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Minimally invasive percutaneous procedures (such as TF and TAx) are the most common. (See Approaches to TAVR.)Minimally invasive valve replacement begins at SGPGI | Lucknow News - Times of India Percutaneous approachesAbout 90% of TAVRs use the TF approach. A sheath is inserted into the femoral artery, through which the guidewire and catheter are fed through the aorta into the heart. The arterial insertion site is typically closed using a vascular closure device, such as a vessel plug, clip, or internal suture. The TF approach may not be suitable for patients with peripheral vascular disease because of potential issues with vessel size.Transcatheter aortic valve repair surgery may be performed with minimally invasive percutaneous heart surgery, in which surgeons perform the procedure through small incisions in the chest.Minimally invasive heart surgery includes surgery performed using long instruments inserted through one or more small incisions in the chest (thoracoscopic surgery), surgery performed through a small incision in the chest, or surgery performed by a surgeon using robotic arms (robot-assisted heart surgery).In robot-assisted heart surgery, a surgeon sits at a remote console, viewing the heart in a magnified high-definition 3-D view on a video monitor. The surgeon uses robotic arms to duplicate specific maneuvers used in open-heart surgeries. These procedures may be available at certain high end sofisticated medical centers currently mostly in India for the latest technological mini-incision heart procedures.Minimally invasive heart surgery may involve a much shorter hospital stay, a much quicker recovery and less pain than open-heart surgery. Minimally invasive heart surgery generally should be performed only by some very specific medical centers with a medical team experienced in performing these types of heart percutaneous procedures.Minimally invasive transcatheter aortic valve replacement (TAVR) may involve either a percutaneous (transfemoral or transaxillary/ subclavian) approach or an open (transapical or transaortic) approach. TAVI procedure include:Transapical approach: Through an incision in the chest between the ribs.Transaortic approach: Through an incision in the upper chest.People may feel relief from their symptoms soon after their TAVI procedure, but others may take a little longer to get back to normal. Warnings:There may be an increased risk of stroke in transcatheter aortic valve replacement procedures, compared to other standard treatments for aortic stenosis in the high or greater risk population.Risks involving bleeding or your blood supply, including formation of a blood clot, high or low blood pressure, limited blood supply, a decrease in red blood cells, or abnormal lab values, bleeding in the abdominal cavity, collection of blood under the skin.Additional risks, including life-threatening infection, dislodgement of calcified material, air embolism (air bubbles in the blood vessels), poor kidney function or failure, nerve injury, fever, allergic reaction to anesthesia or dye, reoperation, pain, infection or bleeding at incision sites, or swelling.TAVI: Transcatheter aortic valve implantationThe less mini-invasive therapy for severe aortic stenosis. There is a severe aortic stenosis therapy available that may help you get back on your feet faster. It’s called TAVI, also called TAVR (transcatheter aortic valve replacement), and it is a less invasive procedure that is designed to replace a diseased aortic valve.This procedure known as TAVI is available to most people depending on their risk for open heart surgery. The options are illustrated below.Illustrations reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2006-2017. All Rights Reserved.Open heart vs. percutaneous approach—surgical considerationschest malformationheavily calcified (porcelain) aortaradiation damagetracheostomy.If percutaneous access was performed, monitor the site distal to the puncture for adequate circulation. When checking vital signs, perform neurovascular assessment of the affected extremity, including color, temperature, pulse, numbness, tingling, and swelling. Assess the insertion site for signs of bleeding, hematoma, and infection. Keep dressings clean, dry, and intact and look for bleeding. Promptly report the need for dressing changes due to bleeding. Dressings may typically be removed 24 to 48 hours after the procedure.Patients at risk for cardiac conduction abnormalities, such as heart block, typically receive a temporary transvenous external pacemaker. Confirm that pacemaker settings match those ordered. Monitor routine laboratory results, such as renal function tests, blood cell counts, electrolytes, and partial thromboplastin times. Report findings of concern.Additional considerations related to open approaches include a chest tube and surgical incisions. Assess incisions for signs of bleeding or infection and observe chest-tube drainage for increases and bleeding.Sources: / Nishimura RA, et al. Circulation. 201;129(23):2440-92; Otto, et al. J Am Coll Cardiol. 2017;69(10):1313-46.TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)Patients with aortic stenosis who are high risk or intermediate risk from surgical aortic valve replacement may benefit from TAVI thereby avoiding open surgery which helps early recovery and improved quality of lifeIndia heart percutaneous mini-incision surgery team.The team establishes surgical risk, they must decide whether SAVR or TAVR is the patient’s best option. (See SAVR or TAVR?) Diagnostic techniques that aid this decision include transthoracic echocardiography (TTE) and multidetector computed tomography (MDCT). MDCT helps find the correct replacement-valve size and identifies possible peripheral vascular complications to ensure the best transcatheter approach. To encourage shared decision making, the team should consider patient and family preferences, goals, and expectations.“Aortic stenosis (abnormal narrowing of aortic valve) increases the stress and strain on the heart muscle, resulting in anxiety which in turn can lead to various symptoms like chest discomfort, shortness of breath, fatigue, lightheadedness, unconsciousness, and even sudden death. If not treated, 50 per cent of these patients can face higher risks or mortality within one to two years from the onset of symptoms”, explained Dr Mehta.“The prevalence of aortic stenosis has a considerable impact on the elderly people in India. About 4.5 lakh patients, remain untreated in India due to treatment gap. TAVI accreditation is an accomplishment to reduce these gaps and provide best services with efficient technology. This procedure is a minimally invasive procedure and is a saviour to the patients with severe symptoms of aortic stenosis”, added Dr Mehta.What is a TAVR? (Also called TAVI)This minimally invasive surgical procedure repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve's place. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI).In order to answer your question there are now mini-incision ( minimally invasive ) surgery that are now a significant benifit over a open heart surgery.What is the TAVI minimally-invasive heart surgery procedure?TAVR approachesApproved TAVR techniques include percutaneous approaches (transfemoral [TF] and transaxillary/subclavian [TAx]) and traditional open approaches (transapical [TA] and transaortic [TAo]), which require small surgical incisions.In the TAx approach, access is gained through the subclavian artery, with a sheath catheter fed into the aortic arch to the aortic valve. Although this approach offers a shorter catheter-insertion route, the smaller vessel can cause difficulty with maneuvering the catheter and may lead to brachial-nerve injury.Open approachesA minithoracotomy is used for access in the TA approach. Benefits include avoiding a diseased aorta or femoral artery, unlimited delivery system size, and easier valve delivery. Drawbacks include risk of myocardial injury, increased risk of wall-motion abnormalities, apical bleeding, and incision pain. Additionally, this technique requires a surgical incision through the chest wall and intubation, increasing patient discomfort and pain.The TAo approach