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  • Body mass index (BMI) > 40.
  • BMI between 35 and 40 and presence of such comorbid conditions as severe obstructive sleep apnea, pickwickian syndrome, obesity-related cardiomyopathy, degenerative joint disease, diabetes mellitus, hypertension, and hyperlipidemia.
  • Failed dietary attempts at weight loss.

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Absolute

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  • Active substance abuse.
  • Severe psychiatric disorders.
  • Pregnancy.
  • Untreated esophagitis.

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Relative

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  • BMI < 35.
  • Age younger than 18 years.
  • Age older than 60 years.
  • Desire to become pregnant within 2 years.

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Expected Benefits

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  • Loss of 50–80% of excess weight.
  • Improvement of comorbid factors.

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Potential Risks

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  • Overall mortality < 1%.
  • Anastomotic leak (1%).
  • Anastomotic stricture (5–10%).
  • Wound complications (infection, hernia) more common with open surgery (15–20%) than with laparoscopic procedure (2–5%).
  • Systemic complications of major surgery (pneumonia, venous thromboembolism, and cardiovascular events).

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  • Operating table capable to accommodate the morbidly obese patient.
  • Extra-large sequential compression device (SCD) stockings.
  • For laparoscopic surgery, video telescopic equipment with two monitors and extra-long instruments (laparoscope, graspers, staplers, ultrasonic dissector, suction/irrigator).
  • For gastric bypass procedure, end-to-end anastomosis (EEA) stapler.

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  • Upper endoscopy if indicated by symptoms (heartburn, regurgitation, dysphagia, epigastric pain, anemia).
  • Right upper quadrant ultrasound to rule out cholelithiasis if indicated by symptoms.
  • Cardiovascular evaluation.
  • Psychiatric evaluation.
  • Nutritionist evaluation.

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Open Operation

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  • The patient should be supine with arms abducted and extended.

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Laparoscopic Operation

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  • The patient should be supine with arms abducted and extended.
  • Split-leg position is preferable.
  • Contact and pressure points should be padded.
  • The patient must be well secured to the operating table.

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Roux-en-Y Gastric Bypass: Open and Laparoscopic

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  • Figure 9–1: The typical port placement for a laparoscopic approach.
  • Following port placement, the abdomen is explored.
  • The jejunum is divided approximately 30–40 cm from the ligament of Treitz and the alimentary (Roux) limb is tagged with Penrose drain.
  • Figure 9–2: Creation of a side-to-side stapled enteroenterostomy 100–150 cm from the stapled end of the alimentary limb.
  • The mesenteric defect is closed with permanent sutures.
  • The omentum is divided with an ultrasonic dissector.
  • A Nathanson liver retractor is used to elevate the left lateral segment, exposing the proximal stomach.
  • The patient is placed into steep reverse Trendelenburg position.
  • Peritoneal attachments between the diaphragm and the cardia at the angle of His are bluntly divided.
  • The lesser omentum is incised at the pars flaccida portion and divided up to the proximal lesser curvature with an endoscopic stapler.
  • A gastrotomy is made in the body of the stomach with an ultrasonic dissector. This will be closed with an endoscopic stapler after anvil introduction.
  • The anvil from a 25-mm EEA stapler is introduced through the 15-mm port site and inserted into the gastrotomy. The anvil tip is brought out through the proximal stomach, near the lesser curvature, between the first and second lesser curvature vessels.
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