Obesity is a disease that develops due to excessive weight gain and is characterized by an increase in fatty tissue in the body. Elements such as excessive caloric intake, and less energy consumption due to decreased physical activity may also cause obesity. It is the second most common cause of preventable death, which comes right after smoking. The most disturbing aspect of obesity is the serious deterioration of quality of life. Men tend to gain more weight around the abdomen (central obesity), while women tend to gain more weight around the hips (peripheral obesity).

Obesity is classified by the body mass index (BMI). The body mass index; calculated by dividing weight (kilograms) by height squared (meters) (BMI = kilo (kg) / height2 (m2)). The obesity classification table of the World Health Organization is as follows:

The primary treatment for obesity is diet. Exercising along with diet facilitates calorie expenditure and thus weight loss. Changing living habits (such as active life, healthy eating) facilitates both weight loss and maintaining the current weight.

If the attempt to lose weight with diet + exercise has failed, endoscopic or surgical options should be considered. Endoscopic approaches like Gastric balloon. At the beginning of the surgical options, Sleeve Gastrectomy surgery (Gastric Tube Surgery) comes first, while alternative surgical interventions are Transit Bipartition and Non-Diverted Ileal interposition surgeries.

There are numerous diseases associated with obesity. The main accompanying diseases when classified according to prevalence are;
Degenerative Joint Diseases, Lower Back Pain, Hypertension, Obstructive Sleep Apnea Syndrome, Gastroesophageal Reflux, Cholelithiasis (Gallstone), Type 2 Diabetes, Hyperlipidemia, Hypercholesterolemia, Asthma, Lethal Heart Arrhythmias, Right Heart Failure, Migraine, Venous Stasis Ulcer, Deep Vein Thrombosis, Fungal Infections, Skin Abscesses, Stress Urinary Incontinence, Infertility, Dysmenorrhea (Menstrual Irregularity), Depression, Abdominal Wall Hernias, Increased risk of cancer (such as uterus, breast, colon, and prostate)

The first criterion to be considered in patients who will be planned for bariatric surgery is body mass index (BMI) and the lower limit is 40. In the presence of obesity and an additional disease (such as diabetes, hypertension, asthma, sleep-apnea), BMI should be over 35.

Other criteria sought additionally in patients who are planned for surgery are to have tried diet and exercise before, to be mentally competent to understand and accept the surgery to be performed, not to have a psychiatric disease, and not to have alcohol-substance addiction.

Obesity surgery is medically defined as bariatric surgery. The laparoscopic vertical sleeve gastrectomy (also known as gastric tube surgery) is the most commonly used and well-known method. It can simply be defined as the removal of approximately 70-80 percent of the stomach and giving the stomach an appearance of a tube/sleeve. The structure and integrity of the small intestines are not touched during the procedure, so the absorption process of foods is not impaired and therefore elemental vitamin deficiencies are not expected if the patient continues the oral intake. The reduction of the stomach size and volume, allows the feeling of satiety to occur earlier with less food consumption. A balanced diet, calorie restriction, and less food intake would allow the patient to lose weight controllable.

Apart from sleeve gastrectomy, other current bariatric surgery alternatives are Transit Bipartition and Non-Diverted Ileal interposition. Gastric Bypass should not be preferred because it causes rapid weight gain in the medium-long term.

The routine approach is to evaluate the patients in the preoperative period and to take possible precautions by determining the risks. All patients should be examined in detail during the process of planning the surgery. The main purpose is to detect and treat possible deficiencies and diseases before the operation, and, if necessary, postpone the surgery.

The assessments that have to be done for this purpose, are; evaluation of the lung (such as chest X-ray, pulmonary function tests, consultation from a pulmonologist), assessment of the heart (ECG, ECHO, cardiology consultation, and further examinations like stress ECG, Holter, or angiography if necessary), psychiatric evaluations (questioning the history of drug use, substance abuse, presence of psychiatric disease, and psychiatric consultation), surgical tests (abdominopelvic ultrasonography, doppler ultrasonography, history of previous abdominal surgeries), internal medicine (non-surgical) evaluations (existence of other diseases and treatments being used, internal medicine consultation, etc.), endoscopic exploration (visual assessment of the esophagus, stomach, and small intestine with endoscopy), laboratory tests (blood work, assessment of liver functions, kidney functions, and establishing the bleeding time).

The medications used by the patients should also be taken into account (such as blood thinners, antihypertensive and antidiabetic drugs, and psychiatric drugs). During the operation, some drugs should be discontinued or replaced with other medications, and re-continued after the surgery, as soon as possible.

In the presence of additional comorbidities (like previous operations, heart attack, lung infections, neurological and psychiatric diseases, hypertension, diabetes, and obstructive sleep apnea syndrome), the patient should be checked in the relevant department, and the evaluations and suggestions of the specialist there should be taken into account.

The medications used by the patient must be evaluated, and their use, dosage, or discontinuation in pre-and post-operative time should be planned.

