamcollsurg.2004.10.039, PMID 15804474 
• Christou, N; Sampalis, J; Liberman, M; Look, D; Auger, S; McLean, A; MacLean, L (2004), "Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients", Ann Surg 240 (3): 416-23; discussion 423-4, doi:10.1097/01.sla.0000137343.63376.19, PMC 1356432, PMID 15319713 
• Wittgrove, AC; Clark, GW (2000), "Laparoscopic Gastric Bypass, Roux en-Y - 500 Patients: Technique and Results with 3-60 Months Follow-up", Obesity Surgery 10 (3): 233-9, doi:10.1381/096089200321643511, PMID 10929154 
• Fontaine, KR; Wang, C; Westfall, AO; Allison, DB et al. (2003), "Years of life lost to obesity", JAMA 289 (2): 187-93, doi:10.1001/jama.289.2.187, PMID 12517229  CS1 maint: Explicit use of et al. (link)
• Peeters, A; Barendregt, J; Willekens, F; Mackenbach, J; Al-Mamun, A; Bonneux, L; NEDCOM, the Netherlands Epidemiology and Demography Compression of Morbidity Research Group (2003), "Obesity in adulthood and its consequences for life expectancy: a life-table analysis", Ann Intern Med 138 (1): 24-32, doi:10.7326/0003-4819-138-1-200301070-00008, PMID 12513041 
• Hutter, MM; Randall, S; Khuri, SF; Henderson, WG; Abbott, WM; Warshaw, AL (2006), "Laparoscopic Versus Open Gastric Bypass for Morbid Obesity: A Multicenter, Prospective, Risk-Adjusted Analysis From the National Surgical Quality Improvement Program", Annals of Surgery 243 (5): 657-66, doi:10.1097/01.sla.0000216784.05951.0b, PMC 1570562, PMID 16633001 

External links

• ASBS Consensus Conference Statement - 2004
• NIH - Gastrointestinal Surgery for Obesity
• NIH Medline Plus - Multiple Links to articles, videos about bariatric surgery
• Metabolic & Weight Loss Surgical Procedures Gallery - Including information on bariatric surgery

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Green tea is made from the leaves from Camellia sinensis that have undergone minimal oxidation during processing. Green tea originated in China, but it has become associated with many cultures throughout Asia. Green tea has recently become relatively widespread in the Western World where black tea has been traditionally consumed.

Green tea has become the raw material for extracts used in various beverages, dietary supplements, and cosmetic items. Many varieties of green tea have been created in the countries where it is grown. These varieties can differ substantially due to variable growing conditions, horticulture, production processing, and harvesting time.

Many claims have been made for the beneficial health effects of green tea consumption, but they have generally not been borne out by scientific investigation; excessive consumption is associated with some harmful health effects but moderate, regular consumption is safe.

History

Tea consumption has its legendary origins in China dating back to more than 4,000 years ago, making it the oldest herbal tea known. Green tea was first brewed in 2737 BC during the reign of Emperor Shennong.

A book written by Lu Yu in 600-900 AD (Tang Dynasty), "Tea Classic" (simplified Chinese: ??; traditional Chinese: ??; pinyin: cháj?ng), is considered important in green tea history. The Kissa Yojoki (????? Book of Tea), written by Zen priest Eisai in 1191, describes how drinking green tea may affect five vital organs, the shapes of tea plants, flowers and leaves, and how to grow and process tea leaves.

Brewing and serving

Steeping is the process of making a cup of tea; it is also referred to as brewing. In general, two grams of tea per 100 ml of water, or about one teaspoon of green tea per five-ounce (150 ml) cup, should be used. With very high-quality teas like gyokuro, more than this amount of leaf is used, and the leaf is steeped multiple times for short durations.

Green tea steeping time and temperature varies with different tea. The hottest steeping temperatures are 81 to 87 °C (178 to 189 °F) water and the longest steeping times two to three minutes. The coolest brewing temperatures are 61 to 69 °C (142 to 156 °F) and the shortest times about 30 seconds. In general, lower-quality green teas are steeped hotter and longer, whereas higher-quality teas are steeped cooler and shorter. Steeping green tea too hot or too long will result in a bitter, astringent brew, regardless of the initial quality, because it will result in the release of an excessive amount of tannins. High-quality green teas can be and usually are steeped multiple times; two or three steepings is typical. The steeping technique also plays a very important role in avoiding the tea developing an overcooked taste. The container in which the tea is steeped or teapot should also be warmed beforehand so that the tea does not immediately cool down. It is common practice for tea leaf to be left in the cup or pot and for hot water to be added as the tea is drunk until the flavor degrades.

