Obesity Center


What is obesity?


Obesity is the accumulation of excessive and abnormal fat in the body to such an extent that it impairs health. Obesity is a chronic disease that is becoming increasingly common worldwide and is one of the main causes of health problems in most countries.  It occurs in 18% of males and 20% of females in developed countries. “Body mass index”, used in the identification of obesity, is calculated by dividing body weight (kg) by height squared (m²). According to BMI, people are classified as low weight, normal weight, overweight, obese, and morbidly obese.

  • Overweight people are people with a BMI in the range of 25 – 29.9,
  • Obese people are people with a BMI in the range of 30 – 40,
  • Morbid obese people are people with a BMI over 40.

What are the health problems caused by obesity?

Some health problems caused by obesity include:

  • Diabetes
  • Hypertension
  • High cholesterol
  • Heart diseases (heart attack, etc.)
  • Stroke
  • Sleep apnea syndrome (intermittent breathing during sleep)
  • Asthma
  • Increased risk of cancer

Does obesity shorten a person’s lifespan?

Yes, studies show that obese people die at a younger age compared to fit people.

What should we do to protect ourselves from such problems caused by obesity?

Weight loss should be achieved through a range of measures ranging from changes in diet and lifestyle to medication. Obese patients who cannot lose weight by using these methods are candidates for bariatric surgery, which enables intake of fewer calories and nutrients. Bariatric Surgery can be applied to patients

  • With a BMI >40 who do not respond to dieting, exercise and medications,
  • With a BMI of 35 – 40 who have health problems such as obesity-induced diabetes, heart diseases and HT, etc.

Are there different surgical methods?

Yes, many surgical methods are used. Among these, the most common surgical methods are:

  • Gastric bypass – is the short name for Roux-en-Y gastric bypass (RYGB) method. In this method, a large portion of the stomach is closed, leaving a small chamber for food. Then, the stomach with reduced volume is joined to the middle portion of the small intestine. This procedure provides a new route in which a smaller amount of food can be taken in and less food is absorbed between the stomach and small intestine.
  • Sleeve gastrectomy – In this method, a large portion of the stomach is taken and turned into a narrow tube, which allows less food to be taken at once.
  • Gastric balloon – In this method, a special balloon is inserted into the stomach by endoscopy. The balloon can remain in the stomach for up to 6 weeks. The amount of food that can be eaten is limited because there is less space left for food during the time the balloon remains in the stomach.

How is surgery performed?

Gastric bypass and gastric sleeve can be performed by open, laparoscopic or robotic methods. In open surgery, a long incision is made in the midline of the patient’s abdomen. Laparoscopic method is performed with the help of camera and flat and thin instruments placed through small incisions made in the abdominal wall. Robotic surgery is a more advanced version of laparoscopic method.

What is robotic surgery?

In the Da Vinci robotic surgical system, surgery is performed through small channels called ports placed through small incisions, as in laparoscopy. The surgeon performs the surgery by sitting in the console of the robotic system, and the surgical instruments of the robot perform the surgeon’s commands simultaneously.


What are the advantages of robotic surgery?


3D Camera

The Da Vinci robotic surgery system has two cameras, each displaying separate images. Thus, unlike laparoscopy, which provides 2-dimensional images, surgery is performed under 3-dimensional images with a sense of depth.  In addition, the operation area is enlarged by 10-12 times with these cameras. Since the camera is under the control of the surgeon, magnified images of the anatomical structures in deep and narrow areas can be obtained. Injuries that may occur during surgery can be minimized.

Surgical instruments

In contrast to laparoscopy using straight and non-twist instruments, the instruments on the arms of the robotic surgery system have the ability to move freely in 7 steps. The ends of these instruments can rotate 540 degrees around their axes and simulate the wrist movements of the human hand thanks to the ‘endowrist’ system.

With these instruments, surgery can be performed in very narrow and deep areas. In addition, with the “tremor scaling” feature of the robotic surgical system, possible handshakes are not transmitted to the instruments in the operation area during the operation, and errors related to human hands can be reduced in the interventions to be performed in risky areas.

Operation of Obesity Patients using Robotic Surgery System

In obese individuals, the fact that the intraabdominal fatty tissue is too high makes the operations technically difficult and increases the risk of switching to open surgery. Robotic surgery enables the obesity surgery to be performed more safely and effectively thanks to its  advantages mentioned above.


How are different surgical methods compared?


Each method to be chosen has benefits and disadvantages.

