Obesity Surgery

Treatment of obesity with diet and exercises or supporting these programs with drug therapies remain insufficient in permanent and satisfying treatment of obesity.

• National Institute of Health (NIH) recommends controlled weight loss for individuals whose BMI >30 kg/m2 and fat individuals with a BMI > 25 kg/m2 value and at least two accompanying disease. (NIH: Clinical guidelines Obes Res6 (Suppl. 2): 51S-209S,1998)
• The average weight loss by 500 grams per week which is obtained with calorie restriction diets provides a healthy weight loss and this is insufficient for long term control of the weight loss.  (Wadden TA, Foster GD: Med Clin North Am84 : 441-461,2000)
• Although rapid weight loss is achieved with very low calorie diets, effects of these diets can not be preserved during a long period.  (NIH: Clinical guidelines Obes Res6 (Suppl. 2): 51S-209S,1998)
• Exercise programs added into the calorie restricting diets are much more effective than diet for preserving the weight loss obtained and for long term control of weight loss even these exercises do not increase weight loss ratios much. (McGuire MT, Wing RR. Obes Res7 : 334-341,1999)
• Behavior therapies may change the eating order, thoughts and behavior styles of the patients with obesity problems; a weight loss by 8 to 10% may be provided within 4 to 6 months when it is supported by diet and exercise.  Such weight loss may significantly reduce problems of the patients with problems due to obesity.  (Blackburn G: Obes Res3 (Suppl. 2):211S -216S, 1995)
• However, a large portion of these patients gain these weights lost, even more. (Tech. Asses. Conf. Pan.: Methods for voluntary weight loss and control. Ann Intern Med119: 764-770,1993)
• Despite a weight loss of 15 kg is obtained with medical obesity treatment and diet within a year, patients gain these weights back within 1 to 3 years.  (NIH Con. Dev. Conf. Sta. March 25-27,1991. Am J Clin Nutr 1992:55:615S-9S.) (Treatment of obesity by moderate and severe caloric restriction. Wadden TA . Ann Intern Med 1993. Oct: 1;119:688-93)
• There is not any drug or drug group appeared as an efficient option for medical treatment of obesity yet.  (Pharmacotherapy for obesity: Haddock CK et al. Int J of Obesity (2002) 26, 262-273)

Why Obesity Surgery?

	Obesity Surgery

Conditions which increase in relation with obesity include Hypertension, Cardiac diseases, Hypercholesterolemia, Diabetes (Type II DM), Sleep-Apnea, Bone and Joint Disorders, Reflux and Vein Disorders (The incidence of co-morbidities related to obesity and overweight: Daphne P Guh, Whei Zang, et al. BMC Public Health 2009, 9:88 doi:10.1186/1471-2458-9-88). WHO reports and recommends that the surgery is the most efficient treatment for obesity and accompanying diseases for the patients with BMI>35 kg/m2 and one or more accompanying disease; and for patients with BMI>40 kg/m2 even no accompanying disease exists (WHO Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO technical report series 894.Geneva: World Health Organistion, 2000).

Obesity and metabolic surgical methods should be assessed as an alternative treatment for the patients with a BMI value between 30 and 35 kg/m2 who receive treatment because of Type 2 Diabetes and can not control their blood sugar levels with standard medical diet and life style changes especially if diabetes-induced cardiovascular risk factors exist. (Declaration of International Diabetes Federation: Bariatric Surgical and Procedural Interventions
in the Treatment of Obese Patients with Type 2 Diabetes. A position statement from the International Diabetes Federation Taskforce on Epidemiology and Prevention-2011)

	Increased Life Quality

What is Obesity Surgery or Bariatric and metabolic Surgery?