Varieties of green tea

Chinese green tea

Green tea is the most popular form of tea in China. Chinese green teas are made from over 600 different cultivars of the Camellia sinensis plant, giving plenty of variety and regional teas. Chinese green teas are traditionally pan-fired, unlike the Japanese steaming process. Other processes in China include oven-dried and sun-dried. Due to the different production process, Chinese teas are said to have a more "earthy" taste than Japanese teas.

• Zhejiang Province is home to the most famous of all teas, Xi Hu Longjing (????), as well as many other high-quality green teas.

• ????? Huiming

• ???? Kaihua Longding

• ???? Hua Ding

• ???? Qing Ding

• ???? Gunpowder

• Jiangsu Province

• ????? Rain Flower

• ???? Que She (Tongue of golden altar sparrow)

• ???? White Cloud

• Fujian Province is known for mountain-grown organic green tea as well as white tea and oolong tea. The coastal mountains provide a perfect growing environment for tea growing. Green tea is picked in spring and summer seasons.

• ?? Mao Feng tea

• ?? Cui Jian

• Hubei Province

• Henan Province

• Jiangxi Province

• ?? Gou Gu Nao

• ?? Yun Wu

• Anhui Province is home to several varieties of tea, including three Chinese famous teas. These are:

• ???? Huangshan Maofeng

• ???? Liuan Leaf

• ?? Hou Kui

• ?? Tun Lu

• ?? Huo Qing

• ??? Wuliqing

• Hyson

• Sichuan Province

• ???? Meng Ding Gan Lu

• ???? Baimei Green Tea

• Shaanxi Province

Japanese green tea

Green tea (??, Ryokucha) is ubiquitous in Japan and is commonly known simply as "tea" (??, ocha). Tea was first used in China, and was brought to Japan by My?an Eisai, a Japanese Buddhist priest who also introduced the Rinzai school of Zen Buddhism. Teas from Japan may be referred to as "Japanese tea" (???, nihoncha).

Japanese green tea is made from the Yabukita (???) cultivar of the camellia sinensis plant. Unlike Chinese green teas which are pan-fired, Japanese green teas are steamed giving them a more "vegetative" or "leafy" taste. The exception is h?jicha, a Japanese roasted tea. Japanese green teas are categorized by the age of the leaves: young leaves are called sench and the more mature, larger leaves are called bancha. Types of tea are commonly graded depending on the quality and the parts of the plant used as well as how they are processed. There are large variations in both price and quality within these broad categories, and there are many green teas that fall outside this spectrum. The best Japanese green tea is said to be from the Yame (??, yame) region of Fukuoka Prefecture and from the Uji region of Kyoto. Uji has been producing Ujicha (Uji tea) for four hundred years, pre-dating the prefecture system. It is now a combination of the border regions of Shiga, Nara, Kyoto, and Mie prefectures. Shizuoka Prefecture produces 40 percent of raw tea leaf.

• Sencha (??, decocted tea)

• Gyokuro (??, Jade Dew)

• Kabusecha (??, covered tea)

• Tamaryokucha (???, lit. ball green tea)

• Bancha (??, coarse tea)

• Kamairicha (???, pan-fired tea)

• By-product of Sencha or Gyokuro

• Other

Other green teas

• Green tea from Ceylon
• Kahwah

Research and health effects

Green tea contains a variety of enzymes, amino acids, carbohydrates, lipids, sterols, related compounds, dietary minerals, and phytochemicals such as polyphenols, flavanols, and caffeine. Polyphenols found in green tea include but are not limited to epigallocatechin gallate (EGCG), epigallocatechin, epicatechin gallate, and epicatechin; flavanols such as kaempferol, quercetin, and myricitin are also found in green tea. Numerous claims have been made for the health benefits of green tea based on its chemical composition, in vitro studies, animal studies, and human epidemiological studies. Preliminary research on many of these claims is promising, but many also require further study to evaluate. In 2011 a panel of scientists published a report on green tea's claimed health effects at the request of the European commission: in general they found that the claims made for green tea were not supported by good scientific evidence. Although the mean content of flavonoids and catechins in a cup of green tea is higher than that in the same volume of other food and drink items that are traditionally considered to promote health, flavonoids and catechins have no proven biological effect in humans.

Cancer

There is no conclusive evidence that green tea helps to prevent or treat cancer in people. A review of existing studies concluded that while suggestive evidence existed, it did not amount to a clear indication of benefit.

Meta-analyses in 2014 found limited evidence that green tea consumption may be associated with a slightly lower risk of esophageal cancer in the Chinese population, a lower risk of lung cancer in women, and a lower risk of oral cancer in Asian people. Another analysis of observational data conducted in 2012 suggested that green tea consumption may have a favorable effect on lung cancer risk. The observed effect was strongest in those who consumed more than seven cups of green tea daily. In 2011, a meta-analysis of epidemiological studies found limited evidence that green tea consumption may be associated with a moderately reduced risk of liver cancer in Chinese and Japanese people.

