Obesity and Metabolic Surgery

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Bariatric or Obesity Surgery

The obesity issue

Obesity is a chronic disease that affects 17% of the population in industrialized countries, although 34% are overweight. It is the biggest cause of preventable death in the world in general and it is defined as an increase in body fat with the subsequent risk of developing multiple complications that affect life quality and expectancy. It affects 300 million people worldwide. The fat limits percentage above which is established the presence of obesity is 33% in women and 25% in men. It has been estimated that this disease causes a health expenditure of approximately 100 billion USD per year in the United States and this means around 5-10% of total health expenditure in Spain. Roughly speaking, it is estimated that life expectancy is shortened by 1 year for every 10 kg (aprox. 22 lb) of excess weight you have. 2.5 million deaths per year worldwide are estimated to be related to the problem of obesity. It is estimated that a man between 20 and 30 years has a relative risk of death above 22% in comparison with the same man without being obese, with a BMI > 45, (this would mean 13 years of life expectancy less).

How to measure and evaluate obesity

The degree of obesity is established with the Body Mass Index (BMI), which relates the individual’s weight to height (BMI = weight in kg / height in m2).

The obesity is measured in degrees, according to the BMI of the patient:
Underweight 18,5 Kg/m2
Normoweight 18,5 – 25 Kg/m2
Overweight 25 – 30 Kg/m2
Obesity (Class 1) 30 – 35 Kg/m2
Severe Obesity (Class 2) 35 – 40 Kg/m2
Morbid obesity (Class 3) 40 – 50 Kg/m2
Super-Obesity 50 – 60 Kg/m2
Extreme Obesity > 60 Kg/m2

Why is obesity so serious?

The morbid obesity predisposes or is associated with a large number of diseases or disorders in various body systems or organs. These illnesses are called co-morbidity and these include arterial hypertension, diabetes mellitus, dyslipidemia, heart failure and heart disease, respiratory failure and sleep disorders (snoring, sleep surface), venous insufficiency, arthritis and joint pain (knee, hip, spine), menstrual disorders, urinary incontinence, gynecologic issues and infertility, hepatic steatosis, cholelithiasis, gastroesophageal reflux and esophagitis, etc. The co-morbidity is associated with a poorer quality of life and an increased mortality. It has been shown an increased incidence of some tumors such as prostate, colon and rectum, pancreas, endometrium, and ovary. In this sense it has been shown that breast cancer is 4 times more common in morbidly obese patients compared to non-obese population. In the same way, it has been shown that morbidly obese patients who have had surgery have reduced the relative risk of mortality, which is at 89% compared to not operated patients. But apart from the problems directly related to physical health, morbid obesity leads to social, employment and psychological problems which are no less important and it is disqualifying in many cases. Issues such as the difficulties with personal hygiene, social seclusion, emotional liability, feelings of guilt and failure, social discrimination, difficulty for finding a partner or work and no end of problems that can be measured in any way and that can affect a person as much as physical illnesses.

When to operate

The surgical operation is recommended to patients with morbid obesity (BMI greater than 40kg / m2). It is also recommended for patients with morbid obesity (BMI between 35-40kg / m2), if they show a severe co-morbidity associated with their obesity or derived from it.

Treatments and surgical techniques

The only medical treatment that has shown to be effective so far has been surgery. Today all operations can be done by laparoscopy without opening the patient (mini-invasive surgery) through small incisions ranging from 5 to 12 mm. There is no “perfect” surgical technique, so you must decide which one best fits in the needs of the patient. When choosing the surgical technique we must take into account several factors such as the surgical risk, the results in terms of weight loss and the possible consequences which may result over time. There are some medications (Sibutramine, Orlistat) that have shown some effectiveness in weight loss of up to 10%, but these have not shown their usefulness to treat morbid obesity.

