OBESITY AND METABOLIC SURGERY

What is Obesity?

In general terms, obesity can be defined as an excessive fat accumulation in the body. The main problem is that the energy intake, i.e., food intake, is higher than the energy consumed. This excess energy is stored in the body as fat. Occasionally, obesity can be accompanied by hormonal disorders. Hence, patients with overweight problems must be examined also with an eye to hormones. Cases of obesity not attributable to hormonal disorders should in the first place be examined in terms of their diet and lifestyle to detect any problematic habits and try to resolve them. Surgical treatment is advised for patients whose treatment by these methods is of no avail and who are considered to derive favorable benefits from surgery. Obesity is a condition that shortens a person’s expected life by an average of 10 years and has adverse effects on social and business life.

According to criteria of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), obesity is diagnosed when your body mass index is 30 kg/m2 or higher. BMI is a person’s weight in kilograms divided by the square of height in meters. For instance, if a person is 170 centimeters tall and weighs 70 kilograms, we first calculate the person’s square of height in meters, which in this case is 1.7 meters multiplied by 1.7 meters equaling 2.89. When 70 kg is divided 2.89, the quotient is 24,22 which means a healthy weight according to the table below. If the same person weighed 90 kg, his BMI would be around 31 (i.e., 90 kg divided by 2.89) in which case the person would be diagnosed obese.

Health risks caused by obesity

Obesity is a systemic disease that affects the whole body. It stands in direct relation to diabetes, hypertension, high cholesterol and also sleep apnea, menstrual irregularities, infertility, herniated disc, mental problems, some types of cancer, and calcification of the joints.

Fighting the obesity

Obesity is very difficult to treat once it occurs. Hence, the key to fight obesity is its prevention, which is only possible by adopting healthy dietary habits and incorporating physical activity into the person’s lifestyle from childhood on. Weight loss through healthy diet and exercise can be achieved in only one or two of ten patients who consult a health professional to seek medical advice for obesity, i.e., whose BMI is above 30. This showcases the importance of preventing weight gain instead of trying to achieve weight loss. Major components in treating overweight are Diet Therapy, Exercise Therapy, Behavioral Therapy, Drug Therapy and Bariatric Interventions. 

Obesity and diabetes

There are several risk factors associated with the development of type 2 diabetes such as age, race, pregnancy, stress, certain medications, family history, high cholesterol, and obesity. Yet, the most important factor accompanying type 2 diabetes is overweight or obesity. About 90% of persons with type 2 diabetes are overweight or obese. Use of insulin to properly control and regulate blood glucose levels is limited in overweight persons, which exposes them to a higher risk to develop diabetes. Type 2 diabetes is largely preventable. Studies have shown that lifestyle changes and 5-10% weight loss can prevent or delay the development of type 2 diabetes in high-risk adults. These studies employed lifestyle interventions such as diet and moderate physical activity (walking 20 minutes a day) were used for weight loss over the course of three to six years, as a result of which the risk of developing diabetes was found to have reduced by 40% to 60%.

How can you know whether you are a candidate for obesity surgery?

Obesity, as one of the most prominent diseases of the modern age that creates a negative impact on almost all organs of the body when left untreated, is an epidemic that continues to spread with each passing day… Endoscopic and surgical methods can be the key in treating the disease when diet, exercise and medication under control of a medical professional prove to be of no avail. If you are overweight and want to change your lifestyle, you may be a potential candidate for bariatric surgery.

If weight loss remains below the desired level…

Surgery is recommended for persons with a BMI over 40kg/m2 if weight loss at desired levels cannot be achieved despite diet, exercise and lifestyle changes.

Surgery is also recommended for obese patients with a BMI over 35kg/m2 who have concomitant diseases such as diabetes, hypertension, sleep apnea, joint calcification, and herniated disc as weight loss is a main factor in treating these diseases.

Finally, a surgery should be offered as an option to patients with a BMI ranging between 30 and 35kg/m2 who are diabetic and whose blood glucose levels remain high despite drug therapy.

You may be a candidate for obesity surgery if you have the following symptoms…

• Type 2 diabetes,
• Obstructive sleep apnea,
• High blood pressure,
• Joint calcification, and/or
• Other symptoms associated with obesity (high cholesterol, vascular narrowing, varicose veins etc.)

Especially if you have serious health problems…

Certain restrictive operations such as gastric banding have lost their effectiveness all across the world. Although malabsorptive operations are high in effect, they are rather preferred if obesity is accompanied by uncontrollable diabetes and hypertension. Nowadays, the most common technique used in obesity surgery with proven effect and efficiency is laparoscopic sleeve gastrectomy which is a restrictive operation.

