Bariatric Surgery

Today, with the tragic effects of the Covid-19 pandemic, obesity is a major health problem in all developed and developing countries. Obesity is a chronic disease associated with many co-morbidities such as type 2 diabetes, cardiovascular diseases, and some cancers. Body mass index measurement is the most commonly used method in the classification of obesity. The limited long-term success of behavioural and pharmacological treatment in patients with severe obesity has led to an increased interest in bariatric surgery. Bariatric surgery is a globally accepted effective treatment option for obese patients. It helps to achieve noticeable weight loss, improves the quality of life, and decreases the risk of co-morbidities associated with obesity.

The indications and contraindications of bariatric surgery are explained here. However, a personalized treatment plan should be applied for each obese patient.

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• High risk associated with anaesthesia
• Higher risk of some cancers (such as breast, liver, prostate, and colon)
• Low testosterone and erectile dysfunction in men
• Gastro-esophageal reflux
• Gout
• Metabolic syndrome (central obesity, hyperglycemia, dyslipidemia and hypertension)
• Obstetric complications
• Infertility associated with polycystic ovary syndrome
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• Increase in all-cause mortality
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Weight gain negatively affects the quality of life and life expectancy drops. Increased weight-related mortality is also a serious public health problem in Europe, 7.7% of deaths are associated with overweight. Obesity, besides being a health problem, also causes high economic costs. The total medical cost of obesity in the United States is estimated at $147 billion, with a per capita cost of $1429 (42% more than non-obese). Non-medical cost is highly correlated with absenteeism and reduced income.

Many parameters are used to measure and define obesity. Waist circumference, total body fat, body fat percentage, body mass index (BMI), and skinfold thickness can be used. BMI (body mass index) remains the most frequently used measure in the classification of obesity. However, it should be noted that a single parameter is not yet sufficient to adequately define obesity and its associated co-morbidities.

BMI is a strong indicator of all-cause mortality and is directly related to the presence of co-morbidities. According to the weight classification, those with a BMI (kg/m2) >25 are considered overweight, and those >30 are obese. BMI <18.5 is considered thin, 18.5-24.9 is normal, 25-29.9 is pre-obesity, 30-34.9 is Class 1 obesity, 35-39.9 is Class 2 obesity, and >40 is defined as Class 3 (morbid) obesity.

Patients belonging to a certain ethnic group (eg, South Asian) are more prone to the metabolic effects of obesity, and obesity-related comorbidities may occur even at lower BMI values. This is why BMI cut-off values must be individualized.

In addition to lifestyle changes (diet, exercise), and medical methods in the treatment of obesity, bariatric surgery is also a worldwide accepted option. The term “bariatric” is of Greek origin and is derived from the word “baros” (kilo). The goal of bariatric surgery is to achieve satisfactory and permanent weight loss. In fact, weight loss is only one of the results of bariatric surgery. Other beneficial results of bariatric surgery are improved hyperglycemia, hyperlipidemia, blood pressure, sleep apnea syndrome, and quality of life.

Because of these positive effects, the term “Bariatric-Metabolic Surgery” has been used more frequently. Bariatric surgical interventions primarily aim to reduce weight and maintain this weight loss by changing the energy balance via reducing calorie intake and regulating the physiological changes that cause regaining weight. Furthermore, some metabolic benefits other than weight loss can be obtained after surgery concerning the effect of incretin and other possible hormonal and neurological changes.

For example, after gastric bypass surgery in diabetic patients, a rapid and continuous improvement in glycaemic control can be achieved within days without significant weight loss. More than forty anastomosis techniques have been defined since the first days of bariatric surgery, and many of them were abandoned over time.

Today, many effective bariatric surgical techniques are applied. These procedures result in weight loss through a combination of gastric volume restriction, malabsorption, and hormonal changes.

Even with highly effective non-surgical procedures, short-term benefits diminish in the long term. However, the effectiveness of bariatric surgery over medical treatment in terms of weight loss, reduction of co-morbidities and improvement in quality of life has been proved in many prospective controlled studies.

IDF (International Diabetes Federation) recognizes Roux-en-Y gastric bypass, laparoscopic AGB, BPD, DD-BPD, and gastric sleeve resection as acceptable procedures. However, IDF recommends only Roux-en-Y gastric bypass and laparoscopic AGB among these methods, due to limited data on medium and long-term effects of sleeve gastrectomy, as well as nutritional and metabolic concerns about BPD and DD-BPD.

These operations should be performed in fully-equipped clinics with surgeons, anesthesiologists, psychiatrists, psychologists, dietitians, and allied health personnel experienced in bariatric surgery. There are many guidelines for bariatric surgery. Although BMI limits values are 40 and 35 in the guidelines, the FDA is working on approving laparoscopic AGB in patients with a BMI above 30.

Many of the existing guidelines reflect expert comments from the 1991 National Institutes of Health (NIH) Consensus Development Conference Statement. Although the NIH website now states that this guide is outdated and should only be used for historical purposes, the NIH criteria are still accepted worldwide.

Patients who are unable to lose weight or maintain their weight for a long time despite continuing appropriate lifestyle changes and medical treatment [6 months], willing to undergo bariatric surgery and surgical follow-up;