Gastroplasty is a surgical procedure performed to decrease the size of the stomach.  This is another procedure that can be performed to reduce weight in obese patients.  In this procedure, the size of the stomach is reduced using stitches by about 60-70% of the existing size.    Gastroplasty aids in reducing weight as the reduced size of the stomach helps hold less volume of food.

Laparoscopic Gastroplasty

In Laparoscopic Gastroplasty, keyhole incisions are made at the abdominal wall to carry out the procedure.  A laparoscope is inserted through one incision and the stomach is stitched.  Laparoscopic Gastroplasty is much superior compared to Endoscopic Sleeve Gastroplasty and Intragastric Balloon as it is possible to do full length stitching of the stomach.  The cost of Laparoscopic Gastroplasty is also less compared to the endoscopic version.

In Sleeve Gastrectomy, part of the stomach is removed.  However, in Gastroplasty, stitches are used to reduce the size of the stomach.  As no cutting is involved, there is less chance of bleeding.  As the stomach is not resected, there is no chance for gastric leak.  It is also less expensive and the duration of anesthesia is also less.  The patient can return early to activities of daily living.  Gastroplasty is also reversible if the patient insists.

Compared to Intragastric Balloon Placement, which is another procedure for weight loss, the results from Gastroplasty are more sustained even after many years.  Intragastric balloon is placed for a period of 12 months, after which the balloon is removed.  The patient may gain weight after the intragastric balloon is removed.  Whereas in Laparoscopic Gastroplasty, the stitches can be retained unless and until the patient insists for removal.  Thus, there is sustained weight loss in Gastroplasty compared to Intragastric Balloon Placement.  Both costs the same only.

The success of all weight loss procedures and Bariatric Surgery also depend on the lifestyle modifications, which the patient has to adhere to.

Advantages

• Sustained results
• No chance of bleeding.
• No cutting involved (Keyhole Surgery)
• No Gastric Leak expected as the stomach is not resected.
• Less Expensive
• Less Duration of Anesthesia.
• Early return to activities of daily living
• Reversible

Other Weight Loss Procedures

There are different weight loss procedures that can be performed.  The doctor may advise the best procedure that suits a person depending on the weight of the patient and other medical conditions.  Other procedures are:

Laparoscopic Sleeve Gastrectomy – It is also known as Vertical Sleeve Gastrectomy or  Gastric Sleeve Procedure.   With Laparoscopic Sleeve Gastrectomy, the outer margin of the stomach that is responsible for the secretion of Ghrelin (hunger hormone) is removed.  The reduced stomach restricts the amount of food intake, and thus helps in reducing weight. 

Roux-en-Y Gastric Bypass – Roux-en-Y Gastric Bypass is also termed Gastric Bypass Surgery.  The stomach is divided into a small upper pouch and a large lower pouch and the small intestine reattached to the upper pouch creating a bypass.  The food thus bypasses the large pouch of the stomach, resulting in less absorption of calories and nutrients.

Mini Gastric Bypass – This is another weight loss procedure which is done laparoscopically. 

Intragastric Balloon Placement – Intragastric Balloon Placement is placing a balloon in the stomach.  A deflated balloon is placed endoscopically through the mouth, and once in the stomach it is inflated.  This helps in restricting the food intake, which aids in weight loss.  Swallowable intragastric balloon is also available, and can be performed based on the choice of the patient.

There are other body shaping procedures, which is effective for removing excess fat from the body.  These include:

Liposuction: Liposuction is a surgical procedure that is used to remove excess fat from specific parts of the body like abdomen, thighs, hips, buttocks etc.

Tummy Tuck:  Tummy tuck is also called abdominoplasty.  It is a procedure to remove excess belly fat from the abdominal area and used to treat hanging abdomen.

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Dr. R. Padmakumar
Dr. D. Madhukara Pai
Dr. Farish Shamsudeen

The post Handbook on Bariatric Procedures appeared first on Dr. R. Padmakumar.

Bariatric deals with Obesity. “Baros” is a Greek word which means heavy or large. Bariatric surgery is also referred to as “weight loss surgery” and is performed on people who suffer from obesity. It includes a variety of procedures like Intragastric Balloon Placement, Laparoscopic Sleeve Gastrectomy, various gastric bypass surgeries, and Sleeve with Hybrid Ileal Interposition. These procedures have proven to be effective in long-term weight reduction, resolution of diabetes, improvement in cardiovascular risk factors and obstructive sleep apnea, etc.

BMI = Weight (kg) / Height (m)2

WHO guidelines 2019 for adults over 20 years old

Pediatric BMI Criteria

For children BMI is calculated and compared with Z score for age.

Children: Other than Indian (Click to view)

https://www.who.int/tools/growth-reference-data-for-5to19-years/indicators/bmi-for-age

Boys – Indian

5-18 years: IAP Boys Body Mass Index Charts (Click Link Below)

https://iapindia.org/iap-growth-charts/

Girls – Indian

5-18 years: IAP Girls Body Mass Index Charts (Click Link Below)

https://iapindia.org/iap-growth-charts/

Z score more than 1.64 or BMI more than +2 SD is considered as obese.
Z score more than 1.04 or BMI more than +1 SD is considered as
Overweight.
Thinness is less than -2 SD.

