WHAT IS OBESITY?
Obesity is the accumulation of abnormal and excessive fat in the body to the extent that the amount of calories taken with food is greater than the amount of calories consumed, resulting in a loss of health. Obesity, which is known as obesity among the people, which significantly reduces the quality of life and shortens the life span, is a very important health problem that is growing and widespread. In the world 1.6 billion people are overweight and 400 million of them are obese. According to the survey, one in four men in Turkey (25%), nearly half of women (44%) were identified obesity. It has become a major public health problem because it has been increasingly common and has caused a large number of comorbid diseases. In other words, obesity is an important disease that can cause high blood pressure, heart failure, fatal vascular diseases and psychological problems when it is not treated, rather than an aesthetic problem which is a common belief.

Associated diseases caused by obesity:
Type 2 diabetes
Hypertension, Coronary artery disease, Heart failure
Respiratory disorders
Metabolic syndrome, Insulin resistance, Cholesterol and lipid height
Menstrual irregularities, Infertility, Birth difficulties, Polycystic over syndrome, Excessive hair
Sleep apnea, Sleep disorders
Gastroesophageal reflux
Depression, Social disharmony
osteoarthritis
Arrival
Brain haemorrhage and stroke
Bile stones
Some cancers, such as breast, large intestine, and prostate cancer (obesity surgery has been reported to reduce long-term deaths from various cancers)
Urinary incontinence

WHO WILL BE EVALUATED AS AN OBJECTS?
The most commonly used measurement method for obesity is the body mass index (BMI), which is recommended for use by WHO (World Health Organization). The BMI is calculated by dividing the body weight in kilograms by the square of the square.

Body mass index value Classification

Below 18.5 kg / m² Weak
18.5 to 24.9 kg / m² Normal overweight
25 – 29,9 kg / m² Overweight
Obese between 30 and 39.9 kg / m²
Those between 40 – 50 kg / mВ Morbid obese
Those between 50 – 60 kg / m² Super Obese
Those over 60 kg / m² Super super obese
WHAT IS RISK FACTORS IN OBESITY DEVELOPMENT?
Excessive and incorrect eating habits such as too much food intake or eating with very calorie foods are associated with a decrease in physical activity, age progression, gender (known to be more likely to be women), a high number of births and short duration of labor, hormonal disturbances, dietary practices, metabolic and psychological factors besides genetic predisposition are among the important factors causing obesity.

Obesity is a result of your life style. This is why the lifestyle change in obesity treatment is very important.

OBESITY TREATMENT
In the treatment of obesity, treatment should be given to the cause. If there is a metabolic cause of obesity, it should be treated first. Proper diet, exercise, drug therapy, psychological support and other treatment modalities should be planned. The patient must be analyzed in detail, and it should be demonstrated whether obesity is caused by any organic cause (genetic, endocrine, neurological) or drug use.

Firstly, a personalized diet and exercise program should be planned by a professional team. Drug therapy should be started if necessary. But despite all the struggles, only about 2-4% of patients with long-lasting morbid obesity can lose weight permanently. In other obese groups, gastric balloon placement or morbid obesity surgery is applied as a life saving.

The false perception in our society is that these initiatives are merely aesthetic. However, if they are not operated on, they are actually in the cradle of a fatal disease, and many (if not treated) are lost to their young age.

Morbid obesity is a very serious disease that shortens life and the most scientifically clear proven treatment is possible with bariatric surgeries. These people can live longer and healthier, up to 10-15 years, thanks to bariatric surgery.

STEP STEP OBESITY TREATMENT
STYLE BALLOON
The stomach balloon is becoming increasingly used in the treatment of obesity. In this method, a hollow balloon is inserted into the stomach using an endoscopic instrument. Then the balloon is inflated. Thanks to the area covered by the balloon placed inside, the feeling of premature satiety and satiety is formed in the patients. However, an important difference from other interventional methods is that the balloon is removed after a certain period (6 months – 1 year). Patients lose between 10 and 20% of their weight over the period, according to their structure.

Who is the Stomach Balloon suitable for?
Body Mass Index As a primary treatment in adults between the ages of 18-65 with a weight loss of 30-40 kg / m2 and weight loss as a result of exercise

In super- or super-super-obesity, ta is used as an auxiliary preparation method in the preoperative period to reduce the risk of surgery and anesthesia.

