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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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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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  • An upper gastrointestinal study with water-soluble contrast is obtained on postoperative day 1 for the following reasons:
    • To rule out obstruction or leak from the gastrojejunostomy following Roux-en-Y gastric bypass (open and laparoscopic).
    • To rule out perforation or obstruction.
    • To document pouch size and band position following adjustable gastric band placement.
  • Early ambulation is encouraged.
  • Deep venous thromboembolism prophylaxis is provided with sequential compression devices and unfractionated or low-molecular-weight heparin.
  • The patient is discharged home on a full liquid diet for 2 weeks. The diet is advanced to pureed and then solid food over the next 4 weeks.
  • Following Roux-en-Y gastric bypass, patients must remain on lifelong supplementation with a multivitamin, calcium, and vitamin B12. They receive a proton pump inhibitor (PPI) for 3 months to prevent marginal ulceration and ursodeoxycholic acid for 6 months to reduce the risk of cholelithiasis.

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Roux-en-Y Gastric Bypass: Open and Laparoscopic

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  • Anastomotic leak.
    • Occurs within 10 days postoperatively.
    • May be treated either conservatively or surgically.
  • Stomal stenosis.
    • Occurs as a late complication, usually within 4–6 weeks of surgery.
    • Most patients respond to endoscopic dilation.
    • Refractory cases require operative revision.
  • Marginal ulceration.
    • Occurs in 5–10% of patients.
    • Patients have epigastric pain or upper gastrointestinal bleeding, or both.
    • Perforation is less common but has been reported.
    • Usually responds to PPI but may require endoscopic or surgical intervention.
  • Internal hernia.
    • May occur as an early or late complication in 3–5% of patients.
    • Patients typically present with acute or chronically intermittent obstructive symptoms.
    • Treatment is surgical.
  • Incisional hernia (may occur in up to 15% of open operations).

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Laparoscopic Adjustable Gastric Band

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  • Acute esophageal obstruction.
  • Gastric prolapse ("slipped band") and pouch dilation.
  • Band erosion.
  • Esophageal dilation or dysmotility.
  • Port and tubing complications (eg, breakage, migration, infection).

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