Asian BMI criteria:

Asian BMI Cut-off points :
More than 25 BMI – Clinical obesity
More than 27.5 BMI – Metabolic Surgery can be performed
(2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and
International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO)
Indications for Metabolic and Bariatric Surgery
Dan Eisenberg, Scott A. et.al. iObesity Surgery volume 33, pages3–14 (2023))

Causes of obesity and overweight

It is due to an imbalance between energy in and energy out. An increased intake of energy-rich foods that are high in fat and sugars and a reduction in physical activity due to the sedentary nature of work make the body switch over to energy saving mode. Genetic factors also play a role in causation of obesity. Excess production of Ghrelin also is a contributing factor.

METABOLIC SYNDROME

Metabolic syndrome is a clustering of at least three of the following five medical conditions: abdominal obesity, high blood pressure, high blood sugar, high serum triglycerides, and low serum high-density lipoprotein (HDL).

Metabolic syndrome is associated with the risk of developing cardiovascular disease and type 2 diabetes. In the U.S., about 25% of the adult population has metabolic syndrome, a proportion increasing with age, particularly among racial and ethnic minorities.

Insulin resistance, metabolic syndrome, and prediabetes are closely related to one another and have overlapping aspects. The syndrome is thought to be caused by an underlying disorder of energy utilization and storage.

Each Propels the Other

Diagnostic Criteria of Metabolic Syndrome

Patient has at least three of the five conditions

• Fasting glucose ≥ 100 mg/dL (or receiving drug therapy for hyperglycemia)
• Blood pressure ≥ 130/85 mmHg (or receiving drug therapy for hypertension)
• Triglycerides ≥ 150 mg/dL (or receiving drug therapy for hypertriglyceridemia)
• HDL-C < 40 mg/dL in men or < 50 mg/dL in women (or receiving drug therapy for reduced HDL-C)
• Waist circumference ≥ 90 cm (35 in) in men or ≥ 80 cm (32 in) in women
  

Minor Components

• Sleep apnea
• NASH
• PCOD
• Hirsutism
• Acanthosis nigricans
• Xanthelasmas

Image showing Acanthosis nigricans

Causes:

1) Insulin resistance with fatty acid influx.
2) Low grade chronic inflammation and oxidative stress.

Deleterious effects of Diabetes Mellitus

Vascular damage:

• micro-vascular (retinopathy; nephropathy and neuropathy)
• macro-vascular (premature and more extensive cardio- , cerebro- and peripheral vascular disease)

Premature mortality and morbidity in diabetes result from such complications.

The Dangerous Cluster of Metabolic Syndrome

• It varies between 7.1 to 42.6 % across counties, 26.1 to 29.8 % in South Asia
• 3 times likely to have MI and stroke
• Five fold risk of developing type 2 diabetes mellitus

Reference – https://doi.org/10.1016/j.cegh.2020.03.018

Health consequences of overweight and obesity

Obesity increases the risk of many diseases like

1. Type 2 diabetes, hypertension, dyslipidemia;
2. Cardiovascular diseases and stroke, which were the leading cause of death in 2012;
3. Musculoskeletal disorders (osteoarthritis);
4. Cancers (endometrial, breast, ovarian, and colon).
5. Liver and gallbladder disease
6. Obstructive Sleep Apnea
7. Infertility
8. Psycho-social disorders

Childhood obesity is a growing concern as these children have an increased risk of insulin resistance, hypertension, breathing difficulties, fractures, and psycho-social problems as well as later in adulthood, have a higher chance of obesity and even premature death.

Treatment for Obesity

The first-line treatments for obesity and overweight include diet, exercise, behaviour therapy, and anti-obesity drugs. But for severe obesity this has limited success and success for long term is very poor. Whenever a patient approaches for weight loss, the screening form is filled and investigations are carried out. Procedure is planned based on BMI, comorbidities, and the investigation results.

The post Obesity Overview appeared first on Dr. R. Padmakumar.

തൈറോയ്ഡ് മുഴകള്‍ കഴുത്തില്‍ അഭംഗി ഉണ്ടാക്കുന്നു. ഗോയിറ്റര്‍ അഥവാ നോഡ്യൂള്‍ വരുന്നതും വളരെ പേര്‍ക്ക് ബുദ്ധിമുട്ടുണ്ടാകുന്ന രോഗാവസ്ഥയാണ്.

