Obesity Surgery

What is obesity?

According to the definition of the World Health Organization, body mass index over 30 is considered a disease called obesity. Body mass index is calculated by dividing the body weight in kilograms by the square of the height in meters. This calculation method may not always provide accurate results for each patient. Individuals, who do intense exercise and have a high muscle mass, may also exhibit high body indexes without having obesity. In order to overcome this problem, methods such as measurement of fat-free body mass, impedance measurement, are also used. However, the most commonly used method is the body mass index.

Why has the rate of obesity increased in recent years?

First of all, the content of the food that we eat has changed in recent years. Foods with much more high-calorie density and containing refined carbohydrates have been started to be consumed. Refined sugar can actually be described as simple sugars that are semi-digested. Since these foods are more durable and cheaper than other complex sugars, their use has increased. Moreover, we made a rapid transition to a sedentary lifestyle with the widespread use of motor vehicles, increased use of television and computers and increased number of people working in desk jobs. With the increased number of people living in big cities such as Istanbul, as well as the decreased number of places to do exercise between side-by-side buildings and heavy traffic, the sedentary lifestyle has become more prevalent. Eventually, a lifestyle with a high-calorie diet but with lower activity, unfortunately, resulted in obesity and numerous diseases associated with obesity.

Which diseases does obesity cause?

Obesity stands out as a factor that triggers or aggravates numerous diseases. Type 2 diabetes, hypertension, cholesterol disorders, cardiovascular obstructions, heart attack, gastric reflux, asthma, fatty liver disease and resulting liver failure, gout, degenerative joint diseases (arthritis), migraine, phlebitis (venous inflammation), polycystic ovarian syndrome and menstrual irregularities are more common in obese individuals. It is also known that the risk of developing cancers of the breast, uterus, large intestine, esophagus, pancreas, kidney, and prostate increases with obesity. The majority of obesity-related diseases improve when obesity is treated, in other words, when patients gain their ideal weight.

What is the treatment of obesity?

  1. Regulation of diet: It is necessary to follow an individual diet determined by dietitians. Weight loss diets to be followed should be consistent with the principles of adequate and well-balanced nutrition. The goal is to make the individual gain an accurate dietary habit and to maintain this habit. Short-term and very low-calorie shock diets not only cause great damage to the metabolism but also cause to gain more weight than the weight lost when the diet is discontinued (Yoyo effect). Therefore, no physician or dietitian recommend short-term and shock-effective diets.
  2. Exercise therapy: Although its weight-loss effect is still controversial, it is certain that physical activity helps reduce the amount of fat tissue and fat mass in the abdominal region, and helps us to be healthier by avoiding the loss of muscle mass when we are on diet. It is recommended that every individual exercise 30 minutes a day, whether the individual obese or not. While programming the exercise for obese individuals, methods to minimize the risk of injury should be used by taking the movement restriction into account.
  3. Behavioral therapy (behavior modification): It is based on the principle of determining the events that cause us to overeat or to be immobile in our lives and avoiding them. It includes self-monitoring, detection of harmful stimuli, restructuring, control of eating behavior, increasing physical activity and social support steps. It is practiced by psychiatrists and psychologists in the form of groups of 10-12 people for 12-20 weeks.
  4. Drug Therapy: The greatest danger under this title is the use of weight-loss drugs purchased from medicinal herbs sellers, internet and even from pharmacies without physician control. By hiding behind a lie that most of them are herbal products and claiming that they are approved by the ministry of health, patients taking substances with unknown content as a drug are in great danger. The number of patients, who lost their lives due to herbal medicine, had to have liver transplantation and stayed in ICU for a long time, are much more than those reported in the press.

VERY IMPORTANT CAUTION: Do not use any other drug for the treatment of obesity other than those prescribed by specialized physicians. It may cost your life.

Surgical Treatment: Bariatric surgery is the best treatment modality for patients who cannot be treated with the above-mentioned conventional methods. By performing the right surgery on the right patient in the right center, a much higher treatment success than all of the other treatment methods is achieved. Diseases such as obesity-related diabetes, sleep apnea, hypertension, gout, metabolic syndrome, cardiovascular diseases, fatty liver disease are also treated to a large extent with bariatric surgery.

