Adiposity
How does morbid obesity develop?
The ever-increasing prevalence of adiposity (synonyms: excessive
fatness, obesity) in the western world is essentially the
result of a positive energy balance over several years.
Adiposity develops if the amount of energy that is stored
in the body through the daily assimilation of the ingested
food is greater than the energy consumption of the body.
This is the cause for more than 90% of the overweight cases.
Besides wrong dietary habits (high-fat meals, irregular
intake of food), a sedentary lifestyle plays a crucial role
in causing an excessive accumulation of body fat. Many of
the social factors as well as factors characterizing our
cultural background facilitate the rapid spread of morbid
obesity, which has reached epidemiological levels according
to the World Health Organization (WHO). These include the
increasingly passive leisure activities (computers, TV),
the strategies used by the food industry for advertising
energy-rich foods and sweets, the growing proliferation
of fast-food and ready-to-serve meals, the permanent surplus
of goods as well as food that is offered as a substitute
to lack of integration and affection due to increasing professional
involvement and competition, as well as social tensions.
Only in a few cases, metabolic disorders or intake of certain
medications lead or contribute to obesity. Intensive research
has been going on for several years on the role of genetic
factors. This cannot be definitely answered at this point
of time.
Overweight
Why is obesity so dangerous?
The condition of obesity can be the cause for several diseases
posing a significant risk or hazard to the body. Hypertension,
increase in blood fat and cholesterol levels, diabetes mellitus,
various joint diseases, sleep apnea syndrome, venous disorders,
as well as psychological balance disorders (depression)
and sexuality disorders occur frequently.
The combination with several accompanying diseases, as it
is the case with metabolic syndrome (obesity, hypertension,
diabetes mellitus and hypercholesterolemia) is especially
dangerous. The risk of a heart attack and stroke in comparison
to the population of normal weight strongly increases as
a consequence of these diseases.
The persistence of the above-mentioned changes leads to
many irreversible changes in the organism, which makes permanent
treatment necessary and can negatively influence the quality
of life as well as significantly reduce the life expectancy
of the affected individual. The social stigma of excess
weight (ideal of beauty) that is common practice in today's
world can most often lead to the isolation of patients,
which in turn can lead to social disintegration with serious
personal and social consequences.
The link between morbid obesity and some malignant tumors
(breast, uterine cancer, colon cancer and prostate cancer)
can be considered as certain.
What treatment options are available?
The prevention and treatment of obesity represent a very
big challenge for all those involved. It is certain that
more than 2 million Swiss people are overweight and their
number is steadily increasing. The increase in childhood
obesity is of particular concern. There are numerous conventional
and surgical treatment strategies to combat this.
The basis of any therapy is the change in lifestyle as well
as a shift in dietary behavior. Despite countless diet programs
and fasting "treatment courses", only a very small proportion
of those affected could permanently maintain the achieved
weight loss. A vast proportion of overweight individuals
gain weight after the termination of dietary restriction
and most often reach weight levels higher than the original.
The cause is the lowered energy metabolism in the course
of controlled diet that subsequently leads to an immediate
weight increase upon restoration of the "normal" diet supply.
In addition, a weight loss of more than 5 kg/a can be rarely
attained even in case of a rigorous, long-term diet.
The increase in physical activity represents another mode
of reducing the excess fat, however, a long-term success
can be assumed only if there is a fundamental and lasting
shift in the habits.
The drug therapy for (rapid) weight loss that is particularly
proclaimed in the media is partly accompanied by serious
side effects and rarely as successful as promised in virtually
all cases according to the available studies and experience.
It does not represent an alternative to the above-mentioned
strategies.
The consequent prevention of obesity, starting from childhood
represents the most unique and promising conservative treatment
option.
Last but not the least, surgical intervention proves to
be the ultimate solution for morbid obesity. This is now
acknowledged even by leading nutritionists.
When does a need for surgery exist?
The WHO classifies the weight of an individual according
to the so-called Body Mass Index (BMI). This characterizes
the body weight in relation to body size and is defined
in kg/m².
One speaks of overweight starting from a BMI of > 25kg/m².
Obesity that is divided into three degrees of severity begins
at a BMI > 30kg/m².
Classification
BMI
Normal-weight
18.5-24.9
Overweight
25-29.9
Obesity degree I
30-34.5
Obesity degree II
35-39.9
Obesity degree III
>40
The need for surgery is basically due to various criteria,
whereby this decision must be made taking into account the
statutory provisions that are based on existing medical
knowledge. These include a consultation with the trusted
doctor, a BMI of at least 40kg/m², an age limit (not greater
than 60 years), a minimum of two years of unsuccessful conservative
obesity therapy, the existence of at least one accompanying
disease (hypertension, diabetes mellitus, hypercholesterolemia,
sleep apnea syndrome, heart disease, etc.) as well as the
condition that the clinical care before, during and after
surgery is done by a team of doctors that is familiar with
the disease pattern of the individual. A surgical therapy
may also be done in some cases with a BMI > 35 kg/m².
How much weight can I lose by means of the operation?
Depending on the nature of the operation, the obese
individual loses between 40-70% of his/her excess weight
(so-called excess weight loss), whereby there is usually
a slight re-increase in the weight occurs after a few years.
The rate of weight loss is highest in the first two years
and subsequently slows down.
What must be clarified before the performance of surgery?
