Today, obesity is one of the most important diseases threatening public health. Despite obesity was predicted to be the most important problem of this century by World Health Organization (WHO) in 1998 and many precautions were taken, obesity continues to be a rapidly growing problem. Obesity is the second reason of preventable deaths after smoking. In other words, it provides many improvements in terms of human health, such as getting rid of obesity and quitting smoking.
After bariatric surgery, major regressions and even, complete recovery is seen in many chronic diseases causing death or continuous drug use. The vast majority of the patients, who have undergone bariatric and metabolic surgery, discontinue taking their medications. After long years of being obese, the person makes a fresh start to life. The important thing is to be psychologically prepared for this new beginning in the best way and not to go back to the old days. You may not always have a second chance at everything in life. However, bariatric surgery reveals such a chance. The surgeon starts this chance by contracting the stomach of the patient via bariatric surgery, however, the main responsibility for using the second chance belongs to the patient. It is obvious that if the patient extends the eating habits in the first year of life to his/her next life, he/she will be healthy and happy for lifetime.
As the indications of bariatric surgery vary according to countries, the criteria accepted by our Ministry of Health are as follows:
1. Body mass index (BMI) ≥ 40 kg/m2 .
2. n case BMI is ≥ 35 kg/m2 , at least 1 obesityrelated comorbidity should accompany. Among these situations;
• Type 2 Diabetes Mellitus.
• Hypertension (High tension).
• Dyslipidemia (disorder in fat levels).
• Sleep-Apnea Syndrome (Respiratory disorder during sleep).
• Obesity-Hypoventilation Syndrome.
• Pickwick Syndrome (sleep-apnea syndrome and obesity-hypoventilation syndrome are seen together).
• Non-alcoholic steatohepatitis.
• Pseudotumor Cerebri (Despite all the findings are normal; “Increased Intracranial Pressure”).
• Gastro-Esophageal Reflux Disease (Escape of Food and Gastric Fluids into the Pharynx).
• Venous Stasis Disease (Stability in the Collecting Circulatory System).
• Severe Urinary Incontinence (Enuresis).
• Arthritis Disease affecting daily life (Joint Inflammation).
Despite bariatric surgery or metabolic surgery has many benefits, it is not suitable for some patient groups. Due to the reason that it may cause some major problems if implemented, the situations in which bariatric surgery should not be performed as stated by our Ministry of Health are as follows:
• Being younger than 18 or older than 65; however, it can still be considered.
• if a serious comorbidity accompanies (such as Type 2 DM, HT).
• Presence of an untreated endocrine disease that also causes obesity (such as Cushing’s syndrome, hypothyroidism, insulinoma).
• Having an untreated eating disorder (bulimia nervosa - eating uncontrollably and trying to lose weight in any way that is harmful to health).
• The presence of an untreated major depression or psychosis (Severe mental health disorders).
• The presence of severe bleeding-clotting disorders.
• The presence of severe heart diseases that will prevent to receive anesthesia.
• Alcohol or substance use.
• Inability to comply with dietary recommendations, such as lifelong vitamin replacement or a calorierestrictive diet.
• Currently being pregnant or having a pregnancy plan within 12-18 months.
• Having a known cancer disease.
• Severe gastroesophageal reflux disease (GERD) (especially for laparoscopic sleeve gastrectomy).
• Portal hypertension (increased pressure in the intraabdominal venous system).
• Gastric by-pass surgery in the patients with Crohn’s disease.
The most commonly performed surgery is the “Sleeve gastrectomy” surgery, known as the “laparoscopic sleeve” surgery. This is followed by “Gastric by-pass” surgery. Apart from these, there are also other surgery methods such as “Mini gastric by-pass”, “Duodenal Switch”, and “Transit Bipartition”.
There are many reasons to have sleeve gastrectomy be the most frequently performed surgery. The first and most important of these is that there is no major change in the digestive system with this surgery. Thus, while the patient is able to lose a large amount of weight between 6 months and 1 year, and also tried to give the least harm. Although weight loss can be achieved faster in other surgeries, many problems such as vitamin deficiencies and hypoglycemia attacks may occur in the patient.
The reason for this surgery to be advantageous than all other bariatric and metabolic surgery operations is that no anastomosis is performed in this surgery. Anastomosis is the combination of two digestive system organs with each other. This is the combination process conducted between the stomach and the small intestine or between two parts of small intestine via the support of sutures or staples. After such anastomosis procedures are conducted, there may be leakage between the sutures, and this poses a great risk. Thus, “laparoscopic sleeve gastrectomy” poses less risks than all the other bariatric and metabolic surgeries.
Since the stomach volume of the patient is reduced via the “laparoscopic sleeve gastrectomy” surgery, the patients cannot eat much after this surgery. This is a restrictive surgery. In other words, the eating of the patients is restricted due to the reduced stomach volume. Also, the level of “Ghrelin” hormone, which is secreted from the removed part and increases appetite, is also reduced.
The aim in all the other bariatric and metabolic surgeries is both restriction and to restrict the nutrient absorption. In such surgeries, besides reducing the stomach volume, it is also provided to have the food pass through a part of the small intestines. Thus, food that passes through a small part of the intestine is less absorbed. In other words, all the calories taken by the patient cannot be absorbed and the unabsorbed calories are excreted via feces. Thus, besides eating less, less calories are absorbed. Via these methodsweight loss is achieved faster than laparoscopic sleeve gastrectomy.
“Gastric By-pass”, which is one of the restrictive + absorption-reducing procedures and the second most frequently performed bariatric surgery in the world, is accepted as the “gold standard” method by many centers in bariatric surgery. It is quite less effective than metabolic surgery methods, which are especially outstanding in the treatment of diabetes. While the probability of recovery of diabetes mellitus via “Duodenal Switch” and “Transit Bipartition” is more than 95%, this ratio is between 85% and 87% in “Gastric by-pass”. However, the operations similar to this surgery have been performed for many years, especially in the patients with gastric cancer. Therefore, our knowledge about the risks that may arise due to this surgery in the long term is more when compared to other methods.
Methods such as “Duodenal Switch” and “Transit Bipartition” are more complex surgeries including more anastomosis when compared to these two methods. However, they give better results in the treatment of metabolic disorders, especially in people with additional diseases such as diabetes mellitus and high blood pressure.
Despite all these procedures have very promising results such as weight loss and treatment of metabolic diseases, these patients should be followed closely. On the other hand, this method has become more preferred in our country as it is in the whole world, as the surgery can be performed more safely with robotic surgery. The biggest problem is that robotic surgery system is not present at all the centers. These systems, requiring serious investments and training costs, have been revolutionary in terms of bariatric surgery. In Robotic Surgery, clearer and sharper vision can be obtained via 3D imaging. In addition, since the surgical instruments used have an articulated structure (this feature is not present in laparoscopy), it imitates the arm and wrist movements of the surgeon and enables to perform extremely sensitive surgical interventions. Flickering and focus shift that may occur in the camera system and surgical arms along with fatigue during the surgical procedure are completely eliminated in the robotic system.