Articles - Dr. Ivaylo Tzvetkov MD, PhD Bariatric Surgeon

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Dr Ivaylo Tzvetkov is a long standing member of International Federation of Surgery for Obesity with positive feedback from patients and colleagues. He is practicing safe and medical based and relevant to highest clinical international standards weight loss surgery. He has performed more than 780 Bariatric procedures in the Read more

Improvements of health and quality of life after weight loss surgery


More than half of the European population is overweight [body mass index (BMI) >25 and <30 kg/m2] and up to 30% is obese (BMI>30 kg/m2). Overweight and obesity are associated with many comorbidities such as: insulin resistance/type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, cancer, liver steatosis, gastroesophageal reflux, obstructive sleep Read more

Who are patients, candidates for weight loss surgery?


According to IFSO / International Federation for Surgery of Morbid Obеsity/ there are a number of widely accepted criteria which make a patient suitable for Bariatric weight loss surgery: Weight greater than 45kg above the ideal body weight for sex, and height. BMI > 40 by itself or >35 if there Read more

Get the best quality for lowest rates

Articles  

Dr Ivaylo Tzvetkov is a long standing member of International Federation of Surgery for Obesity with positive feedback from patients and colleagues. He is practicing safe and medical based and relevant to highest clinical international standards weight loss surgery. He has performed more than 780 Bariatric procedures in the last 12 years with 0.5% of complications. The preference of Dr Tzvetkov is Gastric bypass and mini / one anastomosis / bypass as weight loss procedures, however he offers tailored approach to individual needs of each patient for weight loss surgery. The low prices of offered weight loss surgery do not influence the quality of the healthcare service and Hospital environment, care and Follow up of the patients are the service provided is even better than the care offered in some West European Hospitals.


Improvements of health and quality of life after weight loss surgery

Articles  

More than half of the European population is overweight [body mass index (BMI) >25 and <30 kg/m2] and up to 30% is obese (BMI>30 kg/m2). Overweight and obesity are associated with many comorbidities such as: insulin resistance/type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, cancer, liver steatosis, gastroesophageal reflux, obstructive sleep apnea, degenerative joint disease, gout, and others. It has been demonstrated that weight reduction in short term (1–3 years) leads to a decline in insulin resistance, a better metabolic regulation in patients with diabetes mellitus, a reduction in blood pressure, and a less atherogenic lipid profile. Several investigations have reported impairments in specific domains of Quality of Life (QoL) in persons with extreme obesity. More specifically, these studies have suggested that both health-related (HR-QoL) and weight-related quality of life (WR-QoL) are dramatically impacted by extreme obesity. Encouragingly, both health-related and weight-related quality of life appear to improve following bariatric surgery. Some studies indicate that weight reduction in the severely obese is accompanied by improvements in Health Related -Quality of Life and that a dose-response relationship exists between the magnitude of weight loss and HR-QoL benefits. At present, surgical intervention is the only treatment yielding a more durable weight loss and an improvements in health status and in HR-QoL. In severely obese a Study after weight loss surgery showed over 10 years  that long-lasting weight reduction in the severely obese has a general long-standing positive outcome on HR-QoL.


Who are patients, candidates for weight loss surgery?

Articles  

According to IFSO / International Federation for Surgery of Morbid Obеsity/ there are a number of widely accepted criteria which make a patient suitable for Bariatric weight loss surgery:

Weight greater than 45kg above the ideal body weight for sex, and height.

BMI > 40 by itself or >35 if there is an associated obesity illness , such as diabetes or sleep apnoea

Reasonable attempts at other weight loss techniques

Age 18-65

Obesity related health problems

No psychiatric or drug dependency problems

A capacity to understand the risks and commitment associated with the surgery.

Pregnancy not anticipated in the first two years following surgery

There is considerable flexibility in these guidelines. Patients as young as 12 have been offered surgery. Sometimes a lower BMI between 30-35 is accepted if comorbidities exist.


Epidemy of Obesity as a world disaster till 2030

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One of the Lancet studies confirmed that obesity and overweight is a growing problem worldwide, even in countries that in the past have had problems with lack of food. The study analyzed the change in body mass index (BMI) from 1,698 studies among 19.2 million adults in 200 countries from 1975 to 2014. The researchers found that during this time period the average BMI increased from 21.7 to 24.2 kg/m2 among men and from 22.1 to 24.4 kg/m2 among women. Average BMIs among men were lowest (21.4 kg/m2) in central Africa and south Asia and highest in 29.2 kg/m2 in Polynesia and Micronesia. Among women, average BMIs were lowest (21.8 kg/m2) in south Asia to and also highest (32.2 kg/m2) in Polynesia and Micronesia. During the same time period, obesity prevalence more than tripled from 3.2% to 10.8% among men and more than doubled (6.4% to 14.9%) among women. By comparison, the prevalence of people are underweight, presumably from lack of enough food, decreased from 13.8% to 8.8% among men and 14.6% to 9.7% among women.