In contrast, separate 2014 meta-analyses found limited evidence that green tea consumption is not associated with the risk of developing pancreatic cancer or prostate cancer. The link between green tea consumption and stomach cancer risk is unclear due to inconsistent evidence.

Green tea interferes with the chemotherapy drug bortezomib (Velcade) and other boronic acid-based proteasome inhibitors, and should be avoided by people taking these medications.

Cardiovascular disease

Green tea consumption may be associated with a reduced risk of stroke. A 2013 Cochrane review of randomized controlled trials concluded that green tea consumption for 3-6 months appears to lower systolic and diastolic blood pressures a small amount (about 3 mmHg each). Additional analyses examining the effects of long-term green tea consumption on blood pressure have reached similar conclusions.

Glycemic control

Two meta-analyses concluded that drinking green tea lowers fasting blood sugar, but the effect of green tea consumption on hemoglobin A1c and fasting insulin levels was inconsistent.

Hyperlipidemia

A 2011 meta-analysis of 14 short-term randomized controlled trials concluded that consumption of green tea or green tea supplements decreases the blood concentration of total cholesterol (about 7 mg/dL), LDL cholesterol (about 2 mg/dL), and had no effect on the concentration of HDL cholesterol. A 2013 Cochrane review performed a meta-analysis of longer-term randomized controlled trials (>3 months duration) and concluded that green tea consumption lowers total and LDL cholesterol concentrations in the blood.

Weight loss

There is no conclusive evidence that green tea aids in weight loss for obese people.

Toxicity

Moderate, regular, and habitual consumption of green tea is safe; however, there are reports of liver toxicity in humans after consuming high doses (10-29 mg/kg/day) of green tea extract dietary supplements. High doses of epigallocatechin gallate (EGCG), an abundant catechin found in green tea, have also been found to cause oxidative stress in mice and in vitro.

Production

Growing, harvesting and processing

Green tea is processed and grown in a variety of ways, depending on the type of green tea desired. As a result of these methods, maximum amounts of polyphenols and volatile organic compounds are retained, affecting aroma and taste. The growing conditions can be broken down into two basic types - those grown in the sun and those grown under the shade. The green tea plants are grown in rows that are pruned to produce shoots in a regular manner, and in general are harvested three times per year. The first flush takes place in late April to early May. The second harvest usually takes place from June through July, and the third picking takes place in late July to early August. Sometimes, there will also be a fourth harvest. It is the first flush in the spring that brings the best-quality leaves, with higher prices to match.

Green tea is processed using either artisanal or modern methods. Sun-drying, basket or charcoal firing, or pan-firing are common artisanal methods. Oven-drying, tumbling, or steaming are common modern methods. Processed green teas, known as aracha are stored under low humidity refrigeration in 30- or 60-kilogram paper bags at 0-5 °C (32-41 °F). This aracha has yet to be refined at this stage, with a final firing taking place before blending, selection, and packaging takes place. The leaves in this state will be re-fired throughout the year as they are needed, giving the green teas a longer shelf-life and better flavor. The first flush tea of May will readily store in this fashion until the next year's harvest. After this re-drying process, each crude tea will be sifted and graded according to size. Finally, each lot will be blended according to the blend order by the tasters and packed for sale.

Production by country

Import of Japanese tea

On 17 June 2011, radioactive cesium of 1,038 becquerels per kilogram was detected at Charles de Gaulle airport in France in tea leaves imported from Shizuoka Prefecture, Japan, which was more than twice as much as the restricted amount of 500 becquerels per kilogram designated by the European Union, and the government of France announced that they rejected the tea leaves, which amounted to 162 kilograms (357 lb). The governor of Shizuoka Prefecture Heita Kawakatsu stated that "there is absolutely no problem when they [people] drink them because it will be diluted to about ten becquerels per kilogram when they steep them even if the leaves have 1,000 becquerels per kilogram," which was a consequence of own examinations of the prefecture. Minister for Consumer Affairs and Food Safety Renh? stated on 3 June 2011, that "there are cases in which aracha are sold as furikake [condiments sprinkled on rice] and so on and they are eaten as they are, therefore we think that it is important to inspect tea leaves including aracha from the viewpoint of consumers' safety."

See also

References

Further reading

• "Green tea (Chinese tea)". Cancer Research UK. 7 January 2013. Retrieved December 2014. 
• "Green tea: the elixir of life or just hype?". NHS Choices. 12 June 2013. Retrieved December 2014. 
• Evans, John C. Tea in China: The History of China's National Drink. Greenwood Press, 1992. ISBN 978-0-313-28049-8
• Lam, K.C./Lam, K.S. The Way of Tea: The Sublime Art of Oriental Tea Drinking. Barron's Educational Series, 2002. ISBN 978-0-7641-1968-2

External links

• Green Tea (an overview from the University of Maryland Medical Center)
• NCCIH - Green Tea Side Effects and Cautions (From the National Center for Complementary and Integrative Health)
• WebMD review about the health benefits of green tea

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Bariatric surgery (weight loss surgery) includes a variety of procedures performed on people who have obesity. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestine to a small stomach pouch (gastric bypass surgery).

Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%. However, a study in Veterans Affairs (VA) patients has found no survival benefit associated with bariatric surgery among older, severely obese people when compared with usual care, at least out to seven years.

The U.S. National Institutes of Health recommends bariatric surgery for obese people with a body mass index (BMI) of at least 40, and for people with BMI 35 and serious coexisting medical conditions such as diabetes. However, research is emerging that suggests bariatric surgery could be appropriate for those with a BMI of 35 to 40 with no comorbidities or a BMI of 30 to 35 with significant comorbidities. The most recent ASMBS guidelines suggest the position statement on consensus for BMI as indication for bariatric surgery. The recent guidelines suggest that any patient with a BMI of more than 30 with comorbidities is a candidate for bariatric surgery.

Indications

A medical guideline by the American College of Physicians concluded:

• "Surgery should be considered as a treatment option for patients with a BMI of 40 kg/m² or greater who instituted but failed an adequate exercise and diet program (with or without adjunctive drug therapy) and who present with obesity-related comorbid conditions, such as hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea. A doctor-patient discussion of surgical options should include the long-term side effects, such as possible need for reoperation, gallbladder disease, and malabsorption."
• "Patients should be referred to high-volume centers with surgeons experienced in bariatric surgery."

Recently the International Diabetes Federation issued a position statement suggesting "Under some circumstances people with a BMI 30-35 should be eligible for surgery." When determining eligibility for bariatric surgery for extremely obese patients, psychiatric screening is critical; it is also critical for determining postoperative success. Patients with a body-mass index of 40 kg/m² or greater have a 5-fold risk of depression, and half of bariatric-surgery candidates are depressed.

Classification of surgical procedures

Procedures can be grouped in three main categories: Standard of care in the United States and most of the industrialized world in 2009 is for laparoscopic as opposed to open procedures. Future trends are attempting to achieve similar or better results via endoscopic procedures.

Predominantly malabsorptive procedures

In predominantly malabsorptive procedures, although they also reduce stomach size, the effectiveness of these procedures is derived mainly from creating a physiological condition of malabsorption.

Biliopancreatic diversion

This complex operation is termed biliopancreatic diversion (BPD) or the Scopinaro procedure. The original form of this procedure is now rarely performed because of problems with malnourishment. It has been replaced with a modification known as duodenal switch (BPD/DS). Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum.

In around 2% of patients there is severe malabsorption and nutritional deficiency that requires restoration of the normal absorption. The malabsorptive effect of BPD is so potent that those who undergo the procedure must take vitamin and dietary minerals above and beyond that of the normal population. Without these supplements, there is risk of serious deficiency diseases such as anemia and osteoporosis.

Because gallstones are a common complication of the rapid weight loss following any type of bariatric surgery, some surgeons remove the gallbladder as a preventive measure during BPD. Others prefer to prescribe medications to reduce the risk of post-operative gallstones.

Far fewer surgeons perform BPD compared to other weight loss surgeries, in part because of the need for long-term nutritional follow-up and monitoring of BPD patients.

Jejunoileal bypass

This procedure is no longer performed.

Endoluminal sleeve

A study on humans was done in Chile using the same technique however the results were not conclusive and the device had issues with migration and slipping. A study recently done in the Netherlands found a decrease of 5.5 BMI points in 3 months with an endoluminal sleeve.

Predominantly restrictive procedures

Procedures that are solely restrictive, act to reduce oral intake by limiting gastric volume, produces early satiety, and leave the alimentary canal in continuity, minimizing the risks of metabolic complications.

Vertical banded gastroplasty

In the vertical banded gastroplasty, also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.

Adjustable gastric band

The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today with a mortality rate of 0.05%.

Sleeve gastrectomy

Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

This combined approach has tremendously decreased the risk of weight loss surgery for specific groups of patients, even when the risk of the two surgeries is added. Most patients can expect to lose 30 to 50% of their excess body weight over a 6-12 month period with the sleeve gastrectomy alone. The timing of the second procedure will vary according to the degree of weight loss, typically 6 - 18 months.

• Stomach volume is reduced, but it tends to function normally so most food items can be consumed in small amounts.
• Removes the portion of the stomach that produces the hormone that stimulates hunger (Ghrelin), although the durability of this removal has yet to be confirmed.
• Dumping syndrome is less likely due to the preservation of the pylorus (although dumping can occur any time stomach surgery takes place).
• Minimizes the chance of an ulcer occurring.
• By avoiding the intestinal bypass, the chance of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced.
• Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m²).
• Limited results appear promising as a single stage procedure for low BMI patients (BMI 35-45 kg/m²).
• Appealing option for people with existing anemia, Crohn's disease, irritable bowel syndrome, and numerous other conditions that make them too high risk for intestinal bypass procedures.