involves direct puncture of the aorta through a partial sternotomy or right thoracotomy. Benefits resemble those of the TA approach, with a small working distance to the valve and no limit to access size. In addition to incision and intubation, drawbacks include limited access if the vessel is diseased or the ascending aorta is heavily calcified.The TAVR procedure is performed using one of two different approaches, allowing the cardiologist or surgeon to choose which one provides the best and safest way to access the valve:Entering through the femoral artery (large artery in the groin), called the transfemoral approach, which does not require a surgical incision in the chest, orUsing a minimally invasive surgical approach with a small incision in the chest and entering through a large artery in the chest or through the tip of the left ventricle (the apex), which is known as the transapical approach.TAVR is approved and available for qualifying patients receiving Medicare and Medicaid. More information is available on the Centers for Medicare & Medicaid Services ;(CMS) website. Learn more about healthcare laws and government programs seeking to provide affordable coverage at the HealthCare.gov website(link opens in new window). The Heart Valve CareLine can help you navigate the insurance and medical world as it relates to your diagnosis.Prof Aditya Kapoor said: “Unlike conventional open heart surgical procedure, TAVR involves implant of the valve through a 6-7mm hole versus a 24 mm hole in the normal open heart surgery in the upper thigh.” “It is through this hole that the valve to be replaced is inserted in the body. Thereafter, the valve is inflated and the function is transferred to the new valve,” he added.The TAVI (Transcatheter Aortic Valve Implantation) procedure is currently being performed on those patients who are not suitable for open-heart surgery. The aortic valve regulates the flow of oxygen-rich blood from the heart into the main blood vessel leading to the rest of the body. It is composed of three triangular-shaped flaps that fit neatly together.As the main chamber of the heart contracts, the flaps open up and allow blood to enter into the artery. They then slap shut to prevent blood from flowing back into the heart. As with other parts of the body, over a long period of time this valve can wear out and become dysfunctional.“Aortic-stenosis is, for the most part, a chronic degenerative process of aging.” says Dr. Sam Radhakrishnan, Director of the Cardiac Cath Labs and Physician Lead of the TAVI program at Sunnybrook Health Sciences Centre.About 7 per cent of people over the age of 65 develop aortic stenosis.Typically, the valve becomes caked in calcium deposits that narrow the opening and prevent it from operating properly. As a result, the heart has to work harder to pump blood around the body. Patients may experience chest pains, become quickly out of breath if they exert themselves and may suffer fainting spells as well as other symptoms. Eventually, they develop more serious complications including heart failure.There is no medication that can reverse the damage.“It requires a mechanical solution – the replacement of the valve,” explains Dr. Radhakrishnan.This means patients have had to undergo open-heart surgery. The chest is cut open to expose the heart. The patient is placed on a heart-lung bypass machine while the heart is stopped. The surgeon cuts into the organ and removes the decrepit valve and then inserts a new one – either a mechanical device or one made partly with animal tissue.This has been the standard treatment for several decades. But not all patients can withstand the rigors of open-heart surgery. They are too old and frail, or suffer from too many other health problems, to survive the operation. Roughly one-third of all patients with severe aortic stenosis are considered too high risk for open-heart surgery. Without treatment, their condition only gets worse. About 50 per cent of them die within one to two years without corrective therapies.About 15 years ago doctors began to make significant progress on an alternative therapy known as Transcatheter Aortic Valve Implantation, or TAVI for short. (In the United States, it’s called Transcatheter Aortic Valve Replacement or TAVR.)TAVI represents a Canadian-research success story. Much of the pioneering work was carried out by Dr. John Webb and his team at St. Paul’s Hospital in Vancouver.Rather than cutting open the chest, TAVI accesses the heart through the circulatory system.A catheter – a flexible hollow tube – containing a tightly-compacted replacement valve is inserted into an artery and carefully threaded to the heart. The most common route is through a leg artery, which can be accessed through a small incision in the groin.Once the catheter is in the correct position – literally inside the old aortic valve – the new valve is released from the catheter and expands to its full size. The diseased flaps of the old valve are not removed, but flattened back and serve to anchor the new valve device in place. The new valve immediately takes over the job of regulating blood flow.As an added bonus, the recovery time is much faster for TAVI patients who are typically out of hospital within three to five days. Open-heart surgery patients spend about 10 days in hospital and it takes a long time for their chest incision to heal.TAVI is part of a growing trend in the field of minimally-invasive surgeries. For instance, stents – which prop-open clogged blood vessels – are also delivered to the right spot in the body by way of a catheter.TAVI is not without risks, however. Threading the catheter – about the thickness of a pen – through the blood vessels can cause damage and dislodge plaque deposits. If pieces of that plaque travel to the brain they can block blood flow and trigger a stroke.Furthermore, doctors don’t yet know how long the TAVI valves will last. “We don’t have definitive long-term – more than ten years – data for these patients yet,” says Dr. Radhakrishnan. By contrast, the durability of the valves used for the traditional open-heart surgery has been well documented.Because TAVI is still relatively new and there are uncertainties surrounding the procedure.So that mean TAVI is restricted to those patients who can’t tolerate the traditional approach or they are deemed to be at high risk of suffering serious complications from open-heart surgery.TAVI patients must undergo a series of screening tests before being eligible for the procedure. High-resolution CT imaging machines are used to determine a number of important anatomical considerations to increase the chances for a successful TAVI procedure. For example, CT imaging helps to pick the best entry point for the catheter. If the leg artery poses a risk for complications, the doctors can use an artery under the collarbone or one in the chest wall.This pre-operative investigation also enables the doctors to select the correct size of the replacement valve. (All of these valves are made of animal tissue, attached to a stainless-steel mesh.)During the actual operation, high-resolution X-ray imaging is used to help guide the catheter through an artery to the exact spot in the heart where the new valve will be placed. A team of nurses and doctors from different disciplines– including an interventional cardiologist, cardiac surgeon and cardiac anesthetist – take part in the procedure.Dr. Radhakrishnan believes TAVI will eventually be used in a broader range of patients.“It is still an evolving technique and procedure,” he says. The equipment is changing, too. The catheters are becoming less bulky and newer valves are emerging made by different manufacturers.