The Egyptian Journal of Hospital Medicine (July 2018) Vol. 72 (10), Page

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1 Th Egptian Journal of Hospital Mdicin (Jul 2018) Vol. 72 (10), Pag Formal vrsus Mini- Post Laparoscopic Slv Gastrctom Mohamd Ahmd Mohamd Aamr, Mohb Shorab Eskandaros, Bisho Nag Grgs* Dpartmnt of Gnral Surgr, Facult of Mdicin Ain-Shams Univrsit *Corrsponding author: Bisho Nag Grgs, Mobil: , ABSTRACT Background: obsit nowadas is associatd with comorbiditis that doubl foldd th mortalit as cancr, cardiovascular disas, and diabts. And wight loss b ditar changs and xrcis usuall dos not achiv th dsird wight loss goals. As such, bariatric surgr has bcom th tratmnt of choic for obsit and comorbiditis. Bod contouring and spciall abdominoplast aftr bariatric surgr is a componnt in th tratmnt of th obs patint and is wll accptd b patints, dspit th xtnsiv scarring with all of th surgical procdurs. Thr is vidnc that post bariatric surgr patints who hav subsqunt bod contouring surgr maintain thir wight loss. Aim of th Work: to compar btwn formal and modrn mini-abdominoplast aftr laparocopic slv gastrctom. Patints and Mthods: this comparativ stud includd two groups of thirt patints ach, group I consistd of patints with rdundanc at th vntral part of th abdomn aftr wight loss stabilization at BMI 30 for mor than 6 months post laparoscopic slv gastrctom, whr formal, traditional, abdominoplast was don to thm. Whil group II consistd of patints with rdundanc at th vntral part of th abdomn aftr wight loss stabilization at BMI 30 for mor than 6 months post laparoscopic slv gastrctom, whr modrn mini-abdominoplast was don to thm. Rsults: as rgarding Flank fullnss post Group I rsolvd th flank fullnss xcpt for 10 whil Group II 20 cass still with flank fullnss, thrfor thr was statistical significant diffrnc btwn th two groups as (p valu) = As rgarding uppr abdominal wall bulg condition rsolvd succssfull in 27 cass from group I and onl 10 from Group II, thrfor thr was statistical significant diffrnc btwn th two groups as (p valu) = Conclusion: abdominoplast givs th patint sking wight loss th ncouragmnt and wll to los mor wight and improv his pschological stat, traditional abdominoplast provid a comprhnsiv tratmnt of abdominal wall rdundanc, vn in th most svr cass, th patints gt both functioning and cosmtic improvmnt. Mini-abdominoplast is lss ffctiv, not appropriat mthod to trat patints with lipodstroph of th trunk and fullnss of th flanks post laparoscopic slv gastrctom and bariatric surgris. Kwords: Stud and compar formal, traditional, abdominoplast and mini, abdominoplast post laparoscopic slv gastrctom. INTRODUCTION Obsit nowadas is associatd with comorbiditis that doubl foldd th mortalit as cancr, cardiovascular disas, and diabts (1). And wight loss b ditar changs and xrcis usuall dos not achiv th dsird wight loss goals (1). As such, bariatric surgr has bcom th tratmnt of choic for obsit and co-morbiditis (2). Guidlins rcommnd bariatric opration for morbidl obs patints, dfind as thos with a bod mass indx (BMI) - 40 or patints with a BMI - 35 who hav associatd comorbiditis. And th currnt surgical options for Bariatric Surgr: rstrictiv procdurs lik vrtical bandd gastroplast (VBG), adjustabl gastric banding (AGB), slv gastroctom (SG), malabsorptiv procdurs lik: jjunoilal bpass, biliopancraticdivrsion, duodnal switch procdur (DS) and combind procdurs lik gastric bpass, minigastric bpass. Th doctor chooss th suitabl opration to his patint according gnral condition and accptabilit of patint bod to th opration tp (3). Following massiv wight loss thanks to Bariatric surgris, a nw dformit has mrgd. Th patint oftn xprinc soft tissu dflation with xcss folds of rdundant skin and subcutanous tissu that fails to rtract and hangs from th torso, abdomn. This xcss skin rdundanc can lad to both phsical and pschological problms. Hanging skin folds can impd movmnt and mak it difficult to xrcis. Skin ma bcom macratd and pron to rcurrnt infction in th intrtriginous aras hoodd b ovrhanging tissu. Patints ar oftn mbarrassd b thir nw bod shap and avoid undrssing in front of popl, which has an impact on rlationships. Dspit succssful wight loss following bariatric surgr, a patint s bod imag, Rcivd:21/6/2018 Accptd:30/6/

