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Morbid Obesity

 

Overweight, Adiposity

 

Als anerkanntes Referenzzentrum für Adipositaschirurgie stellen wir Ihnen bei Baermed mit einem Team aus Stoffwechselmedizinern, Anästhesisten, Psychologen und Ernährungsberatern einen separaten Internetauftritt mit allen Informationen zum Thema "Krankhaftes Übergewicht" zur Verfügung.

www.Adipositas.cc German Language

How does morbid obesity develop?

The ever-increasing prevalence of adiposity (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 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, but this theory cannot be definitely answered at this point of time.

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 confirmed.

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 dietary change. 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 change of 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 only promising conservative treatment option.

Last but not 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 older 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); however, there is usually a slight re-increase in the weight 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, it has to be clarified if the costs are covered by the health insurance.

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 obesity treatment. Prior to the surgery, consultation takes place between all patients and the specialists at an 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 the 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 give up 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 band 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 band, 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. Thanks to the operation, a weight loss of 50-70% of excess weight is usually achieved in 2 years. However, secure long-term results for this operation method are still pending.

In some cases, after a gastric band which has been implanted in the past, especially in the absence of weight loss or strong re-increases of weight, the gastric band has to be replaced by a gastric bypass.

All operations require a surgeon who is experienced in both laparoscopic and in particular obesity surgery, as well as corresponding operational and technical requirements.

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 consultation. The patients are informed about the effects of the different methods, the risks, advantages and disadvantages of the method and the surgeon tries to dispel the patient’s 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 ward. In addition, an X-ray test to verify the outcome of the operation is carried out. In case of non-pathological results, patients are allowed to start drinking. Simultaneously, the patient receives physiotherapy to restore the mobility. On the third day after the operation, a further X-ray test is performed. Step by step, the nutrition is built up again. Drains which were introduced during the operation are now removed.

The surgeon visits the patient twice daily to discuss possible questions or problems. Simultaneously, colleagues of the metabolic centre and nutrition advice offer close monitoring.
Upon completion of the nutrition build-up, the patient is usually discharged on the seventh or eighth day after surgery. After a week, another ambulatory monitoring is conducted in our clinic. Your questions will be answered 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) of 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 of the rehabilitation.

 

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