Introduction to Bariatric Surgery and Basic Understanding
Obesity is a chronic disease that is on the rise worldwide and leads to many serious health problems. Diet and exercise programs are usually the first step in combating obesity. However, in individuals with morbid obesity (severe obesity) or obesity-related comorbidities, these methods may be insufficient. This is where bariatric surgery, or weight loss surgery, comes in. These surgeries are performed not just for aesthetic reasons, but also to improve individuals’ quality of life and to control diseases like diabetes, high blood pressure, and sleep apnea caused by obesity. Bariatric surgery is not just a single operation; it is the beginning of a long-term process that requires the patient to change their entire lifestyle. These surgeries work by reducing stomach volume, bypassing a part of the digestive system, or using both methods simultaneously.
Who is a Candidate for Bariatric Surgery?
Weight loss surgery is not suitable for every obese patient. There are specific criteria for these surgeries. Generally, suitability for bariatric surgery is determined by the Body Mass Index (BMI). BMI is calculated by dividing a person’s weight by the square of their height.
- Individuals with a BMI of 40 or more: They are considered morbidly obese and are generally the first candidates for bariatric surgery.
- Individuals with a BMI between 35-39.9 who have obesity-related comorbidities (type 2 diabetes, high blood pressure, sleep apnea, joint problems, etc.): This group is also among the suitable candidates for surgery.
- Individuals with a BMI between 30-34.9 who have uncontrolled comorbidities like type 2 diabetes: New guidelines state that this group may also be a candidate for surgery. The decision for surgery depends not only on these indices but also on many other factors such as the patient’s general health, age, potential to adapt to post-operative lifestyle changes, and psychological state.
How is the Decision for Surgery Made?
Deciding on bariatric surgery is a meticulous process conducted jointly by the patient and the surgeon. This process is usually managed by a multidisciplinary team. The team is not just composed of a surgeon; it also includes an endocrinologist, a dietitian, a psychologist, and an anesthesiologist. The surgeon evaluates the patient’s general health, the risks, and the potential benefits of the surgery. The dietitian analyzes the patient’s eating habits and creates a post-operative nutrition plan. The psychologist assesses whether the patient is psychologically ready for the surgery and if they can adapt to the changes it will bring. Based on all these evaluations, the decision is made whether the patient is a suitable candidate for the surgery.
Main Types of Bariatric Surgery
There are many different methods used in bariatric surgery. These methods are basically divided into two main groups:
- Restrictive Surgeries: These are surgeries that reduce the volume of the stomach, allowing the patient to eat less.
- Malabsorptive Surgeries: These are surgeries that bypass a part of the digestive system, reducing the absorption of nutrients.
- Combined Surgeries: These are surgeries that have both a restrictive and malabsorptive effect. The most common types of surgery under these main groups are sleeve gastrectomy, gastric bypass, and adjustable gastric banding.
Gastric Bypass Surgery (Roux-en-Y)
Gastric Bypass is one of the most commonly performed and effective methods in bariatric surgery. This surgery has both a restrictive and a malabsorptive effect. During the operation, a small pouch is created in the upper part of the stomach. This pouch is about the size of an egg. The rest of the stomach becomes unused but remains inside the body. Then, a part of the small intestine is cut and connected to this small stomach pouch. This way, food bypasses a large part of the stomach and the first part of the small intestine, going directly down from the newly created stomach pouch. This causes the patient to eat less and also reduces the absorption of what they eat.
Sleeve Gastrectomy
Sleeve gastrectomy is one of the most popular bariatric surgery methods today. This surgery has only a restrictive effect. During the operation, about 80% of the stomach is surgically removed, leaving a thin, tube-shaped stomach. This significantly reduces the amount of food the patient can eat. Another important effect of the surgery is the removal of the fundus part of the stomach, where the hunger hormone ghrelin is largely produced. This helps to decrease the patient’s appetite and increase the feeling of fullness after the surgery.
