The obesity problem
As obesity we define the condition that is characterised by an increase in body fat. To objectively define obesity and its severity we use various indicators, the simplest of them being the Body Mass Index (BMI).
In Greece, scientists are warning about the increasing obesity phenomenon. According to data collected by Eurostat, Greece ranks first in Europe for obesity with a percentage of 26.7%, whereas regarding obesity specifically in women, it ranks second along with Great Britain, with a percentage of 17.8%.
Measurement of obesity: BMI
To assess the nutritional status of the body and classify obesity, BMI (Body Mass Index) is frequently used. This index is calculated by dividing a person’s weight by their height squared according to the formula:
BMI = Weight (in kg) / Height ^ 2 (in meters)
Clinical Classification of Nutritional Status:
BMI < 18.5: Underweight
BMI: 18.5 – 25: Normal
BMI > 25: Overweight
BMI > 30: Obese
BMI > 35: Severe Obesity
BMI > 40: Morbid Obesity
BMI > 50: Super Obesity
The causes of obesity
The pathogenesis of obesity is quite complex.
Inheritance is considered to be the most important predisposition factor (20-30%).
Overfeeding during childhood can negatively influence the metabolic rate, increase the number of fat cells and predispose obesity in adulthood.
The influence of different social, educational, economic, and psychological factors. The lack of awareness, sedentary lifestyle and unhealthy diet can easily lead to obesity, while in addition, some psychogenic factors, anxiety and stress favour obesity (psychogenic theory).
In essence, the obesity phenomenon in its larger part is due to the modern era habits, dominated by an abundant, high in sugar, fat and calories diet, as well as sedentary work and lack of physical activity.
Obesity and health risks
Obesity is a chronic disease, significantly reducing life span and quality of life, and it is connected with the occurrence of diseases such as:
• Heart and circulatory system conditions, including hypertension and cerebrovascular accidents.
• Thromboembolic disorders
• Respiratory disorders (chronic pulmonary disease, pulmonary embolism, sleep apnea syndrome, asthma)
• Diabetes
• Hyperlipidaemia and hypercholesterolemia
• Lumbar sciatica and joint disorders
• Skin diseases
• Cholelithiasis
• Gout and menstrual disorders (amenorrhea, dysmenorrhea)
• Some forms of cancer (breast, colon, endometrial, prostate, etc.)
• Depression or other psychological and social problems
• Social isolation
What is accomplished with bariatric surgery
The most important issue that bariatric surgery (obesity surgery) is called to resolve, is the weight loss difficulty and, moreover, the inability to maintain any weight loss achieved with so much effort.
Surgery is not only performed for aesthetic reasons, but mainly for health improvement, as well as morbidity and mortality percentages reduction.
Surgery Types
Bariatric surgery leads to weight loss using one or a combination of the following methods:
Restrictive techniques
These techniques reduce the amount of food that the patient can consume, and increase the time interval during which they feel satiated. This is achieved by shortening the portion of the stomach that stores food.
The are 4 restrictive techniques
1. Adjustable gastric band (Lap-Band)
2. Gastric bypass
3. Vertical banded gastroplasty (by Mason)
4. Sleeve gastrectomy
Mixed absorption reduction and restrictive techniques
The absorption reduction techniques limit the amount of substances that the body can absorb, so that the body is forced to lose extra fat to produce energy. Absorption reduction techniques are typically applied to people with a BMI that is greater than 55-60.
The absorption reduction techniques are the following:
1. Gastrectomy and biliopancreatic bypass (Scopinaro)
2. Gastrectomy and duodenal bypass
3. Gastric bypass with absorption reduction helix (Gastric bypass)
Laparoscopic or open surgery?
When bariatric surgery began, it was originally performed with open surgery. As a result, the patient frequently needed to be placed in the Intensive Care Unit after the surgery. In addition, some postoperative complications emerged, directly connected to the large incision, while resuming normal everyday activities was delayed for several days.
The introduction of laparoscopic surgery changed everything.
Now, bariatric surgery is mainly performed laparoscopically. Through small to tiny holes, we are able to check all intra-abdominal organs in magnification at first, and at the same time perform the operation.
The patient can leave the hospital in a short period of time, with minimum pain, and in very few days they can return to their work.
RESTRICTIVE TECHNIQUES
Adjustable gastric band (Lap-Band)
How does the process of the adjustable gastric band work?
This is the most common method. An adjustable band, made of silicone material, is circumferentially inserted around the upper portion of the stomach, thus dividing it in two parts. The small pouch at the upper part of the stomach can only fit a small portion of food, thus reducing the consumed quantity and the intake of calories.
The diameter of the band determines the rate at which food leaves the new stomach pouch, and is regulated by a special subcutaneous valve.
Advantages of the adjustable band method
1. It is the least traumatic method; given that it is performed laparoscopically.
2. The size of the smaller part of the stomach can be determined with precision, as well as the diameter of the opening between the two parts.
3. No additional surgery is required to adjust the diameter of the opening.
4. It is minimally traumatic, as during the positioning of the band no incisions, suturing or other interventions are required.
