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Duodenal switch, one of the most complicated weight loss surgeries, is also known as vertical gastrectomy with duodenal switch, gastric reduction with duodenal switch, biliopancreatic diversion with duodenal switch, DS or BPD-DS. Duodenal switch packs a one -two punch against obesity.It does so, by combining two surgical techniques: restrictive and malabsorptive.The restrictive component involves reducing the size of the stomach.Your bariatric surgeon would divide the stomach vertically and remove more than 85% of it. The stomach that remains is shaped like a banana and can accomodate about 100 to 150 mls or 6 ounces.
Duodenal switch is a variation of another procedure, called biliopancreatic diversion.But the duodenal switch leaves a larger portion of the stomach intact including the pyloric valve, which regulates the release of stomach contents into the small intestine.As the name suggests, duodenal switch also keeps small part of the duodenum in the digestive system.Food mixes with stomach acids, then moves down to the duodenum, where they mix with bile from the gall bladder and digestive juices from the pancreas. Malabsorptive surgeries restrict the amount of calories and nutrients that the body absorbs.The malabsorptive component of duodenal switch surgery involves rearranging the small intestine to seperate the flow of food from the flow of bile and pancreatic juice.The food and the digestive juices interact only in the last 18 to 24 inches of the intestine, allowing malabsorption. Unlike the restrictive part of the surgery, the intestinal bypass part of the duodenal switch, is partially reversible, if the patient experiences malabsorptive complications.With the duodenal switch, you consume less food than normal, but it is still more than with other weight loss surgeries.Even this amount of food cannot be digested normally, so a large portion of the food passes undigested through the shortened intestine, thereby causing weight loss in the morbidly obese.This surgery is also done laparoscopically.

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The da Vinci Surgical System
Imagine major surgeries performed through the smallest of incisions.Imagine having the benefits of a definitive treatment but with the potential for significantly less pain, shorter hospital stay, faster return to normal daily activities as well as better clinical outcomes! The product is called "da Vinci " in part, because Leonardo da Vinci invented the first robot. He also used unparelleled anatomical accuracy and three dimensional details to bring his masterpieces to life. It provides surgeons with such enhanced detail and precision that the system can simulate an open surgical environment while allowing operation through tiny incisions. With the da Vinci Surgical system hospitals are rewriting accepted standards for surgical care and changing the experience of surgery. This breakthrough technology is an effective minimally invasive alternative to both open surgery and laparoscopy. Through the use of the da Vinci Surgical system, surgeons are now able to offer a minimally invasive option for complex surgical procedures. Some of the major benefits experienced by surgeons using the da vinci over traditional approaches have been greater surgical precision, increased range of motion,improved dexterity, enhanced visualization and improved access, Benefits experienced by patients include a shorter hospital stay, less pain, less risk of infection, less blood loss, fewer transfusion, less scarring, faster recovery and a quicker return to normal daily activities. None of these can be guaranteed, as surgery is necessarily both patient and procedure specific.
While clinical studies support the effectiveness of the Robotic surgeries, individual results may vary,There are no guarantees of outcome. All surgeries involve the risk of complications. Before you decide on surgery, discuss treatment options with your doctor. Understanding the risk of each treatment can help you make the best decision for your individual situation. It may not be appropriate for every individual, it may not be applicable to your condition. A very common question about robotic surgery is will it make the surgeon unnecessary? On the contrary, it enables surgeons to be more precise,advancing their technique and enhancing their capability in performing complex minimally invasive surgery. The system replicates the surgeons movements in real time. It cannot be programmed, nor can it make decisions on its own to move in any way to perform any type of surgical maneuver without the surgeons input. Does the surgeon have any sensations while performing the procedures ? The system relays some force feedback sensations from the operative field back to the surgeon throughout the procedure. This force feedback substitutes for the tactile sensation and is augmented by the enhanced vision provided by the high resolution 3D view. Although seated at a console few feet away from the patient, the surgeon views an actual image of the surgical field while operating in real time through tiny incisions,using miniaturized, wristed instruments. The system does not maneuver on its own outside of the surgeons direct, real time control.
Robotic surgery, a new tehnology in different parts of the world has its disadvantages also. Its uses and efficacy has not been fully determined. There are not many long term studies on this to confirm or deny its effectiveness. The prominent disadvantages to robotics include Time, Cost , Efficacy and its Compatibility with current and existing conditions. Robotic assisted heart surgeries can take nearly twice the amount of time and the patients are under anaesthesia for longer time . It definitely is more expensive.The cost may fall as surgeons gain more experience and start doing it more often but as the system gets upgraded and improved there are chances that the price may even go higher. Only when these systems gain more multidisciplinary use will the cost become more justified. Another disadvantage is the large system in an overcrowded operating room. The robotic arms are awkward and bulky and there are many instruments needed in the small space. For robotic assisted beating heart surgery the space is even smaller because stabilizers are needed. This cramped area can cause interference with the dexterity of the surgeon. The solution is to miniaturize the robotic arms or have larger operating areas. With either solution, robotics is an especially expensive technology. Current operating room instruments are not compatible with new robotic system. Without the correct equipment, tableside assistance is needed to perform part of the surgery. But with time and improvement in technology, these disadvantages will hopefully be remedied.