History of obesity surgery or bariatric surgery extends to middle 20^th century.  The word bariatric has been started to be used to describe the department dealing with causes and treatment of the obesity in the literature in 1965.  The word metabolic is also originated from Greek.  Metabolic means transformation or change of a form into another form.  Buchwald has defined metabolic surgery in his book published in 1978 as “operation of a normal organ or organ system to reveal biological changes to recover an important health problem”.  However, his purpose with this definition was to describe different surgeries applied for very different causes to recover diseases beyond the operation site.  For example, an ulcer in the duedonum is treated through neurotomy of the nerves called vagus which exist on upper healthy parts of the stomach.   However, none of the procedures applied for years has contributed into metabolic surgery definition as much as effects of the obesity surgery for last 20 to 25 years.  By contribution of laparoscopy since early 1990s into the obesity surgery, applicability of obesity surgery has gradually increased.  By increase of experiences on obesity surgery and patients who are operated, articles and observations have started to be shared worldwide that many important and life threatening accompanying conditions of patients who were operated for long term control of excessive weights only because of morbid obesity have recovered without any weight loss.  Recovery of important metabolic problems such as Type 2 Diabetes, hypertension, sleep-apnea, cardiovascular disorders which can not be controlled with drugs and moreover, appearance of such recoveries during very early postoperative period even before weight loss has caused to remember obesity surgery with metabolic surgery.  Therefore, name of American Society of Bariatric Surgery (ASBS) founded in 1983 has been changed as American Society of Metabolic and Bariatric Surgery (ASMBS).

History of Obesity Surgery

Many different operations to restrict gastric volume or absorption of high calorie foods for surgical treatment of obesity have been defined and applied during last 50 to 60 years.

First steps for obesity surgery has been taken by Jwjuno-Ileal Bypass (JIB) operation defined and applied by Kremen in 1954.  JIB operation is separation of about 90% of small intestine from food passage and absorption by connecting first 25 cm part and last 10 cm part of small intestine was completely absorption restrictive.  It has not been applied since 1970s because patients have reported their problems.  However, this has caused important experience accumulation to show that absorption restriction will have vital effects.  As a result of this absorption restriction, it was understood that long term and severe weight losses may be obtained, such technique may be developed and changed or new obesity surgery techniques may be developed under the light of this main philosophy.  Furthermore, it showed importance of close monitoring to wait for long term outcomes which are important to assess obesity surgery and for feeding parameters of the patients.

Mason has developed Gastric Bypass operation in 1967.  Gastric volume is reduced by closing some part of stomach with a stapler and very less small intestine part is separated than jejuno-Ileal Bypass.  When it is applied first, bile flow was connected to the stomach and this created problems for bile reflux.  Then, modifications that will create bile flow from a separate path (Roux-N-Y) have been continued to be applied.  This operation preserves its importance with modifications as the most common operations in the world including USA.

A Genovese surgeon Nicholas Scopinaro has defined Biliopancreatic Diversion (BPD) which includes larger gastric volume but longer small intestine absorption restriction in 1976.  This operation has preserved its actuality until today and it is a current technique which is commonly applied all over the world with a long term body weight success more than 20 years.  Its variation called Switch technique where anatomic valve mechanism at the gastric exit is preserved is commonly performed in USA.

Kuzmak has applied gastric band first in 1990.  Then, adjustable gastric bands with balloon in the inside has become common by development of laparoscopy.

Sleeve gastrectomy operations which has been performed for first stage treatment for super obese patients before their permanent operations has become common within a short period due to efficient weight losses, short operation periods and rapid recovery periods.  This operation has a tendency to be applied more than adjustable gastric band today has needed new revisions because of partial weight gains during long term.  However, the most important cause to prefer sleeve gastrectomy is that gastric tubing (Sleeve Gastrectomy) may be converted into Biliopancreatic Diversion-Duodenal Switch (BPD-DS) or Duodejejunal Bypass (DJB) easily.

New techniques are continued to be developed and applied to control and treat Type 2 Diabetes.  De Paula from Brazil has applied the technique consisted of Ileal Interposition and Sleeve Gastrectomy on 3 patients first in November, 2003 and has reported recovery on Type 2 Diabetes and dependent metabolic problems.  Today, ileal interposition is a proven technique with an experience over 1000 patients and monitoring periods up to 10 years on treatment of Type 2 Diabetes and Metabolic Syndrome.