  • Intragastric balloon: The intragastric balloon is an endoscopic procedure that involves placing a ball of about half a liter of volume in the stomach. The aim is to “occupy” the stomach so patient feels full early when eating. It is not a surgical technique itself and the balloon is not placed by the surgeons, but the gastroenterologists. It is placed through the mouth by an upper endoscopy. Generally, it requires only sedation. The maximum time it can remain in the stomach is 6 months, having to remove it after that time. The idea is that the patient must make a diet re-education during these 6 months, since when the ball is removed the feeling of early satiety disappears, and the patient will gain weight again in case if he or she has not succeeded. The average weight loss is around 25%. There are no studies that have demonstrated long-term usefulness. Its main use is for patients with obesity who do not meet the criteria for surgery and, especially, as an initial weight loss in super-obese patients (BMI> 50 kg/m2) who are going to be operated in order to reduce the operative risk, i.e. as “bridge” treatment to the final operation (to optimize the patient’s clinical situation). An example of its usefulness would be a 210 Kg patient that is proposed to undergo surgery, but who has a high anesthetic and surgery risk due to his weight. By placing the ball we could expect him to lose between 40-50 kg. Once he has reached a minimum weight of 160 kg the ball would be removed (which is no longer effective) and the operation would be carried out, but now with a lower risk because the patient’s condition has improved.
  • Adjustable Gastric Ring (Banding): Its mechanism of action consists in reducing the stomach capacity so the capacity to eat food is limited and the patient feels full quickly when eating. This is the restrictive technique most widely used and is popularly known as gastric ring or banding. It involves placing a ring on the top of the stomach so that it becomes narrower, making difficult the food entrance. This is the easiest bariatric surgical technique and it is the one with the least surgical risk, because the stomach is not cut nor connected with the gut. Its main drawbacks are: 1) there is a high rate of complications, since the ring is a foreign object, and there is a very high level of cases in which the ring has to be removed because it has moved from its original position or even can erode the stomach and penetrate inside of it, 2) this is the less effective surgical technique in terms of achieving an adequate weight loss and it shows a greater re-gain of the weight over the years and 3) it should be made a really strict diet for life, limiting the types of foods; 4) in many patients it causes a poor life quality because it causes repeated vomiting and pain in the pit of the stomach.
  • Gastric bypass: Nowadays, this technique is considered “the standard one” by most of the bariatric surgeons and it is the surgical technique most performed in the world. It involves cutting the stomach in order to reduce its capacity and, at the same time, it is joined with a short bowel (by-pass) so that this tiny stomach is connected to the intestine. In this way, it is associated a certain food malabsorption. The patient eats less and absorbs less of what he or she eats. With this method an adequate weight loss is achieved, accompanied by an adequate maintenance of this weight over the years in most of the patients.

  • Biliopancreatic bypass: The original technique was described by Scopinaro, an Italian surgeon, in 1976. To date it still is a valid operation. There are different modalities of the initial technique, with the duodenal switch as the most used variant, but there are others such as Larrad operation or the Scopinaro without gastrectomy.It is the most aggressive surgical technique, since a large part of the stomach is removed and it is made an intestinal joint that favors a more important malabsorption. It is the surgical technique that achieve the greatest weight loss, but that also results in more long-term complications because of nutritional deficits, that is why it requires a very close monitoring, with a greater need of dietary supplements, minerals and vitamins for life.
  • Sleeve gastrectomy: It is an innovative surgical technique, really promising, but with a lack of long-term objective results. It involves extirpating most of the stomach so that it becomes a gastric “tube”; the new stomach will have a new tubular shape, with a lower nutrient storage capacity. It is believed that the extirpation of this part of the stomach (fundus) plays an important role in the secretion of hormones involved in the feeling of satiety. The initial results are promising and satisfactory and may even replace the gastric bypass as a standard technique when these are long-term hold. The advantage compared to the gastric bypass is that, in this case, there are not connections with the gut, so the surgical risk is reduced and the digestive route maintains its normal anatomy.There are already proven results of weight loss at 5 years after surgery, in which it is shown that the weight loss with this method is similar to that achieved with the gastric bypass.

