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Operating methods

How does the anaesthesia work during an obesity operation?

By | News, Operating methods

Our anaesthesiologist Magnus explains

The purpose of the anaesthesia in bariatric surgery – in addition to making it possible to operate – is to help you feel as good as possible after surgery taking into account pain, nausea, mobilization and temperature control.

When you enter the operating room, you have probably already received a peripheral venous catheter in one arm, at the ward. We will carry out an additional verification of your identity and confirm the type of operation that is planned. In the room there are some people who all have a specific role during the operation: we are 2-3 surgical nurses, 2 surgeons, 1-2 anesthesiology nurses and one anesthesiologist.

You lie down on the operating table and some of the operations team work around you, connect you to surveillance equipment and start preparing the operation. There will be no stings or other painful things that are done in the operating room while you are awake. We also connect our drug pumps to the venous catheter and soon start giving you a small dose of medicine to help you relax before you go to sleep.

Anaesthesia with intravenous drugs in gastric bypass and sleeve gastrectomy

In the pumps there are 2 different medications, propofol (sedative agent) and remifentanil which is a strong analgesic medicine akin to morphine. In some patients, a burning sensation is experienced during the infusion into the vein that goes away with local anesthesia. It is not dangerous and does not indicate that the venous catheter is in the wrong place. Before you fall asleep completely, you breathe pure oxygen through a mask. This is a safety measure. If you experience the mask very unpleasant, we can in most cases lighten some on the mask so it does not close too tightly.

While you’re asleep, we’ll tilt the whole table in the way that we elevate the head end. To ensure that you do not slip during the operation, there is a footplate that you should lie close to with your sole and we also put a seat belt around your legs.

FREQUENTLY ASKED QUESTIONS:

Will I be in pain after surgery?
Most of our patients feel pretty good when they wake up after surgery and some even ask if we should not start operating soon! We will transfer you in a bed to the recovery area and you will be monitored for 1-2 hours before you can get to your room. Approximately 15-20 minutes after the end of surgery, most of the anesthesia has lost its effect and you can expect discomfort similar to post exercise muscle aches in the abdominal wall, as if you had done too many situps the day before. Many also experience pain in their shoulders. This is explained by irritation of the diaphragm and abdominal cavity after the laparoscopic surgery and that these organs share sensorics with the shoulders – so we have done nothing with the shoulders. Some patients have an experience of suction high up in the middle of the abdominal cavity. Often it is effective pain relief to change position and rise up to reduce these discomforts.

You don’t have to worry about suffering from severe pain. You should be so well pain-relieved that you can draw deep breaths, cough, be able to move in bed and relax. Please also see our information video about general anesthesia.
You will get extra pain relief if necessary – but the goal of pain relief is to make your discomfort manageable, not to make you painless! If we were to be too generous with pain-relieving drugs (morphine-like agents), it would greatly contribute to increased nausea, lower your ability to breathe and make you very lethargic. The goal is to help you move as soon as possible and stand up on your feet. This is to reduce the risk of blood clots and lung complications and to get the small intestine up and running again.

What pain killers will I receive?
Pain relief consists of different parts. By default, paracetamol and anti-inflammatory medicine (eterocoxib) are given in tablet form at the ward. During the operation we also give you oxycodone, clonidine and local anesthesia in the abdominal wall where the peepholes will be.

Am I going to feel sick after the surgery?
It’s individual how likely you are to feel sick after surgery. Patients who suffer from motion sickness and have felt ill during previous anaesthisia have an increased risk of nausea. Sleeve gastrectomy patients feel to some extent more ill the first hours after surgery than other types of surgery. In any case, this will pass, usually the first hours or before evening. To reduce the risk of nausea, we provide preventive medicines as a standard, in addition to that we avoid all anesthetic gases and instead sedate using propofol.

Am I completely sedated during the operation?
Yes, it’s the only way to perform laparoscopic operations safely.