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Often called C-difficile, or C- diff, is a type of bacteria that causes symptoms that can range from diarrhea to life threatening inflammation of the colon.Since the commonest cause of this diarrhea is long term use of antibiotics , it is also called antibiotic diarrhea. In recent years C-diff has become more frequent, more severe and difficult to treat.Your risk is greatest if you are taking or have recently taken antibiotics. The risk is higher if you take multiple antibiotics for a prolonged period. Seen more in older age group, recently hospitalized for an extended period. C-diff infections are seen more in nursing home or longterm care facilities. It is found more among patients with weakened immunity and those who have some underlying medical illnesses. Patients who have had some abdominal surgeries or have colon disease such as inflammatory bowel disease , colorectal cancer or previous C-diff infection are also at risk.The antibiotic that most often leads to C-diff infection include fluroquinolones, cephalosporins, clindamycin and penicillins. These drugs can destroy some of the normal, helpful bacterias in your colon. Once established it produces toxins that attacks the lining of the intestine. The toxin destroys cells and produces plaques of inflammatory cells and decaying cell debris inside the colon. Some new strains of C-diff has emerged that are resistant to certain medications and are deadly.
Stool tests like enzyme immune assay and tissue cultures are used to detect this infection.Flexible sigmoidoscopy is sometimes used to confirm the diagnosis. CT scan may be ordered if there is a concern about possible complications like pseudomembranous colitis. Bowel perforation and toxic megacolon are also some of the complication of C-diff.Severe diarrhea may cause dehydration and in some cases kidney function may deteriorate. If not treated promptly this can be fatal.Most common symptoms are, watery diarrhea 10-15 times a day, abdominal cramping, fever, pus or blood in the stool, nausea, dehydration, loss of appetite and weight loss.The first step in treating C-diff is to stop taking the antibiotic that triggered the infection. In an ironic twist, the standard treatment for C-diff is another antibiotic. Usually metronidazole , for mild to moderate and vancomycin, for severe symptoms are the drug of choice. Probiotics are given in conjunction with the antibiotics to restore intestinal flora.For people with severe pain, organ failure or inflammation of the colon , surgery to remove the diseased portion of the colon may be the only option.

