Obesity is the most common metabolic disorder in the Western world. Approximately one third of the population in these countries suffers from some degree of obesity. The Spanish Obesity Society has estimated that in our country 14.5% of the population is obese and 38.5% is overweight. The incidence of childhood and juvenile obesity, which affects people between 2 and 24 years of age, is even more alarming: 14% obese and 26% overweight.
Morbidly obese patients have a higher cardiovascular risk than non-obese individuals. In addition, they are more likely to contract other diseases such as diabetes, neoplasms, dyslipidemia, hypertension or metabolic syndrome. All this considerably reduces life expectancy and quality of life.
In response to this, various non-surgical ways have been tried to reduce pathological body weight, such as dieting, exercise and drugs. However, in the long term, the only treatment with proven efficacy in obtaining permanent and stable results is bariatric surgery. This consists of a series of definitive surgical procedures that usually involve a restrictive component, a malabsorptive component, or both.
What types of obesity surgery are there?
There are currently different types of surgical techniques:
- Restrictive: they reduce the size of the stomach, resulting in less food intake and secondary weight loss.
- Malabsorptive: they produce a decrease in the absorption of ingested food.
- Mixed: they combine the two previous procedures.
These surgical procedures have demonstrated better long-term results than other endoscopic methods, whose manifestations are usually transient, with less weight loss and resolution of comorbidities.
Vertical gastrectomy
This is a restrictive technique that consists of permanently reducing the capacity of the stomach (80%) vertically, including the elimination of the gastric fundus, where the appetite hormone (ghrelin) is produced.
After surgery, the stomach’s capacity for food is significantly reduced from the usual 1200cc of an obese person to about 100-250cc. These changes provoke in the patient a feeling of fullness and satisfaction after eating a small amount of food.
It is currently the most widely used technique in Spain and in the world, representing 50% of bariatric procedures. This treatment presents less technical difficulty, maintains a lasting loss of excess weight, resolves comorbidities and improves survival in obese patients.
Roux-en-Y gastric bypass
It has been the most widely used technique for the surgical treatment of morbid obesity in the last decades. It is especially indicated in patients with BMI > 50 kg/m2 and with bad eating habits (greedy habits, snacking between meals and patients with associated Diabetes Mellitus). In addition, it can be recommended in cases where a restrictive procedure has failed.
The surgical procedure consists in reducing the capacity of the stomach with the creation of a small reservoir (restrictive component) from where the food is directly diverted to the small intestine, which causes a malabsorptive process that actively influences the decrease of fat absorption, having an effect on weight loss.
During the preparation of the Roux-en-Y gastric bypass, two joints are made, one between the stomach and the small intestine and the other at the level of the small intestine, with the objective of modifying the anatomy of the digestive apparatus as shown in the image.
It is a complex technique, but in expert hands the results are excellent in the long term, both in weight loss and in the resolution of comorbidities.
What type of patients require surgery?
Patients with an indication for bariatric surgery must meet one of the following criteria:
- Morbid obesity with a long evolution (3-5 years).
- Age between 18 and 65 years: patients outside this age range could be candidates on a selected basis and after evaluation by a multidisciplinary team.
- Failure of controlled medical or dietary treatment for at least 6 months.
- Indications according to body mass index (BMI):
BMI >40 kg/m2.
BMI >35 kg/m2 associated with comorbidities.
BMI > 30 kg/m2 in type 2 diabetic patients with the aim of improving control of blood glucose levels and cardiovascular risk markers.
Surgery for type II diabetes
On the other hand, there is metabolic surgery which refers to the surgical treatment of type 2 Diabetes Mellitus.
This type of surgery has reported remission of diabetes in 85% of patients and improvement in 15%. It is especially indicated in patients with poor glycemic control. The results are favorable especially in patients between 25 and 65 years of age, glycosylated hemoblobin > 7%, in patients with less than 10 years of disease evolution and in those with a BMI > 30 kg/m2.
Why is surgical intervention important?
Currently it can be said that bariatric surgery is the best method for treating diseases associated with obesity. In addition, after surgery patients have a lower risk of developing new comorbidities, which, according to multiple studies, improves life expectancy by 10 to 15 years.
However, the results of surgery vary according to each pathology:
- Diabetes Mellitus: cure in 80% of cases and 30% reduction in the relative risk of suffering this disease.
- Dyslipidemia: 99% improvement and reduction in the development of hypercholesterolemia and hypertriglycyidemia.
- Arterial hypertension: surgery reduces the prevalence of hypertension by 78% and in the rest, blood pressure levels are better controlled.
- Cardiovascular factors: improvement in cardiac function, which drastically reduces fatal cardiovascular events.
- Sleep Apnea Syndrome: surgery reduces the severity of apnea in all patients and 80% discontinue continuous positive airway pressure (CPAP) treatment.
- Digestive pathology: improvement of gastroesophageal reflux and other functional disorders.
- Cancer and mortality in general: obesity is a risk factor for the development of multiple types of cancer, with this incidence decreasing after surgery.
What preparation is required for obesity surgery?
Prior to the intervention, the patient will be evaluated by a multidisciplinary team in order to obtain the best results after the procedure:
- Endocrinologist assessment: preoperative and analytical study to rule out secondary causes of morbid obesity.
- Endoscopic assessment: upper gastrointestinal endoscopy to study the anatomy and rule out any gastric pathology that might contraindicate surgery or modify the surgical technique.
- Psychological evaluation: study of eating habits and behavioral disorders, as well as the patient’s ability to understand the surgery and aftercare.
After these evaluations, and if there are no contraindications, the patient will start a preoperative diet during the weeks prior to surgery with the objective of losing between 5% and 10% of excess weight before surgery.
How is the recovery?
The surgery is performed using minimally invasive techniques (laparoscopy), which favors a quick recovery of the patient and less postoperative pain. The postoperative hospital stay is between 24-48 hours. Five small incisions are made in the skin and stitches are removed 7 days after surgery.
In addition, during the first 4 weeks, a liquid and semi-liquid diet is recommended, which may include food supplements. Subsequently you can have a balanced diet in which it is advisable to eat 5 times a day and avoid meals out of hours.
Finally, scheduled consultations for clinical and analytical follow-up of the patient should be carried out during the next 5 years. In addition, psychological support will be important during the process of adaptation to lifestyle changes, with the aim of achieving an improvement in quality of life and greater physical and emotional well-being.