BDC #27 - Bariatic Surgery: You better never have to undergo this one !!

Are you currently studying in medical degree, and/or considering which specialist you would like to be, maybe you could consider to become  a Bariatic Surgeon. It's a specialist in bariatic surgery.

WAIT !! What is it?!!

I can give you a hint... It's a type of surgical procedure which gains its popularity due to rapid increase of the number of people with overweight or obesity. 

Ouh yeah... I think you start to get a glimpse of idea. ^^

Practically bariatic surgery includes all procedures related to the attempt of reducing the size of the alimentary tract, such as the stomach or the intestines. You start thinking of gastric bypass surgery? YUP it's one of it.

Basically, in the major cases, overweight or obese people gain their weight due to the massive amount of food they munch each time. It literally expands their stomach capacity every time their overeat, thus the stomach and all of the digestive tract are getting larger and larger.

Based on the US National Institutes of Health recommends this surgery for people with BMI at least 40, and people with BMI 35 and serious complication (e.g. diabetes and high blood pressure). However, lately they reduce the limitation to people with BMI 35-40 with no comorbidities, or a BMI of 30-35 with significant comorbidities. Even, due to the alarming progression of the obesity, the ASMBS guidelines suggest the bariatic surgery to people with BMI more 30 with comorbidities. OK, in medical term, comorbidity is equal to complication. Let's say, if you have diabetes problem, you might have another problem, like heart failure, high blood pressure, blindness.. YUP !! Those are comorbidities. 

 

Image credit: Walter Pories, M.D. FACS.

The image above is the image of several surgical options.

Practically, the bariatic surgery is divided into 3 subtypes with several types of surgical options, as mentioned:

1. Predominantly restrictive procedures : primarily reduce the stomach size

•  Vertical Banded Gastroplasty: also called the Mason procedure or stomach stapling, a part of the stomach is permanently stapled to create a smaller pre-stomach pouch, which serves as the new stomach.
• Adjustable gastric band: stomach is restricted by using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin.  
• Sleeve gastrectomy : the stomach size is reduced to about 15% of its original size. Under a surgery, of a large portion of the stomach is removed, following the major curve. And then, the open edges are then attached together (often with surgical staples) to form a sleeve or tube with a banana shape. The procedure will permanently reduce the size of the stomach and is not reversible.
• Intragastric balloon : This surgery means to insert a deflated balloon into the stomach, and then filling it to decrease the amount of gastric space. The balloon can be left in the stomach for a maximum of 6 months and results in an average weight loss of 5-9 BMI over half a year. Though this procedure is not yet approved in the USA, the Intragastric balloon is approved in Australia, Canada, Mexico, India and several European and South American countries.

2. Predominantly malabsorptive procedures : although it also reduce the stomach size, but the surgeries are based mainly on creating malabsorption.  However, due to the high case of heavy malnourishment after the surgery, the popularity is remarkably decreasing.

•  Biliopancreatic diversion: This complex operation is also known as ''biliopancreatic diversion'' (BPD), or ''Scopinaro procedure''. This surgery is rare now because of problems with malnourishment. It has been replaced with the Duodenal switch, also known as the BPD/DS. Part of the stomach is resected, creating a smaller stomach (however the patient can eat a free diet as there is no restrictive component). The distal part of the small intestine is then connected to the pouch, bypassing the duodenum and jejunum. 
• Endoluminal sleeve: this procedure is still only performed on mice at present, It involves of placing a 10cm long impermeable sleeve into the intestine to block absorption of food in the duodenum and upper jejunum. A study at Massachusetts General Hospital Weight Center and Gastrointestinal Unit found that mice who had the surgery ate 30% less food and lost 20% more weight than counterpart mice, while blood glucose levels returned to normal levels in all mice who had the surgery.

3. Mix procedures : which apply both techniques simultaneously.  

• Gastric Bypass Surgery: A common form of is the Roux-en-Y gastric bypass. A small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration. The gastric bypass had been the most commonly performed operation for weight loss in the United States. It has been considered as the "gold standard" in the U.S.A with a highly strict post-surgical adherence to a gastric bypass diet for healthier pattern of eating.

