Obesity Treatments

Since 2014, it has become the most frequently performed bariatric surgery in the world. By most bariatric surgeons it is considered as a first choice surgery to be performed for the treatment of obesity. It is a restrictive, volume-limiting surgery. The stomach is cut through a tube which is placed through the mouth and approximately 75-80% of the stomach will be removed. The remaining stomach takes the form of a thin long tube. The patient will be satisfied with small portions and weight loss will be achieved. Weight loss rates are similar to other bariatric surgeries. In addition to its restrictive effect, it also contributes to the improvement of diabetes with the hormonal changes it causes. It is primarily preferred in patients with obesity. Vitamin-mineral support is often not required in the long term, as it is not an absorbable surgery.

It is a safe surgery that has been performed for more than 20 years and its long-term results are known. Weight loss and diabetes remission rates are quite good. The fact that it is a single anastomosis increases its reliability. The stomach is turned into a closed tube as the continuation of the esophagus, and the remaining stomach is left in the abdomen. A new pathway is created between the small intestine and the newly formed gastric pouch. The contact of food with the first 150-200 cm of the small intestine is prevented. This situation creates a controlled absorption disorder and provides weight loss; On the other hand, diabetes is controlled by hormonal changes. It is preferred in patients with metabolic problems. Since it is an absorbable operation, vitamin-mineral support may be required in the postoperative period. The disadvantage is that the remaining stomach cannot be reached endoscopically.

It is an endoscopic procedure that does not require general anesthesia and surgery. The approximate application time is 10-15 minutes. It does not require hospitalization, a few hours of rest after the procedure is sufficient. The gastric balloon is inflated with air or liquid between 400-700ml. It creates a volume-restricting effect and limits oral food intake. When combined with a low-calorie diet, it provides an average of 15% weight loss. Nausea, vomiting and cramp-like pain can be observed in the first 48-72 hours after the application. There are balloons that can stay in the stomach for 6-12 months. When the balloons expire, they are also removed endoscopically.

Botulinum toxin is a toxin created by Clostridium botulinum bacteria that causes temporary relaxation in the muscles. Stomach botox is the process of endoscopically injecting botulinum toxin into the stomach tissue. When injected into the gastric tissue endoscopically, it has the effects of delaying gastric emptying and decreasing appetite. It has not been shown to have a weight loss effect on its own. However in combination with a low calorie diet it shows to help in losing weight.

The advantages of the procedure are that it is reversible, does not require surgery, and the rate of side effects is very low. The weight loss obtained in some studies with Botox application seems to be low and more dependent on the diet applied.

After bariatric surgery, sufficient weight loss may not be achieved in some patients. This condition is often due to inadequate surgery if there is no other underlying cause. For example, leaving a large stomach in sleeve gastrectomy or not adjusting the bypassed bowel size well in bypass surgeries. An overlooked metabolic disease may also result in inadequate weight loss in an obese patient who was poorly evaluated preoperatively. For example, undiagnosed Cushing’s syndrome.

In some patients, weight gain is observed after weight loss. Weight regain is observed in approximately 15-20% of patients after bariatric surgery. This may be due to inadequate surgery, patient non-compliance, or an underlying metabolic disease.

The following factors are among the causes of insufficient weight loss or regaining weight in obesity surgeries.

Surgical/anatomical factors:

• The stomach is not sufficiently reduced

• Enlargement of the remaining stomach pouch

• The distance of the stapler line to the pylorus

• Bypassed bowel length

Hormonal/metabolic imbalance:

• Ghrelin, serotonin Pancreatic polypeptide (PP), Glucagon-like peptide (GLP-1), leptin, cholecystokinin… changes in hormone levels

• Pregnancy

• Steroid therapy

• Newly developed cushing’s syndrome

Behavioral/psychosocial factors in the postoperative period:

• Non-compliance with diet

• Inability to change eating habits

• Inability to make lifestyle changes (exercise, sports)

• Anxiety and depression

Although surgical/anatomical factors are at the forefront in weight gain or insufficient weight loss; Behavioral and psychosocial aspects should also be emphasized. These are important because they are preventable and correctable causes.

Before the decision of surgery is made, the patient’s nutritional habits, dietary compliance, current body mass index and co-morbidities must be questioned. The success rate of revision surgeries will be low in patients with weight gain due to post-operative diet incompatibility.

Revision surgeries are planned individually, taking into account the first operation and the characteristics of the patient.

Metabolic surgery is often associated with obesity surgery or bariatric surgery. What we understand by metabolic surgery is surgeries that provide metabolic changes by causing hormonal changes. For example, changes in GLP and neuropeptide Y levels, and changes in insulin resistance and, as a result, normalization of blood sugar.

All obesity or bariatric surgeries also have metabolic effects. Obesity surgeries cannot be considered independent of their metabolic effects. For this reason, all obesity surgeries are also metabolic surgeries. The reverse is also true, all of the surgeries we perform to take advantage of its metabolic effects have weight-loss properties.

As a result, all obesity surgeries are also metabolic surgeries and all metabolic surgeries are bariatric surgeries.