Adjustable Gastric Banding
Gastric banding surgery is a less invasive method compared to other bariatric surgery methods. During this surgery, an adjustable silicone band is placed around the upper part of the stomach. This band acts like a clamp, squeezing the stomach to create a small pouch. This pouch slows down the passage of food and makes the patient feel full more quickly. The band can be adjusted (tightened or loosened) post-operatively with the help of a port. However, it is less effective than gastric bypass and sleeve gastrectomy and has a higher risk of long-term complications, so it is less preferred today.
Biliopancreatic Diversion and Duodenal Switch (BPD/DS)
BPD/DS is one of the most complex and effective surgeries in bariatric surgery. This operation has both a restrictive and a malabsorptive effect and is usually applied to very morbidly obese individuals. The first stage of the surgery is similar to sleeve gastrectomy, where a large part of the stomach is removed. In the second stage, the end of the small intestine is cut and connected to the stomach’s outlet, the duodenum. This significantly shortens the distance where bile and pancreatic enzymes mix with food. This surgery provides very high weight loss, but also carries serious risks of long-term vitamin and mineral deficiencies.
Single Anastomosis Duodeno-Ileal Bypass (SADI-S)
SADI-S is a method that has gained popularity in recent years and is seen as a simpler version of the Duodenal Switch surgery. The first stage of the surgery is the same as sleeve gastrectomy. In the second stage, the small intestine is cut at a single point and connected to the stomach’s outlet, the duodenum. This surgery has a lower risk of complications compared to the classic Duodenal Switch and provides a similar degree of effective weight loss. At the same time, the risk of vitamin and mineral deficiency is also lower.
Endoscopic Weight Loss Procedures
In addition to surgical operations, weight loss can also be achieved through endoscopic methods. These methods are an option for patients who are not suitable for bariatric surgery or are looking for a less invasive solution. The most common endoscopic methods are gastric balloon and gastric Botox.
Gastric Balloon
The gastric balloon is not a surgical procedure. It is a silicone balloon that is endoscopically placed into the stomach through the mouth. After being placed, the balloon is inflated with a sterile liquid. This occupies a portion of the stomach volume and makes the patient feel full more quickly. The gastric balloon is usually removed endoscopically after 6 or 12 months. This method can serve as a bridge for patients who do not want or are not suitable for surgery.
Gastric Botox
Gastric Botox is also not a surgical procedure. Botox injected endoscopically into the stomach slows down the contraction speed of the stomach muscles. This helps food stay in the stomach for a longer period and prolongs the patient’s feeling of fullness. Gastric Botox is usually effective for 4-6 months. While this method does not provide a permanent and effective weight loss as bariatric surgery, it can be an option for certain patient groups.
Risks and Complications of Surgery
As with any surgical procedure, bariatric surgery also has certain risks and complications. These risks vary depending on the type of surgery, the patient’s general health, and the surgeon’s experience. The most common risks include infection, bleeding, anesthesia-related risks, and leaks from suture lines.
Short-Term Complications
Short-term complications usually occur within the first few days or weeks after surgery. These include; pain at the surgical site, nausea, vomiting, suture line leaks, internal bleeding, pulmonary embolism (blood clot), and infections. Early diagnosis and treatment of these complications positively affect the patient’s recovery process.
Long-Term Complications and Nutritional Deficiencies
Long-term complications that may arise after bariatric surgery include vitamin and mineral deficiencies, iron deficiency anemia, osteoporosis, protein deficiency, dumping syndrome, and rarely, intestinal obstruction. Especially in malabsorptive surgeries, it is vital for patients to use vitamin and mineral supplements for life. Therefore, regular doctor check-ups and blood tests are a must after surgery.
