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\title{Medical Management of Patients with Modified Intestinal Bypass: A New Promising Procedure for Morbid Obesity}
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             \author[1]{Abd  M Aly Abd  Elrazek}

             \affil[1]{  Al-Azhar university}

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\date{\small \em Received: 7 December 2013 Accepted: 1 January 2014 Published: 15 January 2014}

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\begin{abstract}
        


Background and Aim: Obesity is a chronic disease that is increasing in prevalence worldwide. Bariatric surgery could be the definitive clue in many situations. Medical management and follow up of patients who have undergone bariatric surgery is a challenge opportunity due to post operative complications. A new modified intestinal bypass (MIBP) operation was designed to maintain good digestion and selective absorption with less medical and surgical complications. Patients and Methods: We experienced 157 patients medical follow up ; 122 females (78.2%) and 34 males (21.8%) , who have undergone a new modified intestinal bypass (MIBP) surgery ; (Elbanna operation) as well as we evaluated Excessive weight loss (EWL), nutritional supplements, motility disorders, and fatty liver for consecutive 3 years after operation. Conclusion: MIBP surgery (Elbanna operation) solved the medical problem of nutritional deficiency post intestinal bariatric surgeries. Our concept changed from maldigestion and malabsorption to good digestion and selective absorption.  Patients and Methods:We experienced 156 patients medical follow up ; 122 females (78.2%) and 34 males (21.8%) , who have undergone a new modified intestinal bypass (MIBP) surgery ; (Elbanna operation) as well as we evaluated Excessive weight loss (EWL), nutritional supplements, motility disorders, and fatty liver for consecutive 3 years after operation.

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\keywords{bariatric, gastrointestinal, obesity, modified intestinal bypass (MIBP), laparoscopic, elbanna.}

