Vertical Sleeve Gastrectomy With Duodenal Switch
Often referred to as simply a 'duodenal switch' procedure, this particular form of bariatric surgery is in fact a vertical sleeve gastrectomy to which a duodenal switch is added. This procedure is also sometimes referred to as a biliopancreatic diversion with duodenal switch.
Of all of the different forms of weight loss surgery available today this is perhaps the most controversial and, though widely performed, there are many surgeons who will not carry out the procedure because of concerns about its long-term effects on a patient's health.
The first part of the procedure is a vertical sleeve gastrectomy in which the stomach is divided vertically and approximately eighty-five percent is removed. The small remaining 'sleeve shaped' stomach, which retains the original outlet to the intestines, functions very much as a normal stomach and this part of the surgery is designed purely to restrict the quantity of food which can be consumed. This part of the operation is a form of 'restrictive' surgery and cannot be reversed.
The second phase of the operation is to create a duodenal switch and this is a form of 'malabsorption' surgery which is largely reversible. Whereas restrictive surgery creates weight loss by physically preventing the patient from eating too much food, malabsorption surgery is designed to restrict the body's ability to absorb calories from a meal as it passes through the digestive tract.
During the procedure the intestine is divided and a small section (usually about 150 cm in length) is used to create a bypass from the duodenum, which is close to the stomach outlet, to a point near the end of the intestinal tract, thus bypassing the bulk of the digestive tract (typically about 500 cm will be bypassed). The result of this bypass (or duodenal switch) is that food passing through the intestine will only mix with the body's digestive juices in the short final section of the intestine below the switch, giving the digestive juices very little time to digest the food and absorb calories from it into the body.
While duodenal switch weight loss surgery has the advantage of providing the patient with weight loss through both restriction and malabsorption, it is the degree to which the malabsorption element predominates in the duodenal switch which gives rise to much of the controversy surrounding this form of surgery. By comparison, the traditional Roux-en-Y operation has a much shorter bypass and the distance over which food mixes with the digestive juices in the intestine is in the region of five times greater.
The argument which many surgeons use against the duodenal switch is simply that so little absorption takes place that there is too great a risk of anemia, protein deficiency and metabolic bone disease. The vertical sleeve gastrectomy with duodenal switch is also arguably the most complex form of weight loss surgery and many believe that it carries an unacceptably high risk of complications.
Despite the risks however, the duodenal switch remains a surgical option and can be very effective, especially in patients with a very high body mass index (BMI).
Sciatica – The Best Position to Relieve Extreme Pain
Sciatica can be a very painful and debilitating condition. It occurs as a result of irritation of the sciatic nerve. This irritation has several potential causes and it is dependent upon what is causing your sciatica as to what will be the best position to relieve it.
First and foremost I would suggest that if your pain is that extreme and constant, you need to speak to a health professional. It is likely you will benefit from a short course of Anti-Inflammatories in order to help settle the pain.
However, getting back to what would be the best position, as I mentioned above, this is likely to depend upon what is causing your sciatica in the first place.
If it is a disc bulge / herniation / slipped disc etc. then lying on your stomach is likely to be the most comfortable position. If your pain is still very sensitive, I would suggest placing 1 or 2 pillows under your stomach to begin with. It would probably be best if you adopted this position for a few minutes every hour or so (if this is practical) or let's just say 'little & often' throughout the day.
If it is the facet joints of your lower back which are irritating the sciatic nerve, then I would adopt a completely different approach. This time you will be wanting to 'flex' your back. An easy way to do this is to lay yourself on your back, with your knees slightly bent, maybe placing a pillow or two under your knees.
Sometimes, the pain can be too sensitive for either of the above positions. If this is the case, I have found side lying is usually best. However, make sure that while in this position, your bottom leg is straight and your top leg supported by one or two pillows (enough so that your top leg is roughly parallel with the bed / floor you are lying on). By adopting this position, you will be encouraging your back to maintain a neutral position and also be stopping your pelvis from dropping forwards & down, which can place increased stress across the sciatic nerve.
In summary, your diagnosis is key, therefore it is important to be able to find out why it is you are suffering with sciatica in the first place. Having said that, it is always important you listen to your body, therefore try out the above positions and which ever you find the most comforting, that's the one to stick with for a while.
Before I finish, it is important I stress that activity is vitally important as well. As your pain begins to settle, it is imperative you start to become more active. By this I mean generally active as in getting up and about, as well as providing yourself with a specific exercise programme in order to address the cause of your sciatica.
How Does The Sleeve Gastrectomy Work?
The vertical sleeve gastrectomy is a restrictive form of weight loss surgery in which approximately 85% of the stomach is removed leaving a cylindrical or sleeve shaped stomach with a capacity ranging from about 60 to 150 cc, depending upon the surgeon performing the procedure. Unlike many other forms of bariatric surgery, the outlet valve and the nerves to the stomach remain intact and, while the stomach is drastically reduced in size, its function is preserved. Again, unlike other forms of surgery such as the Roux-en-Y gastric bypass, the vertical sleeve gastrectomy is not reversible.
Because the new stomach continues to function normally there are far fewer restrictions on the foods which patients can consume after surgery, albeit that the quantity of food eaten will be considerably reduced. This is seen by many patients as being one of the great advantages of the vertical gastrectomy, as is the fact that the removal of the majority of the stomach also results in the virtual elimination of hormones produced within the stomach which stimulate hunger.
Perhaps the greatest advantage of the vertical sleeve gastrectomy lies in the fact that it does not involve any bypass of the intestinal tract and patients do not therefore suffer the complications of intestinal bypass such as intestinal obstruction, anemia, osteoporosis, vitamin deficiency and protein deficiency. It also makes it a suitable form of surgery for patients who are already suffering from anemia, Crohn's disease and a variety of other conditions that would place them at high risk for surgery involving intestinal bypass.
Finally, it is one of the few forms of weight loss surgery which can be performed laparoscopically in patients who are extremely overweight.
Perhaps the main disadvantage of the vertical sleeve gastrectomy is that it does not always produce the weight loss which people would wish for and, in the longer term, can result in weight regain. This is indeed true of any form of purely restrictive weight loss surgery, but is perhaps especially true in the case of the vertical gastrectomy.
Because the procedure requires stapling of the stomach patients do run the risk of leakage and of other complications directly related to stapling. In addition, as with any surgery, patients run the risk of additional complications such as post-operative bleeding, small bowel obstruction, pneumonia and even death. The risk of encountering any of these complications is however extremely small and varies from about 0.5 and 1%. Having said this, the risk of death from this form of surgery at about 0.25% is extremely small.
As a general rule the vertical sleeve gastrectomy is best suited to individuals who are either extremely overweight or whose medical condition would rule out other forms of weight loss surgery. In the case of the former the vertical sleeve gastrectomy would normally form the first of a two-part plan of weight loss, with further bariatric surgery being performed once the patient's weight has fallen sufficiently to allow for other forms of weight loss surgery to come in to play.
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