Intragastric balloon (gastric balloon)

Intragastric balloon involves placing a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5-9 BMI over half a year. While not yet approved by the FDA the intragastric balloon is approved in Australia, Canada, Mexico, India and several European and South American countries. The intragastric balloon may be used prior to another bariatric surgery in order to assist the patient to reach a weight which is suitable for surgery, further it can also be used on several occasions if necessary.

Gastric plication

Basically, the procedure can best be understood as a version of the more popular gastric sleeve or gastrectomy surgery where a sleeve is created by suturing rather than removing stomach tissue thus preserving its natural nutrient absorption capabilities. Gastric plication significantly reduces the volume of the patient's stomach, so smaller amounts of food provide a feeling of satiety. The procedure is producing some significant results that were published in a recent study in Bariatric Times and are based on post-operative outcomes for 66 patients (44 female) who had the gastric sleeve plication procedure between January 2007 and March 2010. Mean patient age was 34, with a mean BMI of 35. Follow-up visits for the assessment of safety and weight loss were scheduled at regular intervals in the postoperative period. No major complications were reported among the 66 patients. Weight loss outcomes are comparable to gastric bypass.

The study describes gastric sleeve plication (also referred to as gastric imbrication or laparoscopic greater curvature plication) as a restrictive technique that eliminates the complications associated with adjustable gastric banding and vertical sleeve gastrectomy--it does this by creating restriction without the use of implants and without gastric resection (cutting) and staples.

Mixed procedures

Mixed procedures apply both techniques simultaneously.

Gastric bypass surgery

A common form of gastric bypass surgery is the Roux-en-Y gastric bypass, where a small stomach pouch is created with a stapler device and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.

The gastric bypass had been the most commonly performed operation for weight loss in the United States, and approximately 140,000 gastric bypass procedures were performed in 2005. Its market share has decreased since then and by 2011, the frequency of gastric bypass was thought to be less than 50% of the weight loss surgery market.

A factor in the success of any bariatric surgery is strict post-surgical adherence to a healthy pattern of eating.

There are certain patients who cannot tolerate the malabsorption and dumping syndrome associated with gastric bypass. In such patients, although earlier considered to be an irreversible procedure, there are instances where gastric bypass procedure can be partially reversed.

Sleeve gastrectomy with duodenal switch

A variation of the biliopancreatic diversion includes a duodenal switch. The part of the stomach along its greater curve is resected. The stomach is "tubulized" with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75-100 cm from the colon.

Implantable gastric stimulation

This procedure where a device similar to a heart pacemaker is implanted by a surgeon, with the electrical leads stimulating the external surface of the stomach, is being studied in the USA. Electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of bariatric surgery.

Eating after bariatric surgery

Immediately after bariatric surgery, the patient is restricted to a clear liquid diet, which includes foods such as clear broth, diluted fruit juices or sugar-free drinks and gelatin desserts. This diet is continued until the gastrointestinal tract has recovered somewhat from the surgery. The next stage provides a blended or pureed sugar-free diet for at least two weeks. This may consist of high protein, liquid or soft foods such as protein shakes, soft meats, and dairy products. Foods high in carbohydrates are usually avoided when possible during the initial weight loss period.

Post-surgery, overeating is curbed because exceeding the capacity of the stomach causes nausea and vomiting. Diet restrictions after recovery from surgery depend in part on the type of surgery. Many patients will need to take a daily multivitamin pill for life to compensate for reduced absorption of essential nutrients. Because patients cannot eat a large quantity of food, physicians typically recommend a diet that is relatively high in protein and low in fats and alcohol.

Fluid recommendations

It is very common, within the first month post-surgery, for a patient to undergo volume depletion and dehydration. Patients have difficulty drinking the appropriate amount of fluids as they adapt to their new gastric volume. Limitations on oral fluid intake, reduced calorie intake, and a higher incidence of vomiting and diarrhea are all factors that have a significant contribution to dehydration. In order to prevent fluid volume depletion and dehydration, a minimum of 48-64 fl oz should be consumed by repetitive small sips all day.

Effectiveness of surgery

Weight loss

In general, the malabsorptive procedures lead to more weight loss than the restrictive procedures; however, they have a higher risk profile. A meta-analysis from University of California, Los Angeles, reports the following weight loss at 36 months:

• Biliopancreatic diversion -- 117 Lbs / 53 kg
• Roux-en-Y gastric bypass (RYGB) -- 90 Lbs / 41 kg
  • Open -- 95 Lbs/ 43 kg
  • Laparoscopic -- 84 Lbs / 38 kg
• Vertical banded gastroplasty -- 71 Lbs / 32 kg

The maximum weight loss occurs in the first 10 months after surgery. More recent studies have demonstrated that the medium (3-8 years) and long term (> 10 years) weight loss results for RYGB and LAGB become very similar. However, the range of excess weight loss for LAGB patients (25% to 80%) is much broader than that of RYGB patients (50% to 70%). Data (beyond 5 years) for sleeve gastrectomy indicates weight loss statistics similar to RYGB.

