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Important questions to the doctor about the surgical treatment of obesity

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Obesity is a serious problem of the XXI century. According to WHO estimates, by 2035 there will be more than half a billion overweight people in the world.

How to help people who can not cope with extra pounds on their own?

The answer is bariatric surgery. This is an effective way for patients to get in shape and overcome concomitant diseases.

Bariatric surgeon, Candidate of Medical SciencesRashid Askerkhanov, in an interview with Tinkoff Magazine, told when it is possible to have an operation to lose weight, whether bariatric surgeries always work and how life changes after them.

WHEN DO YOU NEED BARIATRIC SURGERY?

There are clear indications for the surgical treatment of obesity – this is a body mass index greater than 35 kg / m2 and the presence of diseases associated with obesity: diabetes mellitus, hypertension, arthritis and a number of others.

We not only remove excess weight, the essence of bariatric surgery is not a cosmetic result, but the treatment of concomitant diseases. A body mass index of more than 35 kg / m2 is the second stage of obesity and is already a reason to take a patient for surgery because of the possible consequences of such a condition.

With the help of bariatric surgery, we are trying to change the way we eat by reducing the stomach. That is, we operate on a healthy stomach, trying to make a person start eating normally.

It is impossible to do bariatric surgery only at the request of a person, even if he strongly wants to lose weight. Any operation has certain risks, and they are not small, although in general bariatric surgery is as safe as gallbladder removal or hernia treatment.

WHICH BARIATRIC SURGERIES ARE CONSIDERED THE MOST MODERN?

Now two operations are most often performed:

1. Longitudinal resection of the stomach – it is also called sleeve, that is, "sleeve", or vertical resection. The stomach decreases, the person eats less.

2. Gastroschunting, when the upper part of the stomach is reduced, and then the small intestine is connected to it. It turns out that food bypasses a large stomach, a person eats little, about 50 ml of food, while it is not all absorbed.

There is also an operation to install an intragastric balloon – this is a manipulation that is between conservative and surgical treatment.

The balloon is inserted into the stomach through the mouth and esophagus using a gastroscope. Inside it inflates and takes up half of the free space. It turns out that we reduce the volume of the stomach by half.

The operation is good, but the effect is temporary: the balloon is installed for six months, then it must be removed, its walls are not designed for long-term use.

In any case, the patient must change his lifestyle. Otherwise, the stomach may gradually stretch again, and the weight will return.

 

WHEN DID BARIATRIC SURGERY APPEAR?

Bariatric surgery appeared more than 70 years ago. The first operations were associated with suturing the intestine, reducing its length. They led to malabsorption, that is, a decrease in the absorption of nutrients.

However, after such operations, the weight began to grow again over time, because the small intestine adapted to the changes. In addition, due to food absorption disorders, there was a significant lack of vitamins and trace elements.

Then we developed interventions aimed not only at reducing absorption, but also at reducing the amount of food consumed. This is how bypass surgeries appeared.

The first such operations were not perfect, they were modified – that's how they came to gastroschunting. In the US, this operation is considered the gold standard for the treatment of obesity.

It also turned out that after it, the condition of patients with type 2 diabetes mellitus, hypertension, high cholesterol, arthritis, venous congestion, liver disease and other conditions improves.

Then biliopancreatic bypass surgery appeared, when part of the stomach was removed and the intestines were re-stitched. This operation had a good effect, but after it there were big problems with the intestines and a lack of vitamins.

Later they began to notice that it was possible to do just a longitudinal resection of the stomach without touching the intestines – this operation is about 20 years old.


HOW MUCH WEIGHT CAN YOU LOSE AFTER BARIATRIC SURGERY?

After bariatric surgery, an average of 70% of excess body weight can be lost. The operation does not bring to the ideal weight. A certain percentage of extra pounds remains if the patient does not engage in proper nutrition and increased physical activity.

The first three to four months the weight goes away quickly, then for another year and a half it continues to decline. The time it takes to lose weight depends on the initial body weight: if the original weight was over 200 kg, then it takes two years, if 120 kg – a year.

If the operation was successful, the person will lose excess weight. However, how long the result will last depends on how much the patient was able to change his lifestyle.


HOW DO BARIATRIC SURGERIES AFFECT DISEASES ASSOCIATED WITH OBESITY?