“We are already seeing a lowering of the complications in terms of vascular complications, strokes and mortality,” says Dr. Radhakrishnan“For the first generation devices, the incidence of stroke was close to 5 per cent in the first 30 days after the operation. Now we are seeing stroke rates of 2 to 3 per cent – which are very much in keeping with the stroke rates for traditional open-heart surgery.”Dr. Sanjeev Kalkekar, Consultant, Interventional Cardiology, Apollo Hospitals, Navi Mumbai explained, "In TAVR, a miniaturized valve is inserted through a catheter, a thin flexible tube, from the groin into the heart. The deployed valve reaches the base of the aorta at the site of the previous aortic valve. The doctor then opens a balloon which inflates the valve pushing aside the old valve and overcoming the stenosis or narrowing. The entire procedure is conducted under general anaesthesia or mild sedation, takes about an hour as compared to 5-6 hours required for an open heart surgery."TAVR is a game changer for patients with valve disease in India. While the expenses are more as compared to conventional open heart surgery, the benefits are incomparable. TAVR allows many patients with severe aortic valve stenosis who were previously classified as too high risk or inoperable to be effectively treated, giving them a second opportunity at a healthy life. Interventional cardiology methods such as 'TAVR' has redefined the lives of people with an improved quality of life, even in people aged above 70 years or 80 years. Interventional methods can help many patients who are suffering from severe cardiac risks.The patient showed remarkable improvement. He started speaking normally right after 45 minutes of the procedure and has been discharged from the hospital, in a stable condition.Dr. Sai Satish, Senior Interventional Cardiologist, Apollo Hospitals, Chennai said, "TAVR is a godsend for patients who are unfit for open heart valve replacement surgery. One of the most common form of valve disease is calcification that affects the leaflets (parts which open and close with the flow of blood) of the aortic valve. The leaflets get affected by fat deposition over 10 to 15 years with inflammation and hardening. Patients often present with symptoms only after the age of 70-75 years. At this age, 35% of patients are not suitable for surgery. The catch is that if not treated, 50% of them will not survive for more than a year or two. TAVR can increase the patient's life between 8 to 9 years. So far, the success rate of this procedure in India is around 95%."Mr. Santosh Marathe, COO, Apollo Hospitals, Navi Mumbai, said, "The face of healthcare in the Navi Mumbai region is undergoing a sea change with advanced medical technology available to help address complex conditions in patients. From organ transplants including heart transplants, minimally invasive surgery to interventional cardiology, the incomparable benefits of the latest advances will help patients who are inoperable or at high risk to be treated effectively and get a second opportunity for a healthy life."In Ontario, Canada the provincial government has provided six hospitals with funds allocated for the procedure. (In Toronto, the medical centres include Sunnybrook, St. Michael’s Hospital and the University Health Network.)“We are funded to do 90 TAVI procedures in the coming year,” says Dr. Radhakrishnan, adding that the hospital has the capacity to do more but is limited by its budget.He expects “market economies will undoubtedly bring down the cost of these devices” if research can show that TAVI really is a suitable option for many more patients.Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to [email protected] and follow Paul on Twitter @epaultaylor1-What is the TAVI minimally-invasive heart surgery procedure?2-Minimally invasive valve replacement begins at SGPGI | Lucknow News - Times of India3-What is TAVR?4-A National forum for Transcatheter valve therapies in India5-https://www.accessdata.fda.gov/cdrh_docs/pdf13/P130009c.pdf6-https://www.apollohospitals.com/apollo-news/apollo-hospitals-navi-mumbai-redefines-the-life-of-a-78-year-old-cardiac-patient-by-successfully-performing-transcatheter-aortic-valve-replacement-surgery7-Hinduja Healthcare Surgical receives accreditation for Transcatheter Aortic Valve Implantation - Express Healthcare8-Caring for Patients after Transcatheter Aortic Valve Replacement - American Nurse TodayReferences9-Arora S, Misenheimer JA, Jones W, et al. Transcatheter versus surgical aortic valve replacement in intermediate risk patients: A meta-analysis. Cardiovasc Diagn Ther. 2016;6(3):241-9.10-Arsalan M, Walther T. Durability of prostheses for transcatheter aortic valve implantation. Nat Rev Cardiol. 2016;13(6):360-7.11-Bhatheja S, Panchal HB, Barry N, Mukherjee D, Uretsky BF, Paul T. Valvular performance and aortic regurgitation following transcatheter aortic valve replacement using Edwards valve versus CoreValve for severe aortic stenosis: A meta-analysis. Cardiovasc Revasc Med. 2016;17(4):248-55.12-Ellis MF. Transcatheter aortic valve replacement: An evolving option for severe aortic stenosis. Advance Healthcare Network for Nurses. 2015.13-Kondur A, Briasoulis A, Palla M, et al. Meta-analysis of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with severe aortic stenosis. Am J Cardiol. 2016;117(2):252-7.14-Malaisrie SC, Iddriss A, Flaherty JD, Churyla A. Transcatheter aortic valve implantation. Curr Atheroscler Rep. 2016;18(5):27.15-Merriweather N, Sulzbach-Hoke LM. Managing risk of complications at femoral vascular access sites in percutaneous coronary intervention. Crit Care Nurse. 2012;32(5):16-29.16-Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(23):2440-92.17-Otto CM, Kumbhani DJ, Alexander KP, et al. 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2017;69(10):1313-46.18-Urena M, Hayek S, Cheema AN, et al. Arrhythmia burden in elderly patients with severe aortic stenosis as determined by continuous electrocardiographic recording: Toward a better understanding of arrhythmic events after transcatheter aortic valve replacement. Circulation.2015;131(5):469-77.19-Vahl TP, Kodali SK, Leon MB. Transcatheter aortic valve replacement 2016: A modern-day “through the looking-glass” adventure. J Am Co20-Mitral valve repair and mitral valve replacement21-Reparación y reemplazo de la válvula mitral22-Department of Surgery23-Minimally invasive aortic valve replacement: the Leipzig experience

My short answer: If you find that nutritional factors play an important role in the development of the diabetes, then nutritional intervention will be very effective, provided the patient co-operates.My long answer is below:Successful Diabetes Treatment Requires Patient’s Discipline90% of all diabetes cases are due to type 2 diabetes, which is associated with being overweight or obese. The other 10% are due to type 1 diabetes, which is caused by an autoimmune disease within the pancreas destroying the insulin producing beta cells. Diabetes, type 1 often occurs in childhood (hence the name “juvenile diabetes”), while type 2 diabetes is a condition of the middle aged and older population. There is however an alarming trend: overweight or obese youngsters are also being diagnosed with type 2 diabetes. Here I am discussing type 2 diabetes.Causes that trigger diabetesThere is not just one way to get diabetes; it usually is a multifactorial disease. Sure, genetics play a minor role. But you need to have epigenetic factors to trigger the genes to develop diabetes: eating too much sugar, eating wheat and wheat products, drinking soda drinks that contain sugar or high fructose corn syrup. Alcohol binges can also cause diabetes as can accumulation of excessive weight (a body mass index above 25.0). Even when there is no genetic risk in your family (your family tree has nobody that came down with diabetes and all your ancestors lived into their 90’s), you can still develop diabetes, if you are exposed to one or more of the risk factors mentioned.What is the reason why diabetes occurs?At a Keystone Symposium from Jan. 27 to Feb.1, 2013 in Keystone, Colorado (Ref.1) leading scientific researchers gathered to discuss exactly this question. There seem to be several mechanisms, all of which lead to diabetes. It has been known for some time that in type 2 diabetes insulin resistancedevelops that renders the cells incapable of absorbing blood sugar (glucose) from the blood into the cells. It is because of this insulin resistance that doctors can diagnose diabetes when blood sugar levels are high.Successful Diabetes Treatment Requires Patient’s DisciplineThere are at least 5 mechanisms that are presently known that can cause insulin resistance (and thus diabetes) by itself or in combination. For a deeper understanding of diabetes it