The pulsed CO2 laser consists of a carbon dioxide beam that vaporize the scar without damaging surrounding tissue.
The advantages of CO2 laser are represented by a reduced thermal damage, less bleeding, less inflammation and improved healing.
It is ideal in cases of damaged and inelastic skin (acne scars) because not only eliminates the most superficial layers but is also capable of determining a significant contraction of collagen and elastic fibers in the dermis and thus make the skin more toned.
Another advantage of the C02 laser is the assurance that the areas that are treated are “leveled” always on the desired thickness.
In the field of cosmetic surgery, the CO2 laser, invisible and infrared, has replaced the scalpel in many types of intervention.it can also be used in all types of scars,fractional skin resurfacing.

Anastomosis is used when a hollow organ such as intestine needs to be severed and reconnected to allow fluids to flow through it, most commonly because part of the organ needs to be removed.An anastomotic leak is a breakdown along an anastomosis which causes fluid to leak.Leaks can occur for number of reasons and it is not always the mistake on the part of the surgeon.other reasons could be poor wound healing and unexpected stress and pressure on the anastomosed area.Patients who undergo bariatric surgery usually have multiple comorbidities, such as diabetes, hypertension, poor nutrition, less exercise tolerance, and sleep apnea which puts them on high risk for postoperative leaks.
All factors that improve intestinal blood flow and oxygen carrying capacity should be optimized preoperatively.These include anemia, iron, cardiac function, sleep apnea, preoperative hydration to prevent hypoperfusion and hypotension during surgery.Poor control of diabetes can adversely effect healing and HgbA1c should be stable and less than 6% prior to surgery.decreasing the size of the liver preoperatively affords better visualization of the operative field specially if its going to be a laparoscopic surgery.Steatohepatitis is frequently associated with morbid obesity and a two weeks preoperative low energy diet may help reduce the liver size thus resulting in a technically superior anastomosis.Specific preoperative antibiotic therapy may also help towards preventing postoperative anastomotic leak.

Diarrhea or loose stools is mainly a potential side effect of sleeve gastrectomy with duodenal switch.Diarrhea may be seen with Roux-en-Y gastric bypass,but would not be associated with lap adjustable gastric banding.Post Duodenal switch( DS ),the usual alteration is soft or loose stools.Frank diarrhea is related to fatty acids directly passing into the colon which normally would have been absorbed in the small intestine.Once in the colon they induce irritation.It can also be due to relatively undigested food passing rapidly through the GI tract.A third contributing factor is sorbitol,found in fruits,berries and artificial sweeteners.In the colon it gets fermented.This causes increased gas and diarrhea .The number of loose stools after DS may vary from 2-3 upto 10--20 per day when it becomes really problematic and very inconvenient.Diet is a major influence on bowel movements after DS.Reducing the amount of fat will have a direct beneficial effect on the number and quality of bowel movements.Usually with close questioning some trigger type foods can be identified and avoided.
Both the DS and RNYGBP(Gastric bypass)may unmask previously unidentified lactose intolerance.An early step is to eliminate dairy products completely from the diet. Management of diarrhea(provided there is no identifiable pathologic or dietary factors)is varied.A dose of imodium at bedtime can reduce the early morning onset. If beneficial,some patients stay on a maintainance dose for long term control under doctors supervision.
Many patients may benefit from a course of probiotics.They are a form of natural colonic flora that is administered orally to restore the natural bacterial milieu towards a normal state.In any post operative patients with watery diarrhea,foul flatus and abdominal cramping the doctor may also consider clostridium difficile(c-diff)colitis or antibiotic associated diarrhea.