Excess weight greatly affects the quality of life: for example, it is difficult for a person to move around, it is difficult to build relationships, to serve themselves.

Usually obese people also have a large number of comorbidities. These are diabetes mellitus, high blood pressure, sleep disorders, diseases of joints, veins, endocrine disorders – only 5% of people get fatter due to endocrine diseases, the rest have secondary hormonal problems and are associated with excess weight. Even the risk of getting some types of cancer in overweight people is higher than in those with normal body weight.

After bariatric surgery, many of the problems associated with obesity go away. There are studies that have shown that bariatric surgery leads to significant long-term weight loss, diabetes correction, reduction of cardiovascular risk factors and mortality from 40 to 23%.

A 2021 meta-analysis showed that bariatric surgery is associated with a 59% reduction in all-cause mortality among obese and type 2 diabetes patients and 30% among obese but non-diabetic patients.

After surgery, the quality of life can greatly improve. For example, we have a patient, he is 35 years old, weighing more than 300 kg. He could not walk – they brought him to the department on a stretcher. And it didn't fit on one bed, so I had to connect two. After the operation, he lost twice as much weight – up to 150 kg, found a job, was able to serve himself. And there are a lot of such stories.
 

WHAT RESTRICTIONS SHOULD BE OBSERVED AFTER BARIATRIC SURGERY?

After bariatric surgery, the patient eats a small amount of food. If earlier he sat down at the table and could eat whatever he wanted, now he will have to choose.

A person enjoys eating in the same way, but not in such large volumes as before. Sometimes eating habits also change. For example, if a person liked meat, it can become a heavy meal, there will be a habit of eating more fish. This is also usually good for the patient.

In addition, due to a decrease in the amount of food and its absorption, additional intake of vitamins will be required. During the first year, 3, 6, 12 months after the operation, our patients undergo tests, according to the results we adjust what and in what doses should be taken. Next, you need a lifetime intake of vitamins and minerals.

It is also extremely undesirable to drink alcohol and smoke.

After losing weight, excess skin remains. Its small percentage is reduced, but the rest must be removed. That is, in most cases, then plastic surgery is also required. It is carried out when the weight becomes stable and no longer decreases, usually after a year and a half.


IS IT POSSIBLE TO DO BARIATRIC SURGERY FOR FREE?

I work inMoscow Clinical Research Center, which belongs to the Department of the City of Moscow. Every year we carry out a small percentage of bariatric surgeries on quotas for high-tech medical care, that is, free of charge for patients. This year there were only 20 quotas, and the queue for them is already more than 100 people.

It is clear that not everyone can pay for such expensive operations, but, unfortunately, the state cannot either.

Very expensive consumables are used for bariatric operations. In the regions, there are even fewer opportunities to do such an operation for free than in Moscow.


HOW TO CHOOSE A BARIATRIC CLINIC OR A SURGEON?

The main thing is the surgeon's experience in bariatrics. Bariatric operations have their own specifics of execution. If you turn to a surgeon even with long experience, but who has never worked with bariatrics, the effectiveness of the operation will decrease.

There are many nuances in our work. The surgeon knows them only if he specializes in bariatric operations, attends thematic conferences and forums. It is important that he take the appropriate courses, study with more experienced colleagues.

Even in bariatrics, much depends on the anesthesiologist. Patients with high weight are difficult to enter into anesthesia and intubate, that is, to connect to a ventilator. The anesthesiologist should also have relevant experience.

In addition, the clinic should have a good intensive care unit that works around the clock. Not every private clinic will be able to save a patient in a difficult situation, and anything can always happen in surgery.


FEEDBACK FROM OUR PATIENTS

Victoria
Operation – gastric bypass surgery
Weight before surgery – 160.2 kg.
The weight today is 93.2 kg.
"It wasn't easy, but it was worth it! It was worth everything!!! I do not regret anything from the word "at all." I look younger and can finally plan a pregnancy. It's very nice that this is not marketing, but people are really responsible for the result, there is always feedback from the doctor."

Tatiana
Weight before surgery – 122 kg.
11 months after surgery – 71 kg.

Natalya
The operation is a longitudinal resection of the stomach.
Weight before surgery – 120 kg.
The weight today is 60 kg.

GBUZ Moscow Clinical Scientific Center named after Loginov MHD