Reduced mortality and morbidity

In the short term, weight loss from bariatric surgeries is associated with reductions in some comorbidities of obesity, such as diabetes, metabolic syndrome and sleep apnea, but the benefit for hypertension is uncertain. It is uncertain whether any given bariatric procedure is more effective than another in controlling comorbidities. There is no high quality evidence concerning longer-term effects compared with conventional treatment on comorbidities.

Bariatric surgery in older patients has also been a topic of debate, centered on concerns for safety in this population; the relative benefits and risks in this population is not known.

Given the remarkable rate of diabetes remission with bariatric surgery, there is considerable interest in offering this intervention to people with type 2 diabetes who have a lower BMI than is generally required for bariatric surgery, but high quality evidence is lacking and optimal timing of the procedure is uncertain.

Laparoscopic bariatric surgery requires a hospital stay of only one or two days. Short-term complications from laparoscopic adjustable gastric banding are reported to be lower than laparoscopic Roux-en-Y surgery, and complications from laparoscopic Roux-en-Y surgery are lower than conventional (open) Roux-en-Y surgery.

Costs of Surgery

The costs of bariatric surgery depend on the type of procedure performed and method of payment along with location-specific factors including geographical region, surgical practice and hospital in which the surgery is performed.

The four established procedure types, Roux-en-Y gastric bypass, gastric banding, vertical sleeve gastrectomy (gastric sleeve) and duodenal switch, carry an average cost in the United States of $24,000, $15,000, $19,000 and $27,000, respectively. However, location-specific costs can vary significantly. Quoted costs generally include day-of-surgery fees for the hospital, surgeon, surgical assistant, anesthesia and implanted devices (if applicable). Depending on the surgical practice, quoted costs may or may not include pre-op, post-op or longer-term follow-up office visits.

Adverse effects

Complications from weight loss surgery are frequent. A study of insurance claims of 2522 who had undergone bariatric surgery showed 21.9% complications during the initial hospital stay and a total of 40% risk of complications in the subsequent six months. This was more common in those over 40 and led to an increased health care expenditure. Common problems were gastric dumping syndrome in about 20% (bloating and diarrhea after eating, necessitating small meals or medication), leaks at the surgical site (12%), incisional hernia (7%), infections (6%) and pneumonia (4%) where the mortality was 0.2%. As the rate of complications appears to be reduced when the procedure is performed by an experienced surgeon, guidelines recommend that surgery be performed in dedicated or experienced units. It has been observed that the rate of leaks was greater in low volume centres whereas high volume centres showed a lesser leak rate. Leak rates have now globally decreased to a mean of 1-5%.

Metabolic bone disease manifesting as osteopenia and secondary hyperparathyroidism have been reported after Roux-en-Y gastric bypass surgery due to reduced calcium absorption. The highest concentration of calcium transporters is in the duodenum. Since the ingested food will not pass through the duodenum after a bypass procedure, calcium levels in the blood may decrease, causing secondary hyperparathyroidism, increase in bone turnover, and a decrease in bone mass. Increased risk of fracture has also been linked to bariatric surgery.

Rapid weight loss after obesity surgery can contribute to the development of gallstones as well by increasing the lithogenicity of bile. Adverse effects on the kidneys have been studied. Hyperoxaluria that can potentially lead to oxalate nephropathy and irreversible renal failure is the most significant abnormality seen on urine chemistry studies. Rhabdomyolysis leading to acute kidney injury, and impaired renal handling of acid and base has been reported after bypass surgery.

Nutritional derangements due to deficiencies of micronutrients like iron, vitamin B12, fat soluble vitamins, thiamine, and folate are especially common after malabsorptive bariatric procedures. Seizures due to hyperinsulinemic hypoglycemia have been reported. Inappropriate insulin secretion secondary to islet cell hyperplasia, called pancreatic nesidioblastosis, might explain this syndrome.

Bariatric Surgery in Youth

As childhood obesity has more than doubled over recent years and more than tripled in adolescents (according to the CDC), bariatric surgery for youth has become increasingly common. Society worries that a decline in life expectancy might occur from the increasing levels of obesity. There is an innate moral obligation to provide youth with proper care in order to prevent serious medical complications from obesity and its related diseases. Difficulties and ethical issues arise when making decisions related to obesity treatments for those that are too young or otherwise unable to give consent without adult guidance.

