The patient suffering from Morbid Obesity (MO) is "victim" of a severe disease, which is very difficult to treat and cure.
MO is a disease characterized by excessive fat deposits, caused by multiple factors including hereditary, costly, perennial, progressive, life threatening and complicated with multiple serious conditions.
MO is generally a poorly understood disease by the general public and even by the health professionals. It is, after tobacco, the most common cause of preventable death.
MO is not regular O (obesity). O is simple cold compared with fatal meningitis such as the MO.
MO is a simple headache compared with a fatal brain tumor which is the MO.
MO has reached epidemic proportions in the developed countries, and now is also affecting the undeveloped ones.
Actual information includes:
- OM is hereditary. The actual method of genetic transmission is not known. The individual action on the patient is affected by other facts such as cultural, economic, and psychological factors.
- MO is: Caused rarely by alteration of the endocrine glands.
- It is not caused by a lack of will power?
- It is not a psychological or psychiatric disorder. Morbid obesity predisposes the patient to suffer these conditions. It may be due to an eating disorder although the percentage of the population with an eating disorder is not significant. Lean persons have a "biological gift" that is lacking on the obese.
- MO is also life-style disease. Changes in our routine daily life (cars, machines, PC’s use, sedentary life, lesser sports) have made western world life-style prone to the MO epidemic. In 5 years overweight has grown by 40%, MO by 55% and super-super-obesity by 70%.
B.M.I. (Body Mass Index) is the best measure of the degree of obesity. Is BMI = Weight in Kilograms / height in m2.
Normal |
Inferior to 24.9 |
Overweight |
Between 25 and 26.9 |
Mild |
Between 27 and 29.9 |
Moderate |
Between 30 and 34.9 |
Severe |
Between 35 and 39.9 |
Morbid |
Between 40 and 49.9 |
Superobesity |
Between 50 and 59.9 |
Super/Superobesity |
Over 60 |
Standards Committee: American Society of Obesity Surgery; Obes. Surg. Dec.1997; 7:523
MORTALITY of MORBID OBESITY
The increase mortality rate is directly related to weight increase. Diabetic, hypertensive and younger patients has severely shortened their life span. None of the Ginness Book of Records world heaviest individuals lived over 40 years of age. This significantly increase mortality risk of MO patients reverts to normal after WLS (weight loss surgery).
The number and severity of complications are directly proportional to the severity and duration of obesity and the body's fat distribution (waist/hip ratio)
- Diabetes type II of adult onset
- Hypertension
- Sleep apnea and Pulmonary hypoventilation syndrome
- Gallbladder disease
- Gastrointestinal disorders
- Menstrual irregularities
- Degenerative arthritis
- Venous stasis on the legs
- Snoring
- Coronary heart & arteriosclerosis disease
- Increase of cancer (ovaries, uterus, cervix, breast, prostate, etc)
- Increase risks of surgery
- Accident proneness
- Pseudotumor cerebri
- Difficult evaluation (medical & radiological)
1) Clothing limitation
2) Limitation on daily acts of living, poor hygiene and sanitation
3) Limitation in walking, climbing upstairs
4) Sexual limitations
1) Cost of futile weight loss modalities (13 billions/yr. in the USA)
2) Cost of treating various medical conditions due to obesity
3) Lack of insurance coverage or increase premiums
4) Cost of special clothing and devices to perform daily living
5) High rate of school drop out
6) Difficulty in obtaining good jobs
7) Cost of extra food consumed
Psychiatric complications
1) Depression
2) Suicide
3) Neurotic disorders
4) Social withdrawal
5) Guilt, self hate
Lack of respect for the severely obese is common because society do not accept that the MO is powerless in controlling their weight. This intense prejudice cuts across age, sex, religion, race and socioeconomic status. This promotes psychological distress and the patients are at risk for affective, anxiety and substance abuse disorders.
TREATMENT AND MANAGEMENT
a) Non surgical treatment
1) Diets (Weight watchers, Jenny Craig, Nutrisystem)
2) Supervised modified low calorie diets (Optifast, Medifast)
3) Behavior modifications (Tops)
4) Pills and Pharmaceuticals ( Orlistat = Xenical)
5) Exercise programs
6) Combination of two or more of the above
7) Other dieting treatments (Overeaters anonymous)
Non surgical treatment of MO results in 98% recidivism.
