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500 Poles suffer from severe and extremely severe obesity, which means that their BMI exceeds 40 and 50. We are fifth in the world in the number of obese people, and our children gain weight the fastest in Europe. Surgical treatment of obesity is already reimbursed by the National Health Fund. This is a breakthrough described by prof. Mariusz Wyleżoł, chairman of the Metabolic and Bariatric Surgery Section of the Polish Society for Research on Obesity.
Zuzanna Opolska, Medonet: Yesterday’s patient L is wearing size XL today?
Prof. Mariusz Wyleżoł: I often treat patients who were of the ideal weight by the age of 18. Losing just a kilo each year, they weigh a hundred after 30 years. They already have the first complications of obesity: the onset of diabetes, hypertension, their knees hurt and their calves are swollen. An innocent kilogram in a year, after 30 years, has become a metabolic disaster for the body. But let’s think if we really are able to control our own body weight …
It’s so hard?
If we disturb the daily energy balance by only 20 kcal, we will gain weight in a year. These 20 kcal are only one percent of our daily requirement. It’s also one teaspoon of sugar. It is enough that we add it to tea by accident. We can compensate for this disturbed energy balance by covering, for example, 200 meters on foot. Do you believe that we are able to decide on a daily basis whether we will eat one teaspoon of sugar more or walk 200 additional meters? I do not..
This does not sound optimistic. However, we had years to avoid it.
Of course, because we should think about what we eat and not treat our body as a garbage can. And if we do not feel the signal of hunger, then do not eat for the sake of eating. And certainly not by the way: driving a car or watching TV. Today everything revolves around the plate: meetings with friends, birthdays, holidays, we cook on breakfast TV and compete for taste buds in culinary programs. Probably all of us have a predisposition to develop obesity. And all obesity starts with losing weight.
Because it ends with the yo-yo effect?
Unfortunately yes. In most cases, there is not only an increase in weight by the lost kilograms, but also its further increase. In this way, after several attempts to lose weight, many patients find a body weight well above the initial weight when the decision was made on the first diet. It can be said that such a procedure is not only ineffective, but has the opposite effect, as it leads to the further development of the disease.
We will talk about those who qualify for obesity surgery. What does the doctor consider when sending a patient for such a procedure – BMI, WHR (waist to hip ratio) and fat tissue measurement?
We are becoming more and more critical of BMI, but I must admit that we have nothing better than this indicator for now. Classic indications that have been in force for many years for such operations are BMI over 35 with complications of obesity. Recently, the role of bariatric surgery, or rather metabolic surgery, has been emphasized in the treatment of type 2 diabetes in patients whose body mass index is often below 35. Many scientific societies have adopted such guidelines after a conference in London earlier this year. The Polish Diabetes Society is also considering this possibility.
What about body fat measurement?
It is of major importance in the case of people with excess body weight which is borderline, but resulting from extensive muscle tissue. For example, in soldiers or bodybuilders. According to the BMI they are obese, but when we analyze the body mass composition, there is no basis for the diagnosis of obesity. Then we also have a problem, the patient does not in fact suffer from obesity, but its weight is devastating for the musculoskeletal system, e.g. joints. Of course, the devastation associated with excess body fat is much more dangerous because it leads to metabolic disorders.
Is the patient’s age also the criterion? Apparently, patients over 65 are not operated on?
Suppose you are 65 years old and one day old. She feels young, professionally active, has a family, children and grandchildren. Yes, you have a BMI 36 and you were diagnosed with type 2 diabetes. Doctors tried to treat her with pills and insulin, which unfortunately led to weight gain. Eventually, they offered surgical treatment. And the surgeon checked the social security number and said no. One day too many. This is nonsense. Yes, there are some frames, I mean the upper limit of 60-65 years. But in the case of the elderly, we assess the biological age, not the record age, and qualify for surgery on this basis. It is worth emphasizing that in this case, the goal of treatment is not to extend life expectancy, but to improve its comfort.
What about the lower age limit? Children and young people under the age of 18 are not operated on in the United States.