Which patients are eligible candidates for bariatric surgery?

Patients with a body mass index greater than 40 kg/m2 should be treated by Bariatric Surgery regardless of any other reason. Patients with a body mass index greater than 35kg/m2 and who have a disease that can be treated by bariatric surgery, such as diabetes, hypertension, coronary artery disease or sleep apnea, are also eligible candidates for bariatric surgery.

Moreover, patients with a body mass index in the range of 30-35 kg/m2 are candidates for metabolic surgery. If these patients have a disease such as diabetes, hypertension, heart disease, sleep apnea, surgery should be performed to treat this comorbid disease. The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) recommend these patients to undergo surgery in their treatment guidelines, so these patients are surgically treated abroad. In Turkey, SSI (Social Security Institution) has not yet accepted this condition for the necessity of surgery. Therefore, despite the fact that the surgery has not become widespread among these patients, it has been clearly proved that this surgery is beneficial.

Vücüt kitle indeksi  30-35 kg/m2 aralığında olan hastalar da metabolik cerrahi için adaydırlar. Bu hastalarda diabet, hipertansiyon, kalp hastalığı, uyku apnesi gibi bir hastalık varsa bu eşlik eden hastalığı tedavi etmeye yönelik ameliyatlar yapılmalıdır. Uluslararası Obezite Cerrahisi Federasyonu (IFSO) ve Amerika Bariatrik Metabolik Cerrahi Derneği (ASMBS) kendi hazırladıkları tedavi rehberinde bu hastalar için ameliyat olmayı önermektedir dolayısıyla yurtdışında bu hastalar ameliyat ile tedavi edilmektedir. Türkiye’de ise SGK bu durumu ameliyat gerekliliği için henüz kabul etmemiştir. Bu nedenle bu hastalarda ameliyat yaygınlaşmamış olmayla beraber faydalı olduğu çok net kanıtlanmıştır.

What is a gastric balloon?

In this method, a hollow balloon is inserted into the stomach through an endoscopic device. The balloon is then inflated, creating fullness in the patient’s stomach, giving a feeling of fullness. This method is not a surgery. It does not require general anesthesia, operating room conditions, or any incisions, and does not cause an anatomical or hormonal change. However, it is recommended that it will be safe for the current balloons to remain in the stomach for a maximum period of 1 year. Due to the balloons kept longer, complications, such as gastric or duodenal ulcers and intestinal obstruction as a result of burst balloon, may arise. The effect of the balloon is not permanent. Most of the time, patients regain the weight they lost when the balloon is removed. It is known to be effective in some patients who are not too obese (body mass index of 30-35 kg/m2). However, it should be noted that it is a temporary solution.

How many types of bariatric surgery are there?

There are several surgical methods that can be roughly examined in 3 groups.1- Gastric volume reduction surgeries:

  • Sleeve Gastrectomy: The well-known and most commonly performed surgery among volume reduction surgeries is sleeve gastrectomy surgery. In this surgery, the stomach is transformed into a thin tube and satiation is obtained with a lower amount of food. In addition, a hunger hormone called Ghrelin is secreted from a portion of the stomach. Since this portion is largely removed during sleeve gastrectomy surgery, the appetite also decreases, so patients underwent sleeve gastrectomy surgery gain a form fasting less, saturated more quickly.
  • Adjustable gastric band: In this method, a silicone clamp that can increase or decrease in volume is placed around the stomach and it is aimed to reduce the stomach volume used by the patient. The success rate has been found to be lower than other surgeries since it does not cause any hormonal change. Due to the high complication rates, they are no longer used except in very special cases.
  • Gastric plication: It is based on reducing the volume of the stomach by being folded on itself. It has remained as an experimental treatment method and has not become popular.

2- Surgeries disturbing the absorption of food: These surgeries cause food to bypass some portion of the small intestine. In these surgeries, the aim is to excrete the food taken from the body without being mixed with the blood.