Physician's awareness of the medical significance of MO is very low.
Obesity management is replete with quackery.
Surgery is for MO the only viable alternative today and in the foreseeable future.
b) W.L.S. -Weight Loss Surgery:
Only treatment effective for MO as a long-term control measure. The goals are WL; reduce mortality and morbidity (correction of the co-morbid conditions such as diabetes, hypertension, etc.) and an increase in self-esteem and acceptance by society.
Obesity surgery is only indicated with BMI superior to 40 or if obesity is complicated with other medical diseases (comorbidities) if BMI is over 35.
ANATOMY OF THE DIGESTIVE SYSTEM
 
1.- Mouth: Entry point for food; teeth and tongue chew food and move it to the back of the throat for swallowing. The enzyme amylase starts digestion of starches and sugars (carbohydrates).
2.- Esophagus: Carries food to the stomach. It has no digestive function.
3.- Stomach: Holds food and mixes it with acid and saliva. It has not absorptive function!.
4.- Pylorus: The valve that controls the emptying of the stomach. It helps prevent “dumping syndrome”.
5.- Small bowel: This tube,5 meters (15-30 feet) in length, lies in between the pylorus and the large bowel (the colon). 95% of all digestion is carried out here and it is the most important part of the digestive system. It is divided in 3 parts:
- Duodenum : Two feet long (60 cm). Bile from the liver and pancreatic enzymes (the digestive juices) enter this segment.
- Jejunum : The middle portion of the small bowel.
- Ileum : The lower portion.
The jejunum and ileum are the sections where carbohydrates, proteins and fats are absorbed, as well as vitamins and minerals. Iron and Calcium are absorbed in the duodenum.
6.- Large bowel : Starts at the end of the small bowel. Its main function is the absorption of water and holding the stools. Nutrients are not absorbed here. The appendix joins the bowel at its beginning.
7.- Liver : Nutrients absorbed from the small bowel go the liver via the portal veins. It secretes the bile necessary for fat digestion.
8.- Pancreas : Secretes the enzymes necessary to digest carbohydrates, proteins and fats.
SURGICAL TECHNIQUES
Patients should seek assistance by a qualified general surgeon specialized in bariatric (from the Greek "bari"=weight and "iatrein"=treatment) surgery. Preferably the surgeon should be a member of national (ASBS, SECO, SMCO, GICO, etc.) or international (IFSO) bariatric societies.
The patient should acknowledge that long-term follow up is essential since any WLS operation may have (although rare) secondary effects or complications.
Surgical risk
WLS should always be considered major surgery. The most serious complications are gastrointestinal leaks, deep venous thrombosis and pulmonary embolism and the aggregate risk is less than 1%. Re-do surgery has a higher rate of complications.
Risk and efficacy of WLS must be understood in the context that MO is a chronic, progressive and life threatening disease. WLS is designed to last the patient lifetime but adequate follow up is essential.
Results:
The best measure of WLS used to be the %EWL (percentage of excess weight loss). EW (excess weight) is the difference between actual patient weight and the ideal body weight. Long-term (over 5 years) %EWL should be above 50% to be satisfactory.
Today a more accurate measure is the % Excess of BMI loss = %EBMIL. BMI-25 is considerer after surgery goal BMI for a healthy life.
% EBMIL = 100 – [(Follow-up BMI - 25 / Pre-op BMI - 25) x 100]
Long-term (over 5 years) %EBMIL should be above 55% to be satisfactory.
Besides weight loss, success is also measured by improvement in all co-morbidities and QOL (quality of life) such self esteem, social, physical, labor and sexual conditions.
No all WLS operations give similar results!
All WLS are done by a key-hole technique = Laparoscopy. There is no need to open the abdomen by a large incision. Less infection, minimal hernia rate, less pain, early discharge (less than 3 days)
The aim of all surgeries are a) Have a minimal risk; b) life-long %EWL over 50% in al least 75% of the operated patients; c) Good QOL; d) Minimal reoperation rate and e) Reversible if any long-term complications arises.
WLS operations are classified in:
SIMPLE OPERATIONS: Surgery is performed only in the stomach. They are called restrictive operations because the food intake is restricted. They are
|