I often hear from other doctors that we cannot hurt a child and cut 80 percent of his stomach. But if we are diagnosed with leukemia at a young age, no one doubts that chemotherapy will be given. Although it is harmful and may have various consequences in the future. We treat because it is the only effective method. If we diagnose obesity in a child, who progresses year by year, is abused by peers, feels alienated at school, it is known that in the future he will have little chance of finding a life and work partner, and he is at risk of numerous complications of obesity. . Let us not deny such a child the only possible method of treatment. Let us operate while maintaining the qualification criteria.
What are the criteria in adolescents?
Completed puberty, most often assessed on the basis of bone age, appropriate stage of the disease, emotional maturity, ineffectiveness of conservative treatment and, very importantly, support from the family. For many years, when there were no children’s surgery centers, we also operated on such patients. My youngest patient was 13 years old and weighed 140 kg.
These are probably not common operations in Poland?
Recently, Polish pediatric surgeons have become interested in bariatric surgeries. For several years, they have been used by doctors from the Children’s Memorial Health Institute, and soon they will be joined by surgeons from the Children’s Surgery Clinic in Katowice. I hope that the approach of pediatricians to obese children will also change.
How is it today?
Unfortunately, my experience so far is sad. Once a nurse with a 16-year-old daughter with advanced obesity came to see me. I asked for an additional consultation with a pediatrician. During the visit, the doctor asked her if she lived in the north of Warsaw or in the south. Do you know why?
Not…
Because if he lives in the north of Warsaw, he can run near the Kampinos Forest, and if in the south, then around the Kabacki Forest. And surgery is not needed. In my opinion, pediatricians do not see the problem. Just as there are advanced forms of various diseases, in the case of obesity, regardless of the patient’s age, there are situations when surgery is the only chance. This sixteen-year-old girl had to wait two more years.
Check: What is the diet after bowel surgery?
Got fat?
Of course, and then we operated on her. But this surgical intervention was actually overdue. Why wait two years for the disease to progress, which is associated only with negative consequences for the body?
Which of the methods of obesity surgical treatment gives the best results?
All. A modern bariatric surgeon should use both a gastric balloon, a bandage, a radical sleeve gastrectomy and gastric bypass *. We come across various scenarios, the severity of the disease, and complications. Otherwise, we should treat a twenty-year-old, forty-year-old and sixty-year-old. In other words, a patient who weighs 120 kg and a patient who weighs almost two hundred.
In the social consciousness, treatments to save the obese are a balloon placed in the stomach.
It is an excellent tool whose therapeutic role has unfortunately been distorted. I had patients that the six-month period of using the balloon would allow them to change their eating habits and lead to a permanent weight reduction. Research has shown that many patients returned to where they started after it was removed. The balloon should primarily be treated as a preparatory treatment for bariatric surgery. As in oncology, we are talking about neoadjuvant treatment. In advanced neoplastic disease, we first use preparatory treatment – we provide radiation, we administer chemotherapy. In the case of the most advanced forms of obesity, we first use a balloon, thanks to which we are able to apply surgical treatment in the next stage.
Who is the best method for?
I attach importance to what the patient expects. During the operation, I will spend an hour or two with the patient, take care of him in the ward, and then we will meet once a month. He will be left with the operation for life. I can always suggest – in your opinion, the idea of treatment is not appropriate, because it will either be insufficiently effective or it will be an abuse of medicine.
Each method must be reliably presented to the patient. And he will choose the most appropriate one for him. And he will either enjoy it every day or worry more than once. Besides, as in any field of medicine, there are ups and downs. There are also some periodic fashions. All it takes is a new study whose results will shake the foundations of a given field. My 26 years of experience in bariatric surgery shows that any method, even the currently not used Payne-de Wind (bowel surgery), was better than doing nothing. I hear it from patients too. Because even if these patients were not operated laparoscopically, but more invasively, thanks to these operations they are still alive.
Can you die during such an operation?
