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Bariatric Surgery

What is Obesity?

While welfare was increasing especially in the Western world in the second half of the 20th century and the 21st century, access to food was also facilitated. The price of food cheapened and the foods become diversified. In addition, certain lifestyle changes, such as “fastfood”, night snacks in front of the TV and changed eating habits – all brought by a fast life – are accompanied by the problem of overweight and obesity all around the world. Unhealthy eating habits, chemical substances and hormones in food and tendency to sedentary life style result in abnormal accumulation of fat in the body, also referred to as obesity. The fat does not only accumulate in the subcutaneous tissue, but also in body organs.

How is Obesity Measured?

Many methods have been developed to date to determine stage or grade of obesity. Many of them are expensive and complicated methods. Therefore, body mass index (BMI) is the most practical method that gives most accurate results. There are various formulas of this method, in which calculations are based on weight and height. This index is easily calculated by dividing the weight of person (kg) by the square of height (meter). In addition, it can be automatically calculated as available in the link (http://vucut-kitle-endeksi.hesaplama.net/).  According to American Health Institute, BMI indicates;

  • normal body weight if the index is 20-24.9
  • Overweight if the index is 25-29.9
  • Obesity if the index is 30-34.9
  • Type II Obesity if the index is 35-39.9
  • Morbid Obesity if the index is 40-49.9
  • Super-obesity if the index is 50 and above.

What is Prevalence of Obesity in Turkey?

According to the preliminary report of the study “Turkish Nutrition and Health Research/2010) that is conducted by the Ministry of Health, the prevalence of obesity in Turkey is;

  • 20,5% in men
  • 41.0% in women
  • 30.3% in total
  • 8% in pediatric group. Obesity surgery and metabolic surgery are very successfully carried out in our country.

What are Obesity Surgeries?

  1. Gastric Balloon

Gastric balloon is the simplest method that helps weight loss. In this method, a balloon filled with fluid or air is placed in stomach under endoscopic guidance and minimal anesthesia. The procedure lasts 15-20 minutes. Thus, capacity of food intake is decreased and sensation of fullness is rapidly ensured. With this method, patients may lose 7 to 8 kg in several months. However, this balloon stays in body for 6 months or maximum 1 year and it is removed with endoscopic method within 5 to 6 minutes. Ease of placement and absence of permanent change in body are advantages, but rebound weight gain is a possibility, if patients do not modify lifestyle and follow dietary restrictions. However, patients try, learn and are educated about how to eat in this 6-month to 1-year period. Although this procedure recently lost popularity, it is preferred for patients, for whom surgery poses high risk, or for super obese patients to make them ready for principal morbid obesity surgery. This method can be ideal for individuals with BMI 30-40 kg/m2.

 

  1. Gastric Band

This method began to be used in weight loss surgeries 15 years ago when daily use of close surgeries became widespread. This method is colloquially known as ‘stomach stapling’ since it compresses the stomach immediately under the area where the esophagus enters into the stomach. This method functions by restricting food intake into stomach. Since it does not cause loss of appetite, patients try to find a way to take food and they consume liquid foods rich in calorie such as ice cream or honey. Despite tabloid news, rate of complication and death is lower than other surgical therapies when it is performed by experienced physicians. Even if it seems advantageous since it can be removed at any time and it does not cause a permanent change in body, long-term success rates are low. In other words, even though gastric band is placed, patients may start gaining weight again with consuming high calorie foods which "trick" the “gastric banding”. Moreover, it may be necessary to remove it because of long-term problems that are faced in 30-40% of the cases.

  1. Sleeve Gastrectomy

This is one of the most common methods used for obesity surgery in our hospitals, since it is easy to practice and leads to less complications although it is as effective as other complicated surgical methods. In this method, 80 to 90% of stomach is removed and transformed into a form of tube. This surgery lasts one to two hours and is performed with closed method. Hospital stay is two to three days. Patients can start consuming normal foods after they eat liquid foods for two weeks and soft foods for the subsequent two weeks after the surgery. Vitamin supplements may be required. It is assumed that ‘ghrelin' hormone secreted in gastric fundus is responsible for gaining weight. This hormone regulates the hunger. In this surgical method, fundus of stomach is totally excised and this helps diminishing appetite and losing weight.

Following this surgery, patients lose about 80% of excessive weight within 6 months-1 year. Conditions arising out of abnormal weight, such as sleep apnea and diabetes, disappear within one year. Patients should chew well and eat foods in small amounts after the surgery. Exercise should not be ignored. Calorie-Liquid foods rich in calorie, such as honey and ice cream, should not be eaten in high amounts to avoid weight gain rebound.

  1. Gastric By-Pass

These methods aim bypassing foods directly to duodenum or initial segments of small intestine with no or minimal contact of foods to stomach by removing a part of stomach or without need to remove a part of stomach. Recently, those surgeries can be performed with laparoscopic methods. Comparing to sleeve gastrectomy, surgery-related complications are more commonly accompanied by long-term postoperative metabolic problems in all of these methods. More weight loss is achieved and can be maintained up to 2 years. While they require more vitamin supplements, they bring about problems, such as chronic diarrhea, bad breath etc.

  1. Duodenal Switch

Since duodenal switch directly affects the metabolism, it leads to more weight loss. It is a good method especially for people whose BMI is above 55kg/m2. This surgery not only limits food intake, but it also reduces absorption of foods. It is an efficient therapeutic method for diabetes, hypertension and high cholesterol caused by excessive weight. It is beneficial for patients who consume foods rich in fat as it decreases fat absorption. Although it is one of the obesity surgery methods that ensure the maximum weight loss, it is not a common one due to many peroperative and postoperative complications. Malodorous chronic diarrhea and vitamin and protein deficiencies secondary to decreased fat absorption are common after this surgery.

