Definition – Measurement – Epidemiology
According to the World Health Organization, obesity is defined as the condition of a marked deposit of fat in the body, which negatively affects the health and daily life of the person.
Measurement of obesity is done by calculating the BMI (Body Mass Index), which is nothing more than the patient’s weight in kilograms divided by the square of their height in meters.
Factors that contribute to the creation of hernias are:
1. ΒΜΙ: 18,5-24,9 Normal
2. ΒΜΙ: 25-29,9 Overweight
3. ΒΜΙ: 30-34,9 Obese (class 1)
4. ΒΜΙ: 35-39,9 Obese (class 2)
5. ΒΜΙ: >40 Obese (class 3)
The impact of obesity on the world population is enormous. It is estimated that 33% of the world’s population is overweight or obese. Every second 2.5 people are added to the world population and one of them will be overweight or obese.
Obesity significantly reduces life expectancy, as it is associated with hypertension, hyperlipidemia, coronary heart disease, diabetes mellitus, sleep apnea syndrome, non-alcoholic fatty liver disease and several forms of cancer (esophageal, pancreatic, kidney, breast, endometrial, cervical, prostate).
Finally, every year 2.8 million people worldwide die from a cause directly related to being overweight or obese.
Indications – Contraindications
The patient who is going to undergo Bariatric Surgery, should be obese, have failed repeated attempts to lose weight with conservative means in the past (diet, exercise), have knowledge of the surgical risk and accept it, have strong motivation, be well informed and willing to participate in long-term post-operative follow up.
If the patient fits the above profile, the following indications for surgery apply:
1. Patient with BMI >40
2. Patient with BMI 35-39,9, but with serious accompanying diseases (hypertension, diabetes mellitus, coronary heart disease, etc.), or diseases that directly affect his daily life and quality of life (e.g. serious orthopedic problems, mainly in the lower limbs, as a result of the heavy burden from the increased body weight).
Absolute contraindications for Bariatric Surgery are:
1. Patients who cannot receive general anesthesia.
2. Patients with blood coagulation disorders.
3. Patients with limited life expectancy.
4. Patients with metastatic or inoperable cancer
5. Female patients planning to conceive within the next 12 months.
Contraindications are:
1. Patients who for some reason cannot fit into the general profile described at the beginning of the section.
2. Patients with serious psychiatric disorder.
3. Patients addicted to alcohol or other substances.
4. Patients with malignant bulimia, a condition characterized by mental retardation and an insatiable desire to eat.
5. Patients with active peptic ulcer.
Special Considerations
1. Obesity and age.
The NIH Consensus Conference Statement made in 1991 did not contain any age guidelines. However, it was established that Bariatric Surgery should be performed on patients over the age of 65 because it improves quality of life without altering life expectancy.
Additionally, Bariatric Surgery can also be applied to carefully selected patients who are in adolescence.
2. Obesity and Psychiatric Diseases.
Psychiatric conditions do not preclude Bariatric Surgery, as long as proper perioperative monitoring and support have been ensured and these patients are in good condition at the time of surgery.
Of course, patients with active psychosis, recent hospitalization, suicidal ideation, or a recent suicide attempt should be excluded from any attempt to implement Bariatric Surgery.
3. Obesity and cirrhosis.
Bariatric Surgery can be safely performed in patients with stable, mild cirrhosis. If cirrhosis is an incidental finding during surgery, then the procedure can be safely completed as long as there is no severe ascites, perigastric or esophageal varices, or other evidence of severe portal hypertension.
4. Obesity and AIDS.
Previously, HIV infection was considered a contraindication for the application of Bariatric Surgery. However, today, with the new generation of drugs that drastically slow the progression of the disease and extend life expectancy, Bariatric Surgery can be applied safely and effectively.
5. Obesity and movement.
Patients who cannot be mobilized are a relative contraindication for the application of Bariatric Surgery, because immobility increases perioperative morbidity and reduces postoperative weight loss. However, it is possible to apply it to carefully selected patients with strong motivation.