തൈറോയ്ഡ് മുഴകള്‍ കഴുത്തില്‍ അഭംഗി ഉളവാക്കുന്നതു കൂടുതല്‍ കാലം ചികിത്സിക്കാതിരുന്നാല്‍ ദോഷഫലങ്ങള്‍ ഉണ്ടാക്കുന്നവയുമാണ്. ഇത് കൂടുതലായും സ്ത്രീകളിലാണ് കാണപ്പെടുന്നത്. ഒരാള്‍ക്ക് ഒന്നോ അതിലധികമോ മുഴകള്‍ തൈറോയ്ഡ് ഗ്രന്ഥിയില്‍ ഉണ്ടെന്ന് കണ്ടാല്‍ സ്കാനിംഗ് പരിശോധനയും, സൂചി പരിശോധനയും (FNAC) നടത്തണം. ഈ പരിശോധനയില്‍ കാന്‍സര്‍ സംശയമില്ലെങ്കില്‍പോലും മുഴയുടെ വലിപ്പം നാല് സെ. മീറ്ററില്‍ അധികമാണെങ്കില്‍ ശസ്ത്രക്രിയ ആവശ്യമായി വരും. ഗ്രന്ഥി പകുതിയായോ, പൂര്‍ണ്ണമായോ നീക്കം ചെയ്യണമെന്ന് (ഹെമിതൈറോയ്ഡക്ടമി/ടോട്ടല്‍ തൈറോയ്ഡക്ടമി) സര്‍ജന്‍ തീരുമാനിക്കുന്നത് ദേഹപരിശോധന, സ്കാനിംഗ്, (FNAC) എന്നിവയുടെ അടിസ്ഥാനത്തിലാണ്.

സാധാരണയായി തൈറോയ്ഡ് മുഴകള്‍ വന്നാല്‍ കഴുത്തില്‍ വലിയ മുറിവുണ്ടാക്കുന്ന തുറന്ന ശസ്ത്രക്രിയകള്‍ മാത്രമേ ചെയ്യാറുള്ളൂ. ഇത് വളരെ വലിയൊരു മുറിപ്പാട് കഴുത്തിന് കുറുകെ അവശേഷിപ്പിക്കും. ഇത് പ്രത്യേകിച്ചും സ്ത്രീകളില്‍ അസന്തുഷ്ടിയും, അഭംഗിയും ഉളവാക്കുന്ന ഒന്നാണ്.

എന്‍ഡോസ്ക്കോപ്പിക് തൈറോയ്ഡ് സര്‍ജറി

താക്കോല്‍ദ്വാര ശസ്ത്രക്രിയയിലൂടെ ചെയ്യുന്ന എന്‍ഡോസ്ക്കോപ്പിക് തൈറോയ്ഡ് സര്‍ജറി കക്ഷത്തിനടുത്തുകൂടി വളരെ ചെറിയ മുറിവിലൂടെ ചെയ്യുന്നതിനാല്‍ പാടുകള്‍ തീരെയില്ല. ഹൈഡെഫനിഷന്‍ ക്യാമറയിലൂടെ വ്യക്തവും വലുതുമായ കാഴ്ച ലഭിയ്ക്കുന്നത് ശസ്ത്രക്രിയ സുരക്ഷിതവും പൂര്‍ണ്ണവും ആക്കുന്നു. ദശകള്‍ക്കും പ്രധാന അവയവങ്ങള്‍ക്കും ക്ഷതമുണ്ടാക്കാത്ത ആധുനിക സംവിധാനങ്ങളായ ഹാര്‍മോണിക് സ്കാല്‍പല്‍ ഉപയോഗിച്ചാണ് ഈ ശസ്ത്രക്രിയ ചെയ്യുന്നത്. ഇത്തരം ശസ്ത്രക്രിയകള്‍ തുറന്ന് ചെയ്യുന്നതിനേക്കാള്‍ നല്ല ഫലപ്രാപ്തി നല്‍കുന്നുണ്ട്. കഴുത്തിലെ പ്രധാനപ്പെട്ട ഞരമ്പുകള്‍ സൂക്ഷ്മതയോടെ നിലനിര്‍ത്താനും ശബ്ദവ്യതിയാനം വരാതിരിക്കാനും ഇത് സഹായിക്കുന്നു. കാത്സ്യത്തിന്റെ അളവിനെ നിയന്ത്രിക്കുന്ന പാരാതൈറോയ്ഡ് ഗ്രന്ഥികളിലൂടെ രക്തയോട്ടം നഷ്ടപ്പെടാതെ സംരക്ഷിയ്ക്കാനും ക്യാമറയിലൂടെയുള്ള, വലിപ്പം കൂടിയ കാഴ്ച ഉപകരിയ്ക്കും. മുഴകള്‍ മാറ്റിയശേഷം ഒരു സഞ്ചിയിലിട്ട്  പുറത്തേയ്ക്കെടുക്കുന്നു.

