Surgically Slim by Tomasz Rogula

In ancient ages, obese individual was considered sick. Hippocrates used to say that a fat man should eat modestly and walk long distances. In the Middle Ages, obesity was a sing of prosperity and wealthy life….but was very uncommon. Currently, obesity is again seen as a disease. Diabetes, hypertension, heart attack, acid reflux, back and joint pain, cancer and many other disorders are more often recognized in obese people.

Obesity became epidemic in the United States in recent years. Every forth adult and every sixths child suffers from being fat. Five percent of Americans is morbidly obese, which means their life is at risk. Forty five percent of adult Americans were obese in 1980, while presently this number increased to sixty five percent. 120 billion US dollars is spent yearly to treat obesity-related diseases.

Obesity is usually caused by bad eating habits. We tend to eat whatever, wherever, and in rush. A candy bar, potato chips and hot-dogs are typical daily snacks. In addition, luck of physical activity, free time spent watching TV, leads to decreased calories burn. Obesity secondary to other diseases (like hormonal) is only seen in every seventh obese individual.

The Body Mass Index (BMI) measures weight and height ratio and is commonly used to assess obesity. BMI tells how many kilograms per square meter our body holds. According to researchers, BMI well correlates with a risk of morbidity and mortality. Those with BMI higher then 25 kg/m2 are considered overweight; BMI over 30 kg/m2 means obesity, and over 40 kg/m2   – morbid obesity. Obesity increases risk of death proportionally to the Body Mass Index: folks with BMI over 40 kg/m2 are in twelve-fold increased risk of premature death.

Dietary or pharmacological therapy hardly ever brings satisfactory, sustained weight loss. Majority of patients regain their weight or become even more obese. No wonder if in 1991, the National Institute of Health considered weight loss surgery (so called bariatric surgery) the only effective method of treatment obesity. Bariatric surgery is offered to those, whose BMI exceed 40 or 35 kg/m2 with concomitant, obesity related disorders.

Most often performed bariatric surgery: the Roux-en-Y gastric bypass leads to largely decreased food intake and lowers its absorption from the gut. Patients can not ingest much food due to smaller stomach. Furthermore, swallowed foods are absorbed much slower. These two effects lead to significant and sustained weight loss. Patients admit their appetite is reduced following the surgery. This effect is related to the exclusion of a part of the stomach producing the Ghrelin – the appetite stimulating hormone.

The operation consists of creating a small stomach pouch, while remaining 90% of the stomach is excluded from digestion. The food goes into the stomach pouch first, then into the intestine where it is been digested after transiting about 150 cm of its initial length. The surgery is currently performed laparoscopically.  Special surgical instruments and a small TV camera are introduced to the abdomen through few small incisions. The surgery is observed by the surgeon on TV screens in the operating room. Besides excellent cosmetic results (no scars), patients benefit from short recovery and early return to daily activities and work – much earlier then after traditional surgery.

The effectiveness of surgical treatment is measured by the excess weight loss. Most patients lose about 100 pound within twelve months after surgery, which is equivalent to about seventy percent of their excess weight. Following dietary recommendation, taking vitamins, supplements and physical activity assures persistent effect. Many obesity related comorbidities like diabetes, hypertension, sleep apnea, osteoarthritis, back pain and increased cholesterol, resolve or greatly improve after weight loss surgery.

Gastric banding is another surgical therapy for morbidly obese patients. This operation was already successfully introduced in Europe and Australia and is recently gaining popularity in the United States. It involves placement of a silastic ring around the upper portion of the stomach. It forms a small gastric pouch which is filled with a food. The satiety sensation is achieved early even with small amount of food. This is a minimally invasive procedure, which does not require cutting or stapling the stomach or intestine. The band can be adjusted with a fluid injected into the port located under the skin of the abdomen. It helps accelerating weight loss.

Sleeve gastrectomy is one of the newest methods of surgical treatment of morbid obesity.  It is recommended for very heavy patients whose BMI exceeds 60 kg/m2 with many coexisting diseases. These patients may be at risk of having complications from more complex and longer surgeries. Sleeve gastrectomy is a stage procedure that allows preliminary weigh loss prior to more difficult operation. Sleeve gastrectomy relies on creating a 100 ml tube (sleeve) from the stomach. Consequently, even small amount of food feels such formed stomach causing satiety.  The remaining larger part of the stomach is cut-off and removed from the abdomen.  The surgery is done laparoscopically, without a need of opening the abdomen.

Regardless of method used, surgical treatment of obesity should be done in a specialized center. The Cleveland Clinic Bariatric and Metabolic Institute is a world leading center for treatment of obesity, assuring a multidisciplinary, highest quality professional service. A variety of tests and consultations need to be done prior to surgery. Psychologists and dieticians work with patients to change their life style and eating habits. Patients also attend support groups to share their experience. The Institute recently received a very prestigious certificate “The Center of Excellence” issued by the American Society of Bariatric Surgery and American College of Surgeon. We treat patients from the United States, Canada, Europe and Asia.

Tomasz Rogula, MD, PhD

Forum, 5/2007