  • Gastric bypass enables faster and a higher amount of weight loss, but it’s the most complicated surgical procedure. It may cause problems in the absorption of nutrients and may result in insufficiency of some important nutrients.
  • Sleeve gastrectomy is a safer method because it does not change the course of food or because no new connections are made between the stomach and the intestine. Lack of important nutrients occurs to a lesser extent.
  • Gastric balloon method has become more popular in weight loss. It is safer and easier to apply because it involves no incision or suture in the stomach or intestine. However, it cannot enable as much weight loss as surgical methods do.

The patient and the surgeon discuss the patient’s expectations from the operation, the method to be chosen and associated risks and come to a conclusion before the surgery.

What are the benefits of surgery?

In addition to providing weight loss, it helps resolution of health problems such as diabetes, hypertension, sleep apnea syndrome.

Is it necessary to change diet after surgery?

Yes, the diet of the patient is arranged with the nutritionist.


Obesity Surgery Center


Patients who seek information on the Internet are exposed to an information overload. It should be kept in mind that the information on the Internet may include mistakes or ignorances unless they are provided by a reliable source.
Patients can obtain the most accurate and updated information from fully equipped centers, which have been specialized in obesity surgery. One of the most common mistakes is to make head-to-head comparisons of different methods or equate technical differences of the same method.
A successful obesity surgery can be defined in various ways. It can seen as a certain loss of weight in a short period of time for the patient, however the success in fact can only be achieved with a method as universally accepted by the medical community, which maintain the weight loss over the years with minimum side effects, and minimum complications in the long-term.
There are a few institutions which deal with obesity and associated diseases in our country. Further centers which have an academic approach, working in compliance with international standards are needed.


History of Our Florence Nightingale Morbid Obesity and Metabolic Surgical Center


Objectives:

To raise level of awareness and education regarding obesity disease,
To ensure that preventive and protective measures are taken,
To make scientific studies about obesity and publish them,
To implement, improve, and extend the available modern treatment methods, and give trainings


Structure of the Obesity Center


Our unit provides services with staff specialized in the field. Our organizational structure and groups are as follows:

  • Endoscopic and Laparoscopic Obesity Surgery Unit
  • Anesthesiology and Reanimation Department
  • Endocrinology
  • Psychiatry
  • Exercise and Nutritional Physiology Unit
  • Dietetics
  • Plastic and Reconstructive Surgery

Long-term maintenance of treatments such as diet, sports and medications etc. which can be called conventional methods vary from 5 to 8%. These methods are inefficient although they are very expensive.

It has been repeatedly demonstrated that surgical methods used since the beginning of the last century provide successful outcomes.

Surgical treatment of obesity is not a new phenomenon. Since the beginning of the past century, obesity has been treated with various surgical techniques. However, we can consider the 1990s as the period such surgeries became widely used, which can be associated with widespread of laparoscopic procedures.

Widely used modern surgical treatments of obesity have been carried out by laparoscopy, which makes the procedures easier and painless for the patients who are difficult to operate due to their obesity.

Unlike many conservative centers, surgical procedures should not be considered as the last alternative. Patients should be informed of this alternative and should benefit from it as early as possible.

Patients present to our clinic as the last resort since they usually try all other options except surgery. One of the main objectives is to provide patients with an integrated consultation service.

A traditional approach of center experienced in the treatment of obesity should include developing an obesity profile of the patient, analyzing underlying endocrinological and psychiatric disorders, preparing a diet program, organizing pre- and post-operative physical therapy and exercise programs, and close follow-up of the patient.

The answer to the question “Who should undergo surgery and when?” can only be given with a pre-interview and examination.

According to the international criteria:

Obesity surgery is recommended to people with a body mass index of 40 and above. In case of any concomitant disease (cardiovascular disease, diabetes, articular problems, etc.), patients with a BMI between 35 and 40 are also recommended to undergo such surgery.


Which Procedure?


Several diverse methods have been employed for treatment of obesity. To have an insight about these procedures, we need to understand structure and functions of the digestive system.

The Journey of Food:

Food that we eat is liquified by the saliva after they are broken down into pieces by the teeth. Then, the process of swallowing starts where voluntary and involuntary movements are combined. During that process, the tongue moves up and down to propel food along the esophagus. The movements after this phase are entirely controlled reflexively. Epiglottis moves to shut the passage to the trachea while soft palate rises to close off the nasopharynx (nasal cavity) in order to ensure that food passes down the esophagus. Another factor that ensures that food passes down the esophagus is the pressure difference (approximately 60 mmHg).

After the food passes down the esophagus, it is propelled down to the stomach, where waves ensure that contents of stomach in bolus of food are broken into small particles. While stomach has a certain function of digestion, main absorption takes place in the small intestine. Functions such as absorption of water and storage of stool are carried out by the large intestine.