നാല് സെ.മീറ്റര്‍ താഴെയുള്ള മുഴകള്‍ മാത്രമേ ഇത്തരം ശസ്ത്രക്രിയയിലൂടെ മാറ്റാന്‍ സാധിക്കൂ എന്നത് തെറ്റിദ്ധാരണയാണ്. പത്ത് സെ.മീറ്റര്‍ വലിപ്പമുള്ള മുഴകള്‍പോലും വളരെ സുരക്ഷിതമായി എന്‍ഡോസ്ക്കോപ്പിക് മാര്‍ഗ്ഗത്തിലൂടെ മാറ്റാന്‍ സാധിക്കും. തൈറോയ്ഡ് പ്രാവീണ്യമുള്ള വിദഗ്ധനു മാത്രമേ ഇതു ചെയ്യാന്‍ സാധിക്കുകയുള്ളൂ. കാന്‍സര്‍ ഉള്‍പ്പെടെയുള്ള ഏതു തരത്തിലുമുള്ള മുഴകള്‍ക്കും ഈ പ്രക്രിയ അവലംബിക്കാവുന്നതാണ്. ഒരു ഭാഗത്ത് മാത്രം മുഴ നീക്കേണ്ടവരില്‍ അതുമാത്രം നീക്കം ചെയ്യുന്നതിനാല്‍ പിന്നീട് അടുത്തവശം നീക്കം ചെയ്യുന്നത് തുറന്നുള്ള ശസ്ത്രക്രിയയേക്കാള്‍ എളുപ്പവും സുരക്ഷിതത്വവുമാണെന്നത് എന്‍ഡോസ്ക്കോപ്പിക് ശസ്ത്രക്രിയയുടെ നേട്ടമാണ്. മുഴകളുമായി ബന്ധപ്പെട്ടു വരുന്ന ലിംഫ് ഗ്രന്ഥികള്‍ മാറ്റാനും ഈ ശസ്ത്രക്രിയ സഹായിക്കും. പാരതൈറോയ്ഡ് ഗ്രന്ഥികള്‍ക്കു വരുന്ന അഡിനോമാ മുഴകള്‍ക്കും എന്‍ഡോസ്ക്കോപിക് സര്‍ജറിയാണ് ഉത്തമം.

തൈറോയ്ഡ് പൂര്‍ണ്ണമായി മാറ്റപ്പെട്ടവര്‍ തൈറോക്സിന്‍ ഗുളിക തുടര്‍ന്നു കഴിയ്ക്കേണ്ടതാണ്. എത്രവര്‍ഷം കഴിച്ചാലും ഒരു പാര്‍ശ്വഫലങ്ങളും ഉണ്ടാക്കാത്തതും വളരെ സുരക്ഷിതവുമാണ് തൈറോക്സിന്‍.

തൈറോയ്ഡില്‍ കാന്‍സര്‍ ബാധിച്ചാല്‍ ശസ്ത്രക്രിയാ ചികിത്സയാണ് ഉത്തമം. അതിനുശേഷം റേഡിയോ അയഡിന്‍ സ്കാനും അബ്ലേഷനും വേണ്ടിവന്നേക്കാം. മറ്റ് കാന്‍സറിനുള്ളതുപോലെ കീമോതെറാപ്പി, റേഡിയോതെറാപ്പി എന്നിങ്ങനെ ബുദ്ധിമുട്ടും പാര്‍ശ്വഫലങ്ങളും ഉള്ള ചികിത്സകള്‍ ആവശ്യം വരാറില്ല.

താക്കോല്‍ദ്വാര ശസ്ത്രക്രിയയില്‍ കഴുത്തില്‍ മുറിവില്ലാത്തതിനാല്‍ രോഗിക്ക് എല്ലാത്തരം ജോലികളിലും വേഗം തന്നെ വ്യപൃതരാകാവുന്നതാണ്. ശസ്ത്രക്രിയ നടന്നുവെന്ന് എല്ലാവരോടും സ്വമേധയാ വിളംബരം ചെയ്യുന്ന കലകള്‍ ഇല്ലാത്തത്, ഇക്കൂട്ടര്‍ക്ക് വളരെ ആത്മവിശ്വാസവും സന്തോഷവും നല്‍കുന്നു.

The post തൈറോയ്ഡ് ശസ്ത്രക്രിയ കഴുത്തില്‍ മുറിപ്പാടില്ലാതെ appeared first on Dr. R. Padmakumar.

Abdominal Adhesions

Abdominal Adhesions occur in the abdominal area and may involve pelvic organs, intestine tissues and ovaries. Abdominal adhesions also occur from abdominal incisions or infections like appendicitis, Crohn’s disease, diverticulitis, endometriosis, pelvic inflammatory disease, etc. It is more common in open surgeries than laparoscopic surgeries. It is less common in laparoscopic surgeries because the cuts are smaller. So laparoscopic surgeries are preferred over open surgeries. Lot of abdominal surgeries can be performed laparoscopically, eg. laparoscopic appendectomy, laparoscopic cholecystectomy, laparoscopic gastrojejunostomy, laparoscopic gastroplasty, etc

The symptoms vary depending on the organs and tissues that are involved. If the intestinal tissues are involved in adhesions the symptoms include severe cramping pain and limit the gut movement.  Partial or complete bowel obstruction is caused when a segment of the bowel is tapered by an adhesion. This causes severe pain, nausea and vomiting.

In more severe cases of adhesions, the entire abdominal cavity along with the reproductive organs and intestines are distorted with adhesions. Large and thick bands of adhesions lead to a frozen state of the abdominal area and will necessitate complex surgical procedures.  

Adhesiolysis

Adhesiolysis is a procedure performed to break up and remove adhesions. It is a minimally-invasive procedure. This procedure is also called Lysis of Adhesions. The treatment helps to treat adhesions that cause chronic pain and inflammation.  Antibiotics and medications are prescribed to reduce the chances of infection and to control the pain and discomfort caused by the procedure.