Children and adolescents are still developing, both physically and mentally. This makes it difficult for them to make an informed decision and give consent to move forward with a treatment. Not only do age and maturity level of patients affect their ability to make informed decisions but patients may also be experiencing severe depression or other psychological disorders related to their obesity that make understanding the information very difficult. Young children and adolescents may also have become desperate or feel that there is no other way out of their situation. Decision makers are often overwhelmed with this feeling and strong preconceived conceptions that this will solve all of their problems make for rather uninformed decisions.

History

Open weight loss surgery began slowly in the 1950s with the intestinal bypass. It involved anastomosis of the upper and lower intestine, which bypasses a large amount of the absorptive circuit, which caused weight loss purely by the malabsorption of food. Later Drs. J. Howard Payne, Lorent T. DeWind and Robert R. Commons developed in 1963 the Jejuno-colic Shunt, which connected the upper small intestine to the colon. The laboratory research leading to gastric bypass did not begin until 1965 when Dr. Edward E. Mason and Chikashi Ito at the University of Iowa developed the original gastric bypass for weight reduction which led to fewer complications than the intestinal bypass and for this reason Mason is known as the "father of obesity surgery".

See also

• Revision weight loss surgery

References

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Moringa, native to parts of Africa and Asia, is the sole genus in the flowering plant family Moringaceae. The name is derived from murungai/muringa, the Tamil/Malayalam word for drumstick. It contains 13 species from tropical and subtropical climates that range in size from tiny herbs to massive trees.

The most widely cultivated species is Moringa oleifera, a multipurpose tree native to the foothills of the Himalayas in northwestern India and cultivated throughout the tropics. M. stenopetala, an African species, is also widely grown, but to a much lesser extent than M. oleifera.

Moringa species grow quickly in many types of environments.

Nutritional content

Much of the plant is edible by humans or by farm animals. The leaves are rich in protein, vitamin A, vitamin B, vitamin C, and minerals. A 100-g portion of fresh moringa leaves has 9.3 g protein, 434 mg calcium, 404 mg potassium, 738 ?g vitamin A, and 164 mg vitamin C.

Feeding the high-protein leaves to cattle has been shown to increase weight gain by up to 32% and milk production by 43 to 65%. The seeds contain 30 to 40% oil that is high in oleic acid, while degreased meal is 61% protein. The defatted meal is a flocculant and can be used in water purification to settle out sediments and undesirable organisms.

According to the NGO, Trees For Life International, gram for gram, raw moringa leaves contain 7 times the vitamin C of Oranges, 4 times the vitamin A of carrots, 4 times the calcium of milk, 3 times the calcium of bananas, and 2 times the protein of Yogurt. The nutrients of the powdered leaves are different. Gram for gram, moringa leaf powder contains 10 times the vitamin A of carrots, 17 times the calcium of milk, 15 times the potassium of bananas, 25 times the iron of spinach, 9 times protein of yogurt, 4 times more fiber than oats, and 1/2 the vitamin c of oranges.

Moringa is very susceptible to oxidation similar to apples and avocados and will turn brown if it is exposed to oxygen or light for too long after being picked.

Farming worldwide

Moringa cultivation is on the rise in Honduras and all across South America. Claims are made that it is a profitable means of combating deforestation, but Moringa species are not native to the forests of the New World. As of 2012, support for Moringa farmers is being offered by the Honduran federal government through the Secretary of Agriculture and by private foreign investment firms. The plant's market potential is widespread given its easy growth and high nutrient content. As described below, the plant is valued for its leaves and high-protein seeds. It can also be made into defatted meal. M. oleifera silviculture is being promoted as a means to combat poverty and malnutrition.

M. oleifera is being cultivated in poverty-stricken nations, such as Niger, as a primary source of food and nutrients, and a source of income through sales due to widespread and global marketability.

In Haiti, moringa is planted as a windbreak and to reduce soil erosion. The trees provide many products from oil to soil amendments (fertilizers) and tisanes made from the leaves.

In Mexico, Reserva Las Estacas, in Morelos, includes the cultivation of moringa.

Biodiesel

Moringa is considered a potential oilseed feedstock for biodiesel. Its main advantage is that biofuel produced from it is not in direct competition with food, as the plant produces both biofuel feedstock (seeds) and food (leaves) independently. Moringa seeds contain 30 to 40% oil that is high in oleic acid. Its biodiesel has better oxidative stability than biodiesel made from most other feedstocks. Leaves and seeds can be harvested from mature trees without damaging them.

List of species

• Moringa arborea Verdc. (Kenya)
• Moringa borziana Mattei
• Moringa concanensis Nimmo
• Moringa drouhardii Jum. - bottle tree (southwestern Madagascar)
• Moringa hildebrandtii Engl. - Hildebrandt's moringa (southwestern Madagascar)
• Moringa longituba Engl.
• Moringa oleifera Lam. (syn. M. pterygosperma) - horseradish tree (northwestern India)
• Moringa ovalifolia Dinter & Berger
• Moringa peregrina (Forssk.) Fiori
• Moringa pygmaea Verdc.
• Moringa rivae Chiov.
• Moringa ruspoliana Engl.
• Moringa stenopetala (Baker f.) Cufod.