Surgeries for weight loss are usually divided into three categories:

• Restrictive and malabsorptive surgeries
• Malabsorptive surgeries (limits food absorption)
• Restrictive surgeries (limits food intake)

When is obesity surgery indicated?

Surgical treatment is indicated if a person’s BMI is > 40 kg/m2 or if a person’s BMI is > 35 kg/m2 accompanied by an additional disease (type 2 diabetes, hypertension, sleep apnea, hyperlipidemia, serious joint problems), on condition that risks associated with surgery are ay an acceptable level and that non-surgical treatment attempts have been unsuccessful.

Sleeve Gastrectomy

Sleeve gastrectomy is an obesity surgery where about 80% of the stomach is surgically removed. The newly formed stomach allows for less food intake due to its significantly reduced volume compared to a normal stomach. Secondary weight loss mechanism is the non-release of the hunger hormone called “GHRELIN”. Sleeve gastrectomy is a laparoscopic surgery where the abdominal cavity is accessed through small incisions.

How is the intragastric balloon procedure done? How long does it take?

During the procedure, the doctor advances an intragastric balloon down your throat into your stomach with the help of an endoscope, under mild anesthesia. Then the balloon is inflated to create a feeling of fullness in the patient’s stomach. Intragastric balloon procedure is defined as a nonsurgical technique. Yet, another important aspect in which this procedure differs from other methods is that the balloon is removed after a certain period of time (6 months), meaning that the results are not permanent. Hence, the balloon is used for temporary treatment of obesity; it facilitates and helps to maintain weight loss. It can be helpful if patients lose weight before they undergo obesity surgery, so as to mitigate surgical risks. The procedure takes about 10 to 15 minutes. Since this is a custom procedure applied depending on the amount of weight the patient should lose, our surgeons decide on a case-to-case basis how much to inflate the balloon without causing any harm to the patient. Patients are discharged after some rest. The balloon can stay inside the stomach for 6 months maximum. The patient may regain weight unless an adequate diet or exercise program is adopted after the balloon is removed.

Gastric bypass / mini gastric bypass

Gastric Bypass is an older type of surgery compared to other obesity surgical methods. First, a small stomach with a volume of 30 ml is created using stomach tissue close to the esophagus and gastroesophageal junction. The small intestine is connected to this newly formed small stomach, leaving a certain distance. There are two types of bypass. In the first technique, the small intestine is formed into a loop and connected to the stomach without cutting out any parts of the small intestine. This is referred to as “Mini Gastric Bypass”. In the other technique, some part of the small intestine is cut out and one end is connected to the stomach and the other to the small intestine yet after a certain distance. This is called the “Roux-en-Y gastric bypass”. The mechanism here is both restrictive as is in the case of sleeve gastrectomy, that is the patient’s food intake is limited, and malabsorptive, that is the place where food comes across bile and pancreatic enzymes poured into the duodenum is the small intestine sections far later than normal. This makes it more difficult to digest and absorb food, which adds a malabsorptive mechanism to the procedure. Briefly, the patient will eat less and get less from what he eats. The change in gastrointestinal system hormones here is more pronounced than in sleeve gastrectomy. As a result, there is an increase in both the feeling of hunger and satiety increases, while blood sugar remains stable. This procedure is advantageous as it can help patients lose 60 to 80 % of their overweight. It is a method that restricts food intake.

Transit bipartition

Originally developed by the Brazilian surgeon Sergio Santoro, this surgical technique involves sleeve gastrectomy similar to other techniques, but in contrast, the entire last section of the small intestine is made by providing a second exit to the lower part of the stomach. Thus, the food eaten is passed through all segments of the small intestine. In this procedure, 100 or 120 cm are counted and marked from the point where the small intestine connects with the large intestine. The decision whether 100 or 120 cm are to be applied is made according to the patient’s individual characteristics. Then, another 150 cm are counted, and then the small intestine is cut at 250 cm from the point the small intestine connects with the large intestine. The cut lower end is connected to the stomach, whereas the upper end is connected to the previously marked 100 cm. What is important here is that approximately 1/3 of the food passes through the duodenum, which is the natural way, and 2/3 pass through the last part of the small intestines thanks to the newly made connection.

It’s wrong to think “I can lose weight only if I get surgery”!

According to current data, the risk of death after obesity surgery is less than one percent. These data appertain to full-fledged, well-experienced medical centers, while there will be an inevitable increase in undesirable outcomes if surgery is done in centers with insufficient technical means and low staff experience. Obesity is a systemic disease that affects the whole body. Since the disease is not attributable to the gastrointestinal system alone, any intervention involving the stomach or bowels only will not secure success. Failure to combine weight-loss surgery with changes in diet, lifestyle, exercise and close follow-up is the most important factor to hamper success and disrupt weight loss. Whether performed surgically or non-surgically, teamwork is key in fighting obesity.