If we refer to the results of large studies conducted in the United States, the risk of death in a group of 20 patients was 0,3 percent. It is therefore lower than the risk of death in cholecystectomy, which I believe is widely accepted. The thing about medicine is that we are able to help the vast majority of patients, but there are dramas. We usually charge doctors for the occurrence of complications, forgetting that it may be negligence on the part of the patient who has been neglecting disease symptoms or different anatomical conditions for years. For example, in the case of radical sleeve gastrectomy, we always cut the stomach in the same way. In 99 percent of patients it heals perfectly, and in one percent it does not. The question “why” naturally arises. There are many possibilities. The vessels may have been constructed differently, or the 20-year disease has led to disturbances in blood flow in this area. We cannot predict this. On the other hand, the progress made in recent years in terms of outcomes and safety in treating patients is unimaginable.
Will the new AspireAssist moteda, a pump that sucks a third of the food out of the stomach after a meal and discharges it into the toilet, revolutionize the fight against obesity? Many experts believe that this is simply “mechanical bulimia”.
It is definitely an interesting idea – to suck out some of the consumed food directly from the stomach. However, at present it is difficult to clearly define the place of this device in the treatment of obesity. As with other novelties in medicine, we have great hopes for them, and unfortunately life often verifies them negatively.
And what kind of “slimming” surgery are most often asked by patients?
Unfortunately, patients often use the information available on the Internet. And they find what is screaming the loudest, not the truth. Even online patient forums lie to reality. Some people are euphoric after the operation, they share information about kilograms that go down and centimeters that disappear. Readers think it’s for for them too will be the best solution.
And what happens next with these lean, euphoric ones?
When problems arise and a second operation is necessary, these patients disappear from the forums. There is nothing to brag about anymore.
Do you often need a repeat operation?
Between 2 and 4 percent of patients are re-operated on each year. So, if I operate on 80 patients today, then after a year I will operate on two of them for the second time. After another two years, ten after five, and twenty after ten. Thus, after a decade, surgery still works in XNUMX percent of patients. I leave you to judge whether it is good or bad in the face of our total helplessness when it comes to the conservative treatment of obesity.
Professor Mariusz Wyleżoł, graduate of the Faculty of Medicine of the Medical University of Silesia, in 2010 appointed professor of the Military Institute of Aviation Medicine. A long-time researcher and teacher at the Surgery Clinic of the Medical University of Silesia in Zabrze. He was the chairman of the Metabolic and Bariatric Surgery Section of the Society of Polish Surgeons and the representative of Europe to the Main Board of the International Society for Surgical Treatment of Obesity (IFSO). Currently, he heads the Surgery Clinic of the Military Institute of Aviation Medicine in Warsaw and chairs the Metabolic and Bariatric Surgery Section of the Polish Society for Research on Obesity.
The surgical interventions mentioned in the medical history mean:
1. Gastric balloon – involves endoscopic insertion into the stomach of a soft balloon filled with physiological solution or air for a period of six months. By partially filling the stomach, the balloon provides a feeling of fullness after eating a much smaller meal than before.
2. Band – an adjustable silicone band is placed over the upper part of the stomach, creating a small (30-50 ml) gastric pouch which limits the volume and frequency of meals. The narrowed passage to the lower stomach slows emptying.
3. Radical sleeve gastrectomy – involves the removal of the lateral 2/3 of the stomach, turning it from a bag into a narrow sleeve. It increases the rate of passage of food through the stomach and significantly reduces the secretion of ghrelin (the hunger hormone), because it is produced in the part of the stomach that is removed during a sleeve gastrectomy.
4. Gastric bypass – involves cutting the stomach into a small pouch, which is then sutured with the loop of the small intestine. In this way, a twofold therapeutic effect is obtained: a reduced stomach prevents unrestrained eating, and food flows directly into the small intestine, bypassing the duodenum and about 150 cm of the jejunum, which significantly shortens the effective time of digestion and absorption.
5. AspireAssist – a pump that sucks food from the stomach, a special valve is implanted into the stomach, to which a tube leading to the pump is connected from the outside. About 20 minutes after a meal, this pump sucks a portion (about 30 percent) of the eaten food, which goes straight to the toilet and fills the cavity with water. Many experts believe that it is a device that works on the principle of “mechanical bulimia”.