2 Mohamd Ahmd Mohamd Aamr t al. pschological and Phsical stat ma actuall dtriorat (4). So, patints sk bod contouring and spciall abdominoplast surgr bcaus man ar dpl distrssd b thir apparanc. Ths patints should b no lss than 12 to 18 months aftr bariatric surgr, b stabl in wight for 3 to 4 months, hav a bod mass indx of lss than 30, and b wll-nourishd, with no protin or vitamin dficincis. Procding bfor ths critria ar mt can rsult in rcurrnt skin laxit and dlad wound haling and ma b inconsistnt with th patint's halth insurr's rquirmnts (5). A surv was conductd in 2011 of UK Bariatric Surgons to dtrmin th proprativ counslling that patints rciv on this issu, thir opinions towards post-bariatric surgr bod contouring, and Rsults concludd that Th NICE guidlins on obsit rcommnd that patints undrgoing bariatric surgr should hav information on post-bariatric bod contouring surgr to improv th comprhnsiv tratmnt of ths patints (6). On of th most popular bodcontouring procdurs is abdominoplast; th aim of postbariatric abdominoplast was to rmov th xcss of skin and rdundant fat in ordr to rcrat a slim profil. And bing don aftr bariatric surgr is diffrnt from similar procdurs in thos who hav not bn obs. Th dformit aftr bariatric surgr is mor svr bcaus th skin damag and associatd loss of ton and lasticit do not rcovr, and th laxit is global. That s wh th surgr should b considrd a rconstructiv rathr than an asthtic on. So, bod contouring and spciall abdominoplast aftr bariatric surgr is a componnt in th tratmnt of th obs patint and is wll accptd b patints, dspit th xtnsiv scarring with all of th surgical procdurs. Thr is vidnc that post bariatric surgr patints who hav subsqunt bod contouring surgr maintain thir wight loss (7). It is oftn difficult to prdict whr on th bod ths dformitis will matrializ in a givn patint onl hpothsis. Th wid bradth and varit of dformitis allow numrous surgical options. As Laparoscopic Slv gastrctom toda is th fastst-growing wight loss Bariatric surgr option don producing succssful and sustaind wight loss. W will focus in this stud on comparing btwn formal and miniabdominoplast aftr laparoscopic slv gastrctom. AIM OF THE WORK To compar btwn formal and modrn mini-abdominoplast aftr laparocopic slv gastrctom. PATIENTS AND METHODS Tp of Stud: Prospctiv, comparativ stud. This stud includs sixt patints with abdominal wall rdundanc aftr laparoscopic slv gastrctom. All th patints wr xamind as rgards ag, sx, wight, hight, BMI, gnral xamination, co-morbiditis & associatd vntral hrnia. Th patints wr allocatd into two groups of thirt patints ach, dpnding on which tp of th group will undrgo: Group I: will undrgo formal. Group II: will undrgo Mini Stud Priod: 6 months. Inclusion Critria: Ag ars old. Post laparoscopic slv gastrctom Patints, Infraumbilical abdominal skin folds, 12 to 18 months aftr gastric slv surgr, b stabl in wight for 3 to 4 months, Hav a bod mass indx of lss than or qual 30. Exclusion Critria: Prvious abdominoplast, unstabl bod wight. Blding tndnc, Cardiac problms, Rnal Problms, Pulmonar problms, Abdominal wall hrnia. Stud Sit: Outpatint clinic at Ain-Shams Univrsit. Sampl Siz: 60 patints. Ethical Considrations: Approvd b Ethical Committ of Ain-Shams Univrsit. Informd consnt: This was obtaind from vr patint, including xplanation of th procdur, information about possibl risks and th xpctd complications. Proprativ valuation of vr patint includd: Mdical histor: Th histor also covrd th following: Numbr of childrn and histor of csaran sctions. Histor of othr abdominal surgris. Histor of bariatric surgris. Histor of abdominal hrnias. Exrcis routin. Rspirator histor: asthma, smoking, slp apna. Wight/dit histor. Calculation of BMI: wight in kilograms/(hight in mtrs)². Phsical xamination: Phsical xamination was conductd with th patint not onl in th supin position and standing positions, but whn sitting. Th sitting position is oftn th onl postur in which on can s th aras of rdundanc in th patint who primaril dmonstrats abdominal wall protrusion. 5456

