[Corrective plastic surgeries as a conclusive stage of surgical treatment of patients with alimentary-and-constitutional obesity].

The authors performed analysis of Russian and foreign literature (64 items) dedicated to long-term postoperative problems following corrective plastic surgery for morbid obesity. The analysis shows that literature does not contain clear criteria for patient selection and timing of surgery, and does not provide sufficient coverage of plastic surgical techniques. There are no data on the rate of complications and complex preventive measures.

[Use of regulated silicone bandage in horizontal gastroplasty in patients with morbid obesity]. / Ispol'zovanie reguliruemogo silikonovogo bandazha pri gorizontal'noi gastroplastike u bol'nykh morbidnym ozhireniem.

From 1984 in N.N. Burdenko Surgical clinic of I.M. Sechenov MMA more than 500 horizontal gastroplasties (HGP) were performed for the treatment of patients with extreme degree of alimentary-constitutional obesity. In 1996 for the first time in our country HGP was performed, including laparoscopic method, with use of regulated silicon bandage "Lap-Band" (LB) made by "Bioenterics", USA. Laparoscopic HGP was performed in 29 patients (7 males, 22 females), aged from 23 to 60 years, mean age was 34.2 +/- 10 years. Minimal body weight was 85 kg, maximal--180 kg, mean--131 +/- 27.2 kg. Mean body mass index was 47 +/- 9.9 kg/m2. Open operations were performed in 14 cases, laparoscopic operations--in 15 cases. 11 laparoscopies were performed in initial stages in very stout patients and in the absence of laparoscopic equipment. In 3 cases the conversion from laparoscopic to open operation was necessary: in 1st case because of hemorrhage from lesser omentum's vessels, when hemostasis cannot be performed by laparoscopy; in 2nd case as a result of bronchospasm associated with tense pneumoperitoneum in the patient with bronchial asthma; in 3rd case because of significant enlargement and rigidity of liver left lobe, which didn't permit to create the space for manipulations in cardial portion of the stomach. The mean bed day turnover after traditional HGP with LB and after laparoscopic HGP was 12.2 and 5.4 respectively. Intraoperative complication was observed in one case--hemorrhage from lesser omentum's vessels. One complication was observed in immediate postoperative period, on the 6th day after traditional HGP: the eventration as a result of hard diarrhea due to antibacterial treatment was diagnosed. One more complication was observed in a year after traditional HGP: small stomach evacuatory function disorders as a result of its significant dilatation. These disorders occurred because of gastric mucosa inflammatory edema, decrease of anastomosis diameter and frequent vomiting due to aspirin taking. In this case the repeated operation--bandage's reposition was performed. There were no other complications. The rate of repeated operations was 4% which agrees with literature data.

[Plastic surgery in patients with obesity late after horizontal banded gastroplasty]. / Plasticheskie operatsii u bol'nykh ozhireniem v otdalennye sroki posle gorizontal'nli gastroplastiki.

The results of 361 plastic operations in 296 patients with morbid obesity late after horizontal gastroplasty were analyzed. Plastic and corrective operations aimed at removal of redundant lipocutaneous "aprons" at the anterior abdominal wall, thighs, thoracic wall, gluteal region and the arms, represent a final stage of surgical treatment of patients with morbid obesity. The indications, technique and the results of plastic operations performed from 1985 to 1998, are thoroughly elucidated. The analysis of early postoperative complications has established, that it a reasonable to perform such operations 1-3 years after gastroplasty when body weight stabilizes and there are no vitamin deficiency, iron deficient anemia, hypoproteinemia, hydroionic disturbances or other complications of the later period. Complex prophylactic measures for prevention of pyoseptic and thromboembolic complications in patients with obesity late after gastroplasty permits to avoid severe complications and lethal outcomes in patients after plastic operations.

[Laparoscopic horizontal gastroplasty]. / Laparoskopicheskaia gorizontal'naia gastroplastika.

The analysis of the first 14 operations of horizontal gastroplasty in patients with end-stage alimentary constitutional obesity was carried out, the operations being performed according to standard (9 patients) as well as laparoscopic method (5 patients). The mean body mass made up 133.6 kg, the mean height being 167.8 cm. Patients age was from 22 to 42 years. All the patients operated by laparoscopic method were women. Technique of laparoscopic horizontal gastroplasty is described, indications and contraindications to the operation are established. It is demonstrated, that laparoscopic gastroplasty, as well as previously performed 530 horizontal gastroplasties with the help of fluoric-lausan goffer band, performed in clinic since 1984, in present time is one of the most perspective method of surgical correction of obesity. The application of this method results in substantial and steady decrease of body mass of the operated patients with minimal risk of complications during surgical procedure as well as in postoperative period.

[Surgical interventions in patients with a history of alimentary constitutional obesity]. / Khirurgicheskie vmeshchatel'stva u bol'nykh v otdalënnye sroki posle operativnogo lecheniia alimentarno-konstitutsional'nogo ozhireniia.

Surgical removal of a fat "flap" is a last step of surgical treatment of patients with 3-d and 4-th stage of alimentary obesity. This kind of surgery makes sense only 12-24 months after "small stomach" creation. During this period the weight is stable. A detailed clinical examination and prophylaxis helps to avoid septic and thromboembolic complications that may cause death and usually appear short time after the operation. To minimize postoperative complications and to decrease a risk of repeated anaesthesia and time of stay in a hospital it is necessary to make some concomitant small surgical procedure (cholecystectomy, phlebectomy).