For the first 2 weeks stay on liquid diet.You need 2 quarts of liquid daily to avoid dehydration.sipping slowly is best.Do not try to gulp large amounts,You will vomit.Any low carbohydrate liquids are ok.non dairy based soups are great.
The third week,start pureed food.cream of wheat,oatmeal,and thin mashed potatoes.The types of food you would feed a 5-6 mth old infant.Small amounts of about 1-2 tablespoons will be enough for now.
After the first 3 weeks,you should be able to start a solid diet.add eggs and meat to the diet plan.start slowly and eat very small amounts.Cut your food into tiny pieces.Avoid fibrous foods .watch out for seeds.chew thoroughly before swallowing.The new opening into your intestine is very small and only well chewed food will pass without problems.
If you do not have tolerance to your solid food, go back to liquids for a day or two and try again.Patience is required.
Family members may think you are not getting enough to eat and tempt or urge you to eat more.Resist this.If you are 100 lbs overweight you have enough extra calories in store to support you for few months.

Anatomy and Physiology

Obesity is an excess of body fat. Many factors influence body fat, including lifestyle habits and genetics. There are many ways to treat obesity. Bariatric surgery treats obesity by altering the digestion and absorption of food.

In normal digestion, food moves through the mouth, down the esophagus, and into the stomach. Here, food is mixed with digestive juices. The partially digested material is slowly released into the small intestine.

In the small intestine, digestion is completed. Nutrients and calories are absorbed into the blood stream. There are three parts to the small intestine—duodenum, jejunum, and ileum. Wastes are eventually passed to the colon and released as stool.

There are two types of bariatric surgery. “Restrictive” procedures decrease the size of the stomach so a person feels full quickly. After surgery, the stomach holds about one cup of food; a normal stomach holds 4–6 cups. “Malabsorptive” procedures decrease the absorption of calories in the small intestine. The most common procedure, the Roux–en–Y gastric bypass, is both restrictive and malabsorptive.

Reasons for Procedure

Obesity is a serious health concern. It increases the risk of numerous diseases, some of which include: diabetes, cardiovascular disease, including coronary heart disease, high blood pressure, and stroke, certain types of cancer, gallstones, osteoarthritis, gout, and breathing problems such as sleep apnea.

Obesity is often diagnosed by using the body mass index, or BMI. This is a measure of body fat based on the relationship between a person’s height and weight: 18.5–24.9 is normal weight, 25–29.9 is overweight, 30–39.9 is obesity, 40 or greater is morbid obesity.

Morbid obesity is also defined as 100 pounds over what is considered a healthy weight for a person’s height.

People who carry fat in their abdomen, as opposed to on their hips, are at greater risk for some of the health problems associated with obesity. Therefore, waist circumference is also used to assess weight. A waist circumference greater than 35 inches for women or 40 inches for men is considered high risk.

Treatments

Weight loss efforts should begin with lifestyle changes, such as eating a low calorie, well–balanced diet and exercising regularly. If obesity persists despite an aggressive diet and exercise program, your doctor may advise adding weight loss medications.

If lifestyle changes and medications are unsuccessful or not possible, bariatric surgery may be considered in the following cases: BMI greater than 40, BMI 35–39.9, and a life–threatening condition, such as heart disease or diabetes, severe physical limitations that affect employment, mobility, and family life.

All candidates for bariatric surgery must commit to major lifestyle changes indefinitely after the procedure.

Procedure

In the days leading up to your procedure: arrange for a ride to and from the hospital, and for help at home as you recover; the night before, eat a light meal and do not eat or drink anything after midnight; if you regularly take medications, herbs, or dietary supplements, your doctor may recommend temporarily discontinuing them; do not start taking any new medications, herbs, or dietary supplements without consulting your doctor; you may be given antibiotics to take before coming to the hospital; you may be given laxatives and/or an enema to clear your intestines.

Before the procedure, an intravenous line will be started. Bariatric surgery requires general anesthesia, which puts you to sleep for the duration of the procedure. A breathing tube will be inserted through your mouth and into your windpipe to help you breathe during the operation.

Gastric bypass, technically referred to as Roux–en–Y gastric bypass, is both a restrictive and malabsorptive procedure. There are two surgical methods used for gastric bypass. The open method requires an 8–10 inch incision in the abdomen. The laparoscopic method only requires several small “keyhole” incisions through which your surgeon will pass a laparoscope and surgical tools. A laparoscope is a thin, lighted instrument that projects images of the surgery on a monitor in the operating room.