Can I wake up during the operation?
No. We constantly monitor you during the operation and would notice if something did not look right a long time before you would be conscious. The medicines we use have been used for a long time and we have performed thousands of these operations without it ever happening. Among other things, we monitor heart rate, blood pressure, oxygenation, body movements, breath size, pressure in the airways and your eye movements.

When do I wake up?
You wake up from the sedation to the degree that you can breathe yourself and we can communicate with you in simple sentences immediately after completing the operation when you are still on the operating table. In most cases, patients do not remember these first few minutes afterwards. However, you will be tired in the first few hours after surgery when you are in the recovery unit and most fall asleep for shorter periods there.

Do I get a tube in my throat?
Yes, but only while you’re asleep. You won’t be awake with a tube in your throat.
We use a tube to help you breathe and it is called an endotracheal tube. It goes down the trachea. A second tube goes down the esophagus. In some cases, patients may subsequently experience discomfort in the throat, similar to the onset of tonsillitis. It usually goes over in 1-2 days.

When can I see my relatives?
After you leave the recovery department. Since there are other patients who are waking up in the room, we are not able to receive relatives there. Most often you can call your relatives from the recovery department.

Gastric bypass surgery, pros and cons

By | Body weight regulation, Operating methods

The gastric bypass (GBP) operation has actually been around for more than 50 years, the American surgeon Edward Mason published “Gastric bypass in obesity” in 1967. The first decades this was open surgery, nowadays it is always laparoscopic. We have gained the most knowledge about the long-term effects of the operation from the Swedish SOS study (Swedish Obese Subjects study). In SOS, a small proportion of patients had gastric bypass surgery, the rest had had gastric banding surgery or a VBG. Gastric banding and VBG (vertical band-reinforced gastroplasty) both had the same principle in common, so-called “restriction”. In plain language: make the stomach smaller, so the person with obesity is forced to eat less and lose weight.

Now, however, gastric bypass proved to be in every way superior to banding and VBG in SOS and upcoming studies; it produced better weight loss and more other positive effects on health: including highly effective treatment of type 2 diabetes (even at BMI less than 35).

Gastric bypass effective

Why was gastric bypass more effective than the older methods of banding and VBG? All three procedures give the operated person a smaller stomach, but gastric bypass is different as it at the same time fundamentally counteracts the body’s own defense against weight loss: a GBP leads to the body’s so-called set point for weight (our “weight thermostat”) in the brain being lowered towards normal levels. This is achieved via a variety of positive hormonal effects in the body, which in itself come out of the intestinal bypass that is done during a gastric bypass (but not during banding or VBG). You could say that the operation has its main effect on the brain – even though you only operate in the abdomen!

Gastric bypass benefits

What are the benefits of a gastric bypass operation? It is extremely well proven and over the years refined. We know very well how a GBP should be performed technically by the surgeon. The operation provides very effective weight loss and it lasts a lifetime. You get health effects at all levels (life is extended on average 6.7 years, it is effective treatment of type 2 diabetes, sleep apnea syndrome, osteoarthritis, PCOS, high blood pressure, cardiovascular disease, fatty liver disease, gout and more. In women, the risk ofdying from a cancer ishalved .).

… and cons

What are the disadvantages? Yes there is initially about 3% risk of serious complications (mainly bleeding and leakage). These can be remedied but often require new surgery. The long-term surgical risk is ileus (in this case also called mesenterial herniation) which comes from changing the anatomy of the small intestine during bypass surgery. Ileus results in acute blockage of the intestine and one must seek emergency medical care. They can be cured, but require a new operation. In the past, this was relatively common, the risk was 5-10%, while today it is prevented at the initial operation (one “closes the mesenterial defects“). Today, the risk is instead 1-3% approximately. Other more medical disadvantages are the risk of dumping (lowering of blood sugar and blood pressure after eating certain foods), increased sensitivity to alcohol and impaired vitamin uptake. The latter is easy to prevent with vitamin supplements -but studies prove this to be difficult to maintain for life for patients (who otherwise feel excellent as a rule and perhaps have lost their previous medicines…). More about both pros and cons can be found in the annual report from the Swedish Obesity Surgery Register SOREG.