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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
here are several well-established health hazards associated with obesity e.g.: NASH, type 2 diabetes, heart disease, GERD, GI motility disorders, sexual disorders , depression and others. The risk of development of such complications rises with increasing adiposity, while weight loss can reduce the risk  {\ref [1]}. Weight loss is encouraged in any mean to overcome morbidity and diseases -affecting survival. For patients with BMI ?40 kg/m2 who have failed to lose bariatric surgery become the clue, whatever the laparoscopic bariatric approach is preferred over the open approach \hyperref[b1]{[2]}.Medical management and follow up of patients who have undergone bariatric surgery is a challenge opportunity for a skilled Gastroenterologist, including an assessment and treatment of possible nutritional defects, eating disorders, dysmotility syndrome, elevated liver enzymes and psychosocial problems. Occasionally, patients develop vomiting and nutritional deficiencies as a result of food intolerance and malabsorption respectively after bariatric surgery \hyperref[b2]{[3,}\hyperref[b3]{4]}. As well as chronic medical conditions; D.M, Hypertension and Non Alcoholic Steatohepatitis (NASH) improve after bariatric surgery, clinicians should monitor medications' doses after the surgery in an intimate follow up \hyperref[b4]{[5,}\hyperref[b5]{6]}. Gastroenterologist should have much knowledge -related different and recent bariatric procedures to expect further complications and follow up accordingly. 
\section[{II.}]{II.} 
\section[{Patients and Methods}]{Patients and Methods}\par
follow up; 122 females (78.2\%) and 34 males (21.8\%), aged 21 to 52 years old; (39.7 ± 9.2) mean age, with morbid obesity BMI ?40 kg/m2 who have undergone (MIBP) in the period from December 1999 to December 2010. All subjects have undergone a new modified intestinal bypass MIBP surgery (Novel Elbanna bariatric surgery). Subjects were followed up for 3 years after the novel procedure, as well as we evaluated nutritional supplements, eating disorders, vomiting, and other post operative complications. Follow up included EWL and Evaluation of (ca++), albumin, Hg, iron, zinc, B12 and PC levels at the time of operation, 3, 6 and 12 months postoperatively and every year thereafter for 3 years.\par
We retrospectively reviewed their data, in the Gastroenterology-Bariatric Units of Al Azhar University Hospitals-faculty of Medicine, and other private centers-Arab Republic of Egypt.\par
All patients presented with comorbidities of DM, Hypertension, Cardiac problem, Respiratory failure Type Zinc and hemoglobin decreased at 3, 6 months post operatively. For B 12, significant decrease occurred at 6 th month followed by significant increase in the 1 st year and thereafter. Albumin decreased only between 3 rd and 6 th month otherwise became normal all over the study. Iron shows significant decrease at 3, 6 months and 1 st year post-operative followed by significant increase to normal levels the rest of follow up period. Prothrombin concentrations showed no changes.  showing EWL through 3 years post operative Figure  {\ref 1:} I or NASH at the time of presentation, all patients were non-alcoholic due to religious belief. Alcoholic patients were excluded from our study.\par
The study was conducted with the approval of the Institutional Board committee of Al Azhar University Hospitals Committee-Cairo-Egypt. We received informed written consent form each patient. 
\section[{III.}]{III.} 
\section[{Statistical Study}]{Statistical Study}\par
Statistical analysis was used to determine the association between the BMI and each case group of non-alcoholic patients presented with morbid obesity, Qualitative data of EWL (Excessive weight loss) were expressed as number and percentage.\par
Data were statistically described in terms of mean ± standard deviation (M± SD). Comparison among different time points was done using one way analysis of variance (ANOVA) test with posthoc multiple 2-group comparisons. p values less than 0.05 was considered statistically significant. All statistical calculations were done using computer programs SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows.\par
IV. 
\section[{Results}]{Results}\par
Significant EWL post operatively after three months (35), six months (57\%) , one year (71\%) , two years (80\%) , three years (84\%), followed by nearly a stationary course till the moment.  Most of the element deficiencies in our study occurred in the period of maximum weight loss.\par
No vitamins or minerals supplementations were reported, only dietary intake rich in vitamins, proteins and iron was encouraged.\par
No significant difference between male and female outcome.\par
Post operative complications were reported as follow: Bleeding:  {\ref (}   V. 