 

The other Lancet study showed a substantial worldwide increase in a major consequence of obesity, diabetes, since 1980 by analyzing 751 studies that included nearly 4.4 million people. As the study’s senior author Professor Majid Ezzati from Imperial College explained,“obesity is the most important risk factor for type 2 diabetes and our attempts to control rising rates of obesity have so far not proved successful. Identifying people who are at high risk of diabetes should be a particular priority since the onset can be prevented or delayed through lifestyle changes, diet or medication.” The study found that between 1980 and 2014, diabetes prevalence more than doubled from 4.3% to 9.0% among men and climbed by over 50% from 5.0% to 7.9% among women. This corresponded to the number of adults with diabetes worldwide nearly quadrupling from 108 million to 422 million. In 2014, northwestern Europe had the lowest diabetes rates. Polynesia and Micronesia had the highest (affecting nearly a quarter of adults), followed by Melanesia and the Middle East and north Africa. While not all diabetes cases are related to obesity, obesity is a major risk factor for the more common type of diabetes, Type 2 or adult-onset diabetes. And diabetes can have devastating health consequences such as heart problems, kidney disease and stroke. (Of course, obesity can result in many other health problems besides diabetes, such as cancer and heart disease.)


Gastric Bypass Surgery Diet

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Gastric bypass surgery is a lifesaving procedure. You will lose weight. You will reduce your co-morbidities. You will feel better and look better. However, to be successful (long-term), you have to change your diet.
This sounds simple, but it’s not. Be prepared for a struggle. You’ve spent much of your life building and reinforcing bad eating habits. Those have to change.
Knowing what you can and can’t eat is the first step towards a healthy diet. Your diet for the first five weeks after gastric bypass surgery is important for two reasons.
1. Your safety. Eating the wrong food could put undue pressure on your healing stomach.
2. Resetting your bad eating habits and replacing them with new healthy habits.

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BOMSS Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery September 2014

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2. Postoperative care and biochemical monitoring
It is essential that patients are monitored following bariatric surgery to ensure that they are both meeting their nutritional requirements and to mitigate risks of developing nutritional deficiencies as a result of the surgical procedure. The type and frequency of monitoring should reflect the bariatric procedure, but also the needs of individual patients. There is therefore recognition that nutritional monitoring may need to be individualised. There should be full access to appropriate members of the MDT including the physician if required. Details of the suggested biochemical monitoring by procedure are shown in Tables 2-4.

2.1 Urea and electrolytes, liver function tests
It is recommended that urea and electrolytes (U&E) and liver function tests (LFT) are monitored for all procedures. The frequency of monitoring depends on the procedure. Dehydration can occur in the early stages following surgery with patients finding it difficult to maintain an adequate fluid intake. Abnormal liver function tests due to non-alcoholic fatty liver disease are common or may relate to other conditions and require further investigation. Changes such as low albumin may be a sign of dietary non-compliance or malabsorption especially following the BPD/DS (30-32). However, low albumin levels are not only an indicator of malnutrition but may also indicate underlying inflammation and infection.

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Obesity and heart damage

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Number of obese years a risk factor for heart damage

Johns Hopkins researchers have shown that the number of years spent overweight or obese appear to ‘add up’ to a distinct risk factor that makes those with a longer history of heaviness more likely to test positive for the chemical marker of so-called ‘silent’ heart damage – high-sensitivity cardiac troponin T (hs-cTnT) concentrations – than those with a shorter history, according to an analysis of clinical data collected on more than 9,000 people. The research, ‘Weight History and Subclinical Myocardial Damage,’ published in Clinical Chemistry, suggests that maintaining a healthy weight across the lifespan is important for keeping the heart healthy and minimising damage as people age.

The authors caution that their study wasn’t designed to find or measure a direct cause and effect relationship between being overweight long-term and a higher risk of heart disease, but rather to shed light on possible relationships between the two.

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Gastroesophageal reflux disease and severe obesity: Fundoplication or bariatric surgery?

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Increases in the prevalence of obesity and gastro-esophageal reflux disease (GERD) have paralleled one
another over the past decade, which suggests the pos-sibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.

Read the whole article:

Bariatric or Fundoplication for GERD


Bariatric surgery for treatment of type 2 diabetes

Articles  
Ivaylo Tzvetkov, Krasimir Shopov, Jordan Birdanov, Ivan Jurukov,
Hospital Doverie, Sofia, Bulgaria

Background

• According to recent studies obese patients with type II diabetes who undergo bariatric surgery revert to normal blood glucose and insulin levels and develop a dramatic increase in insulin sensitivity.