is crucial to be aware of these. Without knowing the enemy, you cannot fight it.1. When a person eats too much sugar or fructose the liver converts this into excessive fat that is accumulated in the body’s cells. As a result insulin receptors are becoming inefficient in absorbing sugar from the blood, and blood sugar levels stay high. The pancreas reacts to this by making even more insulin, which after a few years will cause the pancreas to fail in producing insulin. At this point the patient requires insulin or else gets into a diabetic coma.2.Chronic inflammation is another mechanism that has been shown to cause insulin resistance. Obesity, the metabolic syndrome and diabetes have a common inflammatory denominator that results in insulin resistance. Are Diabetes and Inflammation Connected? With the aging process there is also deterioration of mitochondrial function (mitochondria are the mini batteries inside of every cell that are responsible for you having energy). This causes fat accumulation and also insulin resistance. Exercise and weight loss are effective in combatting insulin resistance. Fasting has also been shown to improve insulin sensitivity.3. The metabolism of visceral fat (the type of fat causing the apple appearance in obesity) is highly active and is associated with an increased risk for heart attacks and developing diabetes: Is Visceral Fat Responsible for the Metabolic Abnormalities Associated With Obesity?: Implications of omentectomy The pear shaped woman runs less of a risk, as the fat around the hips is not metabolically active. On the other hand when these women enter into menopause, they also develop abdominal fat (apple-like fat distribution) with a high secretion of inflammatory substances causing insulin resistance, heart attacks and strokes.4. Another mechanism of causing inflammation comes from invasion of organs with fat cells. The development of fat toxicity from these displaced fat cells can also cause insulin resistance. Heart cells have been shown to die from fat toxicity and in the pancreas the insulin-producing cells can be killed by fat toxicity as well causing diabetes or making existing diabetes worse.5. Interestingly another line of research, namely researching binge drinking, has revealed that there is a short-term insulin resistance that lasts for several days until the alcohol has been properly metabolized. It is of concern that adolescents who are experimenting with binge drinking are very vulnerable to develop brain damage from this habit.Consequences of insulin resistanceWe know that insulin resistance is the cause for adult onset, type 2 diabetes. It is entirely preventable. But there are powerful influences on people’s lives that will allow one or more of these factors mentioned to cause diabetes. The most common cause is putting on excessive weight. The reason for this is that people like to eat fast foods, drink sugar-containing sodas, and feast on processed foods, bagels and cookies. The end result is a change of the metabolism with an increase in triglycerides from the liver, an increase in LDL cholesterol, particularly the very low-density lipoprotein sub fractions of cholesterol. It has been known for some time that this is the connection to the high, premature death rates from heart attacks in diabetics, in people with obesity and in people with the metabolic syndrome. Hardening of the arteries is accelerated by the deposition of foam cells in the walls of arteries. These are scavenger cells (macrophages) that have engulfed noxious fats. This leads to narrowed coronary arteries and also a general narrowing of arteries all over the body including the brain vessels. In diabetics hardening of the arteries is accelerated and leads to premature strokes, heart attacks and heart failure, kidney failure, blindness and amputations of limbs.Important tests for borderline diabeticsI you have a fasting blood sugar that is above 100 mg/dL (5.5 mmol), but less than 126 mg/dL (7 mmol) you are considered to be prediabetic or “borderline diabetic”. In this case rather than waiting for disasters in terms of cardiovascular disease, take action and ask your doctor to do the following three tests.a) Arrange for a glucose tolerance test where you are given 75 grams of glucose; then blood tests are taken at one, two and three hours after this challenge dose. These blood tests are checked for blood glucose levels and insulin levels and tell the doctor exactly what is going on in terms of your sugar metabolism. It shows the glucose clearance and also the insulin response from your pancreas.b) Have a hemoglobin A1c test done: it shows how your blood sugars have been controlled over the last 2 to 3 months.c) You also need a VAP (vertical auto profile) test, which tests your lipid profile. Both prediabetics and overtly diabetics have been shown to have lipid profile disorders. Apart from low values in sub fractions of HDL cholesterol this test will also measure the very-low density lipoproteins (VLDL), which has been shown to be responsible for heart attacks and strokes.With these three tests your doctor can tell you more accurately what treatment protocol you require to succeed in controlling or curing your pre diabetes or diabetes.Conventional treatment of diabetesThe conventional treatment of diabetes is to send the patient to a dietician, to ask the patient to do regular exercises and to either start them on hypoglycemic drugs or on insulin injections. Unfortunately the dietician often will encourage the patient to eat “healthy multigrain bread”, which will stimulate your taste buds to eat more sugar, high fructose corn syrup and starchy foods making weight loss impossible. Often the treating physician is satisfied that a hemoglobin A1c of 7% or less is good enough for the diabetic. But non-diabetic people have a hemoglobin A1c of 4% and 5.6%. This should be your goal or you will suffer the consequences of uncontrolled diabetes.This is what I would call the conventional, symptomatic treatment approach. This may be the approach for patients who are not willing to seriously change their lifestyles, but it is more powerful on the long-term to treat diabetes by treating the underlying causes.Alternative treatment approach for diabetesBased on the above discussion regarding the various causes of insulin resistance, it is important to analyze what would be the main contributory factors in your particular case of diabetes.Here are some suggestions:1. If you are on the typical North American diet, also known as Western diet, it would be important to face the fact that wheat, wheat products in processed foods and sugar including high fructose corn syrup are the main culprits in stimulating your appetite and making you a sugar and wheat addict. Ref. 2 describes this in detail and offers 150 recipes to overcome this addiction. For more information just follow this reference text. Essentially it is a wheat-free Mediterranean type diet without rice, pasta and bread. You will shed significant amounts of pounds within a short period of time and feel a lot more energetic (due to revitalization of your mitochondria). At the same time insulin resistance is disappearing, because the insulin receptors are fully functional again. The insulin production of the pancreas will go down to normal levels and fat from the visceral fat storage gets melted away resulting in less inflammatory substances circulating in your blood.2. A regular exercise program in a gym with an aerobic component (30 minutes of treadmill for instance and 20 to 30 minutes of isometric machine exercises) will help you to lower the triglycerides, and increase the healthy HDL cholesterol. It will also improve insulin sensitivity and control inflammation in your body. The best is to exercise 7 days per week. Remember your body works for you 7/7 every week, but for those of you who need a little rest in between 5 days per week is still very good. You may have to adjust your medication and insulin dose downwards, ask your physician about that.3. Cut out alcohol. This may sound radical to you, but studies show this to be true. I have not mentioned cutting out smoking (it is causing inflammation and insulin resistance), because this is an absolute must that is