[Aspirative lipectomy in patients with alimentary-constitutional obesity]. / Aspiratsionnaia lipektomiia u bol'nykh alimentarno-kostitutsionnym ozhireniem.

The results of aspirative lipectomy in patients with 2nd and 3rd stage of alimentary-constitutional obesity are analysed. The effectiveness of lipectomy with surgical creation of a small ventricle and without previous surgery, has been demonstrated. The criteria of patients selection, based on their somatic and psychic features, are formulated. Aspirative lipectomy has certain advantages over other types of plastic surgery as it has the minimal rate of postoperative complications.

[Effect of fragmin, a low-molecular heparin, on hemostasis in patients with alimentary-constitutional obesity]. / Vliianie nizkomolekuliarnogo geparina fragmina na gemostaz u bol'nykh alimentarno-konstitutsional'nym ozhireniem.

The authors conducted comparative study of the hemostasis indices before and in the immediate period after operation for formation of a small stomach in 31 patients with stage III-IV alimentary-constitutional obesity, in 50 patients without obesity who underwent operation on the stomach, and in 15 volunteers. Nonspecific prevention of thrombogenesis was performed in all patients with normal weight and those with obesity. Patients with obesity were given in addition specific thrombogenesis prevention with nonfractionated heparin (group I) and fractionated low-molecular heparin-fragmin produced by KABI (groups II and III). Study of the parameters of the hemostasis system in the postoperative period showed nonspecific prevention of thrombogenesis to be sufficient to reduce the risk of pulmonary artery phlebothrombosis and embolism in most patients without obesity. In patients with obesity the probability of phlebothrombosis and thromboembolism is much higher, in view of which they must be given heparin in addition to nonspecific prevention. Fragmin, as an agent for thrombosis prevention, has certain advantages over nonfractionated heparin and should be used more frequently in clinical practice in patients of the risk group, e. g. with pathological obesity, in a dose no less than 100 U/kg. With the use of fragmin laboratory control before each injection is not needed. Administration of nonfractionated and fractionated heparins must be combined with bandaging of the lower limbs and other measures of nonspecific prevention of thrombogenesis.

[Late results of the treatment of patients with the extreme degree of alimentary-constitutional obesity by the method of formation of a small stomach]. / Otdalennye rezul'taty lecheniia bol'nykh s krainymi stepeniami alimentarno-konstitutsional'nogo ozhireniia metodom formirovaniia malogo zheludka.

The work analyses the results of treatment of 311 patients with extreme degrees of alimentary-constitutional obesity by formation of a small stomach. Fatal outcomes (1.9%) were encountered in the period of operative technique mastering. The late-term results were studied in 167 patients in follow-up periods of up to 3 years. The patients' average body weight was 149.4 kg, average height 166.2 cm, average body weight excess as compared to the ideal weight was 125.6%. Study of the late-term results of the operation showed that the postoperative weight loss depends on the initial weight excess and the diameter of the anastomosis formed between the proximal and distal parts of the stomach. The more the initial excess of weight as compared to the ideal value, the more the loss of body weight is. The diameter of the formed anastomosis should be no larger than 15 mm. Besides loss of weight, the activity of vital organs and systems is normalized after the operation, and arterial hypertension, diabetes mellitus, the Pickwickian syndrome, and metabolic polyarthritis take a milder course. The operation for formation of a small stomach made it possible for the patients to resume their customary occupation, freed them of the threat of invalidation, and reduced the duration of the disability period by 4.3 times. After surgical treatment the nature of the patients' life significantly improved; 95.8% of patients appraised the effect of the treatment as excellent and good.

[Results of surgical formation of small stomach in patients with morbid obesity]. / Rezul'taty operatsii formirovaniia malogo zheludochka u bol'nykh so sverkhozhireniem.

The authors conducted a comparative analysis of the results of surgical treatment of patients with alimentary-constitutional adiposity (ACA) of extreme degrees. Operation for the formation of a small stomach (SSF) was carried out in 41 patients. The results in the same patients were analysed in postoperative periods of more than 2 years. The patients were divided into 2 groups. The first group was composed of 22 patients with morbid obesity and an average body weight of 140.2 +/- 4.47 kg (101.4 +/- 3.83% excess weight). The second group was made up of 19 patients with an average body weight of 170.2 +/- 6.5 kg (average excess weight 169.8 +/- 7.03%). The average weight loss in the first group was 41.9 kg (59.9% loss of excessive weight), the average weight loss in patients with hyperadiposis (second group) was 62.9 kg (99.4% loss of excessive weight). The results of operation for SSF for reducing body weight in patients with adiposity are better than those of vertical gastroplasty.

[Results of the operation for creating "miniature stomach" in the treatment of alimentary-constitutional obesity]. / Rezul'taty operatsii formirovaniia "malogo zheludochka" v lechenii alimentarno-konstitutsional'nogo ozhireniia.

The article analyses the results of surgical treatment of alimentary-constitutional obesity in 207 patients by means of operation for formation of a "miniature stomach". Total postoperative mortality was 2.4%. This index was 4.2% in the period when the method was mastered and 0.89% for the next 112 operations. It is shown that the operation for formation of a "miniature stomach" leads to a significant and stable loss of body weight, recovery from concomitant diseases or essential diminution of their severity, it alters the patients' life for the better and makes it possible for many of them to resume work.