3- Surgeries developed by combining the first two methods

  • Gastric Bypass (Roux-en Y Gastric Bypass): In this method, the stomach is reduced to a volume of teacup, and then the small intestine is connected to the stomach. Both the stomach volume is reduced and foods pass through some portion of the small intestine without being digested. This surgery has been performed for obesity for over 40 years and its long-term results are well-known. It is a surgical method accepted as the gold standard in the treatment of obesity.
  • Mini Gastric Bypass: The stomach is transformed into a tube shape, the small intestine is then connected to this small stomach. It has been shown to be very effective in the treatment of obesity, and especially diabetes. It may be unfavorable to perform on patients with a likelihood of bile reflux into the stomach and esophagus. It is known that good outcomes are obtained with a proper patient selection.
  • Transit Bipartition: Sleeve gastrectomy surgery is performed, also by connecting the small intestine to this tube-shaped stomach, some part of the food is aimed to pass through the normal route, and the other part through the alternative route. In this method, it is expected that foods passing through the normal route will protect the patient from vitamin and mineral deficiencies that will develop in the future. It is also aimed to help the patient through alternative hormones in the control of blood sugar by means of foods to pass through the alternative route. Although it is a relatively new surgical method compared to other methods, early outcomes are promising. Unfortunately, we do not have enough information about the late outcomes.
  • Although several types of surgery, such as duodenoileal bypass, jejuno-ileal bypass, ileal interposition, have been described, we do not have extensive information about their effects, undesirable effects and long-term effects since these surgeries are very selectively performed on very few patients. Such surgeries can be described as promising experimental surgeries rather than miraculous methods.

Which surgery is better?

Not every surgical method can be used for each patient. The ideal type of surgery should be determined based on the patient’s characteristics. For example, performing sleeve gastrectomy on a patient with gastroesophageal reflux may result in an increase in the symptoms associated with reflux. We recommend these patients the methods other than sleeve gastrectomy. The success of bypass methods in the control of diabetes is more prominent compared to sleeve gastrectomy. The patient’s age, dietary habits and the severity of diabetes or sleep apnea are very effective in determining the type of surgery.

Which diseases can be treated with bariatric surgery?

Diabetes, hypertension, sleep apnea, asthma, cholesterol disorders, fatty liver disease, gout, joint diseases such as herniated disc, and even migraine may recover to varying extents. The likelihood of developing breast and uterine cancer is significantly reduced in female patients. Moreover, the likelihood of developing esophageal cancer, kidney cancer, pancreatic cancer, and colon cancer is reduced. Furthermore, the risk of heart attack also decreases.

Why is bariatric surgery more effective and successful than all other treatments?

Because obesity is a vicious circle. As the patient gains weight, it becomes difficult to move, resulting in immobilization of the patient. The patient gains more weight as s/he is immobilized. Here, bariatric surgery breaks this vicious cycle and makes the patient more mobile by eating less food. In addition, hormonal changes caused by the surgery, such as Ghrelin, GLP, insulin, provide an advantage which cannot be achieved with other treatments in terms of both diminishing appetite and blood glucose control.

What is the goal of bariatric surgery?

The goal of bariatric surgery is to provide the patient to lose 50% of his/her excess weight within the first year. For example, let’s assume that an individual with a height of 170cm weighs 170 kg. There is an ideal weight determined according to the age and sex of the individual, let’s say this is 70kg. Therefore, our patient has an excess weight of 170-70=100kg. The goal of the surgery is to make lose 50kg of this amount within the first year.However, the majority of our patients go beyond these goals, attaining their normal weights. It is much easier to attain normal weight by moving more easily and doing exercise after losing the first weight. The patient’s effort is very important for the loss of excess weight after the surgery.

When will I be discharged? When can I start working?

If all goes well, you are discharged on the 3rd or 4th day after the surgery, you can then start working after a rest period of 10-15 days at home. It is unfavorable to lift heavy loads until 3 months. If an undesirable problem arises during or after the surgery or if the normal healing process does not occur due to any reason, the length of hospital stay and recovery time may vary, and hospitalization for a long time or rehospitalization after discharge, until the problem is solved, may be required.

Can I get pregnant after the surgery?

It is recommended that you not get pregnant for at least 2 years after the surgery. In the case of getting pregnant in the early postoperative period, it will lead the patient to fall short of the goal of bariatric surgery, as well as prevent her from losing weight, and the risk of not being able to supply enough liquid and nutrients to the fetus and occurrence of various deficits in the child will increase. It is recommended that our patients thinking of getting pregnant receive birth control support from family physicians in the preoperative period.