given. When it comes to alcohol, the famous 1 drink per day for cardio protective purposes may not show up statistically as a bad effect, but your body will nevertheless get the message and let you age somewhat faster than a person who stays sober all the time. Staying sober will allow your brain to think clearly and adhere to your overall lifestyle approach in treating diabetes. Cutting out alcohol protects your brain (including the hypothalamus), liver and pancreas and prevents the prolonged periods of insulin resistance mentioned above that last for days. By keeping your hypothalamus in good working order, your hormone balance will stay stable for as long as possible until you reach menopause (for women) or andropause (for men). When you reached this milestone, I suggest you engage in bioidentical hormone replacement, which I have reviewed here. Hormones are essential to keep you younger for longer.4. It is useful to monitor your blood sugar with a home glucometer, as this will show you when your blood sugar normalizes. Stay in touch with your doctor at all times, as this will help you in your overall management of your diabetes. Also, you will want to discuss with your doctor that you should have a blood tests called “hemoglobin A1c” measured every three months to see how well your diabetes is controlled. It should be below 7% for sure, but better below 6%. Non-diabetic people have levels of 4% and 5.6%. You may not know that hemoglobin A1c is actually measuring the amount of advanced glycation end products (“AGE”) of red blood cells. These AGE substances essentially are firmly bound sugar/protein compounds that shut down the cell metabolism wherever they are formed. In my opinion it is best to aim at a hemoglobin A1c level of non-diabetic people (4% and 5.6%) to avoid the consequences of tissue damage of all vital organs, which is the reason why long-term diabetics have a life expectancy of 15 to 20 years shorter than non-diabetic persons. Some diabetic patients may benefit from the oral hypoglycemic drug, metformin (brand name: Glucophage), which has anti-inflammatory properties and is used in patients with type 2 diabetes and a high fasting insulin level, but this is a decision requiring your physician’s input.5. Supplements: There are some supplements that are useful to take as an adjunct, like chromium, which helps insulin to transport glucose into the cell; alpha-lipoic acid, an antioxidant, which is useful to prevent glycation (formation of a complex between sugar and protein, which prevents normal cell functioning); and coenzyme-Q10, which supports your heart (A4M recommends 400 mg per day). Other supplements of merit are curcumin, cinnamon, genistein and silymarin (standardized extract of milk thistle), which suppresses a pro-inflammatory molecules, which in turn helps to fight insulin resistance (Ref. 1). Omega-3 fatty acid supplements are anti-inflammatory and will improve insulin resistance as well (dosage 1000mg or more per day). According to Ref. 3 vitamin D3 is useful as a supplement for diabetics, because it activates DNA, is involved in cellular repair and deficiency of it is known to lead to higher mortality rates in diabetics. Ref. 3 recommends between 1000 and 4000 IU of vitamin D3 daily and suggests doing blood tests to measure effective vitamin D3 levels (keep 25-OHD in the blood between 30 and 80 ng/mL).6. Patients whose pancreas no longer produces insulin will need insulin injections, but instead of using long-acting insulin once per day the best results in getting blood sugar control is by injecting insulin three or more times per day using short acting insulin. It is important to always monitor the blood sugar lowering effect by glucometer readings; the injections are best given just before meals (recombinant human insulin is the preferred insulin to be used). Ask your physician or diabetic coach for more details.ConclusionDiabetes used to be a dreadful disease that caused premature heart attacks, strokes, blindness, kidney failure, and limb amputations. With aggressive management of diabetes as well as strict lifestyle intervention this has changed. A diabetic who treats the causes of the illness can have a normal life expectancy. In many cases the initial diagnosis of type 2 diabetes can disappear, when treatment was started early enough and insulin resistance could be stopped in its tracks. Without the patient’s full co-operation disciplining him/herself to follow through on all of these recommendations the caregiver will fail in controlling the patient’s diabetes. It is the patient who owns the problem; it is the patient who needs to make every possible effort and follow through on all of the details of dieting, exercising, blood sugar monitoring using a glucometer and taking the required supplements.Here is my answer to your question: “Can diabetes type 2 be reversed with a diet? If yes, what is it?” Most type 2 diabetes cases have developed as a result of poor diets or overeating. Heavy alcohol abuse may also have played a role. By cutting out refined sugar, starchy foods (potatoes, pasta, bread and rice) including processed foods and wheat this will likely start getting diabetes under control. The patient must do daily gucosometer readings of their own blood sugar and record this. This way they will notice what dietary indiscretions are doing to their blood levels. Often with this approach there will be a significant weight loss, which also helps to control the diabetes better. But the patient must realize that this is a long-term project that will be ongoing. This way you can be successful in reversing type 2 diabetes via a diet alone.More information on diabetes: http://nethealthbook.com/hormones/diabetes/type-2-diabetes/Reference1. http://www.lef.org/magazine/mag2013/oct2013_2013-Keystone-Diabetes-Symposium_01.htm2. William Davis, MD: “Wheat Belly Cookbook. 150 Recipes to Help You Lose the Wheat, Lose the Weight, and Find Your Path Back to Health”. HarperCollins Publishers LTD., Toronto, Canada, 2012.3. Rakel: Integrative Medicine, 3rd ed. © 2012 Saunders. Integrative Therapy; Supplements.

Please explain what and when the procedure was performed. Has the patient been seen since surgery by the physician? What was the reason provided for not seeing the patient?There is a patient abandonment issue. The person doing the surgery should do follow up for any complication related to the procedure he/she performed. Is it because of noncompliance, schedule conflict, non-payment etc?[Edit: Per additional history provided in the Comments section. The article below addresses medical management after bariatric surgery. The physician has tried to work up surgical complications. This is the section regarding nausea and vomiting. The authors mention antiemetic unless there are other issues. I hesitate to second guess what the surgeon’s train of thought is. I do think there should be response to the patient’s communications. I understand the frustration and the cost of repeat emergency room visits. Someone here has suggested contacting the chief of surgery. Post bariatric surgery recuperation can be problematic and I hope the symptoms resolve in time.Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].]World J Gastrointest Surg. 2014 Nov 27; 6(11): 220–228.Published online 2014 Nov 27. doi: 10.4240/wjgs.v6.i11.220PMCID: PMC4241489Medical management of patients after bariatric surgery: Principles and guidelinesAbd Elrazek Mohammad Ali Abd Elrazek, Abduh Elsayed Mohamed Elbanna, and Shymaa E BilasyAuthor information ► Article notes ► Copyright and License information ►This article has been cited by other articles in PMC.Go to:AbstractObesity is a major and growing health care concern. Large epidemiologic studies that evaluated the relationship between obesity and mortality, observed that a higher body-mass index (BMI) is associated with increased rate of death from several causes, among them cardiovascular disease; which is particularly true for those with morbid obesity. Being overweight was also associated with decreased survival in several studies. Unfortunately, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. All obese patients (BMI ≥ 30 kg/m) should receive counseling on diet, lifestyle, exercise and goals for weight management. Individuals with BMI ≥ 40 kg/m and those with BMI > 35 kg/m with obesity-related comorbidities; who failed diet, exercise, and drug therapy, should be considered for bariatric surgery. In current review article, we will shed light on important medical principles that each surgeon/gastroenterologist needs to know about bariatric surgical procedure, with special concern to the early post operative period. Additionally, we will explain the common complications that usually follow bariatric surgery and elucidate medical guidelines in their management. For the first 24 h after the bariatric surgery, the postoperative priorities include pain management, leakage, nausea and vomiting, intravenous fluid management, pulmonary hygiene, and ambulation. Patients maintain a low calorie liquid diet for the first few postoperative days that is gradually changed to soft solid food diet within two or three weeks following the bariatric surgery. Later, patients should be monitored for postoperative complications. Hypertension, diabetes, dumping syndrome, gastrointestinal and psychosomatic disorders are among the most important medical conditions discussed in this review.Keywords: Obesity, Bariatric surgery, Postoperative care, Body-mass index, El bannaCore tip: Obesity is a growing health concern worldwide that impacts the life of individuals both physically and psychologically. There are several well-established health hazards associated with obesity. Additionally, obese subjects are often exposed to public disapproval because of their fatness which significantly affects their psychosocial behavior. Bariatric surgery is one of the definite solutions for obesity. In this review, we will briefly discuss the general guidelines that should be considered before bariatric surgery. Also, we discuss the protocols of patients’ postoperative care and the management of medical disorders that must be considered after bariatric surgery.Go to:INTRODUCTIONObesity is a chronic disease that impairs health-related quality of life in adolescents and children. In 2010, overweight and obesity were estimated to cause 3.4 million deaths, 3.9% of years of life loss, and 3.8% of disability-adjusted life-years worldwide. Obesity is increasing in prevalence, currently, the proportion of adults with a body-mass index (BMI) of 25 kg/m or greater is 36.9% in men and 38.0% in women worldwide[1]. Attempts to explain the large increase in obesity in the past 30 years focused on several potential contributors including increase in caloric intake, changes in the composition of diet, decrease in the levels of physical activity and changes in the gut microbiome. More than 50% of the obese individuals in the world are located in ten countries (listed in order of number of obese individuals): United States, China, India, Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Although age-standardized rates were lower in developing than in developed countries overall, 62% of the world’s obese individuals live in developing countries. Recently, United States accounted for 13% of obese people worldwide, the prevalence of obesity was 31.7% and 33.9% among adult men and women, respectively. In Canada 21.9% of men and 20.5% of women are obese. Reported prevalence rates of obesity include: 27.5% of men and 29.8% of women in Australia, 24.5% of men and 25.4% of women in the United Kingdom, in Germany 21.9% of men and 22.5% of women, in Mexico 20.6% of men and 32.7% of women, in South Africa 13.5% of men and 42% of women, in Egypt 26.4% of men and 48.4% of women, in Saudi Arabia 30% of men and 44.4% of women and in Kuwait 43.4% of men and 58.6% of women Figure ​Figure11)[2].There are several well-established health hazards associated with obesity, e.g., nonalcoholic steatohepatitis (NASH), type 2 diabetes, heart disease, chronic kidney disease, gastroesophageal reflux disease, gastrointestinal motility disorders, sexual disorders, cerebrovascular stroke, certain cancers, osteoarthritis, depression and others[3-10]. The risk of development of such complications rises with the increase of adiposity, while weight loss can reduce the risk. Bariatric surgery could be the definitive clue in many situations[11-15]. Bariatric surgery is one of the fastest growing operative procedures performed worldwide, with an estimated > 340000 operations performed in 2011. While the absolute growth rate of bariatric surgery in Asia was 44.9% between 2005 and 2009, the numbers of procedures performed in the United States plateaued at approximately 200000 operations per year[16,17]. Starting in 2006, the Center for Medicare and Medicaid Services, United States, restricted the coverage of bariatric surgery to hospitals designated as “Centers of Excellence” by two major professional organizations[18]. Medical management and follow up of patients who have undergone bariatric surgery is a challenge due to post operative complications.GENERAL GUIDELINES FOR SURGEONS/GASTROENTEROLOGISTSA well skilled physician or a surgeon has to consider the followings:(1) as the prevalence of obesity increases so does the prevalence of the comorbidities associated with obesity. Losing weight means overcoming illness at the present, complications in future and alleviating the economic burden in the present and future;(2) Overweight; BMI between 25 and 30, technically refers to excessive body weight, whereas “obesity” BMI ≥ 30 kg/m refers excessive body fat, “Severe obesity”, BMI ≥ 35 kg/m, or “morbid obesity” refers to individuals with obesity-related comorbidities. Furthermore, severe obesity and morbid obesity groups who failed dietary and medical regimens are candidates for bariatric surgery;(3) Children obesity; refers to children with BMI > 95th percentile for their age and sex and “overweight” refers to children with BMI between the 85th and 95th percentile for their age and sex;(4) Patients undergoing a bariatric operation should have a nutritional assessment for deficiencies in macro and micronutrients, also with no contraindication for such a major operation;(5) Most of bariatric procedures are performed in women (> 80%) and approximately half of these (> 40% of all bariatric procedures) are performed in reproductive aged women, accordingly, pregnancy planning and contraception options should be discussed in details with women who will undergo bariatric procedures. Fertility improves soon after bariatric surgery, particularly in middle-aged women, who were anovulatory. Additionally, oral contraceptives may be less effective in women who have undergone malabsorptive bariatric procedure. Therefore, it is better to delay pregnancy for 6-12 mo following bariatric surgery. Risk of preeclampsia, gestational diabetes, and macrosomia significantly decrease post bariatric surgery, but the risk of intrauterine growth restriction/small infants for their gestational age may increase. Body contouring surgery is in high demand following bariatric surgery;(6) All bariatric operations are accompanied with restrictive and/or malabsorption maneuvers; less food intake and malabsorption concepts;(7) The most common types of bariatric surgeries performed worldwide are Sleeve gastrectomy (SG): This procedure involves the longitudinal excision of the stomach and thus shaping the remaining part of the stomach into a tube or a “sleeve” like structure. SG removes almost 85% of the stomach (Figure ​(Figure2);2); Roux-en-Y gastric bypass (RYGB): It reduces the size of the stomach to the size of a small pouch that is directly surgically attached to the lower part of the small intestine. In this procedure, most of the stomach and the duodenum are surgically stapled and therefore, bypassed (Figure ​(Figure3);3); The laparoscopic adjustable gastric band (AGB): This is one of the least invasive procedures, where the surgeon inserts an adjustable band around a portion of the stomach and therefore, patients feel fuller after eating smaller food portions (Figure ​(Figure4).4). Bariatric surgical procedures, particularly RYGB, plus medical therapy, are effective interventions for treating type 2 diabetes. Improvement in metabolic control is often evident within days to weeks following RYGB; and(8) Complications reported following bariatric surgery vary