3 Formal vrsus Mini- Post Laparoscopic. RESULTS Tabl (1): BMI rang and man bfor slv and bfor and aftr abdominoplast Grou p BMI BMI Rang Man bfor bfor Slv Slv Stabl BMI Rang bfor Stabl BMI Man bfor BMI Rang 6 months aftr BMI Man 6 months aftr I II Total Tabl (2): Mdical problms of th population. Group DM Hprtnsion Smokr Group I Group II Total Tabl (3): Post oprativ complications Group Group Groups Total P valu I II Hmatoma Sroma Infction Skin Flap ncrosis Flank Fulnss post oprativ Uppr abdominal bulg rsolvd DISCUSSION Obsit is an incrasing worldwid problm associatd with advrs halth ffcts and dcrasd lif xpctanc. Th prvalnc of obsit is incrasing rapidl in most industrializd countris and it is known that obsit is associatd with incrasd risk of cardiovascular morbidit and mortalit. Obsit is growing at an alarming rat. Thus, invstigation into th atiolog, comorbiditis, and tratmnt of obsit has burgond in rcnt ars. Whil novl thrapis both bhavioral and pharmacological hav bn dvlopd and tstd, th man wight losss achivd with nonsurgical approachs hav rmaind virtuall unchangd ovr th past 20 ars. Fortunatl, th modst wight losss achivd with ths mthods ar associatd with significant rductions in obsit-rlatd halth problms. With th most intnsiv availabl tratmnt (i.., bariatric surgr), man patints achiv rmission of comorbid conditions (1). Th surgical tratmnt of morbid obsit has gaind popularit with th dvlopmnt of th gastric bpass opration and th advnt of laparoscopic bariatric procdurs. Bariatric surgr has volvd as a vr ffctiv thrap for morbid obsit. Patints who undrgo bariatric surgr los an avrag of 40 to 84% of thir xcss wight ovr 12 to 18 months (8). Bariatric surgr improvs abnormal lipid lvls, controls hprtnsion, and rducs th risk of diabts b as much as 75%. Ovrall, mortalit from obsit-rlatd problms can b dcrasd as much as 24%. Aftr such dramatic wight loss, patints ar usuall lft with rdundant skin (9). Patints with rdundant skin and subcutanous tissu hav problms of hgin and skin irritation and also mak a prson phsicall unattractiv. Rdundant tissu can lad to pain, intrtrigo, problms of hgin and dcrasd activit (10). Bod contouring in a patint who has massivl lost wight is gnrall not considrd a singl stag procdur. Massiv wight loss lads to similar changs of th abdomn, hips, thighs, flanks, tc., crating th par-shapd habitus. Th majorit of post-bariatric patints has multipl procdurs such as abdominoplast, brast rduction, mastopx, brachio-plast, thigh lift or liposuction, usuall not all prformd at th sam tim. Among ths, th abdominoplast has an ssntial rol in th bod imag rcovr (11). Thr is vidnc that post bariatric surgr patints who hav subsqunt bod contouring surgr maintain thir wight loss (7). So this stud was carrid out to compar formal and Mini- ffct on 60 patints undrgon laparoscopic slv gastrctom and s if thr was ffct on wight loss progrss among thos patints, 30 patints prformd formal and 30 patints prformd mini-abdominoplast. Prvious studis considrd formal as an option for post bod wight loss bod contouring as wll as man othr tchniqus, as blt lipctom, lowr bod-lift, and circumfrntial torsoplast (10,12). But thr was no stud taking mini- as an option for post bod wight loss bod contouring. This procdur, Miniabdominoplast, is much lss commonl prformd than full abdominoplast bcaus most patints prsnting for abdominal contouring has gaind significant wight and /or hav had svral prgnancis, rsulting in xcss skin laxit, stria and muscular diastasis (13). Although miniabdominoplast modrn tchniqu can dal with uppr abdominal wall bulg to som xtnd. Modrn abdominoplast tchniqus rspct ths circulator 5457