Especially in patients with a risk of surgical intervention, this method is preferred.

Who is not fit for the Stomach Balloon?
Gastritis, stomach ulcer
Previous stomach surgery
Broad hiatus hernia (stomach gland)
Pregnancy and breastfeeding
Alcohol addiction
People with impaired bleeding should not be given a stomach balloon.

How is the Stomach Balloon Applied?
Patients must stay open 8-12 hours before the procedure. The process takes about 10-15 minutes on average. Sedation is applied for the patient not to be disturbed. First of all, endoscopy is performed to evaluate food borne, stomach and duodenum. The jellied balloon is then gently shaken from the food conduit to the midline and the balloon is placed in the stomach under endoscopy control. Using a special extension line, the balloon is inflated with serum in the stomach and the process is completed. After the procedure, the patients are kept under observation for a few hours and eventually they are discharged. Patients do not need to stay in the hospital. However, it is very important that the patients are constantly in contact with the doctor at a later stage.

Discomforts that can occur after applying Stomach Balloon

Increase in pre-existing reflux complaints
Swelling and discomfort in the upper abdomen
Stomach ulcer development due to the mess
Nausea and vomiting
The most common complaints after gastric balloon application are nausea, vomiting. These complaints generally decrease within 3-7 days. However, if vomiting continues, it may be necessary to follow the doctor’s supervision or, in rare cases, remove the balloon in patients who are unable to roll the balloon. If the used balloon is an adjustable syringe balloon, some amount of balloon can be downloaded to make it easier to spend. This will help to regress your complaints.

The actual problematic area during balloon application is the risk of regaining weight after the balloon is removed after 6-12 months, since the limitation on the margin is removed. For this, the patient should try to change his / her lifestyle starting from the time he / she is wearing the balloon and follow the program in coordination with his / her doctor.

As a result, balloon placement in the midair is one of the treatment routes with the least side effects and the lowest risk in overweight patients.

OBESITY SURGERY
Morbid obesity is a fatal disease and a “vital” discomfort that must be relieved. It is thought that those who have undergone morbid obesity surgery add 15 years to their average life span.

Who Obesity Surgery Is Applied To?
Diet: Patients who are scheduled to undergo surgical treatment are those who do not have any hormonal disorder and are unable to lose weight with diet, exercise, and medication, or who have returned their pounds. These patients should have been at least 3 years of obesity problem and have failed at least 6 months of dietary exercise and psychological support. Although the chances of these patients to lose weight with diet and exercise are only 2-4%, they should be tried before surgery.

Age: The patient should be between 18 and 65 years old. This age limit may include exceptions depending on the performance of the patient and the additional diseases.

Body mass index: The body mass index should be over 40 or 35-40, and should be accompanied by disease (high blood pressure, diabetes, sleep apnea, joint disorders, reflux disease, etc.).

The World Health Organization reports and suggests that the most effective treatment of obesity and associated comorbidities in patients with VKI> 40 kg / m2 is surgery, even if there is no consensus, in patients with VKI> 35 kg / m2 in the presence of more than one out of the accompanying diseases. The American Diabetes Association and the International Diabetes Federation are reporting that obesity surgeons are superior to all types of treatment in patients with type 2 diabetes who have uncontrolled blood glucose control despite treatment and who have a body mass index greater than 35 kg / they are telling.

Dependency and Psychiatric Disorder: It is necessary that the patient who is to be treated for obesity does not have alcohol or drug addiction, and at the same time psychological level to be able to accept follow-up and nutritional requirements after the risks of surgery.

Pregnancy and Birth: Obesity surgery is recommended to not get pregnant for 24 months.

OBESITY SURGERY TYPES
Obesity surgical methods can be roughly divided into coins

Restrictive operations; It is surgery that restricts food intake by reducing gastric volume. Stomach band and tube stomach operations are the operations of this group.

Operations that reduce or both restrict food absorption and reduce absorption; These operations are generally called bypass operations. During these operations, the varying lengths of the small bowel are separated from the food passage. Thus, the intake of important parts of the calories taken is blocked by the body. Mini Gastric Bypass, R-Y Gastric Bypass, Biliopancreatic Diversion / Duodenal Switch, Duodenojejunal Bypass / Sleeve Gastrectomy are the operations of this type.

