Obesity Surgery

Morbid obesity is associated with an increase in morbidity and mortality, an increase in morbidity and mortality in all age groups, including different populations and genders, due to both itself and its associated comorbidities (such as coronary artery disease, Type 2 diabetes mellitus, insulin resistance, non-alcoholic hepatosteatosis and hypertension). causes a decrease. WHO (World Health Organization) stated that 1 billion people in the world are overweight and more than 30 million people are morbidly obese. Today, the prevalence of morbid obesity is increasing in Turkey as well as all over the world. In Turkey, 30.3% of people are considered to be morbidly obese (20.3% for men, 41% for women), which is consistent with the rest of the world.

Achieving weight loss in morbid obesity patients leads to a decrease in morbidity and mortality, an increase or improvement in the control of accompanying co-morbidities, and a decrease in the risk of cancer development. Every 5 kg/m2 increase in body mass index (BMI) causes a 30% increase in mortality, 10% in cancer-related mortality, and 39% in ischemic heart disease; It has been stated that the average survival rate is 2-4 years when BMI is between 30-35, and 8-10 years between BMI 40-45. While diet, lifestyle and pharmacological treatments are beneficial in mild and moderate obese patients (3-9%), their effectiveness is quite limited in morbidly obese individuals.

In general, the body mass index (BMI) is used to measure the prevalence of obesity. It is evaluated by weight and height ratio (kg/m2).

Obesity is defined as BMI ≥30 kg/m2.

BMI ≥35 kg/m2 severe obesity (severe obesity)

BMI ≥40 kg/m2 morbid obesity

BMI ≥50 kg/m2 is defined as super obesity.

Body fat percentage (%BF) is also used. A BP% ≥25% in men and ≥30% BP in women is considered obesity.

Indications for bariatric surgery in morbid obesity were determined in the NIH (National Institutes of Health) consensus in 1991.

  • BMI ≥40 kg/m2- without comorbidity

  • BMI ≥35 kg/m2 – presence of one or more severe obesity-related co-morbidities

(Hypertension, T2Diabetes mellitus, hyperlipidemia, obstructive sleep apnea syndrome-OSAS, obesity hypoventilation syndrome-OHS, pickwickian syndrome-OSAS+OHS, non-alcoholic fatty liver disease or non-alcoholic fatty liver disease or non-alcoholic fatty liver disease-NASH, GERD, asthma, severe venous stasis syndromes, incontinence, arthritis, severe quality of life deterioration)

BMI 30-34.9 kg/m2 + Presence of DM or metabolic syndrome (can be recommended to the patient, but more evidence is needed on long-term benefit). The International Diabetes Federation recommends bariatric surgery for patients with T2DM and a BMI of 30kg/m2 with suboptimal glycemic control despite optimal medical therapy. The choice of method should be decided by individualizing the treatment. It should be determined according to the purpose of weight loss and or metabolic (glycemic) control. Lower rates of early postoperative morbidity and mortality are observed with laparoscopic methods.

Operation Preparation: In the preoperative period, after routine biochemistry and hemogram, ECG, PA AC radiography, the patients are evaluated by endocrine diseases, chest diseases and psychiatry specialists, and the decision is made for the operation. It is recommended that HbA1c level be between 6.5-7% or lower, fasting blood glucose ≤110 mg/dl, 2-hour postprandial blood glucose ≤140 mg/dl (grade A). An HbA1c level of ≤8% suggests uncontrolled diabetes. Primary hypothyroidism should also be treated before surgery. Pregnancy is not recommended before bariatric surgery and 12-18 months postoperatively. In case of pregnancy, the level of B12, Fe, folate and fat-soluble vitamins should be evaluated. OCS (birth control pills) and postmenopausal hormone replacement therapy should be discontinued 3 weeks before bariatric surgery to reduce the risk of postoperative thromboembolism. Smoking should preferably be discontinued at least 6 weeks before the operation. Smoking causes poor wound healing, development of anastomotic ulcer and deterioration in general patient health.

Surgical: The most effective treatment option in the treatment of morbid obesity is bariatric surgery. In the non-surgical treatment of morbid obesity, weight loss between 3-9% can be achieved in a 1-year period as a result of dietary changes, medical treatments and exercise applications. Today, in line with the increase in obesity, bariatric surgical procedures are performed with increasing frequency. Although perioperative risk is increased in bariatric surgery in morbid obesity and comorbid conditions; Surgical intervention also provides the treatment of obesity and comorbid diseases, thus reducing long-term mortality. Although there is an increased perioperative risk due to morbid obesity and accompanying co-morbid conditions in bariatric surgery, surgical intervention provides treatment for perioperative risks.

Sleeve Gastrectomy (SG): It is a technique that provides weight loss and causes restrictive and hormonal changes in the treatment of morbid obesity. By removing approximately 80% of the stomach, the volume of the stomach is reduced (about 100 ml), and the desire for food decreases by removing the regions that produce the hormone called Ghrelin (ghrelin is mainly secreted by the P/D1 cells in the fundus), which is especially important in the formation of appetite. Ghrelin is a 28 amino acid hormone, also known as the hunger hormone, which has a growth hormone-releasing effect and plays a role in the regulation of energy balance and food intake. Apart from the stomach, it can also be secreted from regions such as the intestine, pituitary, kidney, salivary gland in smaller amounts. It rises in the blood in case of hunger, and its amount decreases with satiety. Although mortality is significantly reduced after SG, the early and late morbidity rates vary between 9-23%. Leakage development from the stapler line was reported between 1-6% and bleeding between 2-7.3%. EWL (Excess weight loss) after SG 49-81%; It was stated that postoperative BMI ranged between 24.4-32 kg/m2.

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