Gastric bypass or gastric sleeve?

In recent years, gastric bypass has had a “cousin” namely sleeve gastrectomy (SG). We will talk more about this in the upcoming blog. Which of the two is best? Well, both are excellent, both have disadvantages. Exactly when which of them is “best” … we actually don’t know for sure. This is being studied in Sweden via the BEST study (where GB Obesitas is involved).

Want to know more? Join us for the next information meeting!

Sleeve gastrectomy -operation, pros and cons

By | Body weight regulation, Operating methods

Gastric sleeve is the alternative name of this operation. It began to be performed in 1988, then as open surgery and as the first half of a more extensive surgery in severe obesity (biliopancretic diversion with duodenal switch). In the late 1990s, sleeve gastrectomy (SG) began to be made laparoscopic and after the turn of the millennium it was increasingly realized that a sleeve “alone” without subsequent bowel disconnection performed well for effective weight loss. After this, gastric sleeve quickly gained a rising popularity and is today the most common obesity surgery in the world, in Sweden it accounted for 45% of all obesity operations in 2018.

Why did sleeve gastrectomy quickly become so popular? Firstly, it is easier for a surgeon to learn (you avoid the intestinal disconnections in a gastric bypass operation), it is perceived as “milder” than bypass with less risk of dumping and no postoperative ileus.

Gastric sleeve mechanisms of action

How does a sleeve work? It is a gastric operation, where you surgically remove 85% of the stomach (you remove the “outer curve” of the stomach). However, you do not operate at all on the intestine. Removed part of the stomach is taken out of the body. There are several mechanisms of action: at the beginning it is clearly restrictive, i.e. the stomach is very small and limiting. In the long run, however, the effect on our hunger hormones is central; just as with gastric bypass, a gastric sleeve lowers our set point for weight in the brain stem to more normal levels. The daily routines required after an SG are the same as after a bypass -you have to adapt to the new anatomy of the stomach, as well as what you can now tolerate or can not tolerate eating and drinking: 5-6 small meals per day, at least 1.5 L of water per day, be physically active and take daily vitamin supplements.

Sleeve gastrectomy pros and cons

This is an excellent operation,as well as with bypass, it has pros and cons. There have been some misconceptions about sleeve gastrectomy; sometimes it has been described as “being able to eat the cake and still keep it” (i.e. gain effective weight loss without having to exert so much, avoid dumping risk and not have to take vitamins) which is definitely incorrect: a sleeve operated person needs to do their daily routines in exactly the same way as a bypass operated one. Exactly when a sleeve is the best to choose we do not know (that’s why GB Obesitas is included in the BEST study). But the following has been our view based on clinical experience so far:

Gastric sleeve does not result in any increased ileus risk, unlike gastric bypass. You generally don’t become as dumping sensitive (which is a bit for better or worse, some patients like that they can dump sometimes). Vitamin uptake is impaired, but probably less pronounced so than after a bypass.

The disadvantages are the risk of worsened reflux symptoms (heartburn, acid reflux) and unclear long-term effect on weight. The operation is also not possible to restore to normal anatomy. However, the effect on wieght loss of a sleeve if necessary (usually due to weight gain) can be strengthened with an additional operation: it can be turned into a gastric bypass or a SASI.

Will sleeve gastrectomy continue to be the world’s most common obesity operation in 10 years? The future and -BEST study -will tell us this. Follow us!

Fast track surgery at GB Obesitas

By | Operating methods, Our research | No Comments

If you can carry out a bariatric procedure in anaesthesia faster without the quality going down, then you have won a number of things: the patient is immobilized for a shorter period of time which reduces the risk of blood clots; the anaesthesia itself becomes shorter and produces less side effects.