The most commonly used mobit obesity surgery is tube stomach surgery because it is easier, it can be applied in a shorter time, and the risk is partly less.

The surgical patient to be administered;

Additional diseases,
Body mass index
It should be determined according to the eating habits.
Stomach Band
It is aimed at weight control based on volume restriction by wrapping the band to narrow the transition to the upper part of the stomach. Because the results are not satisfactory, the application frequency is gradually decreasing. The complication rate due to handcuffs and the need for serious patient adaptation are 50%.

Sleeve Gastrektomi (Tube Stomach)
In the restrictive surgery group, scientific studies have shown that insulin sensitivity hormones such as small intestine-derived GLP-1 are activated. For this reason, it is not right to treat only as a restrictive surgery. Tube surgery is the process of removing 75-80% of the longitudinal length of the stomach, and is only an obesity practice. Despite the fact that most centers are offered ‘candy surgery’, even in obese Type 2 diabetics, the rate of diabetes control is 50-55%. You can examine the surgical methods for diabetes under the title Metabolic surgery.

Gastric Flushing
It is a process of sewing on its own in 3 rows in 2 rows after liberation of the left outer wall of the scalp and is known as stomach folding. Stomach volume is a restrictive procedure. Hormonal and physiological changes do not occur. Long term weight and diabetes control rates are not very effective.

Combined operations (both restrictive and disruptive)
Roux-Y Gastric bypass and Minigastric bypass are two surgical procedures in this group. While these surgeons play an early role in volume restriction in weight control and blood sugar control, these effects are the consequences of small bowel bypass in the long term. This method, which is accepted as the gold standart surgery in the world in the sense of obesity surgery in many centers in the world, is a negative result about the procedure of long term diabetes development in patients in the long term, necessity of revision surgery in 25% of patients and lifelong vitamin, mineral and iron dependent position of some of the patients .

Absorbent Surgery Operations
Duodenal Switch and Biliopancreatic Diversion surgeries are the most effective obesity surgeries known. Long-term success rates in obese Type 2 diabetes patients are over 90%, both in terms of weight control and in terms of diabetes control. However, besides this positive effect, the patients have iron, mineral and vitamin dependency for life, and the change in toilet habits due to impaired absorption is the most important social problem.

Who Surgery Which?
Patients who are candidates for surgery with a morbid obesity cause should be well informed that a single operation can not be solved and a second attempt may be needed in the future, and Tube gastrectomy should be the primary option in this context.

“By-pass” methods are often used as the first surgical procedure in the presence of very old type 2 diabetes with a body mass index above 60 (super super-obese) or long-acting insulin.

In the stomach by-pass, the problem of not being able to “endoscopically” leaving behind a large stomach epidemic without leaving it “blind”, and the difficulties of translating another intestine when it fails, has changed the meaning and significance of this initiative. In our clinic, the stomach by pass is now only recommended as a second surgery option for a previously unsuccessful tube stomach operation.

However, the “tube stomach” initiative, which has similar effects on weight and sugar control; even if it fails many years later, it can be easily converted to any other amelia. For the second time, a tube can even be re-sleeved and by-pass methods can be stored as a last chance for further use.

As a result, the decision on which patient to perform the surgery is largely linked to the characteristics of the patient. Whether or not there is any obesity surgeon in the first place is important in this decision. The presence of Type 2 diabetes and control, the age of the patient and the experience of the surgical team and the dominance of all bariatric surgical procedures also play a role in this selection. If surgery is not an obstacle; all the characteristics of the patient should be revealed and the most appropriate intervention should be carefully planned by discussing the pros and cons of the treatment options with the patient himself.

How risky is obesity surgeon?
Surgery that treats obesity is in “major surgery” (major surgery) and rarely involves some risks, just as it is after all surgeries. These risks also increase in proportion to the patient’s weight and age.

It is of utmost importance that all “possible” complications and side effects are well known and the patient is fully perceived by the “risk” issue. Morbid obesity is already at a much higher risk than the surgeon’s risk in their present condition! So that; morbid obesity is 10-15 years earlier than their age if they are not treated surgically. This is scientifically proven to be “clear”. It is therefore worth re-emphasizing that we are not talking about obesity at a level that only raises esthetic concern.

First of all, it should not be forgotten; morbid obesity itself is a life-threatening fatal disease.