\section[{Discussion}]{Discussion}\par
Obesity is a chronic disease that is increasing in prevalence worldwide. In 2010 the prevalence of obesity was 35.5 and 35.8 percent among adult American men and women, respectively. In Canada more than 27 percent of men and 23 percent of women are obese. Reported prevalence rates of obesity include 23 percent of men and women in the UK (2009), 24 percent of men and 34 percent of women in Mexico (2006) and 9 percent of men and 27 percent of women in South Africa (2003). \hyperref[b6]{[7,}\hyperref[b7]{8,}\hyperref[b8]{9]}. These data and those from other countries are indicative of a major international epidemic, a steady and distressing increase worldwide.\par
The medical rationale for weight loss in obese subjects is that obesity is associated with a significant increase in mortality and many health risks affecting quality of life including type 2 diabetes mellitus, hypertension, dyslipidemia, stroke, NASH and coronary heart disease.\par
Large epidemiologic studies have evaluated the relationship between obesity and mortality, in order to monitor patients, especially those with NASH \hyperref[b9]{[10]}. In general, greater BMI is associated with increased rate of death from all causes and from cardiovascular disease (CVD) and NASH-induced decompensated cirrhosis. This is particularly true for those with severe obesity. Being overweight also appears to be associated with decreased survival in some studies \hyperref[b10]{[11,}\hyperref[b11]{12,}\hyperref[b12]{13]}. Unfortunately obesity became a worldwide stigma, currently obese subjects are often exposed to public disapproval because of their fatness affecting significantly their psychosocial behavior. All patients who are obese (BMI ?30 kg/m2) should receive counseling on diet, lifestyle, and goals for weight management. Individuals with BMI ?40 kg/m2 and those with BMI >35 kg/m2 with obesity-related comorbidities who have failed diet, exercise, and drug therapy, bariatric surgery should be considered.\par
Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated >340,000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 449 percent between 2005 and 2009, the number of procedures performed in the United States have plateaued at approximately 200,000 operations per year \hyperref[b13]{[14,}\hyperref[b14]{15]}. All bariatric operations concerned with restrictive and / or malabsorption maneuvers; less food intake and malabsorption concept. The most common operations performed worldwide are Roux-en-Y gastric bypass (RYGB), the laparoscopic adjustable gastric band (GB), and the sleeve gastrectomy (SG). 
\section[{Unfortunately many complications reported following}]{Unfortunately many complications reported following}\par
Volume XIV Issue I Version I  Reanastomosis is performed between the proximal jejunum and the terminal ileum 100 cm from the ileocaecal valve. Duodenum, Proximal 50 cm of jejunum and 100 cm of terminal help the physiological absorption.Preservation of the anatomical biliary drainage and enterohepatic circulation are the most procedural advantage. Fundal resection performed to get maximum effect on appetite and satiety.   We reported only one case mortality due to cardiogenic shock. However, we reported many complications as listed in results. Patients who underwent this procedure did not show significant complications, including arthritis, protein malnutrition, vitamin deficiencies, cirrhosis, neurological complications or renal failure. The most common causes of early rehospitalization are nausea, vomiting, abdominal pain, abdominal distension, dehydration, early hypoglycemia and wound problems.\par
Patients with eating disorders, distension or motility disorders should be evaluated clinically; prescription of triple therapy of prokintetic drug, natural anti-spasmodic and PPI was very effective especially in early post operative period in all patients. Lifestyle changes are important component of managing motility disorders includes smoking cessation, head of bed elevation, and avoidance of chocolate, caffeine, spicy foods, alcohol, beverages, fatty meal and other foods that exacerbate GI symptoms. Also lifestyle changes are very important as initial approach for those presented with mild or infrequent symptoms of vomiting and or GERD. The problematic fatty accumulation (Fatty Liver) was reported due to rapid loss of weight which recovered clinically and disappeared sonographicaly after 1 year of the procedure, ultimately we recommend I gradual loss of weight with a maximum 7-8 Kg/month loss of weight. All patients presented with comorbidities of DM, hypertension, cardiac problem, respiratory failure, NASH, sexual life disorders and / or psychosocial intolerance showed significant impro-vement either clinically or by U/S,CT, Respiratory tests or echocardiography investigation modalities. We always stress the importance of eating all meals, particularly breakfast. Adolescents have undergone bariatric surgery should be informed that skipping meals does not help with weight control, unfortunately may promote weight gain and nutritional deficiencies.\par