  1. Mini Gastric By-Pass

It is a modification of gastric by-pass which can be practiced more easily. After a long gastric pouch is created, the cranial 2-m segment of small intestine is connected to the gastric pouch. Even though surgery time is shorter and the method is less expensive, it is very effective in managing type 2 diabetes and achieving weight loss. Therefore, it is increasingly getting popular. The most important disadvantage is the risk of cancer in the remaining part of the stomach, since endoscopic follow-up is not possible.

Who are good candidates for Obesity Surgeries?

Good candidates are patients with BMI >35, who has comorbidities caused by obesity such as diabetes and hypertension, and patients with BMI>40. However, the surgery should be considered, if weight loss fails despite diet, medication treatment and regular exercise for 6 months. In addition, contraindications include patients, who cannot tolerate general anesthesia, have heart disease and/or psychiatric disorders, and patients, who have giant gastric hernia and resultant esophagitis.

Do Not Be Late For Treatment of Obesity!

Although lifestyle modifications that include limitation of calorie intake and increasing the daily activity, underpin the treatment of obesity, it is not easy to follow and sustain. Although losing weight with diet and exercise is more healthy, it may be too slow and try the patient’s patience.  Unless the life philosophy is substantially modified, quick weight gain is inevitable. Efforts mostly become ineffective. A Swedish study demonstrated that the long-term success rate of diet, exercise and supportive treatment, which were regarded as the pillars of the weight loss once upon a time, is around 2 percent.

The medications that are taken to lose weight have very hazardous side effects, and moreover, the success rate is only around 10 percent. The medical treatment should always be planned and supervised by an endocrinologist or metabolism specialist or an internist, who is experienced in this field, along with a dietician and psychologist. Treatment must be maintained for at least 6 months. Thus, a lucky group that accounts for 2-3% of patients can get rid of this disease. If weight loss fails, other methods can be investigated with a clear conscience and the weight losses also reduce the risk of other methods.

 

Which Surgery is Appropriate For You? 

Preference of a certain method varies depending on the personal characteristics and the experience of the surgeon. The principle “the surgery with least complication is the one, which the surgeon is most experienced” applies to these surgeries. There are two basic mechanisms that underlie all slimming surgeries; limitation of food intake and inhibition of food absorption. Since the sleeve gastrectomy and the bypass techniques use both mechanisms concomitantly, the appetite is reduced and thus, the weight is lost more easily on the contrary to the gastric band, where the patients suffer from hunger.

Postoperative Weight Loss

Postoperative reduced gastric volume and gastric digestive capacity requires that the patients are followed up with a special diet program. Nutrition is regulated liquid foods with particular calorie intake per millimeter in postoperative 2 weeks. The diet is maintained with liquid- solid foods, which do not cause protein deficiency in following weeks. Daily calorie and nutritional needs of the person should be calculated by a dietician who is a specialist in obesity surgery such that it will not impair general health and cause any disease secondary to deficiency of nutritional elements and a diet program should be prepared.

What Are Preoperative Considerations?

Routine preoperative tests are supplemented by cardiology, psychiatry, dietetics and pulmonary medicine consultations and pulmonary function tests in order to maximize the safety of these procedures. Moreover, patients are recommended to eat liquid foods for 2 days before the surgery in order to reduce the edema in the liver and the surgical site.

 

What are Postoperative Considerations?

Each patient is given a list that addresses the postoperative eating style before the discharge; patients are also asked to visit dieticians and general surgeon at periodical intervals and to start jogging 1 week later. Minimum 30-minute jogging is necessary every day. Patients can start swimming 1 month later and doing sports 2 months later. 

What are Potential Problems?

  • Patients are asked to present for follow-up consultation in postoperative Month 1, Month 3, Month 6 and Year 1. The patient should immediately call the primary physician, if redness and discharge in the wound, body temperature above 38 C, abdominal pain, nausea and vomiting are recognized within several days after the surgery. While the problem may be unimportant, there can be a serious condition.
  • The most common postoperative problems are fatigue and tiredness. Tiredness may arise out of rapid weight loss and stress due to surgery. In this case, fluid and protein consumption should be increased and patients should do sports regularly.
  • Eating fast, in high amounts and at frequent intervals and drinking liquids while eating may cause vomiting. If vomiting persists in spite of those measures, we suggest the patients to present for follow-up visits.
  • Constipation may occur. In this case, patients should increase fluid intake. Exercises should be done daily. Moreover, iron supplement pills may cause constipation.
  • In cases of gastric resection, dumping syndrome is probable, although rare, which is accompanied by symptoms, such as nausea, vomiting, diarrhea, hypotension, sweating and gastric cramps. It occurs as a result of consuming intensely sugary foods. Heavy desserts should be avoided before meals. Moreover, as recommended in our diet list, fluids should not be drunk with foods.
  • Hair loss and cramps in legs may be secondary to vitamin, mineral and protein deficiencies. If deficiencies are found in regular follow-up visits, vitamin supplements should be used.
  • Weight loss is usually completed at the end of 1 year. Patients, who do not attend control visits regularly and do not follow the recommendations, can face weight gain problems again.
  • Patients should not get pregnant for 12 months after surgery.