5. It causes no irreversible damage. The Lap-Band system can be removed without any issues, although this is not the purpose of its original placement.
6. The average operating time is between 30 and 90 minutes, and the patient usually returns home within 24 hours after the laparoscopic surgery.
7. 60%-80% of the extra weight is lost within 12-18 months.
8. After the surgery, the reversal of any health issues caused by obesity is achieved in a very large percentage of the cases.
Are there any possible complications with the adjustable band method?
Every surgery carries the possibility of complications. More than a decade of experience on the laparoscopic placement of gastric bands (Lap-Band), on more than 200,000 patients, has shown that with the laparoscopic method, complications are extremely rare. Some unusual complications can be microhaemorrhage, inflammation of the incision, problems caused by the adjusting valve in the subcutaneous area, the dilatation of the oesophagus and the upper portion of the stomach above the band, and the sliding of the band. All these cases are fully treatable without risking the patient’s life.
Gastric bypass
During this surgery, a small pouch is created at the upper part of the stomach and in addition a small bypass of the intestine is created, reducing the small intestine to 5 meters. The average operating time is between 2 to 4 hours, and the average hospitalisation time is 4-5 days.
This method leads to a loss of 65-85% of the additional weight, and to the improvement or complete regression of the accompanying disorders, such as hypertension, type II diabetes and sleep apnea syndrome. Complications, although rare, include narrowing of the gastrojejunostomy, internal hernias, anastomotic ulcer and misalignment of the suture line.
Laparoscopic vertical banded gastroplasty
It is a method proposed to patients with a BMI of over 40, but it is no longer frequently used. We use the automatic stapler and a non-adjustable band or mesh, to form a small pouch at the upper part of the stomach. This surgery is more traumatic in comparison with the gastric band, because it requires a partial incision of the stomach. The operation lasts 1-2 hours and the patient remains in the hospital for 1-4 days. The same weight loss as with the gastric adjustable band is achieved, but requires the division of the stomach, while it gives more intraoperative and perioperative complications. Not frequently used.
Sleeve gastrectomy
The sleeve gastrectomy (that could be described as a “gastric sleeve”) includes the removal of a large part of the stomach, in parallel to a narrow tube (sleeve), along the lesser curvature of the stomach. Thus, the capacity of the stomach is reduced by 75%, and food follows its natural course. The duration of the surgery is 1-2 hours and the patient can leave the hospital within 2 to 4 days.
A main drawback of the method is that there is no long-term monitoring of results (follow-up). This surgery must pass the test of time and gain acceptance by the community of surgeons.
MIXED, RESTRICTIVE AND ABSORPTION REDUCTION SURGERY
Gastric bypass with absorption reduction helix
A large portion of the stomach is automatically isolated using staples as to form a smaller pouch to hold the food.
Then, the small intestine is cut under the duodenum and is anastomosed to the stomach pouch that has been formed. This way, the digestive track is shortened, and the absorption of some substances is reduced (absorption reduction).
Gastrectomy and biliopancreatic bypass (Scopinaro)
Gastrectomy and duodenal conversion
These methods are especially effective for the treatment of morbid obesity to people that have BMI over 65-70 (super obese).
In these two surgeries, a portion of the stomach is removed. The small intestine is cut at its last part, and is anastomosed at the remaining stomach.
Only a very small portion of the small intestine remains (approximately 1.5 meters) to absorb food. It leads to 80% extra weight loss within 2 years.
However, these techniques are more complex and have a higher risk of complications, such as liver failure, cirrhosis, anaemia, kidney stones, hypovitaminosis, gallstones, etc.
In addition, they involve a form of “mutilation” since parts of the stomach and small intestine are removed. Another disadvantage is the fact that these operations are irreversible.
This type of surgery lasts approximately 4 hours, and the patient usually stays in the hospital for 5 days.
The members of the specialised team
Surgery is not the golden treatment for weight loss. The only definite way for someone to lose weight and maintain this result is, regardless of the surgery type, having a support group consisting of:
• A surgeon, specialised in laparoscopic surgery and experienced in obesity surgery.
• A qualified psychologist, and a qualified psychiatrist to help the patient adapt to the new conditions.
• A qualified dietitian to help with meal planning.
• A gastroenterologist
• An endocrinologist
Diet in recovery
After the surgery, a special diet is required until the stomach recovers. At the beginning only the consumption of low-carbohydrate liquids is allowed, such as tea or broth, and later on low-fat pureed foods, such as pureed fruit. Later, the diet may include a variety of food in small quantities.
What should be the patient’s lifestyle after the surgery
The patient has already taken a very serious decision to address the problem of morbid obesity, that’s why they must strictly follow the doctor’s instructions. Following the meal schedule and all other instructions is very important. The patient should also avoid sweets and alcohol, as they can move past the band without providing a feeling of satiety, and they can lead to weight regaining. Furthermore, the patient must begin to walk, exercise and remain active for the rest of their life.