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When patients who had weight loss surgery in the past require other procedures to correct the complications or undo the ill effects of their original operation, it is called a revisional weight loss surgical procedure.The clients who seek revisional surgery may have lost their weight only to gain it back or some may have had inadequate weight loss. There are also those patients that had ill effects of their primary operations including ulceration and stricture, in the case of Roux en Y gastric bypass, and slippage and erosion , in case of adjustable gastric banding.There are some patients who have been able to lose the weight and keep it off; however, this comes at the cost of a near constant nausea and frequent vomiting.The failure of the primary surgery is frequently blamed on the patient, however that is usually not the case. A less than ideal outcome of a weight loss surgical procedure can be traced back to a procedure that did not work for that particular patient. Its just like trying a number of blood pressure medications to find the one that works best for them. Alternatively, the procedure may have delivered the best outcome possible which may be inadequate for that particular patient or the condition. Conditions that require revisional weight loss surgery include;
1) Weight regain after initial weight loss.
2.) Inadequate weight loss.
3) Dumping syndrome.
4) Marginal ulcers.
5 ) Solid intolerance.
6) Anemia
7) Nutritional deficiencies.
8) Significant bowel dysfunction.
10) Infected ports and bands (implanted devices)
11) Erosion or slippage of the adjustable band.
12) Recurrence or only partial resolution of comorbid conditions.
13) Stricture or narrowing at the site of bowel anastomosis.
Complication of Roux en Y gastric bypass are dumping syndrome, marginal ulcers and persistant nausea vomiting with solid intolerance, inadequate weight loss or weight regain. In almost all the cases the best option for Roux en Y gastric bypass that is in need of revision is the duodenal switch operation. Adjustable gastric banding ( Lap Band) placement as a weight loss surgery for a primary Roux en Y may only be indicated for patients that have had initial success of weight loss followed by weight regain. This however, should be in the absence of dumping syndrome, marginal ulcers or reflux disease, which can potentially get exacerbated by placement of a band on top of the gastric pouch.
Adjusting the length of the common channel, alimentary limb, allows a revisional weight loss surgery to be tailored to the patient's needs. In case of a patient having a revision of Roux en Y for persistent nausea and vomiting with an adequate weight loss, a relatively long common channel and alimentary limb ( percentage based ) will be set for the patient, thus preventing any further weight loss yet correcting the persistent nausea and vomiting issue. In contrast, a patient that is seeking revision of a failed gastric bypass to duodenal switch for inadequate weight loss or weight gain will have a relatively shorter common alimentary channel (percentage based) in order to maximise the amount of weight loss. Revising a failed gastric bypass from proximal to distal Roux en Y is seen to be a poor choice in the majority of patients due to the fact that the distal gastric bypass has the worst nutritional safety profile of all the known surgical procedures. Consult your bariatric surgeon for any complications post gastric bypass. This can be corrected by a revisional surgery.

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Atelectasis is the most common post operative pulmonary complication by which tissue oxygenation may be compromised in the elderly. It affects a quarter of all patients recovering from abdominal or thoracic surgeries. . Atelectesis, a failure of part of the lungs to expand, usually develops during the first or second postoperative day. Contributing factors in the aged are shallow breathing, obstruction of the airway with secretions, pain (which results in smaller tidal volumes), immobility, a transient decrease in surfactant production, a weakened cough reflex and decreased ciliary movement. Atelectasis as a result of any of these factors can lead to a mismatching of ventilation and perfusion and thereby, to arterial hypoxemia.
Areas of alveolar collapse or atelectasis are prone to infection. if an area of the lung remains atelectatic for greater than 72 hours, pneumonia is likely to develop. In the elderly, taking agressive measures to prevent atelectasis is preferable to treating pneumonia that may result from it. Frequent incentive spirometry maneuvers with an inspiratory hold, turning every two hourly, early ambulation and mobilization as soon as the vitals are stable, are important therapeutic interventions. Pain management without the use of sedatives, that depresses respirations, can also prevent alveolar compromise.
If atelectasis does develop, strategies such as administration of chest physiotherapy for mobilizing secretion, hyperinflation therapies such as IPPB ( Intermittent positive pressure breathing) or CPAP ( Continuous positive airway pressure) and moderate suctioning may help remove secretion, reverse atelectasis and aid in the reexpansion of lungs.

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