What are the risks of bariatric surgery?

Bariatric surgery, similar to the other surgical interventions, also involves various risks. The accepted risk of developing complications during the first bariatric surgeries is around 2-5%. In other words, 95-98% of the patients are discharged without any problem and begin their new lives. Higher success rates have been achieved in the surgeries performed by the general surgery, bariatric surgery unit of Marmara University.Postoperative risks roughly include:

  1. Leak: The most important and feared risk is the development of leak due to changing anatomical structures in the gastrointestinal tract. Although it most commonly arises in the first week after the surgery, there are patients known to develop leak one month after the surgery. If a leak develops, it may result in prolonged length of hospital stay, repetitive endoscopic, radiological or surgical interventions, admissions to intensive care, and even death due to intraabdominal infections. In order to prevent the development of leak, it is very important that the surgical technique is developed and standard methods are carried out by experienced surgeons. Leak test during the surgery and intervention to the leaks detected at that time also reduces the possibility of postoperative leak. Again, smoking, uncontrolled diabetes, and untreated pulmonary diseases increase the risk of leak. Despite all these measures, the leak rate in the world’s leading bariatric surgery centers is around 1-2%.
  2. Bleeding: There is a risk of bleeding after every surgery. It is known that the rate of developing bleeding after bariatric surgery is about 1-2%. The use of blood thinners (aspirin, clopidogrel, coumadin, heparin etc.) by the patient for another reason increases the risk of postoperative bleeding. Bleeding may occur into the abdomen (internal bleeding) or into the digestive tract (gastric bleeding). It is known that a correct surgical technique and the use of tissue adhesives are effective as a precaution. The vast majority of these bleedings stop spontaneously. Sometimes, the patient may require to be given blood and blood products. This may rarely require re-surgery to be able to stop bleeding. Severe bleedings may be life-threatening.
  3. Deep vein thrombosis: After the surgery, obese individuals are at high risk in terms of developing blood clot in the leg veins, called deep vein thrombosis, resulting in obstruction of various vessels of the body, most commonly in the lungs. In order to avoid this condition, it is of vital importance to wear compression stockings and air compression stockings to administer blood thinner injections (low-molecular-weight heparin) and to mobilize and walk in the early postoperative period.
  4. Vomiting: It is known that some of the drugs administered during anesthesia cause vomiting in the early postoperative period. However, this effect usually disappears spontaneously within the first 1-2 days. In cases of prolonged vomiting and malnutrition, the gastrointestinal tract should be checked for the development of obstruction. In sleeve gastrectomy surgery as well as gastric bypass surgeries, both mechanical and functional obstructions to various extents may develop, although very rarely. In such a case, obstruction should be eliminated with endoscopic or surgical treatments.
  5. Internal Herniation: It is a very rare and a very late complication of the surgery. It may develop after any type of intraabdominal surgery. Since the location of anatomical structures is changed during the surgery, new potential spaces may form. The small intestines can usually enter these spaces and get jammed, causing gangrene, and if it is not surgically intervened at once, the result may be life-threatening. It may even develop years after any surgery.
  6. Surgical site infections: Microbial infections may develop in the superficial or deep surgical sites. If an abscess develops, it may require to be discharged and treated with various antibiotics.
  7. Exacerbation of pre-existing diseases of the patient: In particular lung diseases, hypertension and heart failure may exhibit a slight exacerbation in the early postoperative period. However, in later periods, these diseases will relieve and even heal to a large extent when the patient loses weight.

NOTE: The abovementioned statements indicate specific risks for bariatric surgeries. Any digestive tract surgery may involve risks not specified here. Furthermore, the risks of the drugs used, blood and blood products transfusion, anesthesia and hospitalization are not indicated.

Can we minimize these risks?

One of the most effective factors for the outcomes of the surgery is the experience of the surgeon and his/her team. The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has determined 25 bariatric surgeries per year as the limit, pointing out that the complications of surgeons or teams performing surgeries under this rate may be higher.

Smoking cessation in the preoperative period (at least 20 days), keeping blood sugar and blood pressure under control and weight loss of 5-10% within 3 weeks before the surgery by eating low-carbohydrate foods are factors that reduce the risk of surgery and increase the success. In addition, it is necessary to use the correct technique and proper and quality surgical materials during the surgery and not to use the disposable materials again and again.

