Treatment of Obesity – Possibilities of Modern Surgery

Which conditions are associated with obesity?

There are numerous diseases and conditions associated with being overweight. We will briefly mention the most important of them as:

  • Atherosclerosis is a pathology of vessels of different caliber as a result of the deposition of lipids in their wall. Among the risk factors for its occurrence are hypertension, dyslipidemia, high blood sugar, and obesity. All the mentioned factors have a high frequency in obesity, which makes the danger of a fatal manifestation of atherosclerosis – such as a heart attack or stroke – very high.
  • hypertension
  • dyslipidemia – increased LDL- and decreased HDL-cholesterol, hypertriglyceridemia
  • type II diabetes – associated with obese people after 40 years of age. In this type of diabetes, cell resistance to insulin occurs due to obesity. Then, despite high blood glucose and insulin, they cannot use them. A rejuvenation of type 2 diabetes is observed in connection with the increase in overweight in children.
  • obstructive sleep apnea – patients cannot breathe due to relaxation of the muscles of the pharynx and excess fat in the area closes the airway from its weight. These people snore loudly, sometimes stop breathing – apnea, and wake up. This reflects on the quality of sleep.
  • others – gastroesophageal reflux, gallstones, joint problems, reproductive disorders, depression, and others also have their etiological component in excess body mass.

What is bariatric?

Bariatrics is a branch of medicine dealing with the causes, prevention, and treatment of obesity – both pharmacologically and surgically.

Overweight and obesity are reaching pandemic proportions (an epidemic of particularly large proportions). Their root cause is multiple and complex. Despite popular belief, they are not just the result of overeating. More and more studies prove that there is often a genetic component behind pathological obesity. And while specialists are still delving into the etiology and pathogenesis of this disease, patients are forced to fight it throughout their lives.

Among the causes of obesity are genetic predisposition and heredity, environmental factors, metabolism, nutritional disorders, but also endocrine diseases such as hypothyroidism and hypercorticism (we should also mention overweight during treatment with corticosteroids).

The treatment of obesity is complex and highly dependent on the patient’s motivation and willingness to cooperate with the doctor. There are not a few programs for diet, behavior change, active physical activity, as well as medications that suppress appetite, block the absorption of nutrients, and others. The mentioned approaches are coming to the fore in the fight against obesity. In many cases, however, they give an unsatisfactory momentary effect, and one cannot speak of a long-lasting one at all.

When to start an operative intervention in the fight against obesity

Significant weight loss and retention of the effect of morbid obesity is difficult to achieve. According to statistics, only 5% of patients cope with this problem through the mentioned approaches. However, the majority regain all the lost pounds within a year of resuming their normal regimen. This yo-yo effect is also associated with health risks.

When behavioral changes regarding nutrition, physical efforts, or appropriate medication do not show any effect, surgery may be considered. In order to proceed with it, an assessment of the state of health by doctors, nutritionists, and psychologists is necessary. When the risks of serious illness and death associated with obesity outweigh those of complications from one operation, the latter may be attempted. There are also criteria for the intervention of a surgeon

  • BMI (body mass index)>40, which means 45 kg above the normal body mass for men and 35 kg above the norm for women
  • BMI between 35 and 39.9 for patients who have serious health problems related to being overweight.

Bariatric surgery does not replace diet and physical activity in the fight against excess weight. In fact, the long-lasting effect of the operation is highly dependent on the patient’s cooperation in following a certain diet and an active lifestyle.

Surgical interventions are of several types – restrictive, malabsorptive, and mixed. In the first, the volume of the stomach is reduced, which makes patients feel full early in the meal. So they consume less and eat more slowly. In the second method, the consumption is not limited, but the ingested food is absorbed by the body to a lesser extent. The third combines these mechanisms.

What operational interventions are implemented?

Vertical banded gastroplasty – clamps are placed in the upper part of the stomach near the esophagus in a vertical direction, and the opening to the rest of the stomach is narrowed with a ring. This slows down the emptying of the organ and gives the feeling of its fullness.

A variant of the operation is the placement of a silicone band in the upper part of the stomach, most often laparoscopically. The last method – adjustable gastric banding or “lap band” is extremely popular in the USA and some Western European countries. These two methods are extremely restrictive. They do not affect the absorption of substances.