• Sleeve gastrectomy with duodenal switch: It is a variation of the biliopancreatic diversion includes a Duodenal switch. The part of the stomach along its greater curve is resected. The stomach is "tubulized" with a residual volume of about 150 ml. This volume reduction provides the food intake restriction component of this operation. This type of gastric resection is anatomically and functionally irreversible. The stomach is then disconnected from the duodenum and connected to the distal part of the small intestine. The duodenum and the upper part of the small intestine are reattached to the rest at about 75-100 cm from the colon. 
  (credit to the link above for the explanation)

• Implantable Gastric Stimulation: This procedure implants a device similar to a heart pacemaker, with the electrical leads stimulating the external surface of the stomach. The electrical stimulation is thought to modify the activity of the enteric nervous system of the stomach, which is interpreted by the brain to give a sense of satiety, or fullness. Early evidence suggests that it is less effective than other forms of Bariatric Surgery.

As mentioned before, Bariatic surgery is supposed to be the final effort to help overweight and obese people to lose weight. It is due to the fact that after the surgery, the patient will only get a highly restricted diet. Immediately after the surgery, the patient is only allowed to gulp only sugar-free clear liquid diet until the digestive tract is recovered. Afterward, the diet will get a little more solid with the addition with sugar-free salt-free dietary products, pureed fruit, and mashed potato (YAY !!!). But STILL, it's a baby food !!! Post-surgery, the patient will definitely vomit every time they overeat than the baby portion. They even have to take daily multivitamin pill for life to compensate the highly reduced absorption of essential nutrients. UWAH...it is definitely not nice !!!!

THAT IS WHY... I tell you guys, before it's too late, and we have to control our food intake. Even before we are suggested to undergo this surgery, imagine how hard is life with an overweight body??!! We don't have to have a superskinny body like super models, NO... it's also not healthy...

As long as we are in a proper balance of body proportion, it's GOOD !!

Stay healthy... stay in shape !!!!

  

BDC #26 - Dyscalculia: It doesn't mean they are cloddish

It's been quite a sometime since my last post.. Well, I can't help it. It's SUMMER!!! And I am already in a holiday MODE... But, I still have to keep myself in check, before my real holiday next week. So, I would like you guys to be familiar with something.

I believe you all already quite familiar with dyslexia, but.. Do you know about Dyscalculia? Well, you can guess from the word, calculia. Yes... It's about calculating, numbers, mathematics... Combined with dys-, it's obvious that it's related to some kind of "doing badly". 

Dyscalculia is a popular name of mental disorder with the code DSM-IV 315.1 Mathematics Disorder. It is defined as a difficulty in learning and comprehending arithmetic, fundamentally it is an inability to conceptualize numbers abstractly in comparative quantities. 

Are wondering now, isn't it simply because they are retarded? NO, they are not!! Although, yes, some of those who has dyscaculia have IQs comparatively below average, ACTUALLY the patients are disperse amongst all ranges of IQ. Up to now, there is no globally joined research or survey about dyscalculia, based on separated organization, they predict that dyscalculia effects between 3.6-6.5% of population (link). The ratio of male and female is around 50% each. 

There is no exact reason of dyscalculia itself, but researchers have made some hypothesis regarding the cause, especially a brain disorder on the broadmann area 40 and angular gyrus, at the junction between the temporal and parietal lobes of the cerebral cortex. (I know!! It sounds difficult, but it's nearly impossible to simplify it, when it comes to medical terms.. They LOVE difficult words...) It is hypothesized that this disorder might effect the working memory which is important in maintaining the abstract image of numbers while calculating. OK.... maybe it will be easier if I say, there is some oddity in the RAM while the computer processing the data before permanently saving it into the hard disk, or displaying it as an output on the screen. Thus, it always comes out as an ERROR. 

They are some signs to identify people with dyscalculia as given below

There is no standardized classification of dyscalculia, however, there are some parties proposing the subtypes.

According Ireland, they divided dyscalculia in to:

• Quantitative dyscalculia, is a difficulty in counting and calculating.
• Qualitative dyscalculia, is a result of difficulties in comprehension of instructions or the failure to master the skills required for an operation. When a child has not mastered the memorization of number facts, he cannot benefit from this stored "verbalizable information about numbers" that is used with prior associations to solve problems involving addition, subtraction, multiplication, division, and square roots.
• Intermediate dyscalculia involves the inability to operate with symbols, or numbers.