Adhesiolysis procedure comes with some risks such as infection, headache, dural puncture, swelling, increasing pain, excessive bleeding, or discharge from the incision site. The doctor provides special instructions and medications that have to be followed without fail to reduce the risk of complication.

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Obturator Hernia – Symptoms

Symptoms of Obturator hernia include:

• Bowel obstruction
• Abdominal bloating
• Pain
• Constipation
• Nausea
• Vomiting

Causes of Obturator Hernia

Aging can cause loosening of muscle mass and fatty tissue and the intestine enters the obturator canal. Multiple child birth and obesity can also cause obturator hernia. It can be diagnosed by imaging tests like CT scan, ultrasound scan or MRI scan of the abdomen.

Treatment

Obturator hernia can be treated with Laparoscopic surgery. The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort. The surgeon then makes a small incision in the abdominal wall and inserts a laparoscope to view inside of the abdominal cavity and associated organs. The surgeon makes few more incisions to insert two more instruments and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the weak spot of the abdominal wall to prevent the possibility of reoccurrence of hernia. Later the incisions are closed with self dissolving sutures.

After the surgery, medications are administrated to reduce pain and discomfort of the surgery. The patient can leave the hospital in a day or two and resume normal life in a week’s time.

Advantages of laparoscopic hernia surgery include:

• Small incisions
• Lowers chance of infection
• Less postoperative pain
• Reduced hospital stay
• Minimal scars
• Faster recovery time

Hernia – Other Types

Videos Related to Hernia

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Symptoms of Femoral Hernia

• Sudden groin and abdominal pain
• Nausea
• Vomiting

Diagnosing Femoral Hernia

Femoral hernia causes pain in the abdominal area. The doctor suggests various tests to diagnose its presence including ultrasound scan or CT scan.  The hernia can get complicated when they gets strangulated or obstructed causing extreme pain while lifting heavy objects or during bowel movements.

• Hernia obstruction –The bulged tissues gets stuck in the femoral canal resulting in excessive pain, nausea and vomiting.
• Hernia strangulation –The strangulated hernia causes restriction of blood flow to the area and gets trapped in the femoral canal. The condition requires emergency surgery to restore the blood supply to the area.

Causes

There are many factors that lead to the formation including:

• excess strain during bowel movement
• constipation
• heavy weight lifting
• obesity
• Chronic cough

Treatment

The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort caused by the condition. The surgeon makes a small incision in the abdominal wall and inserts a laparoscope to view the internal abdominal cavity and associated organs. A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached. After investigation, the surgeon makes few more incisions to insert hernia repair tools and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the femoral canal to prevent the possibility of reoccurrence of hernia in the canal. Later the incisions are closed and sutured. The surgery takes around 45 minutes to one hour to complete. After the surgery, meditations are administrated to reduce pain and discomfort from the surgery. The patient can leave the hospital in a day or two and are instructed not to do any heavy tasks like weight lifting. Diet rich in fiber content and adequate fluid intakes is instructed. The laparoscopic surgery has several advantages with a faster recovery time and minimal scars.

Femoral Hernia vs Inguinal Hernia

Both Femoral Hernia and Inguinal Hernia occurs at the groin area.  However, there are key differences in both these hernias.

Compared to Inguinal hernia, femoral hernias carry a higher risk of leading to strangulation.  Strangulation in hernia is life threatening as it cut off the supply of blood.

Other types of hernia

• Inguinal hernia
• Hiatal hernia
• Ventral Hernia
• Obturator Hernia
• Umbilical hernia
• Incisional hernia

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• Parathyroid surgery
• Bariatric surgery
• Gallbladder surgery
• Primary hyperthyroidism

Author: Dr R Padmakumar et al.

Contents

1. Introduction
2. Functions
3. Deficiency Causes
4. Correlation of calcium level in vitamin D deficiency
5. Primary hyperparathyroidism
6. Obesity & After Bariatric Surgery
7. Gallbladder Disease & Vitamin D Deficiency
8. Treatment

Introduction:

Vitamin D is a fat soluble vitamin and produced by skin (from cholesterol) when exposed to ultraviolet B radiation (“sunshine vitamin”) and also obtained from dietary sources, including supplements. Most important components, vitamin D3 (cholecalciferol) comes from fortified foods, animal foods (fish, eggs and liver) and can be made internally when skin is exposed to ultraviolet (uv) radiation from the sun and vitamin D2 (ergocalciferol)

• Deficiency: 25 (OH) D levels below 12 ng/ml
• Inadequate: 25 (OH) D levels between 12-20ng/ml
• An adequate: 25 (OH) D levels between 20-50ng/ml
• Excessive: 25 (OH) D levels over 50nglml

Excessive intakes of vitamin D can lead to high levels of calcium (hypercalcemia). The symptoms of this are weakness, confusion, constipation, loss of appetite and development of painful calcium deposits. To avoid this, advice to keep the supplement intake below the tolerable upper limits.