Viliopancreatic diversion is an operation that, due to severe malnutrition complications, is now applied exceptionally. With it, ¾ of the stomach is removed, which reduces its volume and suppresses the production of hydrochloric acid. The end of the small intestine is connected to the thus-formed end of the stomach, and its initial part, including the duodenum, where the bile and pancreatic ducts open, is connected to the small intestine near its transition to the colon.

In this way, the bile and enzymes from the pancreatic juice come into limited contact with the ingested food, and it is absorbed depending on the level of connection of the proximal section to the distal one. A variant of this operation is Biliopancreatic diversion with a “Duodenal Switch ” or sleeve gastrectomy with a duodenal switch. With it, only the peripheral part of the stomach is removed and a “sleeve” is left from the beginning to the pylorus of the stomach and the beginning of the duodenum.

The latter is then severed and connected to a more distal section. This avoids food contact with bile and pancreatic enzymes. This intervention is an example of a combined surgical intervention. Another such operation is the most frequently used in bariatric surgery – the gastric bypass. Combined methods have been proven to be the most effective and have the least negative consequences for patients.

Gastric bypass (Gastric Bypass Roux-en-Y ) – by means of clamps placed in the upper part of the stomach, a small cavity is formed, isolated from the rest of the organ. This cavity empties directly into a distal portion of the small intestine connected to it.

The proximal one, which follows the natural course of the gastrointestinal tract after the isolated part of the stomach connects to the lower part of the intestine. Thus it resembles the letter Y, hence its name. Gastric bypass reduces the volume of the stomach to 15ml (normally it can stretch up to 1000ml), and the small cavity is in an area that is difficult to stretch, which maintains a certain volume.

When consuming a small amount of food, the patient feels full and this limits the amount of intake. However, with time, the size of the connection with the intestine increases, as well as the reservoir function of the latter. Then a loss of body mass has already been achieved and this ensures weight maintenance.

What is the patient’s postoperative regimen?

More than 100,000 bariatric surgeries are performed annually in the United States. After 50 years of experience with gastric bypass, this intervention has become the “gold standard” in bariatrics, and the operative technique and postoperative care are constantly being improved.

In recent years, both in all directions of surgery and in bariatrics, laparoscopic intervention has widely entered. It is significantly more gentle for the patients, they recover faster and there are fewer complications.

After the operation, patients must follow a certain diet and acquire certain eating habits in order for its effect to be long-lasting. The most important thing is that these patients eat only 2-3 times a day, no more. Otherwise, they will bypass the “bypass”. It is important to eat slowly, chew the food well, and stop when you feel your stomach is full. It is desirable to take liquids between separate meals, not during them. Low-calorie foods and drinks are recommended. All this must be accompanied by adequate motor activity.

What are the possible complications?

Mortality after surgical intervention depends on complications that occurred as a result of previous factors such as the degree of obesity, cardiac pathology, obstructive sleep apnea, diabetes, and history of pulmonary embolism. Mortality for laparoscopic intervention is 0-0.11%, and for open surgery – about 0.6% for a 30-day postoperative period. Complications are those observed in any operation on abdominal organs, as well as those from the bypass itself:

  • infection
  • hemorrhages
  • venous thromboembolism and subsequent pulmonary embolism
  • hernia, intestinal obstruction
  • bypassing the anastomosis,
  • narrowing of the anastomosis
  • ulcers around the connection site
  • gall stones
  • dumping syndrome – a condition of rapid emptying of the stomach to the small intestine, causing nausea, vomiting, diarrhea, dizziness loss of consciousness, and sweating.
  • malnutrition – inadequate intake of vitamins and minerals can lead to severe iron-deficient or vitamin B12-dependent anemia, hyperparathyroidism, osteoporosis, severe neurological deficits, vision disorders, etc. This implies additional intake of these substances.

The effect of the surgical intervention depends on the age and general condition of the patient, the weight before, and the possibility of physical exercises. Other factors are the operation itself, the motivation of the patient, the desire to follow the doctors’ guidelines, and the support from relatives.

Clinical studies indicate that the greatest loss of body mass occurs in the first 18-24 months. Up to 50% of it in the first 6 months, and up to 77% by the end of the year. Patients with a higher BMI lose more weight. The clinical picture is also significantly affected by diseases associated with obesity – diabetes, hypertension, obstructive sleep apnea, and depression.

The quality of life, the psychological attitude, the social contacts, and the opportunities for work are improved. Achieving these results depends on the patience and strict behavior of the operated.

Related Articles

Back to top button