based upon the procedure performed. Cholilithiasis, renal stone formation and incisional hernia could be the delayed phase complications; on the other hand, bleeding, leaking, infection and pulmonary embolism could be the early phase complications following the bariatric procedure. The overall 30-d mortality for bariatric surgical procedures worldwide is less than 1%.Roux-in Y Gastrectomy, sleeve gastrectomy. and adjustable gastric band.POST OPERATIVE CARE AND FOLLOW UPEarly post operative period; (1-3) d post bariatric surgeryPatients undergoing a bariatric operation are admitted to the post-anesthesia care unit (PACU) immediately at the conclusion of the operation. Usually, on postoperative day (POD) one, we begin oral therapy in tablet or crushed-tablet and liquid form if there is a naso-gastric tube after the gastrografin leak test. A basic metabolic profile (e.g., complete blood count, electrolytes, renal function, liver function, prothrombin time and partial thromboplastin time) should be obtained every 12 h for the successive two PODs, then every 24 h for another 3 d. Oxygen is administered by nasal cannula and weaned thereafter. The likelihood that, early specific complication, will arise for a given patient is determined by the nature of the procedure, the anesthetic techniques used, and the patient’s preoperative diseases. Respiratory problems are common complication in the early postoperative period following bariatric surgery. Patients with significant comorbidities, particularly neuromuscular, pulmonary, or cardiac problems are at a higher risk for respiratory compromise, but any patient can develop hypoxemia following bariatric surgery. For prophylaxis against Deep Venous Thrombosis (DVT) following bariatric surgeries, ultrasound evaluation is recommended for all patients, D-dimer test should be applied for suspected patients with DVT, especially after long operative time, repeat ultrasound or venography may be required for those with suspected calf vein DVT and a negative initial ultrasound investigation[19,20].Late post operative monitoringAfter the PACU period, most patients are transferred to the inpatient surgical postoperative unit. For the next 24-72 h, the postoperative priorities include ruling out an anastomotic leak following laparoscopic RYGB or laparoscopic SG. If no leak is observed, patients are allowed to start a clear liquid diet and soft drinks. The postoperative care team cares for the following: control of pain, care of the wound, continuous monitoring of blood pressure, intravenous fluid management, pulmonary hygiene, and ambulation. Post-bariatric nausea and vomiting is directly correlated with the length of the surgery; it also increases in females, non-smokers, and those patients with prior history of vomiting or motion sickness. Prophylaxis with pharmacologic treatment before the development of post operative nausea and vomiting significantly reduces its incidence after surgery[21-23].After hospital dischargeDiet: Usually patients are discharged 4-6 d after surgery. Most patients are typically discharged from the hospital on a full liquid diet, patients should be taught to keep monitoring their hydration and urine output. Approximately two-three weeks after surgery, the diet is gradually changed to soft, solid foods. The average caloric intake ranges from (400) to (800) kcal/d for the first month, and thus the daily glycemic load is greatly reduced. We encourage patients to consume a diet consisting of salads, fruits, vegetables and soft protein daily.To control the epigastric pain and vomiting, patients should be taught to eat slowly, to stop eating as soon as they reach satiety and not to consume food and beverages at the same time. For most patients suffering chronic vomiting, prokinetic therapy and proton-pump inhibitors (PPIs) should be considered. Patients, who underwent SG, LAGB or RYGB, benefit from a well-planned dietary advancement. Patients should understand that the surgery has changed their body but not the environment, they have to choose healthy foods, do not skip meals and to visit the dietitian regularly in the first 12 mo after surgery. However, if food intolerance develops, patients may choose a more vegetarian-based diet. Nevertheless, fresh fruits and vegetables are usually tolerated without a problem. The daily protein intake should be between 1.0 to 1.5 g/kg ideal body weight per day[24]. The biliopancreatic diversion/duodenal switch (BPD/DS) is a malabsorptive procedure for both macro- and micronutrients. Hence, we encourage higher protein intake of 1.5 g to 2.0 g of protein/kg ideal body weight per day, making the average protein requirement per day approximately 90 g/d[25,26]. Alcohol is better prevented in the first 6-12 mo after surgery[27].Monitoring: Patients should generally have their weight and blood pressure measured weekly until the rapid weight loss phase diminishes, usually within 4-6 mo, then again at 8, 10 and 12 mo, and annually thereafter. Patients with diabetes are encouraged to check their blood glucose daily. Glycemic control typically improves rapidly following bariatric surgery. Patients maintained on antihypertensive or diabetic medications at discharge should be monitored closely for hypotension and hypoglycemia, respectively, and medications should be adjusted accordingly. We recommend that the following laboratory tests be performed at three, six, nine months and annually thereafter: (1) Complete Blood Count; (2) Electrolytes; (3) Glucose and Glucose Tolerance test; (4) Complete iron studies; (5) Vitamin B12; (6) Aminotransferases, alkaline phosphatase, bilirubin, GGT; (7) Total protein and Albumin; (8) Complete lipid profile; (9) 25-hydroxyvitamin D, parathyroid hormone; (10)Thiamine; (11) Folate; (12) Zinc; and (13) Copper.Complications following the surgical treatment of severe obesity vary based upon the procedure performed. Secondary hyperparathyroidism, Hypocalcemia, Gastric remnant distension, Stomal stenosis/Obstruction, Marginal ulcerations, Cholilithiasis, Ventral incisional hernia, Internal hernia, Hiatus Hernia, Short bowel syndrome, Renal failure, Gastric prolapse, infection, Esophagitis, Reflux, Vomiting, Hepatic abnormalities and dumping syndrome are common late-phase complications after bariatric surgery. However, the clinician should aware of complications specific for every bariatric procedure[28,29]. Before therapy, the clinician should understand that the impact of various bariatric surgeries on drug absorption and metabolism are scarce. On the other hand, RYGB and other malabsorptive procedures that significantly exclude the proximal part of the small intestine, decrease the surface area where most drug absorption occurs and may result in a reduction in systemic bioavailability[30-32].Go to:COMMON MEDICAL CONDITIONS FOLLOWING BARIATRIC SURGERYHypertensionHypertension is not always related to obesity, and dietary interventions do not assure the normalization of blood pressure. However weight loss, whether by an intensive lifestyle medical modification program or by a bariatric operation, improves obesity-linked hypertension. Patients should be monitored weekly until the blood pressure has stabilized, and patients may need to resume antihypertensive medications, but often at adjusted doses[33].DiabetesPatients with diabetes should have frequent monitoring of blood glucose in the early postoperative period and should be managed with sliding scale insulin. Many diabetic patients have a decreased need for insulin and oral hypoglycemic agents after bariatric surgery. Oral sulfonylureas and meglitinides should be discontinued postoperatively as these medications can lead to hypoglycemia after bariatric surgery. Metformin is the safest oral drug in the postoperative period, since it is not associated with dramatic fluctuations in blood glucose. RYGB is associated with durable remission of type 2 diabetes in many, but not all, severely obese diabetic adults. However those who underwent LAGB generally exhibit a slower improvement in glucose metabolism and diabetes as they lose weight in a gradual fashion[34,35].RefluxMedications for gastroesophageal reflux disease (GERD) may be discontinued after RYGB and Laparoscopic AGB, however, SG has been