In the Roux–en–Y gastric bypass procedure, your surgeon will use surgical staples to create a small compartment, which will serve as your new stomach. This pouch will hold about one cup of food. The lower portion of the stomach continues to secrete digestive juices, but does not receive food.

Next, your surgeon will cut the small intestine well beyond the stomach and bring one free end up and attach it to the pouch. He or she will then attach the other free end lower down on the small intestine, creating a Y–shape. By bypassing the lower stomach and the first part of the small intestine, fewer calories will be absorbed as food passes though this new pathway.

Banding techniques are restrictive procedures. They help decrease food intake in two ways: by shrinking the stomach to a small pouch and making a tiny opening from the pouch to the rest of the stomach. Food moves slowly through this opening. These factors make you feel full quicker and for a longer time.

In vertical banded gastroplasty, your surgeon will place staples across your stomach to create a small pouch on top. Food will move from this pouch through a tiny opening into the lower stomach and the rest of the digestive tract. To prevent stretching, your surgeon will wrap a rigid, plastic band around the opening.

For adjustable gastric banding, your surgeon will wrap an inflatable band around the top of the stomach. As the band is inflated, it will squeeze the stomach to create a small pouch and a narrow opening into the larger, lower portion. This may be done though tiny incisions using a laparoscope. The band may be adjusted at any time.

In biliopancreatic diversion, which is a malabsorptive procedure, your surgeon will begin by removing part of the stomach, leaving only a small pouch behind. Next, he or she will sew the small intestine to the pouch. This creates a direct route from the pouch to the end of the small intestine. The duodenum and jejunum are bypassed, so few calories and nutrients are absorbed.

For all methods of bariatric surgery, your surgeon will close your incisions with staples or stitches. You will then be brought to the recovery room.

Risks and Benefits

Obesity itself is a risk factor for complications in any surgery. Risks associated with bariatric surgery include: nutritional deficiencies, abdominal hernia, gallstones, infection, heart and lung problems, blood clots in the legs, which can travel to the lungs, complication of the general anesthesia, and/or death.

Additional risks associated with restrictive procedures include: vomiting from eating too much or not chewing enough, band slippage, breakdown of the staple line leading to leakage of stomach juices into the abdomen, ulcers that may bleed.

Patients who have a malabsorptive procedure may also experience dumping syndrome, which occurs when stomach contents move too quickly through the small intestine. Symptoms, which occur after eating, include: nausea, weakness, sweating, faintness, and diarrhea.

If post–surgical lifestyle changes are made and maintained, the benefits of bariatric surgery include: long–term, consistent weight reduction, for some people, 100 pounds or more may be lost, improvement in many obesity–related conditions, such as decreased blood sugar and blood pressure, and enhanced self–esteem.

In gastric bypass surgery, or any procedure, you and your doctor must carefully weigh the risks and benefits to determine whether it’s the most appropriate treatment choice for you.

After the Procedure

After your procedure, the breathing tube will be removed and you will be taken to the recovery area for monitoring. You will be given pain medication and your diet will be gradually advanced over several days. If you had a laparoscopic procedure, you can expect to be discharged home in 2–5 days. After an open procedure, your hospital stay may be longer.

Once you are home, be sure to contact your doctor if you experience: signs of infection such as fever and chills, redness, swelling, increasing pain, bleeding, or discharge at the site of your incisions, cough, shortness of breath, or chest pain, worsening abdominal pain, blood in the urine or stool, pain, burning, urgency, or frequency of urination, persistent nausea and/or vomiting, pain or swelling in your feet, calves, or legs, any other worrisome symptoms.

You may be out of work for 4–5 weeks. For best results after bariatric surgery, you’ll need to practice lifelong healthful habits. These include exercise and specific nutrition guidelines. It will be essential to meet regularly with your healthcare team to help you stay on track.