4 Mohamd Ahmd Mohamd Aamr t al. principls. Th main principl is to oprat with th most minimall invasiv tchniqu that will ild th bst achivabl asthtical rsult. Undrmining is mainl prformd in th midlin ara antrior to th lina alba and both rctus muscls, including th mdian zons of adhsion first dscribd b Lockwood and spcifid b Lockwood (14). This stud was takn to suppos if th modrn miniabdominplast can b option in bod wight loss post slv vrsus formal as most popular bod contouring tchniqu, and if it has th sam ffct or can ncourag to loss mor wight and maintain th progrss of th patints aftr stabilit of wight loss for mor than 6 months at BMI 30. In this stud 50 fmal patints and 10 mal patints fmals this dosn t' go with th work of Sozr t al. (15) who had all thir 151 patints wr fmals. And dosn't go with othr workrs Al t al. (16), Dini t al. (11) who had fmal to mal incidnc of 2:1. Howvr, this ma b attributd to th socioconomic class of Ain-Shams patints who wr th subjct of this stud. Th man ag of th studid groups of patints in this work was 31 ars a pit oungr than that of Al t al. (16), Dini t al. (11) (43.6 ars) and it was 42 ars for Sozr t al. (15). Again this diffrnc ma b attributd to th fact that in low socioconomic classs th ldrl patints ar not concrnd with th problm of attractivnss. A littl bit mor than th work of Sozr t al. (15), Dini t al. (11), traditional abdominoplast (man oprativ tims was 162 minuts) but th formal tchniqu still mor than th mini (man oprativ tims was 121 minuts). Major complications lik dp vin thrombosis and pulmonar mbolism wr not rgistrd in this stud. All patints in this stud rcivd prophlactic anticoagulants. Most of th studis had similar rsults Dini t al. (11), Sozr t al. (15) had onl on patint with postoprativ pulmonar mbolism dspit anticoagulant prophlaxis du to Antiphospholipid Sndrom. Th commonst postoprativ complication in this stud in both groups was sroma formation (70% in group I and 63.33% in group II). Sozr and his collgs in had a low incidnc of sroma formation aftr traditional abdominoplast (4%). This ma b rlatd to th fact that th magnitud of dissction in this stud was mor than that of Sozr t al. (15), this is bcaus most of th patints of this stud wr mor obs (man bod mass indx was 30), whil that of thir studis was 26. All ths patints wr managd succssfull b rpatd ndl aspiration with stril prcautions undr covrag of broad spctrum antibiotics; also abdominal bindr was applid (da and night). This incidnc was corrlatd to sstmic factors in th patints as blding tndnc, drug intak (aspirin), diabts, incrasd BMI, and th plan of flap dissction; th mor suprficial th plan as in sub and suprascarpal dissction, th lss th incidnc of sroma, th sam rsults was mntiond b Khan. (21). Mor or lss similar to that of this stud (40%) and an minor diffrnc was du to th dgr of dissction, as th bod mass indx for patints of this stud was 34 in comparison to 32 in Dini t al. (11). Partial wound dhiscnc in this stud was ncountrd in 10% of patints of group I and didn't occur in an of patints of group II which is lowr than that of Al t al. (16), Dini t al. (11) (18%) and much highr than that of Sozr t al. (15) (3%), again this is du to th highr bod mass indx in this stud. Th asthtic umbilicus is an ssntial goldn goal in th opration of abdominoplast. A goal that is achivd mainl b th island pdicl flap tchniqu prformd with an tp of xcpt for mini-abdominoplast. Th limitation of this tchniqu is mainl du to factors rlatd to umbilical proprativ disordrs ssntiall paraumbilical hrnias that impair th vascularit of th island umbilicus and forcd us to mak a noumbilicus and this tp of patints wr xcludd from ths studis. Onl in mini-abdominoplast, th tchniqu and dcision of th short incision will affct th asthtic shap of th umbilicus. Man authors pointd out that th incidnc of postoprativ complications incrass with incrasd bod mass indx (17,18). Howvr, as what