associated with an increased incidence of GERD in some procedures. Recurrent GERD symptoms after RYGB, particularly when accompanied by weight regain, should raise the possibility of a gastrogastric fistula between the gastric pouch and remnant, and should be investigated by an upper GI contrast study or CT scan and referred to the bariatric surgeon. Upper endoscopy is the best investigation to exclude other esophagogastroduodenal disorders. GERD may be associated with esophageal complications including esophagitis, peptic stricture, Barrett’s metaplasia, esophageal cancer and other pulmonary complications. Failure of the PPI treatment to resolve GERD-related symptoms has become one of the most common complications of GERD after bariatric surgery. Most patients who fail PPI treatment have Non Erosive Reflux Disease and without pathological reflux on pH testing. In patients with persistent heartburn despite of medical therapy, it is reasonable to recommend avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger GERD-related symptoms[36-38].Nausea and vomitingNausea and vomiting can often be helped by antiemetic or prokinetic drugs, however, some patients have chronic functional nausea and/or vomiting that does not fit the pattern of cyclic vomiting syndrome or other gastrointestinal disorders, hence particular attention should be directed to potential psychosocial factors post bariatric surgery. Therefore, low dose antidepressant medications and psychotherapy should be addressed. On demand CT scan and Gastroscopy could be the gold standard investigations in chronic situations[39,40].Marginal ulcerationDue to increased risk of ulcer formation from nonsteroidal anti-inflammatory drugs (NSAIDs), these medications should be discontinued postoperatively, especially after RYGB. NSAID use is associated with an increased risk of bleeding. If analgesic or anti-inflammatory treatment is needed, the use of acetaminophen is preferred in a dose of 1-2 g/daily[41-45]. Other factors associated with increased risk of ulcer formation are smoking, alcohol, spicy food, gastrogastric fistulas, ischemia at the site of surgical anastomosis, poor tissue perfusion due to tension, presence of foreign material, such as staples and/or Helicobacter pylori infection. Diagnosis is established by upper endoscopy. According to our strategy, all patients should undergo diagnostic upper endoscopy to exclude congenital or GI diseases prior to bariatric procedures. Medical management is usually successful and surgical intervention is rarely needed[46-48].Go to:DUMPING SYNDROMEDumping syndrome or rapid gastric emptying is a group of symptoms that most likely occur following bariatric bypass. It occurs when the undigested contents of the stomach move too rapidly into the small intestine. Many patients who underwent bariatric bypass experienced postprandial hypoglycemia. However, the dumping syndrome usually occurs early (within one hour) after eating and is not associated with hypoglycemia. It is presumed to be caused by contraction of the plasma volume due to fluid shifts into the gastrointestinal tract. Dumping syndrome may result in tachycardia, abdominal pain, diaphoresis, nausea, vomiting, diarrhea, and sometimes, hypoglycemia. The late dumping syndrome is a result of the hyperglycemia and the subsequent insulin response leading to hypoglycemia that occurs around 2-3 h after a meal. Dumping syndrome is a common problem that occurs in patients who have undergone RYGB and when high levels of simple carbohydrates are ingested. Accordingly, patients who have experienced postgastric bypass bariatric surgery should avoid foods that are high in simple sugar content and replace them with a diet consisting of high fiber and protein rich food. Eating vegetables and salad is encouraged; beverages and alcohol consumption are better avoided[49].Go to:PSYCHOSOMATIC DISORDERS/DEPRESSIONMany patients usually experience enhanced self esteem and improved situational depression following weight loss. Depression often requires continued treatment, specially that, many patients with severe obesity often use food for emotional reasons. Therefore, when those patients experience a small gastric pouch postoperatively they may grieve the loss of food. Many studies documented the relationship between eating disorder and anxiety disorder, depression or schizophrenia[50,51]. Displaced emotions can result in somatization with symptoms of depression and psychosomatic disorders. It is important that clinicians recognize the psychological aspect of food loss after bariatric surgery, and reassure patients that the symptoms are related to the small gastric pouch size. Antidepressants often help to decrease the anxiety related to grieving associated with food loss, although the use of antidepressants needs to be approached with an empathetic style. Behavioral and emotive therapies are reported to be very helpful[52,53].Go to:OUTCOMEBariatric surgery remains the only effective sustained weight loss option for morbidly obese patients. The American Society for Metabolic and Bariatric Surgery estimated that in 2008 alone, about 220000 patients in the United States underwent a weight loss operation. The optimal choice for type of bariatric procedure, i.e., RYGB, SG, AGB or the selected surgical approach, i.e., open versus laparoscopic depends upon each individualized goals, i.e., weight loss, glycemic control, surgical skills, center experience, patient preferences, personalized risk assessment and other medical facilities. Laparoscopic sleeve gastrectomy is the most common bariatric procedure. However weight re-gain after long-term follow-up was reported[54-58]. Prospective studies and reviews report a general tendency for patients with metabolic disorders to improve or normalize after bariatric surgery. However weight loss is highly variable following each procedure. Recent studies have evaluated the potential impact of obesity on outcomes in organ-transplant recipients, for example bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure[59-63].Go to:RECENT ADVANCES IN BARIATRIC SURGERYA modified intestinal bypass bariatric procedure (Elbanna operation), reported a novel surgical technique designed to maintain good digestion, better satiety, and selective absorption with less medical and surgical complications (Figure ​(Figure5).5). This procedure preserves the proximal duodenum and the terminal ileum and thus preserving the anatomical biliary drainage and enterohepatic circulation[64,65].Figure 5Novel ElBanna surgical procedure.Recently, a novel bariatric technique dedicated; Modified Elbanna technique in childhood bariatric, showed promising success in pediatric surgeries (non published data).Go to:CONCLUSIONThe rising prevalence of overweight and obesity in several countries has been described as a global pandemic. Obesity can be considered like the driving force towards the pre-mature deaths. It increases the like hood for the development of diabetes, hypertension and NASH. The American Heart Association identified obesity as an independent risk factor for the development of coronary heart disease. In order to minimize post-surgical cardiovascular risk, surgical weight loss may become a more frequently utilized option to address obesity. Currently, bariatric surgery passes through a plateau phase, hence medical management and follow up of patients who have undergone bariatric surgery is a challenge.Go to:FUTURE RECOMMENDATIONSChildren obesity has become one of the most important public health problems in many industrial countries. In the United States alone, 5% of children have severe obesity. It is imperative that health care providers should identify overweight and obese children so as to start early counseling and therapy. To establish a therapeutic relationship and enhance effectiveness, the communication and interventions should be supported by the entire family, society, school, public media and primary health care. Bariatric surgery could be considered in complicated cases that failed all other options.Go to:FootnotesP- Reviewer: Amiya E, Firstenberg MS, Narciso-Schiavon JL S- Editor: Tian YL L- Editor: A E- Editor: Lu YJGo to:References1. 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