In 2007, Ricardo Cohen from Brazil has described Duedojejunal Bypass technique including bypass of initiation part of small intestine.  Then, he has applied this technique with sleeve gastrectomy and standardized.  He has shown its efficiency on control of Type 2 Diabetes.  Articles continue to be published on applicability of the surgery with same method and control on Type 2 Diabetes from different regions of the world.

Obesity Surgery is a surgical discipline which can not be separated from metabolic Surgery and will be referred together.  Especially, superiority of obesity surgery techniques which have been developed for 60 years for treatment of morbid obesity and particularly treatment of Type 2 Diabetes and metabolic problems appeared due to Type 2 Diabetes has been proven strongly.  Therefore, not organizations which interest in obesity surgery only, but also organizations such as American Diabetes Association (ADA) , International Diabetes federation (IDF) which includes endocrinologists and diabetes specialists who deal with diabetes treatment worldwide report that obesity and metabolic surgery methods are superior and achievement permanency is longer than all other treatments for patients with Type 2 Diabetes and BMI>35 kg/m2 who can not be controlled with drug therapy.

Obesity Surgery Classification

1. Gastric Volume Reducing Operations:

Gastric volume reducing operations aim to reduce meal portions.  Calorie intake is reduced by reducing meal portions.  So, patients intake less calories.

A. Adjustable Gastric Band: A plastic band is placed into the gastric orifice laparoscopically (by opening small holes on the abdomen).  It is recommended most because it is the easiest procedure.  It lasts shorter than other methods.  The balloon placed inside is inflated with a fluid and gastric orifice is narrowed and dilated.  Complication ratio is very high during long term.  No weight loss is obtained when fluids with excessive calories are taken.

B. Sleeve Gastrectomy: It has become an operation preferred by centers which increase gradually during last 15 years.  The stomach is narrowed longitudinally.  Since cells secreting hunger hormone are removed, it affects hormonally as well.  It does not spoil normal anatomy.  It does not cause absorption decrease.  Efficiency period is longer.  Partial weight gains may appear due to gastric enlargement after 4 to 5 years.  It is preferred most because it may be converted into another metabolic method easily.

2. Operations Reducing Small Intestine Length:

These operations are generally called bypass operations.  Parts of small intestine with different lengths are separated from food passage in these operations.  So, intake of significant part of calories is prevented by the body.   This prevention is not only for calorie foods undesired.  Vitamins such as A, D, E, K, proteins and minerals which are required for a healthy life are also malabsorbed.  Patients who have these surgeries should take vitamin supplements for lifetime.

A. Mini Gastric Bypass: It is the easiest bypass surgery.  Food can not be absorbed from approximately 2 meters of small intestine.  Gastric volume is reduced in a certain proportion.  The bile flow coming from the liver is directed to the stomach, it has gastric ulcer risk due to irritation by bile.  Vitamin and mineral use for lifetime is essential.

B. R-Y Gastric Bypass: It is the most common bypass operation in the world, especially in USA.  It both reduces gastric volume and small intestine distance partially.  It is hardly reversible operation.  It provides efficient weight loss.  Weight gains up to 35% may occur within 5 years.

C. Biliopancreatic Diversion/Duodenal Switch: It is an operation which is based on BPD operation applied by Scopinaro first in 1976. It is applied reliably for more than 40 years and presents a great efficiency on treatment of both obesity and diabetes.  Portions are bigger because a wider gastric volume is left. Supplement use for lifetime is essential because of vitamin and mineral deficiency.  It has been shown that effects last over 20 years.

D. Duedonejejunal Bypass/Sleeve Gastrectomy: It has been applied by Brazilian surgeon Cohen.  It is applied with sleeve gastrectomy.  It is similar with Biliopancreatic Diversion/Duodenal Switch (BPD/DS).  However, it causes less absorption disorder than BPD/DS operation.  Efficiency on obesity is same with BPD/DS.  Drug use for lifetime is essential because of vitamin and mineral deficiency.