In the postoperative period, it is very important to be able to reach the surgeon or someone reliable from his/her team when a problem arises. Therefore, we recommend that patients planning to undergo the surgery out of the city where they live to stay in that city for at least two weeks. In order to prevent clot formation in the legs, compression stockings and blood thinner injections should be used.

Does bariatric surgery increase the risk of heart attack?

Obese individuals are already at high risk in terms of heart attack and death. In a study conducted on more than 4000 patients in Sweden, obese patients, who underwent and did not undergo bariatric surgery, were followed up for 18 years, and these results were explained in 2013. It has been shown that the risk of heart attack, which may result in death, is reduced by half in patients undergone bariatric surgery. In the same study, it was also observed that the risks of stroke and even cancer development were significantly reduced in patients undergone bariatric surgery.

What do I need to pay attention to after bariatric surgery?

Before undergoing bariatric surgery, it is necessary to discuss with the dietitian and to get detailed information about the diet after the surgery. You will be given a diet program that you can easily follow. The changing anatomy and hormones with the surgery will help you follow this diet. It is also advisable not to do heavy exercises during the first 3 months. Exercises that do not force your body such as walking and swimming will be more suitable for the first 3 months. 3 or even preferably 6 months after the surgery, you can participate in any exercise program you desire. A more active lifestyle is essential to achieve the ideal weight.Moreover, participating in regular follow-ups is very important in the postoperative period. If nothing goes wrong, you will need to come to the follow-up visits every 3 months in the first year, every 6 months in the second year and then once a year. Probably the drugs you use for diabetes, blood pressure, cholesterol or sleep apnea will change, the doses will be reduced or cut. In addition, some deficiencies may develop due to both malnutrition and absorption disorders in the body, no matter what type of bariatric surgery has been performed. Iron, vitamin B, calcium and other vitamin and mineral deficiencies are usually easy to treat if they are noticed during the follow-ups. However, if you skip your follow-ups, long-term deficiencies lead to serious problems. This is so important that many centers do not perform surgery on patients stating that they will not be able to participate in regular follow-ups. As long as you are under control, you do not need to be afraid of any deficiency.

Do I regain weight after bariatric surgery?

At least 85-90% of patients start a new life and continue their life without regaining weight after bariatric surgery (no matter which surgery is performed). However, about 10% of patients complain about regaining the weight they lost or inability to lose enough weight. There may be several reasons for this.

  1. The surgery may not have been performed based on the original technique.
  2. An appropriate surgery may not have been chosen for the patient.
  3. The patient may not exercise or may be consuming too much sugary foods.
  4. The patient may have alcohol and/or substance dependence.
  5. Some vitamin and mineral deficiencies may cause this.
  6. Stenosis and/or enlargement in the stomach may cause to regain weight.

In the case of regaining weight, it is necessary to determine the exact cause of this with the examinations to be carried out, to perform a psychiatric and endocrinological evaluation and to perform revision surgery only on appropriate patients. Since revision surgery has a higher risk than the first obesity surgery, it should be performed only by experienced surgeons. Assoc. Prof. Samet Yardimci, MD has been performing revision surgery with a very low-risk rate for a long time.

Which surgery for which patient

The patient group in which sleeve gastrectomy is preferredThe body mass index of the patient is the first determinant. Performing bypass surgery in patients with a body mass index greater than 60kg/m2 may be too risky to be acceptable. Therefore, sleeve gastrectomy surgery is suitable for these patients in the first place. In addition, patients with inflammatory bowel disease and intestinal adhesion due to previous surgery are not eligible for bypass surgery.

In general, sleeve gastrectomy surgery is not recommended for very young and very old patients and for patients who have to use immunosuppressive drugs.

The patient group in which sleeve gastrectomy is not preferredSleeve gastrectomy surgery may not be sufficiently effective especially in people who are keen on very sugary foods and beverages (we prefer bypass procedures in these patients).