happnd in this stud, all ths authors concludd that all ths complications rsolvd with minor tratmnt and follow up within 3 wks (11,15). Th patints in this stud had no long hospital sta (man tim for hospital sta was 3 das for both groups) which was similar to othr studis. Most minor postoprativ complications could b managd in out patint clinic (17,18). Th man hospital sta in both groups of this stud was th sam 3 das for both groups. So th addition of circumfrntial abdominoplast did not chang th hospital sta. Also th rst tim whn th gt hom was th sam (3 wks). Dini and his collgs (11) in 2008 had idntical rsults. Th skin flap ncrosis occurrd in 3 cass from th whol population, th 5458

5 Formal vrsus Mini- Post Laparoscopic. wr from group I and thir ducational lvl was noticd to b illitrat, 2 of thm wr diabtic onl and 1 was smokr and Hprtnsiv. Wound infction was ncountrd in 13 patints in this stud, which was tratd b intra-vnous antibiotics and wound drainag. It has bn documntd b clinical and xprimntal studis that cigartt smoking has advrs ffcts on wound haling and surgical rsults of diffrnt surgical procdurs (19). Th findings in this stud showd a positiv ffct of cigartt smoking on wound complications following abdominoplast which is consistnt b ths documntd studis. Th last factor in our practical stimation of th rsults of th tchniqus usd is th patint satisfaction, although ma not b basd on a scintific bas, t it rprsnts a goldn goal in th practical work. It is notd that th proprativ counsling and propr adjustmnt of th patint's xpctations was vr ssntial in improving th scors of satisfaction in th stud that xcdd 70% of ovrall patints studid. As a whol all patints in this stud wr uniforml plasd with thir rsults. Th wr plasd with thir nw imag. Bsids, all th patints with proprativ smptoms and back pain notd an improvmnt aftr thir abdominoplast. Most of th authors had idntical rsults (20). CONCLUSION givs th patint sking wight loss th ncouragmnt and wll to los mor wight and improv his pschological stat, traditional abdominoplast provid a comprhnsiv tratmnt of abdominal wall rdundanc, vn in th most svr cass, th patints gt both functioning and cosmtic improvmnt. Mini-abdominoplast is lss ffctiv, not appropriat mthod to trat patints with lipodstroph of th trunk and fullnss of th flanks post laparoscopic slv gastrctom and bariatric surgris. CONFLICTS OF INTEREST Thr ar no conflicts of intrst. REFERENCES 1. Burgura B and Tur J (2015): Mdical managmnt of obsit [Chaptr 3]. In: Brthaur SA, Schaur PR, Schirmr BD, ditors. Minimall invasiv bariatric surgr. 2nd dition. Nw York: Springr. 2. Dan AG and Lnch R (2015): Histor of bariatric and mtabolic surgr [Chaptr 4]. In: Brthaur SA, Schaur PR, Schirmr BD, ditors. Minimall invasiv bariatric surgr. 2nd dition. Nw York: Springr. 3. David E, Artrburn, Anita P Courcoulas (2014): Bariatric surgr for obsit and mtabolic conditions in adults, BMJ., 349:g Magdalno R, Chaim EA, Parja JC t al. (2011): Th pscholog of th bariatric patint: what rplacs obsit? A qualitativ rsarch with Brazilian womn. Obs Surg., 21(3): Münzbrg A, Laqu S, Yu K (2015): Rzai- Zadh and H.-R. Brthoud. Rviw Apptit and bod wight rgulation aftr bariatric surgr, Obs Rv., 16(1): Lnds H, Chidi E, Victoria R (2011): Post-bariatric surgr bod contouring in th NHS: A surv of UK bariatric surgons. JPRAS Journals, 65(4): Grignaffini E, Grico MP, Brtozzi N t al. (2015): Post-bariatric abdominoplast: our xprinc. Acta Biomd., 86(3): Sugrman HJ, Wolf LG, Sica DA t al. (2003): Diabts and hprtnsion in svr obsit and ffcts of gastric bpass-inducd wight loss. Ann Sur., 237: Obid F, Falvo A, Dabidn H t al. (2005): Opn Roux-n-Y gastric bpass in 925 patints without mortalit. Th Amrican Journal of Surgr, 189(3): van Huizum MA, Roch NA, Hofr SO (2005): Circular blt lipctom: a rtrospctiv follow-up stud on prioprativ complications and cosmtic outcom. Annals of Plastic Surgr, 54(5):

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