Death risk
The lethal risk of gastric minus obesity surgery varies between 0.1 and 0.4%. In this case, a lethal risk of 1 to 4 is acceptable when viewed in terms of profit / loss ratio. Lethal risk is 2.5% or less when heart bypass surgery is considered. Coronary by-pass surgeries are currently performed all over the world at this risk. It is therefore important that you do not exceed the accepted risk ratio for the surgery at the universal level.

What are the side effects and complications of obesity / obesity surgery?
The risks of morbid obesity surgery are “general” risks due to overweight and undergoing anesthesia wart operation and possible side effects and complications specific to obesity surgery.

General risks:
a. Anesthesia:
Thanks to modern anesthesia technology and new drugs, the risks of anesthesia have been reduced to almost negligible levels (1/20 000 – 1/30 000).

Clot formation in the legs and pulmonary embolism:
Excess weight; if an operation under general anesthesia is also performed, it increases the susceptibility of the legs to the formation of clots in deep veins. So obesity is a clearly proven risk factor for this type of clot formation. General anesthesia and prolongation of the operation time are additional risk factors for clot formation. The use of “blood thinners”, a low molecular weight heparin, and special “pneumatic” pressure stockings applied directly to the legs, can greatly reduce the risk of this clot formation. Another effective measure of reducing the risk of clot formation is that patients will be operated from the first postoperative hours. Therefore, obes people can do all sorts of operations with the effective taking of some measures. We are trying to minimize the risk by starting low molecular weight heparin before surgery and maintaining it for 10 days postoperatively, using air pressure socks during surgery and postoperatively, and mobilize our patients at an early stage. The shortening of the operation time in proportion to the experience of the surgical team is also an important factor that reduces the risk.

Special side effects and complications
In stomach / tube stomach and stomach by passi operations, the stomach and small intestines, which are hollow organs, are cut from certain points and restructuring is performed. The most feared complications in the early period are; this is due to leakage or bleeding from the cut and closure lines. Despite all the attention and precautions in order to prevent their occurrence, it can be seen in 1-2%. The main point here is that these complications are noticed early in the postoperative period and necessary intervention is done quickly.

It may be necessary to intervene in an emergency with endoscopic, sometimes laparoscopic procedures. Fugitive is an extremely rare condition and it is very important to be noticed early. On the first postoperative day, a radio opaque liquid is poured into the mouth to check for leaks. This is because early outbreaks occur in the first two days after surgery. Patients should be warned in terms of signs of fever and unexplained abdominal pain for late leaks after the 3rd day after discharge. Leakage can be resolved by endoscopic clipping, stenting, percutaneous drainage in CT guidance, and sometimes in cases where they have failed to reoperate. The important thing is that the faecal is recognized immediately and the treatment is done immediately.

Long-term results after stomach reduction
Patients lose weight seriously. If most diabetes is not based on very long years, they may go into remission or complete remission, hypertension and elevated cholesterol level. The conditions that require orthopedic surgery for the spine and the striae can be removed. Sleep apnea improves and sleep has a meaning. Especially the fat that is formed in the liver is lifted. Females who can not have children increase fertility and males improve their sexual functions. It is close to all of the patients with these surgeries; they are more confident, more hopeful, and much healthier. The life of the patients is about 10-15 years.

Long-term problems related to obesity surgery can also be seen. Rarely (1-4%) can develop stenosis in the tube stomach and stitching lines, if necessary after-pass (stomach by-pass or duodenal switch) surgery. Continued excess weight loss, increased reflux symptoms, and a lack of tolerance to solid food, especially meat, in particular, are clinical signs of “stenosis”. These conditions are not difficult to identify and can be expanded with endoscopic balloon applications. rarely, re-surgical intervention may be required for strictures

Do I gain weight again after obesity surgery?
The most important problem in the long term is; it is a tendency to gain weight again. However, the likelihood of weight gain at a morbid obesity level is less than 3-4% in a patient who also has recommended dieting and exercise programs after a tube stomach or stomach by-pass. 7-8 years after surgery, the stomach is left behind and this can ultimately result in a reduction in the effect of restricting food intake and, in some cases, in weight gain. If back weight gain is again at morbid obesity level; in such cases it may be necessary to turn the tube stomach operation into a stomach by-pass or a “duodenal switch”.