Choosing the Right Methods Plays Vital Role in Bariatric Surgery

Obesity is now considered as a chronic disease  and prevalence of  obesity  is increasing both in the world and in Turkey day by day. Obesity is generally caused by  excessive  food intake and imbalance of spending the food taken, sedentary life,  lack of physical activity and unhealthy diet. Also obesity has strong association with many diseases such as cardiovascular diseases, diabetes and cancer.

Continuation of human life depends on energy continuity. In other words, just like a car being fueled, nutrients must be taken in the same way. However, there is a difference here. When you eat ,stomach  grows bigger  like a muscle and shrinks when it is  empty. However, at this point, the stomach becomes unable to shrink due to nutritional deficiencies and lack of physical activity. The activity of hormones connected to the growing stomach increases on the surface, which stimulates  appetite . After a while, even with the litte amount of food consumption., the food is stored .So the person complain   about the diet that causes weight gain  and other diseases and  wants to try surgical methods 

Preoperative Preparation for Bariatric Surgery

Before obesity surgery, the patient must definitely have a preparatory period. A multidisciplinary evaluation is essential during the preparatory period. An internal medicine, gastroenterology, endocrinologist need  to evaluate the patient. For example, whether there is a hernia in the stomach, the patient's gender, obesity-related  diseases   should be determined and the surgical method should be chosen accordingly. For example, the aim is  for the patients with high body mass index and heart disease, to recover quickly with gastric sleeve surgery . If desired, a second surgery is performed. In addition, it should be checked whether the patient had undergone this type of surgery before and the method should be determined accordingly.

The situation is different for those who have had tube stomach surgery before.

If the patient has previously had gastric sleeve  surgery and gained weight, it is necessary to examine the reason for this failure. If there are technical or patient-related  causes, performing a second  surgery to the patient may be more risky than a normal patient. Each case should be considered individually, and how a new surgery should be performed, and which surgery to choose should be evaluated in a multidisciplinary manner. The result of the  evaluation should be shared with the patient, the patient should be informed correctly, and then the surgical process should be decided together with the patient.

Rapid weight gain can lead to death

No matter how many diet plan is followed, a patient with a Body Mass Index over 35 regains the weight he loses No diet works forever. However, in order for surgical methods to be successful, it is necessary to apply the right  method in the right patient and  follow the patient's control process. In addition, it should never be forgotten that complications may occur in the body of patients who gain weight rapidly for surgery, proteins decrease in the body of a person who gained weight in a short time to undergo surgery and this prolongs recovery time . It should not be missed that the operations of people who reached certain Body Mass Index in a very short time to be operated ,might be unsuccessful and can lead to death.

The gastric band was once the most popular weight loss surgery. Now, it's slowly being relegated to the dustbin of medical history

In the application defined as gastric band  and lap band, a cuff shaped  silicone band is attached to the upper part of the stomach just below the esophagus and the stomach is divided into two parts. The foods consumed  are collected at the top and do not pass to the bottom. However, this method is no longer popular. Because hormonal activity is ignored here. While hormones send signals to the brain to stimulate feeding, but   the stomach with the band does not allow this and continue to have hunger . Since the person is hungry and continues to eat, that causes vomiting . The most important feature of the band  is that it can be inflated by giving liquid to the chamber inside. It is necessary to take fluid from this reservoir every 15 days and give fluid to this reservoir. When the patient does not go to the doctor, he might  experience complications such as inflammation. Also, the gastric  band is not suitable for those who desire to become pregnant. With the growth of the uterus during pregnancy, it may happen that the band slips upwards or into the stomach wall. In addition,  patients regain weight after the   band removal,so it doesnt bring long term success.
In obesity surgery, methods vary according to gender, weight, disease, age, and whether women will become pregnant in the future. Surgical methods used in obesity treatment can be listed as follows:

• Sleeve Gastrectomy: Anatomically stomach shaped like question mark. With gastric sleeve   surgery, the upper ,the  question mark- shaped part of stomach is removed, stomach becomes like  exclamation mark . In this way, the stomach reaches to  volume between 100-150 ml. There are also hormones of leptin and ghrelin in the part removed by surgery. Removing  ghrelin contributes  to weight loss and reduce hunger. Gastric sleeve method has permenant successs if it is carried out on the right patient. Patients should be seen by the nutritionist before and after the operation. The nutritionist  job here is to prescribe suitable diet to patients. Passage x-ray should be applied to the patient between 24-48 hours after the operation. This is a radiological examination that reveals whether there are any complications after surgery. The risk  associated with this surgery is that complication develops within 48 hours  If there is no compication, the patient is given liquid nutrients for 15 days.
  After 15 days, the food  given by the nutritionist must be consumed according to the amount given and by passing through the meat grinder.After a month , the food given by the nutritionist should be eaten by  properly chewing 
• Gastric Bypass Surgery: With  this method, the stomach is not bypassed as it is thought, the small intestines are bypassed. Gastric bypass surgery is also  performed laparoscopically. 
  With this surgery, while reducing the volume of the stomach, it also affects the absorption of the food taken into the body and causes excretion without being beneficial to the body.  The most important disadvantage of this surgery is that some deficiencies of vitamins may occur in the following days due to malabsorbtion of some required nutrients. It is recommended to do exercises directly after gastrict sleeve surgery however after gastric bypass surgery  weigh loss occurs without doing exercise. However, the length of hospital stay is longer than Sleeve Gastrectomy  . Patients are discharged in gastric Sleeve surgery within 2-4 days but for gastric bypass surgery within 4-6 days. In both methods, it is necessary to acknowledge  the patients about the   risk of the first 48 hours after surgery
• Mini Gastric By-Pass: In this method, since a long gastric tube is created, the small intestine piece is combined into the stomach. Although the operation time is shorter and the cost is less, the effect of eliminating type 2 diabetes and weight loss  is successful. Also, in this method, the bowel movements of the patients are quickly restored. While the amount of foods eaten by the method decreases, some of them are excreted without being absorbed. Like all obesity surgeries, this method is also being  applied in those who cannot succeed weight lose with diet, exercise. Also known as Roux-en-Y Gastric Bypass, this method is very effective on diabetes, but this surgery cannot be applied to patients who want to become pregnant. Because in this method, intra-abdominal anatomy is changed also vitamins such as B9 and B12 are lost with oils. In addition, the uterus that grows with pregnancy may cause complications while suturing during surgery.
• Duodenal Switch: Like gastric bypass,Duodenal Switch  is one of the operations that have both restrictive and absorption reducing effects. Duodenal Switch is also recommended for diabetic patients with very high Body Mass Index. With this surgery, a huge mass loss is achieved. Patients who are applied to the method should stay in the hospital longer. Frequent diarrhea can occure after the  surgery. Therefore, after asking patients whether they want to lose weight or not, these side effects should be explained.  Operation takes approximately 2 - 2.5 hours, but patients are expected to stay in intensive care for 1-2 days. Patients who undergo passage x-ray for control should be followed by the endocrinologist and dietician with the  surgical team.

Prepared by Memorial Medical Editorial Board.