What is Obesity?

The parameter used for obesity is Body Mass Index (BMI). It is calculated by dividing your weight to the square of your height in square meter units. [BMI=weight(kg)/square of height (m2)].

According to the classification of WHO, BMI for the normal individuals shall be betweeen 20-24.9. The values between 24-29.9 means over weighted, 30-34.9 Stage l Obesity, 35-39.9 Stage ll Obesity, 40-49.9 Stage lll Morbid Obesity, BMI> 50 Super Obesity. ¹

Individuals at Stage II and higher obesity stages are recommended diet under regular physician control and participation to the exercising programs.

Despite about 15 kg weight loss is accomplished in the first 1 year with the medical and diet treatment of obesity, the patients regain the lost weights in 1 to 3 years. ^2,8 Moreover, yet no medicine or medicine group has proved to be an effective alternative in the medical treatment of obesity.  ³

When we look at the world in general, it may be seen that obesity is not a problem of only the developed countries but serious obesity problems can ben seen also in developing countries such as Turkey due to imbalanced nutrition.

Surgery: Why, When and by Whom?

The conditions known to severe with obesity are hypertension, heart diseases, hypercholesterolemy, diabetes (Type 2 DM), Sleeping-Apnea, Bone and Joint Disorders, Reflux and vena disorders. ⁴  WHO states and recommends that; in case one or more of the accompanying diseases are present, the patients with BMI>35 and patients with BMI>40, even no related findings are present, should be treated with surgery as the most effective alternative.¹ 

The Applied Surgical Options

We can group the operations performed for the treatment of obesity under three main titles;

1. Volume Restricting Operations

a. Adjustable gut Band (AGB)

Inserting a fully laparoscopic adjustable band to the entrance of the gut and reducing the volume of the gut accordingly. The application is easier whem compared to others and periods of staying in hospital are shorter. It may be narrowed or extended depending on the weight loss. Since frequent adjustment will be necessary, you should prefer a health centre close to your physician. It has high complication rates in medium and long range.

b. Sleeve Gastrectomy (SG)

It is the procedure to narrow the gut with use of special staples under laparoscopic method. Since leakage is possible through staple line after the operation, it requires longer monitoring in hospital (5-7 days). It provides equivalent, and even better, weight losses than AGB. No serious complications are reported after the early post operative period. It does not require quite frequent monitoring. Partial weight gains may be seen in long term.

2. Absorption Reducing Operations

a. Duodenojejunal By-Pass (DJBP)

b. Illeal Transposition

DJBP is by passing big amounts of small intestine and enables a fast passing of nutrition from gut to the last part of small intestine. This fast passing provides a very intense and quick weight loss however may cause important metabolic problems due to serious lack of vitamins and minerals. It requires strict monitoring protocols. Illeal Transposition and DJBP are not being used for the actual fatness treatments anymore.

3. Combined Operations

a. Roux-Y Gastric By-Pass (RYGB)

b. Biliopancreatic Diversion (BPD)

These are unions of both volume restricting and absorption reducing operations. RYGP uses special staplers under fully laparoscopic method and separates about 35 cc volume of the entrance of stomach from the rest and connects the same to the small intestine.

Staple leakages are possible in early post operative period. It has low complication rate in long and medium term. Since it provides lesser absorption restriction when compared to BPD technique, it has nearly the weight loss effects of absorption reduction operation however does not cause serious absorption disorders. Life long use of iron and vitamin pills is sufficient and required. It does not require strict and close monitoring contrary to the adjustable gastric band. It has low weight gain rates in long and medium term.

Biliopancreatic diversion operation leaves about 300 cc wider gastric pocket when compared to RYGP. However a longer small intestine portion is by passed. The patients then may consume bigger portions of meals than RYGP procedure, however a more restricted absorption is the case. This then sufficiently requires life long use of iron and vitamin pills.

The first studies related to the treatment of fatness has started by Kremen in 1954 with a published study on the nutrition effects of illeal by-pass operation .⁵  In 1967, Mason had for the first time described the Gastric By-Pass operation for obesity treatment ⁶, and in 1996 Wittgrove and Clark had published first laparoscopic R-Y by pass series .⁷

In the present time, Roux-Y gastric by pass is being recommended as the golden standard treatment for morbid obesity.

References :

• WHO. Obesity: preventing and managing the global epidemic. Report of a WHO Consultation. WHO technical report series 894.Geneva: World Health Organistion, 2000.
• Gastrointestinal surgery for severe obesity: National Institutes of Health Concensus Developement Conference Statement March 25-27,1991. Published: Am J Clin Nutr 1992:55:615S-9S.
• Pharmacotherapy for obesity: a quantitative analysis of four decades of published randomized clinical trials. Haddock CK et al. International Journal of Obesity (2002) 26, 262-273
• The incidence of co-morbidities related to obesity and overweight: A systematic review and meta-analysis Daphne P Guh, Whei Zang, Nick Bansback, Zubin Amarsi, C Laird Birmingham, Aslam H Anis BMC Public Health 2009, 9:88 doi:10.1186/1471-2458-9-88
• An experimental evaluation of the nutritional importance of proximal and distal small intestine. Kremen AJ, Linner JH,Nelson CI:  Ann Surg 1954;140:439-443
• Gastric Bypass in Obesity. Mason EE, Ito C: Surg Clin North Am 1967;47:1345-1351.
• Laparoscopic gastric bypass, Roux-en-Y: technique and results in 75 patients with 3-30 months follow-up. Wittgrove AC, Clark GW, Schubert KR Obes Surg 1996; 6: 500-504
• Treatment of obesity by moderate and severe caloric restriction. Results of clinical research trials. Wadden TA . Ann Intern Med 1993. Oct: 1;119:688-93