Obesity Surgery Bariatric Surgery
General Surgery Specialist
Doç. Dr. Muzaffer AL
Obesity Surgery – Bariatric Surgery
What is Obesity?
We can define obesity as excessive obesity that leads to very serious fatal diseases, negatively affects the quality of life of the individual and shortens his/her life. Obesity, which occurs as a result of excessive fat accumulation in the body and must be treated, continues to be an important health problem in our country and in the world. Increasing mortality rates due to obesity-related concurrent diseases have increased the importance of combating obesity. According to recent data, approximately one third of the female and one fifth of the male population in our country is obese.
Which obese patients should undergo surgery and is there an age limit?
Yes, we usually operate on patients between the ages of 18-65. Patients with a body mass index of 40 and above without any additional disease or with a body mass index between 35-40 with additional diseases such as type 2 diabetes, cardiovascular disease, sleep apnea syndrome, serious psychological problems related to obesity, fatty liver, reflux disease, serious joint and knee problems.
How is Obesity Measured?
Some measurements are used to determine that we are obese. These are Body Mass Index and waist circumference measurement.
How is Body Mass Index calculated?
A simple calculation is made. Body mass index (BMI= body mass index) can be calculated by dividing our weight by our height in square meters (kg/m2)
The World Health Organization (WHO) obesity test classification is as follows.
Body Mass Index (body mass index)
35-40 Advanced Obese
40-50% orbid obese
50 and above super obese
The amount of body fat is as important as where it is deposited in terms of risk. Fat accumulation around the abdomen causes more risk than fat accumulation in the hips and other parts of the body. A simple method for measuring risk is waist circumference.
For metabolic diseases in men, a waist circumference above 94 cm is considered an increased risk and above 102 cm is considered high risk, while above 80 cm is considered an increased risk and above 88 cm is considered high risk in women.
Why is obesity a dangerous disease?
After a certain stage, obesity leads to diabetes and hypertension and these complications occur at a very early age in “morbid” obese people. These comorbid problems that develop due to obesity are called “comorbidity” in medicine. As it is known, the number one cause of death in our time is still atherosclerosis and both diabetes and hypertension are the most important risk factors for the development of atherosclerosis.
80% of Type 2 Diabetes
55% of hypertension
35% of ischemic heart disease
It is responsible for 7-41% of cancer cases!
Obese people develop serious knee problems at a very early age, urological problems such as urinary incontinence, respiratory problems, sleep apnea and a number of other very serious problems at a young age.
Sleeve Gastrectomy Surgery
Sleeve gastrectomy, popularly referred to as stomach reduction surgery or sleeve gastrectomy, is the most common weight loss surgery performed worldwide.
To whom is sleeve gastrectomy (sleeve gastrectomy) surgery performed?
As with all morbid obesity surgeries, standard rules apply:
– Body mass index (BMI) >40;
– BMI>35 and comorbid diseases such as type 2 diabetes, high cholesterol, sleep apnea, degenerative joint disease, high blood pressure
– The patient has been unable to lose weight despite diet and regular physical activity for at least 6 months or has gained back more than the weight lost.
What is the mechanism of action of the surgery?
Gastric sleeve gastrectomy (SG) causes weight loss by 2 mechanisms:
1) Mechanical restriction by reducing gastric volume and impairing gastric motility;
2) Hormonal modification of ghrelin production by removing a large portion of tissue. Ghrelin is a 28 amino acid peptide secreted by the occintic glands of the gastric fundus. It is a potent orexigenic (appetite-stimulating) peptide mediated by activation of its receptors in the hypothalamus or pituitary region. The gastric fundus contains 10 to 20 times more ghrelin per 1 gram of tissue than the duodenum. In sleeve gastrectomy surgery, resection of the fundus is also performed, eliminating the main site of ghrelin release, thus reducing appetite.
Gastric Bypass Surgery
Morbid obesity is a major health problem in many countries. It is associated with serious life-threatening comorbidities. Unfortunately, many studies have proven that non-surgical approaches to weight loss are doomed to fail. There is good evidence that bariatric surgery is the most durable and effective way to combat morbid obesity in terms of long-term weight loss. Gastric bypass is one of the gold standard surgeries today. It relies on several mechanisms: restriction, malabsorption and changes in gut hormone secretions. It both restricts food intake and reduces the absorption of the food eaten. Like all obesity surgeries, Gastric Bypass surgery is applied to obese patients who cannot lose weight with diet and exercise. It is applied with two different methods. RNY AND MINI-GASTRIC BYPASS
How is R-N-Y Gastric By-pass performed?
Laparoscopic or robotic surgery is performed through millimetric incisions. The main surgical steps to perform gastric bypass are as follows:
1) Creation of an isolated 25 mL gastric pouch,
2) Creation of a Roux-en-Y gastroenterostomy into the gastric pouch. The length of the duodenojejunal limb is usually 30 to 50 cm (up to 75 cm if BMI >50). The length of the gastrojejunal limb (or Roux limb) ranges from 100 cm for Body Mass Index (BMI = weight in kg/square of height in meters) <50 to 150 cm for BMI >50.
This method involves a combination of two weight loss mechanisms.
– The primary mechanism is mechanical restriction through the creation of a 25 mL upper gastric pouch;
– The secondary mechanism is malabsorption: The Roux limb delays the mixing of nutrients with bile and pancreatic fluids while preserving the entero-hepatic cycle of bile salts. This second mechanism improves insulin sensitivity in obese type 2 diabetic patients by stimulating gut-derived hormones.
Mini Gastric Bypass Surgery
In recent years, a surgical technique known as single anastomotic gastric bypass or mini gastric bypass has been developed. This procedure, originally described by Rutledge in 1997, is a simplified form of Roux-en-Y bypass by performing a single anastomosis with a significant reduction in technical complexity, shorter operative time and a potential reduction in morbidity and mortality.
Several studies have demonstrated the benefits conferred by this procedure, including excess weight loss and treatment of comorbidities (type 2 diabetes, high cholesterol, sleep agne syndrome, high blood pressure, etc.) equivalent to those observed after Roux-en-Y gastric bypass. Weight loss, both by reducing food intake and by reducing the absorption of the food eaten. Improves insulin sensitivity by early stimulation of intestinal hormones by food
How is Mini Gastric Bypass (MBG) performed?
It is performed laparoscopically and/or robotic. It consists of a long duct that runs from the bottom of the goose foot to the left of the His angle. The tube is similar to, but more importantly not identical to, the stomach pouch. The MGB contains a large gastro-jejunal anastomosis to the anti-colic ring of the jejunum 150-200 cm distal to the Trietz ligament. The strength of the MGB lies in the fact that it is both a “non-blocking” restrictive procedure and has a significant fatty food intolerance component with minimal malabsorption.
A gastric pouch of approximately 15-18 cm (50-150 ml) and a gastroenteric anastomosis (biliopancreatic loop) in a pre-colic isoperistaltic loop of 200 cm in duodenojejunal aspect.