Functions:

The need for vitamin D goes way beyond preventing and treating rickets. Various researchers have claimed that vitamin D benefits are associated with the following:

1. Enhancing intestinal absorption of calcium and phosphorus
2. Prevention of osteoporosis and osteopenia
3. Allowing proper functioning of parathyroid hormone
4. Lowering blood pressure in people with hypertension
5. Lowering incidence and severity of cardiovascular disorders
6. Decreasing the incidence of type 2 diabetes: research has shown that those with blood vitamin D level over 25ng/ml had a 43% reduced risk of developing type 2 diabetes compared with those with levels under 14ng/ml
7. Decreasing inflammation: research has shown a decrease in levels of C-reactive protein , a marker of inflammation , with increased levels of vitamin D to just below 21ng/ml
8. Reducing risk of allergies in children and adolescents
9. Prevention of dental caries
10. Prevention and treatment of depression
11. Possibly helping with erectile dysfunction (ED)
12. Regulating cholesterol levels in the blood: it has been shown that without adequate sun exposure, vitamin D precursors turn to cholesterol instead of vitamin D
13. Decreasing mortality rate of certain cancers
14. Increase immunity
15. Deficiency in pregnancy may lead to gestational diabetes, pre eclampsia and small infants

Deficiency – Causes:

1. Inadequate sun exposure
2. Limited oral intake
3. Impaired intestinal absorption
4. Primary hyperparathyroidism
5. After bariatric surgery
6. After Gallbladder surgery
7. Parathyroid removal
   • Accidental during thyroid surgery
   • For parathyroid adenoma or hyperplasia

Correlation of calcium level in vitamin D deficiency

• If parathyroid function is normal
• When primary hyperparathyroidism

In vitamin D deficiency due to reduced oral intake or reduced sun exposure ,Vitamin D level and calcium level will be low with normal parathyroid function. Calcium level will be high and vitamin D will be low when primary hyperparathyroidism exists.

Primary hyperparathyroidism

• There is high calcium level in the blood
• May present with parathyroid tumor
• High PTH takes calcium from the bone and shut down calcium absorption
• There will be low vitamin D

Obesity and After Bariatric Surgery

Research has begun to show a relationship between BMI and vitamin D deficiency. A study done on 2,187 overweight and obese subjects, found that those with a BMI above 40 had 18% lower serum vitamin D levels than those with a BMI under 40. Some possible reasons for this are lower intakes of vitamin D , less exposure to sunlight (uv) radiation and a higher distribution volume of vitamin D . Even with exposure to sunlight, there remains a risk for deficiency.

Morbid obese patients have a higher incidence of high PTH and low vitamin D even before surgery compared with normal individuals.

In gastric bypass: low calcium absorption due to bypassed duodenum and jejunum may be the cause.

In sleeve gastrectomy the vitamin D and calcium level are maintained within normal limits compared to bypass surgery.

Bariatric Surgery

Bariatric Surgery deals with the study of obesity, the causes, prevention and treatment of obesity. Different weight loss procedures are Laparoscopic Sleeve Gastrectomy, Roux-en-Y Gastric Bypass, Mini Gastric Bypass, Laparoscopic Gastroplasty. Intragastric Balloon Placement is a non-surgical weight loss procedure.

Bariatric Surgery Sleeve Gastrectomy Roux-en-Y Gastric Bypass Gastroplasty Intragastric Balloon Placement

Gallbladder Disease and Vitamin D Deficiency

Low vitamin D may cause gallbladder stone formation

Gall bladder removal may reduce vitamin D and magnesium levels. This may be due to reduced absorption of fat soluble vitamins (D, E, A and K).

People with compromised liver or digestive function are often vitamin D deficient. Exposure of skin to the sun’s UVB rays enables body to manufacture vitamin D. However, this process occurs in the liver and kidneys. Here people with a sluggish liver often do not manufacture vitamin D adequately.

Gallbladder Surgery

The gallbladder is an organ that helps in the digestion process. Gallstones is a common cause of Gallbladder disease. Laparoscopic Cholecystectomy is a procedure performed to remove the gallbladder from the body

Laparoscopic Cholecystectomy

Treatment

1. Sun rays exposure
2. Increased oral supplements
3. When the blood level of vitamin D is below 30 ng/ml, a minimum of 1,000 IU/day will be needed for children and 1,500 to 2,000 IU/day of vitamin D3 for adults.
4. Another rule of thumb is for every 1 ng/ml increase in blood level one need is an additional 100IU/day.
5. In obese patients , with malabsorbtion syndromes and patients on medications affecting vitamin D metabolism, it is advised to have a higher dose (two to three times higher , atleast 6,000-10,000IU/day) of vitamin D to treat deficiency to maintain a 25(OH)D level above 30ng/ml, followed by maintenance therapy of 3,000-6,000IU/day.
6. After parathyroid removal , may be wise to have a concomitant replacement of vitamin D with calcitriol (0.25-1mcg/day). Dependence on calcium supplementation for more than 6 months shows permanent hypoparathyroidism; which will necessitate continued use of such medications.