In patients with reflux (a condition where stomach contents go back up into the esophagus), there may be some increase in the reflux complaints as a result of sleeve gastrectomy. We also take this condition into consideration in patient selection. In addition, we can say that sleeve gastrectomy surgery is unfavorable in patients with a large stomach hernia.

In the treatment of diabetes, sleeve gastrectomy may not be as effective as bypass. The decision should be made by considering how long the patient has diabetes, what drugs s/he uses, whether or not his/her blood sugar is under control, and whether there are any complications associated with diabetes.

The patient group in which bypass surgery is preferred

It is known that Roux en Y Gastric bypass is the most effective treatment method in eligible patients with a variety of diseases such as obesity, diabetes, high blood pressure, sleep apnea, called metabolic syndrome. It is therefore considered to be the gold standard. We have very long-term results. The long-term effects of this surgery, which has been performed for more than 40 years, are well-known and reliable. When any new surgical technique is developed, it is compared with Roux en Y bypass, and if it is as effective as it is, it may become widespread. Although many surgeries have been performed and abandoned in the history of surgery for obesity, no surgery has become effective as Roux en Y bypass. Surgeries such as gastric band, duodenal switch, ileal interposition, gastric plication (folding the stomach’s wall inside itself) have been shown as rivals to Roux en Y bypass surgery in the past; however, they are almost never used in today’s modern surgery and have become history.

Nowadays, mini gastric bypass and transit bipartition surgeries are also presented as rivals to Roux-en Y bypass. Although they are surgeries with proven efficacy and safety on diabetes treatment in the short term (3-4 years), we do not have enough information about its long-term (after 10 years) results.

In brief, the type of bariatric and metabolic surgery should be determined individually. An ideal bariatric and metabolic surgeon should be able to perform all these surgeries with comprehensive knowledge of the digestive tract and decide which surgery to perform depending on the characteristics of the patient.

Will I use lifelong vitamin pills after bypass?

In our society, people, who did not undergo bariatric or metabolic surgery, actually also have a high rate of vitamin deficiency. Patients, who experience rapid weight loss, may have some vitamin and mineral deficiencies, whether they underwent bypass or sleeve gastrectomy.

Is weight regain more common after sleeve gastrectomy compared with the bypass?

In fact, the history of sleeve gastrectomy surgery has the answer to this question. Sleeve gastrectomy surgery was first started to be performed as part of a biliopancreatic diversion surgery. When it was started to be performed, as it was considered that for some patients who should undergo two surgeries a single session was risky and that it would be more appropriate to perform the second surgery after sleeve gastrectomy. When it was realized that some weight has been lost after the first surgery, even the surgeon who performed the surgery was surprised since there was no need for a second surgery in 75% of the patients.However, since one-fourth of the patients still needed a second operation, in this case, it was too early to declare it as a single operation. After the conducted studies and a few changes on the technique, sleeve gastrectomy has been started to be performed as is known today. Unfortunately, sleeve gastrectomy surgery carried out with the latest technique may fail to provide adequate weight loss in 10 to 15% of patients.

It is more guaranteed if I had a bypass. Do I regain weight after bypass?

Unfortunately, it is possible to regain weight after gastric bypass surgery even though it is low. Although the possibility of regaining weight is lower compared with sleeve gastrectomy, the potential of revision is not as likely as in sleeve gastrectomy when weight gain occurs.

What is metabolic surgery?

Metabolic surgery is a surgery used to treat diabetes. In fact, although very similar techniques are used with bariatric surgery, the goal here is not to provide too much weight loss, but to increase the strength of the current insulin of the patient to obtain blood sugar control. A certain amount of weight loss is absolutely obtained, but it can also be performed safely on patients who are not morbidly obese and it has been proved to be effective.

Is it possible to surgically treat diabetes?

Type 2 diabetes is a surgically treatable disease. Unfortunately, not every patient is an eligible candidate for surgery for diabetes. Body mass index (BMI) is an important parameter for the selection of patients who will benefit from surgery. It has been accepted by the international metabolic surgery association and its member scientists that patients with a BMI greater than 30 would highly benefit from the surgery. The key point here is that the patient’s own insulin reserve should be sufficient. In order to assess this, fasting blood glucose, insulin and C peptide levels should be evaluated. With the right patient selection, 90% of patients with type 2 diabetes are likely to get rid of this disease.
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