Morbid Obesity
Morbid obesity is currently considered as the pandemic of the 21st century.
What is morbid obesity?
Obesity is the excessive accumulation of energy in the body as fat, and the amount of excess fat — especially its location, which determine the condition's severity. The location of fat deposits in the upper body poses the greatest threat to health through increased risk of cardiovascular or cerebrovascular disease.
We can differentiate between android and central, where the accumulation of fat in the neck, trunk, upper abdomen, and facies (more common in men), who are at a greater risk of cardiovascular disease and diabetes. Gynecoid or peripheral obesity, where fat accumulates in the lower body: hips, buttocks, and thighs (more common in women), who suffer from venous disorders of the legs, accompanied by knee and spine osteoarthritis.
Therefore obesity is a chronic disease that is caused by excessive calorie intake, and lack of calorie expenditure (physical activity). This contrast creates an accumulation of energy as fat. It is a disease that results in other conditions or diseases (which doctors call comorbidities) that threaten the lives of obese people, such as diabetes (excessive blood sugar), hypertension (high blood pressure), dyslipidemia (high cholesterol and triglycerides in the blood), cardiovascular disease (angina, arrhythmias, heart attack), respiratory (snoring, sleep apnea possibly requiring CPAP breathing machines), osteoarthritis of the knee (joint pain), lower limb varices, and urinary incontinence etc. It is chronic because it is a disease that evolves over time and is worsened by various diets, for instance those with a yo-yo effect.
How do we measure obesity?
It's not as easy as comparing someone who weighs 100 kg. and measures 1.70 meters in height to another measuring 1.55 meters and weighing the same.
Therefore doctors and nutritionists use BMI: Body Mass Index, also called Quetelet Index, which is a calculation to measure the degree of obesity that a person has. It is a number calculated by dividing the person's weight (in kilograms) by height, and squared (in meters). BMI is used for both adolescents and adults, and is interpreted according to World Health Organization standards:
Body Mass Index
• Ideal weight: BMI between 19 and 25
• Slightly overweight: BMI between 25 and 30
• Mild obesity: BMI between 30 to 35
• Severe obesity: BMI between 35-40
• Morbid obesity: BMI between 40-50
• Super or extreme morbid obesity: BMI between 50-60
To obtain your Body Mass Index (BMI), you can enter your information into our BMI Calculator
Morbid obesityis obesity in which the BMI is more than 40. Within that range and above it is severe obesity, it is easy to deduce that a person suffering from this disease will have all or nearly all of the comorbidities cited above.
These are patients who have tried various methods to lose weight, from fad diets to pharmaceuticals, and liposuction to intragastric balloon.
It is known and proven today that the only effective treatment for these patients is bariatric surgery (surgical techniques or operations to treat obesity).
Surgery is recommended for those with the following:
• Patients with a BMI greater than 35 accompanied by any of the above cited conditions: diabetes, hypertension etc.
• Patients with a BMI greater than 40, who do not show signs of comorbidities, but who can expect to eventually develop them.
These criteria are determined by the IFSO (International Federation of Surgery of Obesity)
Based on personal experience with more than three thousand surgeries to treat obesity, we intend to explain the different surgical techniques, their advantages and disadvantages, so that both patients and physicians alike can distinguish their differences.
Morbid Obesity Surgery
Bariatric Surgery
The following are surgical procedures that are performed to treat obesity. Surgery is based upon the objective to decrease energy intake and reduce absorption of nutrients. Resulting from this objective are: restrictive surgeries that affect the stomach by reducing its size; malabsorptive surgeries that affect the intestine by creating a bridge between the stomach and intestine; and combination surgeries, affecting both organs.
There are two forms of operating: by laparotomy (which is conventional or open surgery), and by laparoscopy (unopened). The latter is done through five holes between 12 and 5 mm in size, through which are performed the techniques identical to open surgery.
Laparoscopic surgeryavoids or reduces the risks posed by open surgery, such as infection of the surgical wound, incisional hernias, respiratory problems, and problems of thromboembolism due to recovery and ambulation. Not to mention, postoperative pain from laparoscopic surgery is minimal.
Pure Restrictive Techniques
Pure restrictive techniques reduce stomach capacity, making it 20 or 30 times smaller than before surgery, without affecting the intestine or more concisely, without affecting the absorption of food (which is why they are called pure restrictive).
Currently there are three techniques:
• Vertical Banded Gastroplasty. VBG: A section of the stomach is stapled at the upper level, in the lesser curvature, creating a pouch of about 30 cc. A band is placed in the distal part of the staple, which encircles the pouch.
• Gastric Band: ring (cinch or gastric belt). A band or ring is put around the upper part of the stomach, which results in a smaller stomach cavity so that the patient will eat less.
• Sleeve Gastrectomy: the stomach is sectioned vertically, forming an elongated tube and the extraneous section is removed; it is an irreversible technique.
Pure restrictive techniques present a significant problem: three out of every four cases regain weight and return to the same weight as before surgery. We do not recommend this type of surgery as a primary treatment. Pure restrictive techniques can be performed as a first step to treat morbid obesity before undergoing combination surgeries.
Postoperative patients learn to eat easily-digested foods that are lighter and can be eaten in greater quantities and, owing to an unchanged absorption of nutrients, they quickly regain the lost weight. It is therefore very important that the patient undergoing a bariatric surgery of any type be aware that they not only must change their dietary habits, but also their lifestyle habits: how to eat (what, how, when, how much, and how often), and they must practice consistent physical activity.
POSE: This technique attempts to reduce the stomach endoscopically through the mouth. It is performed under general anesthesia and it is a technique that's considered investigational, due to patients failing to lose weight after undergoing this procedure.
Malabsorptive techniques
Malabsorptive techniques consist of sectioning the stomach and leaving a capacity of approximately 500 cc. The duodenum, which is the first portion of the small intestine, is sectioned or cut, bridging the intestine to up to 60-100 cm. before it reaches the colon, where it is anastomosed (spliced), thereby diverting bile and pancreatic secretion. This achieves a significant reduction in food absorption, and therefore weight loss.
This surgery prevents the patient from regaining weight and is considered the most effective surgery.
The most serious problem it poses however, is malnutrition due to deficiencies in vitamins, trace elements, calcium, iron, etc. and it produces diarrhea (along with its unpleasant symptoms). The postoperative patient will have to take vitamin supplements his or her entire life.
Given that patients of the various surgeries present these complications, which are sometimes difficult to control, combination techniques are performed.
Combination techniques: Gastric Bypass
The gastric bypass is a combination technique, including a restrictive part, where the stomach's size is reduced, as in the pure restrictive (resulting in eating less), and a malabsorptive part, featuring a gastro-intestinal bridge, which occurs at around 250 cm of intestine (and decreases the area of absorption of nutrients) and, without causing the side-effects of either one technique or the other, allows sustained weight loss over time.
In such surgery, it is not necessary to supplement with vitamins and trace elements, although patients must undergo annual checkups to detect any deficiency before it before it becomes serious.
Today gastric bypass surgery is the most commonly performed surgery in the world. Laparoscopic gastric bypass surgery is considered to be the best and most effective technique available to treat morbid obesity, i.e. the "Gold Standard" of bariatric surgery.