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Laparoscopy: As the name suggests ‘Laparo’ means abdomen, ‘Scopy’ means vision. The surgeon visualizes the inner parts of the patients body through the laparoscope which is a small cut (incision 5-10 mm) on the abdomen. The magnified (up to 20 times larger) vision of the interior parts through the telescope is quite different from the traditional open surgery. Due to the small incision inflicted on the patients, it is also known as Minimally Invasive Surgery (MIS), Band – aid surgery and rarely pin hole surgery.

Doctors, patients and their bystanders can now relax. The conventional methods of open surgery by cutting and stitching body parts are soon going to be extinct. Thanks to the advancement of Science and Technology in the medical field.

Origin and History

The first laparoscopic surgery was performed in dogs in 1902 by George Kelling of Dresden Germany. The first laparoscopic surgery in humans was conducted by Hans Christian Jacobaeus of Sweden in 1910. The first laparoscopic Cholecystectomy (removal of gallbladder) in humans was done in 1987 in France. The introduction of high definition camera, medical monitor and good electro surgical units made the procedure easier. In India the procedure is in practice for the past 20 years and is getting popular due to its very high advantages over conventional surgery.

How it works

The laparoscope, a telescopic rod lens system, is put through the small incision made around the umbilicus of the patient. The system is connected to a video camera (single chip or three chip). A fiber optic cable system connected to a ‘cold light source (halogen or xenon)’ is used to illuminate the operative field. The patient’s abdomen is distended with carbon dioxide gas to create a working and viewing space for the surgeon. Carbon dioxide is used as it is familiar to the human body and gets removed by the respiratory system if it gets absorbed through tissue. The surgical equipments are introduced into the abdomen through two 3mm incisions (punctures) made near the earlier entry. The skilled surgeon, by looking at the monitor can perform surgery with precision and perfection.

Advantages of Laparoscopic Surgery

Since only two or three tiny incisions are made in the abdomen the patient feels less pain. It reduces blood loss, compared to traditional open surgery. There is less need for blood transfusion, hence less chance for acquiring infection like Hepatitis B, HIV, Malaria etc. There is significant reduction in scar and wound infection. Scant use of antibiotics and painkillers is possible unlike in open surgery. Hospital stay for patients is limited to one or two days. Shorter hospital stay means less burden for the patient and relatives. Unlike open surgery, fast recovery through laparoscopic method saves money and consumption of medicines. The patients can return to normal work and profession within a shorter period. As external snitching is completely avoided, Laparoscopic method provides excellent cosmetic outcome. The diseased organ is tackled inside the abdomen and intestines are not brought out to be in contact with outside environment as in open surgery. Hence chance of adhesion (sticking together of intestines) is minimized in laparoscopy to the least.

Laparoscopy enables doctors for better diagnosis. Since the organs are seen in magnified form, the surgeon performs with high precision. There is less chance of contact with blood and tissue fluids. Hence less chance for surgeon and staff to contract dreaded infections.

The surgeon can visualize the entire abdominal cavity of the patients, by just turning the telescope in all directions. Laparoscopic method helps in detecting alternate pathology than one which is entertained pre operatively; which is not possible in open surgery due to limited access and vision. As one can start feeding the patient early in laparoscopy, the gastrointestinal problems are also minimized and nutrition is well maintained. Finally patients is highly benefitted. Use of advanced energy sources like harmonic scalpel reduces tissue damage and hence the resultant recovery time and tiredness.

Laparoscopy – Prospective fields

Laparoscopic treatment and surgery are ideal in the case of removal of gallbladder (laparoscopic cholecystectomy) , appendix, ovary, uterus etc. It is very good for, hernia repair, bowel surgery and surgery on kidney and for surgery for weight reduction. The term Arthroscopy refers to the keyhole procedure for treatment of bone and joint problems and thoracoscopy for the procedure in chest.

How can the diseased organs be taken out through small opening ?

Usually the organs or affected parts removed are not too big. An appendix, gall bladder, cyst wall etc. are of small size which can come out through the one 10mm Incision made earlier. For females, specimen like uterus comes out through the vagina without any need for abdominal incisions. If necessary, using instruments like morcellator the specimen can be sucked out in smaller pieces completely.

Is cancer treatment possible?

Laparoscopic treatment has many advantages in detecting and removing tumors. Eight major scientific studies have proved that laparoscopic surgery is better than open surgery for surgically treating cancer. Postoperative complications in lungs, veins, intestines etc are significantly reduced by the fact that patients are not confined to bed after laparoscopy. As wounds are less, patients need not wait for the wounds to heal and early initiation of chemotherapy is possible. Waiting for wound healing makes the microscopic reminant Cancer to grow before chemo tackles it. Cancers of uterus, intestine, kidney etc. are tackled laparoscopically all over the world. Laparoscopy avoid major negative laparotomies which increase the tiredness, sickness of patients when the tumour is not surgically removable.

Laparoscopy and Hernia surgery

Hernia is protrusion of contents of abdomen through defect in abdominal wall. The treatment is to repair these defects by supporting with a mesh. In conventional surgery one has to cut all layers of the abdominal wall to place this mesh; obviously causing major wound, pain and sometimes weakening of tissues. In laparoscopy the procedure is done through 1 cm incision much away from the defect and a much larger mesh can be placed right at the place of starting of hernia. Being more physiological, the outcome is superior with very very less chance of recurrence compared to open surgery. No need for 3-6 months rest as in open surgery. Even multiple hernias can be tackled through the single 1 cm incision plus two 3 mm punctures rather than cutting long at each place.