On the other hand, Kosc, a neuropsysiologist from Czechoslovakia, tried to describe the dyscalculia into six types:

• Verbal dyscalculia, refers to difficulties in naming the amount of things.
• Practognostic dyscalculia, refers to difficulties in manipulating things mathematically — for example, comparing objects to determine which one is larger.
• Lexical dyscalculia, refers to difficulties in reading mathematical symbols; including operation signs (+, -, :, x, /, etc ) and numerals.
• Graphical dyscalculia, refers to problems in writing mathematical symbols and numerals.(I know it looks similar.. but if you check on dyslexia and dysgraphia, reading and writing need different skills. That's why there is time when you can read but you can't write or/and spell it properly)
• Ideognostical dyscalculia, refers to problems in understanding mathematical concepts and relationships.
• Operational dyscalculia, refers to problems in performing arithmetic operations. 

(I have no comment for the last 2 subtypes, since I don't understand the difference either. =P )

Dyscalculia really effects the patients' selves-esteem, since it really hinders them from daily working nowadays. The numbers of job they could do is more likely cut down by half. Isn't it highly discouraging for them? It isn't like they are (pardon me) idiot.. they simply can't understand those numbers... the numbers are just like floating in their head and make them sick.

However, as parents, friends, teachers, and educators, there are some thing that we can do to help them in studying. 

• first of all, BE PATIENT... if you are not patient enough, just move your ass and let other people do the job
• use graph paper, block, figures, and any other physical tools, to help them imagine it easier
• instead of forcing them to memorized the multiplication tables, explain the difference and the logic of the numbers. Like I said, they are not idiot... they do have logic.
• introduce the mathematics skills from the more concrete examples first. 

My last advice, the world is definitely not ended, if we can't solve the difficult mathematical problems. Let the experts do that. What is more important is to encourage people with dyscalculia to concentrate more on their strengths. As long as they can calculate their change while shopping, it's enough for daily life.

 

     

        

The Tale of a Boy in a Coffee Shop #36

"There was one lady near my house, I think around 5 years ago. She was around the same age as my mother, but she looked kinda senile. She just sat on rocking chair at the porch, stared emptily to the garden. Her husband was quite a pity, I think. He worked and also took care of his wife. It were just the two of them. Later, I knew that she lost her newborn baby due to miscarriage. It destroyed her inside out."

The awkward air floated as the young boy let his story half finished. However, the two ladies waited for him patiently, as they felt there was a continuation.

"Around a year later, the husband decided to move back to his wife's parents house. He hoped that her parents could help him to take care of her while he helps them do the farm."

"But I think, if only that lady could let the baby go, and started a new life with her husband, try to get another baby.. they might have another chance of life."

The two ladies kept in silent for two minutes.

"I think you actually know how to let it go. Doesn't he, Granny?" The young lady smiled and went to the kitchen, continued her works.

"Do I?" the young boy looked at the old lady.

The old lady smiled, "There is a saying, Don't regret it because it's over, but be grateful because it happened."

"It's OK to keep the memory, as long as you have the right feeling over the memory, then you know how to deal your lost."

The young boy touched the rim of his glass, circling it with the tip of his index finger several times, "Indeed."      

The Tale of a Boy in a Coffe Shop #35

"Why do you think we have to let them go, Little Boy?" The old lady stroke the young boy's head softly. The deep honey coloured hair was so soft that her fingers could through it smoothly.

The young boy looked at the old lady with his deep blue eyes. He was looking for an answer, why did he have to let go on something. 10 seconds passed, the old lady still waited on him patiently. Indeed, even a short 10-second felt so long in a conversation.

"Because, hem... probably because to let our selves in peace?" The young boy answered uncertainly.

The young lady, who was listening while continue preparing some menus for lunch, stopped her hands and threw her sight to those two. She was interested.

"Why did you say it's for our own peace?" The young lady asked with deep interest in her voice.

"Is it wrong?" The young boy touched the rim of his glass nervously, he didn't expect that his answer would lead to another question on him. It had been a while since he had his last deep conversation.

"Again, it's not about right or wrong, boy. Like I said, you just have a unique logic, and I am interested. Don't take it negatively," the young lady smiled at the young boy tenderly.

"Oh, I see." The young boy exhaled in relieve. "Well, I think when we mourn over something that we lost, we actually torture our selves with grief. The longer we mourn, the longer the torture is. I think it's frustrating to a certain point and definitely unhealthy. That's why I said, if we could let it go, it's for our peace."

What a smart explanation, both the ladies thought, like a telepathy.