References

External links

• Mark Olson's Moringa Home Page: Photos and information on all 13 species
• [1] Mark Olson's Moringa blog - information on frequently asked Moringa questions
• The Magic Tree: Info about moringa in different languages
• Purdue University: Moringa oleifera
• Trees for Life Moringa Site

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"Weight Loss" is the collective name for the first and second episodes of the fifth season of the American comedy television series The Office, and the show's 73rd and 74th episodes overall. Written by Lee Eisenberg and Gene Stupnitsky, and directed by Paul Feig, the episode first aired as a single 60 minute show in the United States on September 25, 2008 on NBC. "Weight Loss" guest stars Amy Ryan as Holly Flax, Dale Raoul as Ronni, and Rich Sommer as Alex.

The series--presented as if it were a real documentary--depicts the everyday lives of office employees in the Scranton, Pennsylvania, branch of the fictional Dunder Mifflin Paper Company. In this episode, the whole office participates in a company-wide weight loss contest. Pam (Jenna Fischer) is in New York City for art school, which causes her and Jim to have to adjust to being temporarily apart. An awkward tension between Michael (Steve Carell) and Holly (Ryan) develops after she accepts a date with another man. Meanwhile, Angela (Angela Kinsey) and Dwight (Rainn Wilson) continue their secret relationship despite that Angela's wedding to Andy nears.

Plot

The office partakes in a company-wide weight loss competition, with the prize of extra vacation days for the winning branch. Initially enthusiastic, the competition eventually weighs on the staff, especially Kelly Kapoor (Mindy Kaling) who stops eating and tries numerous diets, eventually passing out during one weigh-in. Corporate responds with a memo that staff should not resort to drastic weight loss measures. The Scranton branch ends up losing the competition, although Stanley Hudson (Leslie David Baker) is proud of his individual results.

Pam Beesly (Jenna Fischer) begins a three-month graphic design class in New York. Wanting to see her, Jim Halpert (John Krasinski) meets Pam for lunch at an interstate rest stop between Scranton and New York City. He proposes to her outside in the pouring rain, and she accepts ecstatically.

Plotting his return to the company, Ryan Howard (B. J. Novak) apologizes to various people around the office for his past behavior. Most notably, he apologizes and then proceeds to ask out his former girlfriend Kelly Kapoor (Mindy Kaling), only to be rejected when she tells him that she is dating Darryl Philbin (Craig Robinson).

Holly Flax (Amy Ryan) yells at Angela Martin (Angela Kinsey) for chastising Kevin Malone (Brian Baumgartner), still believing he is mentally retarded. He awkwardly reveals he is not retarded, and an embarrassed Holly apologizes and walks away. Holly continues to show interest in Michael Scott (Steve Carell), now with a David Brent style goatee, until she catches him talking to a pregnant Jan Levenson (Melora Hardin). Holly then goes out on a date with Oscar's yoga instructor, and buys Counting Crows tickets as a surprise for their next date. When he never calls her, Michael berates the yoga instructor to Holly's pleasure, then offers to buy the tickets from her only to tear them up.

Phyllis Lapin-Vance (Phyllis Smith) takes over the Party Planning Committee by blackmailing Angela with her knowledge of Angela and Dwight's secret affair. After Angela shoots down all of Andy's wedding ideas, she warms up to him until he tells her that he booked his a cappella band to play at their wedding.

Toby Flenderson (Paul Lieberstein) is briefly seen in a Costa Rican hospital due to a neck injury while zip-lining.

Reception

In the 18-49 demographic, "Weight Loss" earned a 4.9/11 ratings share. The episode was watched by 9.1 million viewers.

Jim's proposal to Pam ranked number 2 in phillyBurbs.com's top ten moments from the fifth season of The Office. Dwight and Angela carrying on their affair in the hidden corner of the warehouse during business hours ranked number 7 on that list. Writer Jen Weilgus described Dwight's line, "We done good in there, Half Pint," as the best quote of the season. Ryan's return as a temp in this episode, tied with his second return appearance in the episode "Dream Team", ranked number 5 in the list. Travis Fickett of IGN claims, "It's another terrifc mix of character and comedy is perfectly balanced." At the end of the article he says that, "The Office remains one of the funniest, best written, best performed and one the best shows of TV. Period." "Weight Loss" was voted the second highest-rated episode out of 26 from the fifth season, according to an episode poll at the fansite OfficeTally; the episode was rated 8.92 out of 10.

References

External links

• "Weight Loss" at NBC.com
• "Weight Loss" at the Internet Movie Database

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