The Importance of Psychological Evaluation
Bariatric surgery is not just a physical change but also a major psychological change process. Therefore, pre-operative psychological evaluation is of great importance. The psychologist evaluates the patient’s eating disorders, emotional eating habits, and ability to adapt to post-operative changes. The patient is informed in advance about the depression, anxiety, and body image issues that may be experienced in the post-operative period, and a support plan is created.
The Role of the Multidisciplinary Team
A successful bariatric surgery process requires much more than just a surgeon. The multidisciplinary team approach meets all the needs of the patient before and after the surgery. The surgeon manages the technical part of the operation, the dietitian creates the nutrition plan, the psychologist supports the patient’s mental health, the physical therapist organizes the exercise program, and the endocrinologist monitors hormonal balance and comorbidities. This teamwork ensures that the patient is best prepared for the surgery and achieves long-term success.
Pre-operative Preparation Process
Pre-operative preparation is a critical stage for the success of the operation. Patients should quit smoking, reduce alcohol consumption, and start a special diet recommended by their doctor a few weeks before the surgery. This diet usually causes the liver to shrink and allows the surgical area to be seen more clearly. In addition, the patient undergoes all medical tests to check for any health problems that may prevent the surgery.
Life After Surgery: Diet and Nutrition
The first few weeks after surgery are one of the most challenging periods for patients. Nutrition starts with clear liquids immediately after surgery and gradually progresses to pureed foods, and then to soft solid foods. To adapt to the new size of the stomach, patients must eat very small portions and slowly. Protein intake is very important to preserve muscle mass. Patients must strictly follow the nutrition plan recommended by the dietitian in the post-operative period.
The Importance of Physical Activity
Weight loss surgery is not a sufficient solution on its own. Physical activity is a must to maintain weight loss and adopt a healthy lifestyle. After surgery, patients can slowly start with walking and progress to more intense exercises with their doctor’s approval. Regular exercise not only accelerates weight loss but also preserves muscle mass, speeds up metabolism, and has positive effects on mental health.
Post-operative Monitoring and Follow-up
Bariatric surgery is not a one-time procedure. Regular doctor follow-up after surgery is vital for long-term success. Patients should have very frequent check-ups (monthly or quarterly) with their doctor and dietitian, especially during the first year. During these check-ups, the patient’s weight, nutritional status, and blood values are monitored. When any nutritional deficiency or health problem is detected, necessary precautions are taken.
Its Effect on Diabetes and Other Health Problems
Bariatric surgery not only provides weight loss but also creates extraordinary positive effects on obesity-related comorbidities. Diseases such as type 2 diabetes, high blood pressure, sleep apnea, and high cholesterol can improve or disappear completely in a short time after surgery. Especially for patients with type 2 diabetes, surgery offers a chance to stop insulin and other diabetes medications or to significantly reduce their dosage.
The Role of Family and Social Support
The process of change after bariatric surgery can be both physically and emotionally challenging for the patient. Family and social support are of great importance during this process. Family members should help the patient adapt to new eating habits, encourage them to exercise, and provide emotional support. Joining post-operative support groups is a great way to share similar experiences and stay motivated.
Gastric Plication
Gastric plication is a method that has started to gain popularity in recent years but has not yet become as widespread as sleeve gastrectomy or gastric bypass. During this surgery, a part of the stomach is folded inward with surgical stitches. This procedure reduces the volume of the stomach. The biggest advantage of gastric plication is that no part of the stomach is removed, and no changes are made to the digestive system. However, there is not enough data on its long-term effectiveness and complication rates yet.
Conclusion: A New Beginning, Not an End
Bariatric surgery is one of the most important steps taken to get rid of the disease of obesity. However, it should be remembered that this is not a magic wand. Surgery only provides the patient with a tool to lose weight. The real success comes when the patient adapts to the new lifestyle after surgery, changes their eating habits, and makes regular exercise a part of their life. Bariatric surgery is not just a physical transformation, but also a new beginning that allows individuals to regain their self-confidence, improve their quality of life, and step into a healthier future.
