The jejunum was positioned in a C configuration to facilitate placement of the Endo-GIA stapler for division. The Endo-GIA stapler was placed through the right upper abdominal mm port and applied perpendicular to the jejunum and parallel to the mesenteric vascular arcade to create the biliopancreatic limb and Roux-limb. The white cartridge was used to minimize staple line bleeding. Then the gastrojejunostomy was performed.
We proceeded to open the jejunum and introduce the CEEA device, enlarging the left upper quadrant hole for the 12mm trocar. Then we proceeded to extract the CEEA machine with the protective bag to avoid contamination of the surgical wound. Then the anastomosis was reinforced by means of two fixing points to release tension. The next step was to measure the bowel to locate the place to perform the anastomosis. An end-side jejuno-jejunostomy was performed. By means of hook dissection, enterotomies were performed at the biliopancreatic corner and antimesenteric border of the Roux-limb.
The Endo-GIA stapler with the 60mm white load was inserted through each enterotomy and applied to create the end-side anastomosis. The surgery was completed by closing the mesenteric defect with a running suture. An internal hernia resulting in a bowel obstruction may develop if the defect is left unclosed. We recommend a permanent suture to minimize reopening of the defect. The surgery took 91 minutes. The patient started oral intake 24 hours after the surgery and left the hospital on the 3 rd postoperative day. The patient currently has a successful outcome. HBP and type 2 DM were solved and she currently needs no medication today.
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Translating weight loss into agency: Men's experiences 5 years after bariatric surgery
Vignette 2: Self-reliance. He was married, employed, and considering retirement in the next five years. He had strong feelings about self-reliance and was determined to lose weight on his own. Provider: You mentioned you have struggled with your weight since your mids. Have you ever considered weight loss surgery? Patient: No. Weight loss surgery is the easy way out.
Me, I want to give it another try on my own first. A Tell me what you think is going well with your eating right now. Patient: Well, I cut out soda and sweet tea. That was a problem. I was having about six per day. I also stopped taking second helpings at dinner too.
Provider: Some things you think are helping with weight loss are cutting out sugary drinks and reducing portions, and you see some other areas for improvement. Patient: I guess because the weight loss has slowed down. This always happens. I lose weight easily at first and then I get frustrated and give up. At that time I was running six miles every day.
The 70 pounds I lost was years ago. I was younger and could really exercise. Now, I have knee problems and back pain. CR-guess about meaning. I need to lose pounds at least. There are things that I want to be able to do like travel with my wife now that the kids are out of the house. I want to be healthy enough to enjoy my retirement when that time comes, which might be in five years. Provider: You have a vision for your future and have thought a lot about the kind of life you want to live when you retire. Provider: Losing weight is very important to you for many reasons A.
How confident are you that you can achieve your weight loss goal with dieting like you are doing now? Provider: So, you lack confidence for success and at the same time your motivation to lose weight is high CR-double sided. It is more complicated than that. We know that with lifestyle changes alone the initial goal for weight loss is 5 to 10 percent of initial body weight. For you, a 5 to 10 percent weight loss represents 15 to 30 pounds. So, with your recent efforts you have been successful at achieving a pound weight loss that is within the range expected.
However, we also know that for the majority of patients, maintaining that weight loss is challenging. Bariatric surgery is associated with more weight loss and better chances at keeping it off. Depending on the operation, weight losses of up to 20 to 35 percent17 can be observed after the first year. For you, that would represent an additional weight loss of 75 to pounds. That degree of weight loss has a more positive impact on obesity-related diseases like metabolic syndrome and sleep apnea.
But there is more to learn about bariatric surgery in order to help you make an informed choice about whether it is the right treatment for you. Would you like to hear more? Vignette 3: Dietary change challenges. Following are prepared vignettes that demonstrate conversations with patients who have decided to undergo bariatric surgery but are struggling with changing behaviors in preparation for it. She ate many meals away from home. She was employed, married, and had several adolescents in the home. She was struggling to reduce the frequency of eating out and making healthy choices when she did dine out.
I know achieving a healthy weight is important to you. Provider: You met with the dietitian last month and talked about the recommended dietary changes in preparation for SG. What changes do you think are going well so far? Awareness is an important first step in making positive lifestyle changes. My family complains about my cooking, and I am tired when I get home from work. If nothing is planned for dinner, we end up eating out a lot or getting fast food. My husband does help out with the grocery shopping at times, but no one really cooks or plans meals. Provider: So, the dietary changes that are required to get ready for bariatric surgery might be good for your whole family, like hitting a reset button.
CR-continuing the paragraph and metaphor. My husband and I have talked about that a little bit. If we all worked together, it would be easier to make healthy changes. Provider: You have decided to take an important step toward improving your health, which will benefit you and your family. You are aware that in order to experience the best outcome after bariatric surgery, you will need to make some significant changes in your current eating habits, the number of times per week you eat out in particular. S If you think it would be helpful, I can share with you some things we know are important factors to being successful.
Provider: As you have already identified, reducing how much you eat is very important. But what you are eating is equally important because of how your body reacts to the nutrient composition of certain foods. So, if you eat high-fat foods after bariatric surgery, you will start to regain weight even if your portions remain small. Many of the obstacles that you identify may not change with the SG, like your busy schedule or challenges in meal planning and preparation.
