Obesity: Its surgical treatment

BMI is easily calculated based on height (m2) and weight (kg) and those with an index greater than 35-40 should receive medical preparation and care to reduce their weight.

Patients need a detailed pre-operative check-up including blood tests, cardiac and pulmonary assessment, gastroscopy, abdominal ultrasound, etc. Other factors such as previous operations, dietary habits and the patient’s mental state must be taken into account before deciding to operate

Basic categories of interventions
The two main categories of interventions are those that cause food intake restriction and those that cause food malabsorption. In the first category, the main one is the elongated gastrectomy (Sleeve gastrectomy) which is also referred to as a gastric sleeve. The second category includes gastric bypasses. In addition to the classic gastric bypass, there are several other operations depending on the restriction or malabsorption they cause.

Lengthening gastrectomy is primarily a restrictive type of surgery, meaning that the patient can no longer take in large amounts of food and thus achieve weight loss. However, in addition to the limitation, there are also hormonal effects that help with this purpose. The first concerns the reduction of Ghrelin, which is a hormone of the stomach dome, and after the operation its levels are reduced, with the result that there is no strong feeling of hunger. The second concerns the effect on gut and adipose tissue hormones that are related to stomach emptying and the feeling of satiety.

Gastric bypasses are more dynamic interventions to treat morbid obesity. Most of the stomach is bypassed, as well as a large part of the small intestine. This has the result that fats and carbohydrates are not absorbed sufficiently, thus leading the patient to lose weight, but also to better manage type 2 diabetes.

How are the operations performed?
The operations are performed laparoscopically and the hospitalization usually lasts two days. Patients are discharged with instructions and for the first days receive a liquid diet. They gradually return to a normal diet, based on the good quality of food, which is rich in protein, and the avoidance of all concentrated calories (sweets, ice creams, alcoholic beverages, nuts, soft drinks, etc.) which, if taken by the patient, will reduce the effectiveness of interventions. Taking nutritional supplements, monitoring at regular intervals and regular physical activity (brisk walking, swimming, gym) of all patients are necessary conditions for the success of the operations.

Surgical complications are fortunately rare, but when they do occur they are serious. The most serious complication of the procedure, at a rate of 1-5%, is escape (exit of gastric contents into the abdomen due to failure of the gastric suture line). It usually occurs in the first two weeks and is noticed by fever, tachycardia and pain. Most patients are treated conservatively with good results, but some may need reoperation or even have a long hospital stay.

The results regarding weight loss are good and for the first three years they are comparable, of the elongated gastrectomy (gastric sleeve) with those of the gastric bypass (gastric bypass), approximately that is a loss of 65-75% of the patient’s excess weight. After 3-5 years gastric bypasses have better retention of excess weight loss.

Weight regain may occur after years in a small percentage of patients and may lead to conversion of the operation to another operation.

IN CONCLUSION
In conclusion, we can say that elongated gastrectomy (gastric sleeve) and gastric bypass are the best methods for treating morbid obesity and cover the largest number of operations performed worldwide for the treatment of malignant obesity.

Written by:

George P. Stavropoulos

Surgeon Deputy Director of the 4th Surgical Clinic & Head of the Bariatric Surgery Department HYGEIA

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