الفهرس 
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Abstract
Summary
Obesity is simply defined as ”excessive amount of
body fat” and should be considered a chronic disease, as it
has definite mortality and morbidity.
The lack of direct methods has led to development of
various models and indirect methods for estimation of fat
and fat-free mass, all of which are imperfect and require a
number of assumptions.
The most widely accepted measure of obesity is the
body mass index (BMI) which equals patient weight in
kilograms divided by the square of his or her height in
meters. Morbid obesity is having a BMI greater than 40
kg/m2 or a BMI greater than 35 kg/m2 with concomitant
obesity-related morbidity.
Appetite is influenced by many factors that are
integrated by the brain, most importantly within
hypothalamus. Signals that impinge on the hypothalamic
centre include neural afferents, hormones and metabolites.
The incidence of obesity is steadily rising. Morbid
obesity is associated with a large number of problems.
Several of these problems are underlying causes for the
earlier mortality associated with obesity and include;
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coronary artery disease, hypertension, impaired cardiac
function, adult onset diabetes mellitus, venous stasis and
hypercoagulability leading to an increased risk of
pulmonary embolism, increased risk of uterine, breast and
colon cancer and necrotizing panniculitis.
The primary goal of treatment is to improve obesity
related co-morbid conditions and reduce the risk of
developing future co-morbidities.
Treatment of morbid obesity should begin with
simple lifestyle changes, including moderation of diet and
initiation of regular exercise such as walking. The
treatment of associated co-morbidities should be addressed
expeditiously.
Adjuvant pharmacologic treatments should be
considered for patients with a BMI >30 kg/m2 or with a
BMI >27 kg/m2 who also have concomitant obesity-related
diseases and for whom dietary and physical activity therapy
has not been successful.
However, because the only effective treatment for
morbid obesity is bariatric surgery, these are the initial
steps to be taken in preparation for the more definitive
treatment. Bariatric surgery offers the only means of
delivering sustained weight loss.
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Bariatric surgical techniques are divided into two
groups: malabsorptive and restrictive procedures. In
general, restrictive procedures are simpler to perform and
are accompanied by less procedural complications than
malabsorptive procedures.
The original purely malabsorptive procedures such as
jejuno-ileal bypass are no longer performed due to their
unacceptably high late complication rate. They have been
replaced by restrictive or combined operations. Open
surgery has largely been replaced by a laparoscopic
approach. The most common operations performed are:
vertical banded gastroplasty, adjustable gastric banding,
biliopancreatic diversion and Roux-en-Y gastric bypass.
The sleeve gastrectomy is a new tool in the surgical
treatment of the morbidly obese and the superobese
patients. It was conceived as the restrictive part of a more
complex procedure that combines malabsorptive and
restrictive concepts: the biliopancreatic diversion with
duodenal switch.
In recent years, laparoscopic sleeve gastrectomy
(LSG) as a single-stage procedure for the treatment of
morbid obesity is becoming increasingly popular. Of
continuing concern are the rate of postoperative
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complications and the lack of consensus as to surgical
technique.
Patients elected for SG should have complete clinical
and multidisciplinary evaluation and preparation.
SG consists of creating a maximal gastric reservoir
or tube of 150 to 200 ml but, as an isolated procedure, the
gastric pouch size usually varies from 60 to 120 ml.
SG achieves weight loss by gastric restriction and
decreasing the circulating level of ghrelin hormone which
play a key role in the energy balance.
SG does not involve alterations in the small bowel
anatomy and is therefore rarely associated with metabolic
complications. It is also simpler to perform with less
procedural risks when compared with malabsorptive
operations and achieve good weight loss. This reduction in
mortality and major complications has lead to their current
popularity