We recommend early therapy with IV Pantoprazole and prokintetic medications if marginal ulceration detected endoscopicaly.\par
In a Conclusion, now bariatric surgery passes through a plateau phase, medical management and follow up of patients who have undergone bariatric surgery which is a challenge opportunity, accordingly the novel (MIBP) El Banna operation concept is to change maldigestion and malabsorption concept of bariatric procedures to good digestion and selective absorption. 
\section[{VI.}]{VI.} 
\section[{Limitation of the Study}]{Limitation of the Study}\par
Our methods of research, clinical and even surgical skills played the major role in all information mentioned in the study, hence we encourage other researches from different countries may show more significant results according to different environments, dietary habits and cultures. 
\section[{VII.}]{VII.} 
\section[{Future Recommendation}]{Future Recommendation}\par
Whatever obesity is a worldwide epidemic, affecting also children, we have to innovate techniques in pediatric bariatric surgeries, accordingly to save our children from pre-mature morbidities and mortalities, El banna pediatric modified technique ; New Bariatric surgical technique in pediatric obesity, could be a new innovation in coming days !\begin{figure}[htbp]
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\noindent\textbf{1} \par 
\begin{longtable}{P{0.24714673913043478\textwidth}P{0.08084239130434782\textwidth}P{0.08777173913043478\textwidth}P{0.08546195652173913\textwidth}P{0.08315217391304348\textwidth}P{0.09008152173913044\textwidth}P{0.08777173913043478\textwidth}P{0.08777173913043478\textwidth}}
Time of\tabcellsep Pre.Op\tabcellsep 3 months\tabcellsep 6 months\tabcellsep 1 year\tabcellsep 18 months\tabcellsep 2 Years\tabcellsep 3 Years\\
Follow Up\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
EWL\tabcellsep 0\tabcellsep 35\tabcellsep 57\tabcellsep 71\tabcellsep 78\tabcellsep 80\tabcellsep 84\\
\%\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Calcium\tabcellsep 2.3\tabcellsep 2.1\tabcellsep 1.9\tabcellsep 2.5\tabcellsep 2.4\tabcellsep 2.4\tabcellsep 2.3\\
(mmol/L)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Albumin\tabcellsep 39.8\tabcellsep 38.7\tabcellsep 36.1\tabcellsep 39.1\tabcellsep 40.5\tabcellsep 41.2\tabcellsep 42.8\\
(g/L)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Iron\tabcellsep 9.6\tabcellsep 8.8\tabcellsep 8.0\tabcellsep 9.0\tabcellsep 9.6\tabcellsep 10.1\tabcellsep 10.6\\
(umol/L)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Zinc (umol/L)\tabcellsep 11.1\tabcellsep 10.7\tabcellsep 9.8\tabcellsep 11.8\tabcellsep 12.2\tabcellsep 12.7\tabcellsep 12.6\\
Hg\tabcellsep 121.2\tabcellsep 116.9\tabcellsep 119.2\tabcellsep 122.8\tabcellsep 121.6\tabcellsep 120.4\tabcellsep 123.8\\
(g/L)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Vit.B12\tabcellsep 341.3\tabcellsep 328.8\tabcellsep 295.2\tabcellsep 367.5\tabcellsep 360.6\tabcellsep 351.3\tabcellsep 376.4\\
(Pmol/L)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Proth.Con.\tabcellsep 92.3\tabcellsep 90.6\tabcellsep 92.7\tabcellsep 91.0\tabcellsep 92.5\tabcellsep 93.9\tabcellsep 92.6\\
\%\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.04108333333333333\textwidth}P{0.36124999999999996\textwidth}P{0.4476666666666666\textwidth}}
Serial\tabcellsep Reported Complication\tabcellsep Number \& percentage of patients\\
1\tabcellsep Bleeding\tabcellsep (3.1\%); 5 patients\\
2\tabcellsep Leak\tabcellsep ( 2.5 \%) ; 4 patients\\
3\tabcellsep Infection\tabcellsep ( 0.6 \%); 1 patient\\
4\tabcellsep Internal Hernia\tabcellsep ( 0.6 \%); 1 patient\\
5\tabcellsep Incisional hernia\tabcellsep (1.3\%) ; 2 patients\\
6\tabcellsep Abdominal Distension\tabcellsep (31.2 \%); 49 patients\\
7\tabcellsep Vomiting\tabcellsep (41.4 \%); 65 patients\\
8\tabcellsep Motility disorders\tabcellsep (41.4\%); 65 patients\\
9\tabcellsep Hypoglycemia (Early)\tabcellsep (5.09 \%); 8 patients\\
10\tabcellsep Hypoglycemia (Late)\tabcellsep (1.9\%) 3 patients\\
11\tabcellsep Cholilithiasis\tabcellsep (0.6 \%); 1 patient\\
12\tabcellsep Renal Stone\tabcellsep (0.6 \%); 1 patient\\
13\tabcellsep Failure to lose weight\tabcellsep (0.6 \%); 1 patient\\
14\tabcellsep Failure to gain weight\tabcellsep (1.3\%) ; 2 patients\\
15\tabcellsep Pulmonary embolism\tabcellsep -\\
16\tabcellsep Mortality\tabcellsep 1\end{longtable} \par
 
\caption{\label{tab_3}Table 2 :}\end{figure}
 			\footnote{© 2014 Global Journals Inc. (US)} 		 		\backmatter  			 
\subsection[{Sleeve bypass}]{Sleeve bypass}			 			  				\begin{bibitemlist}{1}
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\end{document}
