Obesity and bariatric surgery: what do you need to know?

Obesity and bariatric surgery: what do you need to know?

Publication date: 18-10-2022

Updated on: 28-04-2023

Topic: Nutrition

Estimated reading time: 1 min

Obesity is a chronic and debilitating disease that affects about 11% of the Italian population, a number that is steadily increasing. Excessive body weight results in major alterations, both physical and psychological, and affects, often significantly, the lives of those who suffer from it.

Energy and desire to move diminish with every pound that is added to the body, also causing the difficulty of performing movements. Thus, even a walk or playing with children can become difficult due to significant sweating, shortness of breath, and pain. As numerous studies have now shown, it is closely linked to diseases such as diabetes, heart disease, hypertension, and cancer.

The good news, however, is that obesity can also be treated with bariatric surgery. The important thing is to rely on centers that have solid experience and specific expertise in the field.

But which procedures are the most effective? In what cases can bariatric surgery be used? We asked Professor Stefano Olmi, head of the General Surgery and Oncology Unit, Center for Advanced Laparoscopic Surgery and Obesity Center at the Policlinico San Marco, about this.

Hazards of obesity

Obesity is not only a disease itself, but can also promote the occurrence of other diseases.

"Excess weight overloads the joints and spine, leading to major diseases of the osteo-articular system in the long run. It also affects sleep, leading to the so-called "obstructive sleep apnea syndrome," characterized by numerous micro-awakenings of which one is unaware, but which result in important fatigue from the moment of waking up in the morning. 

Obesity results in complex metabolic diseases that easily become chronic and are difficult to resolve with medical therapy. Hypertension, cardiovascular disease and diabetes mellitus are just some of the most important diseases favored and aggravated by obesity. 

Finally, those suffering from morbid obesity have an increased risk of developing neoplasms (colon, breast), gastro-esophageal reflux (it is associated with 30% of patients), urological, dermatological and psychiatric issues," explains Professor Olmi.

When diets and drugs are not enough: bariatric surgery

Bariatric surgery or obesity surgery now offers the possibility of achieving weight reduction in patients with morbid obesity resistant to pharmacological or dietary therapy. 

"The weight loss that is achieved with this type of surgery results in a major change in the lives of patients. In addition to fostering an important improvement in the self-perception, with all the associated psychological benefits, it can lower the risk of development and aggravation of related diseases. Especially in the case of diabetic patients, surgery has been shown in several studies to be more effective than medical therapy alone," the specialist emphasizes. 

That is why, in case of morbid or complicated obesity, the only therapeutic solution is bariatric surgery.

"In recent years, in Italy and the rest of the world, there has been an increasing use of bariatric surgery for the treatment of obesity and the metabolic syndrome, both due to an expansion of health care services through the various SICOB Centers of Excellence (Italian Society for Surgery of Obesity and Metabolic Diseases) in the country, and because of increased awareness by the population and General Practitioners of the extent of the problem and the severity of obesity."

When is bariatric surgery indicated?

"According to the guidelines of the American Society of Metabolic and Bariatric Surgery and of the Italian Society of Obesity Surgery, bariatric surgical treatment is indicated only when the patient has severe morbid obesity, i.e., obesity with a body mass index (BMI) >40 or when it is between 30 and 39 and is associated with at least 1 major obesity-related disease: hypertension, diabetes mellitus, sleep apnea, joint disease, etc.," Professor Olmi notes.

The age of patients eligible for surgery ranges from 18 to 68 years old.

"Surgery can be considered in patients with BMI (body mass index) between 30 and 35 and in patients over the age of 65 only if there is approval from a special multidisciplinary team, consisting of several professionals (anesthesiologist, surgeon, general physician) who, after ascertaining the presence of reduced quality of life given by obesity and the presence of resulting comorbidities, assess the risk-benefit ratio of the surgical procedure and give approval for the surgery."

Relative contraindications to the surgery are severe heart failure, unstable angina, terminal lung disease, cancer under active treatment, portal hypertension, alcohol/drug dependence, cognitive impairment.

Preoperative pathway

Of great importance, in preparation for bariatric surgery, is the preoperative pathway, which is essential to study the patient so that the most appropriate surgery is chosen, the current health status is known, any misrecognized pathologies are assessed, and the patient is better prepared. 

"At the preoperative pathway, the patient is evaluated by several specialists experienced in bariatric surgery. It is thanks to the collaboration of these different figures, both preoperatively and postoperatively, that bariatric surgery finds its source of success," explains the specialist.

The multidisciplinary team that evaluates the patient who is a candidate for bariatric surgery consists of:

  • surgeon;
  • anesthesiologist;
  • cardiologist;
  • psychologist;
  • nutrition specialist. 

"Psychological examination may show elements of absolute contraindication to surgery. Thus, psychosis, including schizophrenia, drug addiction, alcoholism, previous experience of sexual violence, instability of marital relationship, previous suicide attempts are elements that preclude taking the surgical route.

The dietary examination is used to clarify the time and mode of onset of the obesity condition, its progress over time, the duration of remission periods, and the occurrence and severity of relapses. Additional element is the prominence of the coincidence of eating disorders, and binge eating in particular, influencing the choice of surgery.

Depending on the results of common blood tests and instrumental evaluations performed (gastroscopy, manometry, abdominal ultrasound, polysomnography), additional evaluations by other specialists, such as endocrinologist, gastroenterologist, hepatologist, pulmonologist, psychiatrist, may also be required. 

The intertwining of different professional figures is indispensable for the proper evaluation of the patient, confirmation of the surgical indication, and the choice of the most effective diagnostic-therapeutic strategy, taking into account that each qualified center has in its background at least one of the restrictive, mixed, or malabsorptive interventions," Professor Olmi emphasizes.

In patients with gastroesophageal reflux symptoms or the presence of esophagitis at gastroscopy, esophageal manometry is also performed to assess the pressure of the valve that lies between the esophagus and stomach (LES or lower esophageal sphincter). This examination is critical to the choice of surgery to treat acid reflux as well.

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