Our surgical team led by Dr. Gislason has been working on creating as smooth processes around surgery as possible for more than ten years. We have two surgeons working on the patient at each surgery procedure, which reduces the surgical time for a gastric bypass or sleeve gastrectomy to an average of 35 minutes. The turnaround time between two patients in the operating room is, thanks to good teamwork, 10-15 minutes (in the normal hospital environment the switching time between surgeries is often 30-60 minutes). This means that we can operate more patients per day, without any individual patient in any way getting worse care or attention. It also makes it possible for us to keep prices down on our private operating packages.

This fast track concept attracts other teams from Europe and the rest of the world to make study trips and learn how to get the flow to work better at their home clinics. These study visits are organized in cooperation with Medtronic -maybe you will meet a visiting colleague when you are staying with us!

The concept has also been described in research articles by our team (Link No. 1), and we have authored chapters on the subject in textbooks for bariatric surgeons – see below!

Gislason H, Jacobsen HJ, Bergland A, Aghajani E, Nergard BJ, Leifsson BG and Hedenbro J. Fast Track in Bariatric Surgery: Safety, quality, teaching aspects, logistics and cost-efficacy in 8000 consecutive cases. Book chapter in: Minimal Invasive Bariatric and Metabolic Surgery. Principles and Technical Aspects. Eds. Lucchese M & Scopinario N. Springer 2015.

Link No 1: https://w ww.ncbi.nlm.nih.gov/pubmed/22116595

Distal gastric bypass and SASI -alternatives to standard operations

By | Operating methods, Our research | No Comments

The basic operations with us, as in the rest of Sweden, are the surgical procedures gastric bypass and sleeve gastrectomy. These complement each other in a good way, both in terms of advantages, disadvantages and efficiency. For the vast majority it is enough to choose between these two.

But sometimes we see special cases; one example is those with an extra high BMI (BMI above 50). Here, a “regular” gastric bypass can often be quite sufficient even in the long run -but not always. What to do then?

 

Alternative options to standard gastric bypass

Our surgeon team has researched the alternatives to standard gastric bypass -you will find a list of publications below. In order not to make it all too technical and complicated, one can say that the effectiveness of the surgery can be adjusted based on how long a portion of the intestine is disconnected (if the extra-long section of the bowel is disconnected, it is called a distal gastric bypass) or how long a part that remains from the mini-stomach to the large intestine-thus how many centimeters of small bowel that are exposed to the food after the procedure. The shorter this distance is, the more effective weight loss -but also the higher the risk of side effects.

A new option, at high BMI or when a gastric sleeve does not prove to work fully, is the operation SASI (single anastomosis sleeve ileal bypass). Watch our information video here on our site here for more information on SASI!

We will look at your specific situation in connection with our first visit with checklisting. If you might be eligible for any of our more “special” procedures, we’ll discuss it with you. Then we also discuss what special things you will need to consider afterwards (for example, more ambitious follow-up with blood tests, etc.).

 

Scientific work on surgical methods

Leifsson BG, Gislason H. Laparoscopic Roux-en-Y gastric bypass with 2-metre long biliopancreatic limb for morbid obesity: Technique and experience with the 150 first patients. Obesity Surgery 2005;15:35-42.

 

Nergaard BJ, Leifsson BG, Hedenbro J, Gislason. HG. Gastric bypass with long alimentary limb or long pancreato-biliary limb-Long-term results on weight loss, resolution of co-morbidities and metabolic parameters. Obes Surg 2014;24:1595-1602.

 

Shah K, Nergard BJ, Fagerland M. Gislason H. Limb length in gastric bypass in super-obese patients – importance of total alimentary small bowel tract. Accepted for publication in Obesity Surgery.

 

Shah K, Nergard BJ, Fagerland M. Gislason H. Distal gastric bypass – 2 m bilipancreatic limb construction with varying lengths of common channel. Accepted for publication in SOARD.