The clarifying information that is supposed to precede surgery
is given by a physician who is experienced in the therapy
of obesity. For this purpose, several consultations and
close cooperation with the doctor are usually necessary.
As part of the preliminary investigations, in addition to
the weight history and dietary habits, the secondary diseases,
social environment (family, work), a psychological assessment
and the readiness of the patient for cooperation are questioned.
Moreover, the costs to be borne by the health insurance
have to be clarified.
The decisive factor is the presence of an interdisciplinary
team (metabolic physician, obesity surgeon, anaesthetist,
intensive care doctor and psychologist). This is required
for the competent and holistic care of the patient. This
prerequisite has been met by us through the very close permanent
cooperation with the colleagues of the metabolic centre,
the highly competent team for anaesthesia and intensive
care medicine and the psychologist who are specialized in
the treatment of obesity. Prior to the surgery, consultation
takes place between all patients and the specialists at
a interdisciplinary obesity board.
At the time of entering the hospital, the diagnostics is
supplemented and concluded through some tests (laboratory,
ECG, X-ray of the lungs, lung function test) that are necessary
for the operation.
Surgical techniques
For operative treatment of obesity, we have different methods
for selection, whereby minimally invasive technology is
used without any exception if there are no contra-indications
(exclusion criteria). This leads to a significant reduction
in general and specific risks.
All techniques base upon the mechanisms of restriction (restriction
of food intake by reducing the size of the stomach), malabsorption
(restriction of food intake by delayed merging of food and
digestive juices) or their combination.
In addition to the reported mechanisms, hormonal mechanisms
play an important role because a reduction in the sensation
of hunger is achieved through the operation.
The gastric bypass is based on the combination of diet restriction
and malabsorption. For this purpose, a small proportion
of the stomach is separated from its remainder and then
reunited with a small-intestinal loop. Thus in addition
to the reduction of the stomach size, a delayed merging
of the ingested food / drink and the bile and pancreatic
juices that are needed for digestion is achieved. As a result
of the newly created passage, insulin production is influenced
in such a manner that within 3 months, up to 80% of type
II diabetic patients can forego their medication or insulin
therapy. The weight loss is usually at 70% of excess weight
loss in the first year after surgery.
The (controllable) gastric tape creates a pure restriction.
It is placed around the upper part of the stomach also by
minimally invasive technique, as a result of which a small
"pre-stomach" is created. The width of the gastric tape
allows to be controlled by a so-called port control system
that is used under the skin. Through the implantation of
a gastric tape, the size of the food-processing portion
of the stomach is strongly limited in a mechanical manner.
Moreover, a sense of full stomach is quickly achieved. The
average weight loss is about 50% of excess weight upon good
compliance (cooperation) of the patient.
Another restrictive procedure is the gastric tube formation.
This is also based on the principle of dietary restriction,
but the feeling of hunger is suppressed in this case through
reduced gastric acid production and hormonal effects.
The operation involves the complete removal of a stomach
portion while leaving a narrow gastric tube. Even this surgery
takes place by means of laparoscopic techniques. Through
the operation, a weight loss of 50-70% of excess weight
is usually achieved in 2 years. However, a secure method
for long-term results is still pending.
In some cases, after a gastric tape that is implanted in
the past, especially in the absence of weight loss or re-increase
of weight, there is a need to remove the gastric tape and
place a gastric bypass in the same operation.
All operations require a surgeon who is experienced in both
laparoscopic and in particular obesity surgery. Moreover,
operational and technical requirements have to be met.
Which operation is the right one for me?
This question can be answered only after a thorough survey
of the history, diagnosis and diagnostic findings and the
peri-operative risks in the joint consultation. The patients
are informed on the effects of the different methods, the
risks, advantages and disadvantages of the method and cleared
of doubts. What is important is the assessment by a team
of doctors and psychologists experienced in obesity therapy.
What happens after surgery?
After the surgery, the patient is transferred to the intensive
care unit where he/she usually spends time until the next
day. On the day of operation, a visit is carried out by
the operator. An evaluation of important parameters, as
well as a first discussion on the operation process is accomplished
during the course of the visit.
On the first day after surgery, the patient is relocated
to the normal station. In addition, an X-ray test to verify
the outcome of the operation is carried out. In case of
non-deviant result, patients are allowed to start drinking.
Simultaneously, movement is tried to be restored by using
physiotherapy. On the third day after the operation, a further
X-ray test is performed. This is followed by the stepwise
introduction of the meals. Drains that are introduced during
the operation are removed.
The patient is visited by the surgeon twice daily to discuss
possible questions or problems. Simultaneously, colleagues
of the metabolic centre and nutrition advice offer close
care.
Upon completion of the stepwise introduction of meals, the
patient is usually discharged on the seventh or eighth day
after the surgery. After a week, another ambulatory monitoring
occurs in our clinic. Your questions can also be answered
in this case and first impressions regarding the operation
results will be discussed.
What must be respected in future?
All obesity surgical interventions require a long-lasting
and professional rehabilitation. The aim is to avoid complications
as well as monitoring and ensuring the long-term success.
They include, in addition to clinical examination and regular
weight control, the recording of laboratory parameters and
the current eating habits. As a result of the operation,
there is a need for the substitution (supplementing) some
vital materials (iron, vitamins, calcium). Due to the massive
weight loss in many cases, it is necessary and desirable
to consult a plastic surgeon in the course.