• Surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. Bariatric surgery is an option for people who have a body mass index (BMI) above 40. Surgery is also an option for people with a BMI between 35 and 40 who have health problems like type 2 diabetes or heart disease.

Who needs Bariatric surgery ?

• Bariatric surgery should be considered in persons with a body mass index (BMI) above 40—about 100 pounds of excess weight for men and 80 pounds for women. Persons with a BMI between 35 and 40 who suffer from type 2 diabetes or life-threatening cardiopulmonary problems such as severe sleep apnea or obesity-related heart disease may also be candidates for surgery. In addition, a person with obesity-related physical problems that interfere with employment, walking, or family function may be a candidate.
  Body mass index is determined by dividing a person's weight in kilograms by height in meters squared. To determine BMI using pounds and inches, multiply the patient's weight in pounds by 704.5, then divide the result by the patient's height in inches, and divide that result by the patient's height in inches a second time.
  An NIH consensus conference on the surgical treatment of obesity recommended consideration of surgery in patients with a BMI of greater than 40 kg/m2 without medical complications or a BMI of greater than 35 kg/m2 if a severe comorbidity were present. Other factors to consider are:

  *BMI > 35 kg/m2 and significant obesity comorbidity (e.g., hypertension, diabetes, sleep apnea, pickwickian syndrome, incapacitating osteoarthritis)
  *Documented failure to keep weight off or to prevent further weight gain using aggressive medical management that has included behavioral, pharmacologic, and low-calorie-diet components
  * Psychological ability to comprehend the expected changes in dietary intake necessary following surgery to achieve and sustain weight loss
  *Willingness to maintain continued medical management following surgery, including visits to registered dietitians, internists
  * Adult, nonpregnant, absence of drug addiction or chronic disease unrelated to obesity

COMPLICATIONS FROM BARIATRIC SURGERY ?

• Weight loss from dieting or bariatric surgery further increases the risk of gallstones. The incidence of new gallstones has been estimated at 12% during very-low-calorie dieting and 38% after successful gastric bypass surgery. Higher initial BMI and greater absolute rate of weight loss are significant and independent predictors.

  Large and rapid weight loss has been shown to increase the prevalence of inflammatory hepatitis. One case report describes the development of occult cirrhosis in a patient whose preoperative liver biopsy was normal. Two series of patients who had liver biopsies pre- and postweight reduction have been reported. The increase in the prevalence of hepatitis is not due to surgical therapy but rather to the weight loss itself

How the surgery was developed

• The concept of gastrointestinal surgery to control obesity grew out of results of operations for cancer or severe ulcers that removed large portions of the stomach or small intestine. Because patients undergoing these procedures tended to lose weight after surgery, some physicians began to use such operations to treat severe obesity.

  The first operation that was widely used for severe obesity was the intestinal bypass. This operation, first used 40 years ago, produced weight loss by causing malabsorption. The idea was that patients could eat large amounts of food, which would be poorly digested or passed along too fast for the body to absorb many calories. The problem with this surgery was that it caused a loss of essential nutrients and its side effects were unpredictable and sometimes fatal. The original form of the intestinal bypass operation is no longer used.

  Gastrointestinal surgery alters the digestive process. The operations promote weight loss by closing off parts of the stomach to make it smaller. Operations that only reduce stomach size are known as “restrictive operations” because they restrict the amount of food the stomach can hold.

  Some operations combine stomach restriction with a partial bypass of the small intestine. These procedures create a direct connection from the stomach to the lower segment of the small intestine, literally bypassing portions of the digestive tract that absorb calories and nutrients. These are known as malabsorptive operations.

  There are several types of restrictive and malabsorptive operations. Each one carries its own benefits and risks.

  Restrictive Operations
  Restrictive operations serve only to restrict food intake and do not interfere with the normal digestive process. To perform the surgery, doctors create a small pouch at the top of the stomach where food enters from the esophagus. Initially, the pouch holds about 1 ounce of food and later expands to 2-3 ounces. The lower outlet of the pouch usually has a diameter of only about 3/4 inch. This small outlet delays the emptying of food from the pouch and causes a feeling of fullness.

  As a result of this surgery, most people lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only 3/4 to 1 cup of food without discomfort or nausea. Also, food has to be well chewed.

  Restrictive operations for obesity include adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG).

  Malabsorptive Operations
  Malabsorptive operations are the most common gastrointestinal surgeries for weight loss. They restrict both food intake and the amount of calories and nutrients the body absorbs. The two operations are called Roux-en-Y gastric bypass (RGB) and biliopancreatic diversion (BPD).
  

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Patient Safety In Anesthesiology

• Complications from anesthesia have declined dramatically over the last 25 years. Since 1970, the number of anesthesiologists has more than doubled and, at the same time and at virtually the same rate, patient outcomes have improved. In just the last decade, estimates for the number of deaths attributed to anesthesia have dropped 25-fold from 1 in 10,000 anesthetics to 1 in 250,000 today.

  All this has occurred during a time when the youngest of premature infants in neonatal units survives intricate, lifesaving procedures and 100-year-old patients undergo and recover from major surgeries that were once thought to be impossible.

Fact about Anesthesiology Assistant ?

• AAs currently work in sixteen states.
  The states in which AAs work by a license, regulation, and/or certification are:
  Alabama
  Florida
  Georgia
  Kentucky
  Missouri
  New Mexico (university hospital settings)
  Ohio
  South Carolina
  Vermont

  The states in which AAs are granted practice privilege through physician delegation (meaning the physician can specifically request an AA for the particular procedure):
  Colorado
  District of Columbia
  Michigan
  New Hampshire
  Texas
  West Virginia
  Wisconsin

  
  The federal government recognizes and uses AAs.
  Both the Department of Defense and the Department of Veterans Affairs authorize the use of anesthesiologist assistants to practice under the TRICARE insurance program.