Gastric Band
Gastric banding is a technique in which a ring is placed in the upper part of the stomach, near the esophagus, in order to create increased pressure (25-30 mm Hg) during the passage of food and, by extension, create resistance to flow. According to various studies, weight loss ranges from 36-56% of excess weight over a 5-year period, while at 10 years this percentage is estimated at 48%.
The method shows a high rate of conversions (i.e. conversion of the gastric band to another form of Bariatric surgery due to ineffectiveness or complications), while there are quite a few patients who ultimately choose to simply remove the band without proceeding with another form of Bariatric surgery.
In our country, the gastric band was extremely popular for several years, but its use has been significantly limited in recent years due to poor results compared to other Bariatric surgeries.
Sleeve Gastrectomy (Sleeve Gastrectomy)
Sleeve Gastrectomy is a purely restrictive surgery, which consists of removing most of the stomach and creating a narrow, elongated gastric tube. At the same time, ghrelin levels (the hormone responsible for the feeling of hunger) are reduced, a finding that appears to be maintained over time.
Weight loss with this technique is significant. Various studies have shown that the rate of excess weight loss can reach 70% in 3 years and 60% in 5 years.
Regarding concomitant diseases, sleeve gastrectomy can – over a 5-year period – improve or completely eliminate diabetes mellitus by 66%, hypertension by 50% and hyperlipidemia by 100%.
Gastric By-pass
Gastric bypass is a technique that achieves weight loss in three ways:
1. Restrictive, because it reduces the capacity of the stomach by creating a small gastric pouch.
2. Malabsorptive, because it bypasses a large part of the small intestine, thus reducing the absorption surface.
3. Hormonally, because it increases the levels of the hormones PYY and GLP-1, resulting in an increased feeling of satiety. At the same time, it reduces the levels of ghrelin, also known as the “hunger hormone”, thus reducing the feeling of hunger. However, the latter action (regarding ghrelin) appears to be transient and lasts for a few months.
Over a 10-year period, gastric bypass leads to a loss of excess weight of 52-68%.
At the same time, improvement or complete remission of concomitant diseases (diabetes mellitus, hypertension, dyslipidemia, asthma, gastroesophageal reflux, sleep apnea syndrome) is observed. In most of these, the improvement or complete remission is long-lasting. The only exception is diabetes mellitus, which appears to recur in 62-75% of cases after the second postoperative year.
Mini Gastric Bypass
This is a technique that is clearly easier than classic gastric bypass, as it involves fewer anastomoses.
It acts both restrictively, since it reduces the capacity of the stomach, and malabsorptively, since it bypasses a large part of the small intestine (approximately 200 cm).
It has very good results both in losing excess weight and in improving or even completely relieving serious accompanying diseases.
The method is implicated in the development of alkaline gastritis, as the cholangiopancreatic fluids necessarily pass through the gastroenteroanastomosis and therefore come into contact with the gastric mucosa. However, the rates of symptomatic alkaline gastritis presented in the literature are extremely low.
Cholopancreatic Diversion
Cholopancreatic diversion is a technically difficult procedure, which has:
1. Restrictive in nature, because it significantly reduces the capacity of the stomach.
2. It is malabsorptive in nature, because it bypasses most of the small intestine and allows food to mix with bile and pancreatic juices – and therefore the absorption of nutrients – only in the last 50 cm of the terminal ileum.
Cholopancreatic diversion has impressive results in extremely obese patients (BMI>50), or in patients who have failed to lose weight with other Bariatric techniques. It brings the best results compared to other Bariatric surgeries, with a loss of 75% of excess weight and 98% remission of diabetes mellitus, while it has impressive results in the treatment of other serious concomitant diseases.
The disadvantage of the method is the nutritional complications, with significant deficiencies mainly in proteins, iron, calcium, vitamins D and A. Aggressive supplementation and lifelong monitoring of the patient are therefore required in order for the method to be successful.