High-risk patients must be hospitalized and treated before the operation.

The patient is discharged from the hospital in 2-3 days after sleeve gastrectomy surgery. The first day of the operation is spent resting, water drinking and short walks are started at the 6th hour after the operation, and the next day, walks are continued at frequent intervals. On the second day, foods such as soup, ayran and juices are started, and on the third day,the patient is discharged.

After the Transit Bipartition and Non-Diverted Ileal Interposition surgeries, the hospital stay is 4 days in total.

Oral water intake begins in a controlled manner 6 hours after the operation. The next day, nutrition is provided with controlled fluid consumption and intravenous fluid support. In oral nutrition, clear liquid support is given (such as water, tea, sugar-free drinks, grain-free soups). Following the gas discharge of the patient, the transition to watery soups, yogurt, ayran, lactose-free milk, kefir is provided. This process continues until the end of the 2nd week.

Between weeks two and four, a transition to a puree diet is made (eggs, omelettes, cream cheeses, fruit-vegetable purees, pureed vegetable dishes, meat-fish and chicken, minced meat). In addition, soft fruits can be consumed during this process.

From the 1st month, a controlled diet with solid food is started.

Dietitian support and recommendations should be followed throughout the nutrition process. We provide follow-up of our patients with a dietitian after the surgery.

The period with the highest weight loss after surgery is the first month. The reasons for this are a low-calorie diet with liquid foods and the loss of excess fluid in the body, along with normal fat loss. After the balance is achieved, weight loss is parallel to the lost fat. The average weight loss seen in the first month is 5-15 kilograms.

In the following months, the average weight loss is between 1-4 kilograms per month. The increase in weight loss is related to how active the person is and how much exercise they do.

Surgery is not applied to patients with a body mass index below 30.

Surgery is contraindicated to patients with severe heart failure, uncontrolled cardiovascular disease, end-stage lung disease, cancer or treated for cancer, cirrhosis in the presence of portal hypertension, uncontrolled substance or alcohol abuse, and people with severely impaired intellectual capacity.

Although every surgical intervention has some complications and risks, there are complications and risks specific to each surgery. What scientifically important is the occurrence and treatability of these complications.

Complications that can be seen in laparoscopic sleeve gastrectomy are; bleeding through surgical incisions, wound problems (such as surgical site infections, and poor wound healing), specific complications (like surgical site bleeding, and leaks after the disruption of the site’s integrity), positional complications of the structural integrity of the stomach (strictures throughout the passage, twisting of the stomach around itself (torsion), etc.), post-surgical complications unrelated to the surgical site (such as lung infections, urinary tract infections, heart problems), long-term complications (weight loss faster or slower than expected, ineffective/inactive weight loss or weight gain, vitamin and mineral deficiencies).

The incidence of these complications ranges from one percent to 1 in 10 thousand to even 1 in 100 thousand. At this point, what’s important is the early diagnosis of preventable complications and the application of appropriate treatment when they occur. Likewise, identification of the causes that increase the risk of complications even before the surgery (such as the presence of other diseases, smoking, alcohol, other factors affecting wound healing, or other diseases that may increase the adverse side effects of anesthesia) and if necessary removing these risk factors first, reduces the prevalence of the complications considerably. Similarly, precautions for postoperative complications can be taken (such as early mobilization, respiratory muscle training, strict aftercare and follow-up, and early initiation of appropriate medical treatment) to ensure the process is completed without any problems.

Another important point in the postoperative period is the early detection and appropriate treatment of undesirable complications. The fact that “Early diagnosis saves lives”, which is always said in diseases such as cancer, is valid for every aspect of medicine, especially in surgical complications. Unfortunately, failure to diagnose a complication at an early stage that can be brought under control with appropriate treatment can cause the situation to worsen and may become uncontrollable and untreatable. Therefore, it is important to inform and check in with the patients at every step and to follow up with the patient closely after the surgery. It should never be forgotten that the experience and knowledge of the surgical team is the most important component in the management of surgical complications.

Gastric balloon is an endoscopic approach. The procedure is performed with sedation and general anesthesia is not taken. It is aimed to provide fullness and early saturation by placing a balloon endoscopically into the stomach.

Depending on the type of balloon used, the duration of the balloon in the stomach varies between 6-12 months. Although the potential for weight loss is acceptable, rapid weight regain following the removal of the balloon is inevitable in approximately 90% of patients.

Perhaps the only effective use of intragastric balloon placement is in super-obese patients (in patients who are planned for surgery but who cannot be operated due to high anesthetic risk) in order to achieve weight loss in a short time (for example, reducing the person from 200 kilograms to 170 kilograms) followed by surgery with relatively lower risks.

Another patient group suitable for its safe use is those who want to lose weight but do not meet the surgical criteria (patients with a BMI of 25-30), for whom relatively less weight loss can be targeted. It can also be applied to patients who are not considering surgery.