Our point of view

The gastric bypass by laparoscopy is currently the standard technique, i.e. it is the technique through which we evaluate the others. This technique has shown a better balance between “risks, benefits and advantages”. We consider it to be the most suitable for most of the patients, because we achieve excellent results in terms of quantity and durability of the weight loss (60-70% weight loss). In addition, its technique is so standardized that complications rates have decreased roughly. The sleeve gastrectomy is a promising technique. Its main advantage is that, if it fails, we can use the gastric bypass or the biliopancreatic diversion. We consider it in young patients with “a whole life ahead” (typically younger than 25 years), patients with no morbid pathological obesity who require a surgical treatment (BMI 35-40 kg / m2) and those with a high operative risk for any reason. It is currently used as a “bridge” or precursor treatment to a more aggressive final surgery for super-obese patients, in order to reduce their weight and consequently their surgical risk. We consider this operation as first choice, especially in young patients with a low BMI (about 40 kg / m2). Also, we often recommend to use it in older patients (over 55), who are associated with a high surgical risk and, as a bridge operation in super-obese patients with a BMI above 60 kg / m2. We rarely contemplate the adjustable gastric ring and biliopancreatic diversion techniques as techniques of first choice.

Tips and very important clarifications

The bariatric surgery IS NOT AN AESTHETIC SURGERY TECHNIQUE. Its aim is not to obtain beauty and sculptural silhouettes. Its purpose is to achieve a weight loss which is enough to improve and/or cure and/or prevent diseases associated with obesity. Depending on the patient’s intrinsic factors such as the age, the sex, the body fat distribution or the weight and BMI before surgery, it is common that after a successful operation and after stabilized weight loss they are stretch marks, folds or skirts because of the excess of skin which may result unpleasant for the patient and whose only solution is plastic surgery. There must be a lifetime monitoring in order to identify possible nutritional and/or metabolic deficiencies although the patient is stabilized. Such monitoring should be performed by a specialist in endocrinology and nutrition. These controls should be more rigorous during the first year (every 3 months), although the patient will need to make at least an annual review with analysis once the weight loss is stabilized. In case of relocation, you should contact a specialist in endocrinology and nutrition in the new place of residence to continue the monitoring. Although the patient has lost enough weight and has a BMI in the normal range, the “metabolism” will still be the one of a person with a tendency to accumulate fat who will use any excess of caloric intake to turn it into fat and store it in the body. It is important to understand that WE DO NO HAVE A “BLANK CHECK” THAT ALLOWS US TO EAT ANYTHING WE DESIRE AND WE MUST MONITOR OUR FOOD INTAKE, WITHOUT THIS BEING AN UNACHIEVABLE GOAL. SURGERY HELPS US TO ACHIEVE THESE OBJECTIVES, BUT IT DOES NOT ACHIEVE THEM ITSELF.

Experience and results

When these operations are performed by experienced surgeons, the results are excellent, getting rates of serious complications below 5% and less than 1% of mortality rate. At the same time, it is important to perform these operations in centers which are well equipped with technology and professionals and ready to respond to any contingency that may arise during the post-surgery period. We have a very broad experience, and we have been dedicated to bariatric surgery since almost its beginnings, more than 10 years ago. Dr. Poves has performed over 250 laparoscopic gastric bypass without mortality to date and a complication rate which is under the usual average. He performs the operations in CM Teknon, in Barcelona, where he has the appropriate technology, the required medical support and an intensive care unit at his disposal. We must not forget the excellent restoration of the facility, which will make the surgical process more comfortable for both the patient and their companions.

Metabolic Surgery

The metabolic surgery is very new. We know as metabolic surgery the surgery that allows solving or improving metabolic disorders, being the most important diabetes mellitus type II. Although treatment is not yet widespread and there are no long-term results, it is very promising, having shown in successive works that most of the patients with diabetes mellitus type II can control their blood sugar levels without requiring medication or decrease roughly the need of it. The surgical operation we recommend is the duodeno-jejunal by-pass, which can also be performed laparoscopically.

By-pass duodeno-jejunal

This operation consists in making food pass from the stomach directly to the intestine, preventing their passage through the duodenum and the first segments of the jejunum. Patients undergoing this type of operation are not necessarily obese. The initial effect is a normal weight loss attributed to the bypass, but it is stabilized generally after 6 months. The effect that has this method in the decrease of the blood glucose levels do not depend on the weight loss, but on the fact that food does not pass through the excluded digestive segments.