Obesity & Diabetic Surgery

Laparoscopic method may be the only safe option in bariatric surgery. Bariatric surgery is considered when the body mass index (BMI) is more than 35. It is really difficult to perform open surgery in obese patients and they go in for respiratory and wound complications. Highly desirable results are obtained by a laparoscopic approach which gives a very good access to the stomach.

Laparoscopic bariatric surgery brings back obese patients to normalcy by getting rid of the extra fat which was causing various medical illness like diabetes, high blood pressure, high cholesterol, cardiac illness , breathing difficulty , joint pain, cancers , infertility etc. Keyhole surgery gives excellent result in attaining long term resolution of Diabetes Type II.

Laparoscopy in Gynecology & infertility

All gynaec procedures can be performed very successfully by laparoscopy and gives much better results in infertility. Taking out baby (Cesarean) may be the only procedure which may necessitate a wound. Opening abdomen for the removing uterus or cyst of any size is unnecessary as the laparoscopic surgery accomplish better outcome.

Thyroid surgery (Endoscopic Thyroidectomy)

The surgical solution available in most of the places is open thyroidectomy which involves a large transverse cut across the lower part of the neck. This definitely leads to an unsighty scar which is not acceptable, especially for women. The endoscopic thyroidectomy – the keyhole or minimally invasive technique is a very good alternative to other methods. It gives excellent cosmetic outcome especially when done by an axillary approach. It gives equal or even a better surgical outcome as far as the actual thyroid nodule management is considered.

The earlier belief was that the endoscopic no neck scar option for thyroid swellings are applicable to lesions of less than 4 cm size. But we have observed that swellings of size of even 12 – 15 cm can be tackled very successfully through this method. The only pre-requisite will be a surgeon with good experience, in both laparoscopic surgeries and thyroid surgeries. Any kind of pathologies like benign or cancerous nodules, thyoiditis can be safely tackled by endoscopic thyroidectomy.

Thoracoscopy

Keyhole surgery is an excellent method for treating disease in the chest. Lung cancers, & recurrent pneumathorax (air leak) , chest wall tumors and infection can be tackled through 1 cm cut using telescopic system. In conventional surgery (Thoracotomy) the 30-40 cm incision with rib cutting-mainly for access and vision cause extreme discomfort to patient at every breath for at least six months. The procedures can be performed with high precision and perfection with out these troubles when performed by the thoracoscopic method.

Previous Surgery & Associated medical Illness

Previous open surgery or laparoscopy in not a contra indication for laparoscopy. Medical illness like diabetes, Hypertension, asthma, cardiac illness though increase risk for anaesthesia the laparoscopic surgery can be performed comfortably without increasing the risk . Less need for confinement to bed in laparoscopy actually reduces the post op complications in these patients with comorbid illness. Laparoscopic surgeries can be performed under regional anaesthesia (spinal / epidural) when general anaesthesia cannot be given.

What are the risks in Laparoscopy?

Laparoscopic procedures do not carry any additional risks, as nothing which can harm the body is used . Surgery related risks are very minimum compared to open surgery. The safety of the patient and the precision in treatment have increased manifold with the availability of ultrasonic and radio frequency instruments. Keeping blood in reserve is mostly not needed unlike in open surgery. Pain and infection after surgery is extremely rare for the patients in laparoscopy. The diseased organ is removed completely and no chance of recurrence of the problem, only because procedure was done laparoscopically.

There is no need for physical rest for the patient and can resume normal diet in twelve hours. No special preparation is required prior to laparoscopy. Four to six hours of fasting which mandates anaesthesia requirements is sufficient.

Training

A good hand, eye coordination is required for laparoscopy. Lack of trained surgeons in laparoscopy is a major problem in India like other parts of the world. After sustained training to surgeons with easy availability of sophisticated instruments; major hospitals are now getting fully equipped to handle laparoscopic surgery. Surgeons should not give a prolonged illness & discomfort by a wound when patient comes for an illness which can be cured by surgery in 24hrs. Every surgeon should learn Laparoscopy and practice it. Lap surgery has taken away the fear of surgery-the pain. It is very pleasing to see patients walking around even on the 1st day after undergoing major surgery laparoscopically . But open surgery patient is confined to bed and require many persons to help, even to move.

Financial advantage

Through laparoscopic surgery costs higher than open surgery, it has its own advantages financially. For laparoscopic surgery, a patient need not stay in the hospital for more than two days. It will be week long stay in the hospital for open surgery. Prolonged stay in hospital incurs expenses for accommodation, food, medicine etc. The patient after laparoscopic surgery can join work much sooner than those undergoing open surgery. This will have an impact on the income of family. The expenses incurred for bystanders and their availability are minimized in the case of laparoscopy. These indirect expenses definitely over weighs the apparent direct cost for laparoscopy.

The wound related problem like infection, adhesion and hernia leads to further expenses in open surgery group even later.

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