• However, the mechanisms involved are unknown.

• The Bariatric procedures, which develop such a rapid decrease in blood glucose and insulin levels are the malabsortive procedures as gastric by pass, duodenal switch and bilio-pancreatic diversion.

• Laboratory studies with diabetic rats, which underwent bariatric procedures showed improved glucose tolerance and decreased fasting blood glucose.

• Type II diabetes continues to be associated with high rates of morbidity and mortality, leading to both financial and social burdens.

• Obese patients has normal blood glucose, glycosylated hemoglobin and insulin levels and fourfold increase in insulin sensitivity without continuation of diabetic medication 2 to 4 weeks after Bariatric surgery.

• Bariatric surgery is going to be more aggressive in the last five years and attempts to apply that kind of surgery even to patients with BMI of 30 kg/m2.

• Bariatric surgery for type 2 diabetes must be performed within accepted international and national guidelines. This requires appropriate assessment for the procedure and comprehensive and ongoing multidisciplinary care, patient education, follow-up and clinical audit, as well as safe and effective surgical procedures. National guidelines for bariatric surgery in people with type 2 diabetes and a BMI of 35 or more need to be developed and promulgated.
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Comparing Surgical Procedures

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Here’s a quick and informative overview of the advantages and differences between both types of weight loss surgeries performed at RMH, the LAP-BAND® System and the Gastric Sleeve.

LAP-BAND® System

Gastric Sleeve

DESCRIPTION

A restrictive procedure during which an adjustable gastric band is placed around the upper part of the stomach. This creates a smaller stomach pouch, which restricts the amount of food that can be consumed at one time and increases the time it takes for the stomach to empty. As a result, patients achieve sustained weight loss by limiting food intake, reducing appetite, and slowing digestion

A thin vertical sleeve of the stomach is created using a stapling device, and the rest of the stomach is removed (about 85%). The sleeve is about the size of a banana. This procedure limits the amount of food you can eat and helps you feel full sooner. It allows for normal digestion and absorption. Food consumed passes through the digestive tract in the usual order, allowing it to be fully absorbed in the body.

ADVANTAGES

  • Lower short-term mortality rate than gastric bypass
  • Minimally invasive surgical approach
  • No stomach stapling or cutting, or intestinal rerouting
  • Adjustable
  • Reversible
  • Lower operative complication rate than with gastric bypass
  • Low malnutrition risk
  • Intermediate initial weight loss
  • Less frequent follow-up required
  • No implant required
  • Laparoscopic approach is possible
  • Removes part of the stomach that produces Grehlin (hunger hormone)

DISADVANTAGES

  • Slower weight loss
  • Regular follow-up critical for optimal results
  • Requires an implanted medical device
  • In some cases, effectiveness may be reduced due to slippage of the LAP-BAND® Adjustable Gastric Banding System
  • In some cases, the access port may leak and require minor revisional surgery
  • Stomach cutting and stapling required
  • Intermediate complication rates
  • Higher short-term mortality rates than the gastric band
  • Nonadjustable and nonreversible
  • Longer hospital stay and recovery
  • No long-term data

RESULTS

A review of published studies showed many laparoscopic adjustable gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB) patients achieve comparable weight loss at 3 years and beyond (55% for LAGB and 58% for standard RYGB).

RISKS

Mortality rate: 0.05%
Total complications: 9%
Major complications: 0.2%
Most common include:

  • Standard risks associated with major surgery
  • Nausea and vomiting
  • LAP-BAND® System slippage
  • Stoma obstruction
  • Risks associated with any surgery, including death
    • 0.39% short-term
  • Gastroesophageal reflux disease (GERD) 
  • Gastritis
  • Gastric stricture
  • Marginal ulcer
  • Leak from staple line along the stomach

COSTS AND INSURANCE

Generally speaking, all three procedures may be covered by insurance, but check with your employer or your surgeon’s office for specific information about your policy. Costs of LAP-BAND® Adjustable Gastric Banding System surgery, gastric sleeve, and gastric bypass surgery will vary depending on the site where the surgery occurs (in-patient or out-patient), the type of bypass procedure (laparoscopic or open), and how long you are required to stay in the hospital.

RECOVERY TIMELINE

  • Hospital stay is often approximately 24 hours
  • Most patients return to normal activity in about 1 week
  • Full surgical recovery usually occurs in about 2 weeks
  • Hospital stay is approximately 48 hours
  • Most patients return to normal activities in about 2 weeks
  • Full surgical recovery is about 3 weeks