How Do We Have Feeling of Satiety?

Feeling of satiety depends on many factors. It is influenced by social, cultural and personal factors. Physiological studies that have been conducted recently showed that the feeling of satiety is induced by some hormons resulting from the contraction and relaxation of the stomach, leading to the feeling of fullness in the hypothalamus region of the brain.

Obesity surgeries are also called BARIATRIC SURGERY (baro=weight; -iatric = a branch of medicine).

The procedures used for treatment of obesity can be divided into four categories:

  • Restrictive procedures
  • Malabsorptive procedures
  • Both restrictive and malabsorptive procedures
  • Procedures effective on the center of satiety

1. Restrictive Procedures

Gastric banding is the most common restrictive procedure. Commonly known as stomach stapling, it helps with weight loss by restricting the size of the entrance to stomach and providing an early feeling of fullness. Gastric banding procedure can be performed both laparoscopically or openly. Laparoscopic procedure is the ideal one.

There are a few points that should be understood about gastric banding;

Sleeve gastrectomy (reduction of the stomach into a tube) is another restrictive procedure. The stomach is reduced laparoscopically using special instruments. It is less simple than gastric banding. It is used as an alternative to the gastric banding in super morbid obese patients. Although it provides good outcomes, gastric volume may get enhanced over time from time to time, resulting in weight regain.

Recently wide use of gastric balloons help to decrease the amount of gastric space in order to restrict the amount of food that can be eaten. Gastric balloon procedure is difficult to comply with. In the first postoperative days or weeks, nausea and vomiting are common. There is a noteworthy number of patients who ask removal of the balloon before getting adjusted to it.

2. Malabsorptive Procedures

These procedures are not widely used anymore. In these procedures, the upper part of the small intestine is rerouted to allow food to reach the large intestine so that small intestine is bypassed. These procedures are no longer performed.

3. Restrictive Plus Malabsorptive Procedures

A common form of these procedures is gastric bypass surgery. It is one of the most efficacious methods used in morbid obesity surgery. However, it requires a very experienced team as it is a very complicated technique. It is an irreversible technique as flow direction of the stomach and intestines are intervened.

4. Procedures Effective on The Center of Satiety

Such procedures are becoming widely accepted. The most known and common technique is the use of an adjustable prosthesis implanted on the fundus area of the stomach (ENDOGAST). It is much less discomforting to the patient compared to the balloon technique, where a balloon is swallowed into the stomach with fluid. Nausea and pain are the most common problems in patients who are treated with gastric balloon. These problems which are observed during the first adaptation period (complaints are reduced within 3 to 5 days although it may extend up to 2 weeks) are not experienced in gastric prosthesis. No complaints are observed as it is only 7 grams in weight. It is endoscopically placed and removed. It is the most commonly used procedure in our clinic.


New Obesity Treatments


Surgery is the most satisfying method among obesity treatments. The surgical procedures have a higher chance of success. Obesity surgery, as in other surgeries tends to be less damaging for the patient. These methods that we will start to implement soon are as follows:

Endoscopic Methods

These are obesity treatment methods where patients are made sleep or sedated and treated with the help of an endoscope without any need for an incision. These methods can be categorized into several groups.

1. Endosleeve Method: It is a method where a thin plastic impermeable hose is placed inside the stomach, the duodenum, and the small intestine. It is experimental since there is no reliable clinical study yet.

2. Endoscopic Stapling Methods: These are methods where the stomach is reduced by incision without any drilling by stapler-like devices used in laparoscopic operations. Available methods become popular in addition to Stomaphyx and TOGA.

3. Endoscopic Sewing Techniques: Many companies make research on these techniques. The stomach space is reduced endoscopically without any for operation. New products by Bard Endocinch, Olympus Eagle claw, Ethicon are very promising.

Laparoscopic Methods

Single-hole obesity surgeries are becoming popular. At present, sleeve gastrectomy operations are carried out through a single hole. Another type of surgery, which is at the experimental stage, gastric sleeve plication (sleeve operation without gastric resection by suturing folds).

Electrical Methods

Methods such as electrical stimulation of stomach (pace maker), vagal nerve stimulation etc. demonstrated a feeling of satiety.

Drugs:

The idea of using next-generation medicines becomes more popular as mechanisms of appetite are elucidated. Next-generation drugs target hormones involved in the mechanism of fullness and the central nervous system.

THESE METHODS WHICH MAY BECOME ALTERNATIVES TO SURGERY ARE CLOSELY FOLLOWED-UP. SUCH PROCEDURES WILL BE INITIATED VERY SOON.



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