Making changes in your eating habits will be challenging, but you have identified some really important reasons to do so. Vignette 4: Food as primary coping mechanism. She was single, employed, and had been in counseling in the past for stress reduction. She was scheduled to undergo RYGB and, since she used food as a primary coping strategy for negative emotion, she worried about not being able to rely on food for stress and mood management.
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The dietitian told me about the dumping syndrome and that those types of foods may make me feel sick. C-using a metaphor. Patient: I really want to do well after surgery. It would be awful to go through all of this just to gain the weight back, or to feel sick all the time. Food is my emotional crutch. I often turn to food for comfort. Provider: You are worried that after RYGB when stress comes up at work, it will be hard to resist eating something sweet to calm you down, to comfort you.
That worries me a lot. Ever since I was a little kid, I remember eating when I was upset. My mom was critical about my weight and put me on my first diet when I was 12 years old. She was always watching what I ate so, I used to sneak food into my room so that no one would see me eating. Then, when I went to college, I gained a lot of weight from school-related stress.
I kept this pattern of emotional eating when I started working. Food has been my companion for as long as I can remember. Provider: Eating for emotional comfort has been a long-standing pattern of behavior for you. I mean, if I take this drastic of a step for weight loss, I want it to work.
Provider: Right now you lack confidence in your ability to control emotional eating. CR-guessing at meaning. I always try to avoid my favorite foods when I diet, but I can never do that for very long. Eventually, I get stressed out and turn to sweets for comfort. Then I feel like a failure and give up on my diet. Provider: It may even seem that dieting makes the problem worse. My office environment is horrible.
My co-workers bring in treats every day. One of my friends who had RYGB told me that surgery fixes your stomach but not your head. Provider: You have obviously put some thought into the negative consequences of emotional eating on your weight, and you have a lot of insight about some of the challenges you may encounter after surgery.
A If you would like, we can talk more about what other patients who struggle with emotional eating have tried when dealing with emotional distress after RYGB. This is a common issue and you certainly are not the only patient who has these concerns. Provider: RYGB is what we call a metabolic operation that produces the opposite effect on many hormones in your body when compared to dieting. What this means is that even though you will be eating smaller amounts of food during the first year, you will feel less hungry and experience fewer cravings and desire for sweets.
As the body adapts to the operation and weight loss reaches a plateau, many patients say that hunger and desire for sweet or salty comfort foods increases, usually around 9 or 12 months after surgery. What are some of your ideas about things you could try right now to manage stress and negative emotion O? Vignette 5: Depression. She was struggling with motivation and anticipated that her mood would improve if she could lose some weight.
Provider: I know the purpose of our visit today is to talk about weight management.
Translating weight loss into agency: Men's experiences 5 years after bariatric surgery
Often, when people have complex health problems, they also have low mood. When I reviewed the pre-surgery paperwork you completed, I noticed that your score on the depression screener is elevated. In particular, you endorsed feeling down and bad about yourself nearly every day. I hate how I look. I think if I could just lose some of this weight, I would be a lot happier. I know I will be happy once I lose weight. Provider: You are hoping that a lot of things in your life will be different when you lose weight. I have to use a motorized scooter to get around.
If I can lose weight, I could do all these things again. Provider: I can see why not being able to do all of those things would make you feel pretty bad about yourself A. You are hoping that weight loss will help you return to doing the things in your life that you value. I spend of all of my energy just trying to get through my day. I spend most of my days alone while my husband works.
Pretty much I just watch TV all day or lay in bed. I have to do something. CR-reflection of feeling and guessing at meaning. We sort of have different ideas about what healthy eating is. He brings home take-out food a lot and likes his sweets. I end up eating them too. Provider: You are unable to do any of the grocery shopping or meal planning and preparation because of low mood and low motivation. Provider: When you are ready to begin making some of the changes you and the dietitian discussed, where would be a good place to start? I feel down a lot and struggle with motivation.
But I know if I lose weight, I will feel better. Do you think if your mood were more positive you might be able to make changes in your diet O? Provider: I understand feeling that way. A I have worked with many patients with low mood and weight challenges. After you meet with her, we can schedule a follow-up appointment to return to a weight management plan for you. How does that sound? Who Can Learn MI? Previous research has shown that many different types of healthcare providers can learn how to apply MI effectively in the clinical setting.
Think of the patient as the expert on his or her own life and the how, when, and why change should occur for him or her. Being a partner in change does not imply that healthcare providers ignore their professional training.
For example, if a patient plans to fast for several days to lose weight, asking them about what they know about potential negative consequences of fasting would be important. Or, if a sedentary patient with cardiovascular disease and weight concerns sets a goal to start running three miles every day this week, a discussion about healthy exercise goals would be important. During conversations about weight loss, provider empathy and reflective listening result in higher patient satisfaction and patient perception of choice about treatment options.
Becoming a skillful practitioner of MI takes time and regular practice. Initial instruction in an immersion workshop by a trained and credentialed motivational interviewing expert is recommended, ideally followed up with periodic consultation and feedback from others proficient in MI. Recommended Readings 1.
Miller WR, Rollnick, S. Motivational Interviewing: Helping People Change.
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New York: The Guilford Press, Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother. Rosengren DB. Guilford Press, Guilford Publications, References 1. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. Sjostrom L. Review of the key results from the Swedish Obese Subjects SOS trial—a prospective controlled intervention study of bariatric surgery.