W hilst a sixth of humanity doesn't reach the daily intake of calories required to maintain adequate homeostasis in developed countries, we assist the so called "epidemic of the 21st century": obesity. In the developed world we have extremes like the USA with 1.5 million morbidly obese and 4 million of seriously obese, or France and Nordic countries with very low numbers. Spain is situated in the middle of these, however, this isn't negligible if we take into account that 6,9% of the health system budget is spent on treating obesity related problems ( Delphi study).
The shortening of the life expectancy of a person is directly related to obesity. With 50% excess weight, the risk of death doubles after 12 years and five times more if also diabetic. In a study of 200 morbid obese between 23 and 70 years of age the mortality was 12 times greater than normal in the group of 25 to 34 years of age and in the group of 35 to 44 increased another 6 times. 25% died of deaths related to obesity in the 7 year follow up . O besity is the second cause of avoidable death in the united States after ttobacco .
The marked degrees of obesity shorten life spans in relation to the metabolic symptoms they generate. Illnesses like arterial hiper tension (25%), diabetes mellitus (25%), coronary illnesses (5%), respitory insufficiencies (10%), increase in colesterol and triglycerides (30%), gout (20%), osteoarticulate problems (40%) and others such as sleep apnea, gallblader stones, infertility, varicose veins and malignant tumors which in men is 33% higher and in women 55% are associated directly with obesity, To this has to be added the determining factors that the obese suffer, in so far as socially, work and family. The blame usually attributed to their illness, they think they are obese due to a lack of continence, glutony, nothing further from the truth. The latest studies highlight obesity as a multifactor metabolic illness in which the will of the patient has nothing to do with it. It is frequent that the morbidly obese suffer psychiatric disorders (depression, lack of self esteem, suicidal tendencies) in relation to their excess of weight. All these disorders are corrected with the loss of weight, The incidences of mental illnesses in these patients, once they recuperate their normal weight, is the same as that of the general population.
¿Who is obese and to what degree?
Currently the easiest way to measure the degree of obesity is via the body mass index (BMI) Which is calculated dividing weight (in kg) by height (in squared meters). With this parameter normal weight is considered to be between 18.5 and 24.9 (In Spain up to 26.4 is considered normal) with excess weight being between 25 and 29.9, obesity grade I between 30 and 34.9 obesity grade II between 35 and 39.9, obesity grade III or morbid obesity more than 40 and super obese or grade IV with more than 50.
¿Does obesity need treating?
The answer is always yes, since the loss of only 10% of excess weight in patients obesity grade I and II, notabley improves the associated illnesses that these patients usually suffer. The main problem presents itself on trying to maintain this loss with time. The individualised treatment of the diet the increase in physical activity and even the medication colaborate in this group of patients. Paitients with grade II obesity and important associated illnesses are candidates for the most agressive treatments in specialised units and even bariatria surgery. Patients with grade III and IV obesity are candidates for surgery when they fulfil certain requirements:
- BMI above 40 or 45kg above normal weight.
- Adequate medical treatment failure.
- Maintaining morbid obesity for more than 5 years
- Existence of associated illnesses (HTA, diabetes, gout etc).
- Absence of serious psychiatric illnesses and toxic habits.
- The existence of acceptable surgical and anaesthetic risks.
¿Is medical-Dietary treatment viable?
Grades I and II of obesity, should be treated in a doctors consultation on a basis of correct eating. (careful with miraculous diets), modifying dietary habits, increasing physical activity and even medication. To achieve a loss of 10% of the weight is considered a success and correlates with an increase in quality of life and an improvement in the illnesses associated with obesity. To achieve these losses, in the case of morbid obesity is more difficult, they are not sufficient to improve the patients state and are very difficult to maintiain over time. The probabilities of achieving this and maintaining the loss in 5 year controls don't exceed 2 to 4% according to different studies
Although it is very true that a pnderal loss of 10 % in patients with obesity grade I and II results in great benefits if it is maintained, this is not sufficient in patients with more than 40 BMI. This amount is insufficient to obtain benefits and are more difficult to achieve and maintain. The failure of medical treatment of these patients, measured after 5 years, is around a minimum of 96 %.
Surgical treatment of morbid obesity has three different basic techniques to which we can recur.
Restrictive procedures , thier objective is that the patient reduces their food intake. They are simpler and reversible but give a worse quality of life, as once the patient eats a little too much they start to be sick. It is successful in aproximately 50% of cases .
Malabsorption procedures , as its name indicates, it provokes the drastic decrease in the absorption of nutrients, It needs strict postoperative medical control, as it can cause important nutritional deficiencies. It is the most successful in so far as weight loss and the most complex in so far as surgical techniques. It is indicated in patients with extreme obesity, with more than 50 BMI. The expected results are achieved in 90 of 95 % of patients.
Mixed procedures , reduce the stomachs capacity at the same time as producing moderate malabsorption. The standard technique is the gastric by pass, which can currently be carried out via laparoscope . The higher the BMI, the lower the possibility of completing the procedure without opening, to the point that patients with more than 50 BMI are recommended to follow this procedure by opening from the start or to use a intragastric ball (which is put in place via the mouth by endoscope, it swells in the stomach and this way decreases the capacity of the same and the patients appetite. It can only be used for 6 months, to loose the first kilos and help the patient get to laparoscopic surgery. The benefits of the laparoscope are that it is: less painful, less days in hospital, better post-operatory recuperation, the eventrations which in these patients reach 40%, rarely occur and are small (trocar orifice). Achieving the expected result with this technique is approximately 90%.
As with all the surgically procedures, recurring to these procedures entails a morbidity (complications due to surgical intervention) of approximately 10% and mortality (death due to the surgical intervention) of approximately 1%. The most serious complication which could arise from the surgery is the disruption of an internal suture between the two handles of the intestine or between the intestine and the stomach.
This forces the ingestion to be put back and re-operate, depending upon the magnitude of the same. With hope in new medical investigations coming up with guidelines for medical treatment for morbid obesity in the future, currently surgery offers the answer to what can seem a monstrous challenge for health systems. With this reality as a framework and on the bases of our ample experience in laparoscopic surgery (more than 2.000 interventions), a team of hospital specialists composed by surgeons, anaesthetists, endoscopists, intesivists and specialized medical assistants, we faced the challenge of creating an Obesity Surgical Unit at your service
Source: Consensus Meeting SEEDO 2000
- (Spanish Society for the Study of Obesity)
Juan E Basualdo Ormeño
Coordinator of the Minimally Invasive Surgery Unit at Instituto Médico Miramar
Coordinator of the Obesity Surgical Unit at Instituto Médico Miramar .
Email: email@example.com firstname.lastname@example.org
30 days after surgery
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