© Borgis - Postępy Nauk Medycznych 5b/2013, s. 49-54
*Artur Binda, Paweł Jaworski, Wiesław Tarnowski
Chirurgiczne leczenie otyłości
Surgical treatment of obesity
Department of General, Oncological and Gastrointestinal Surgery, Centre of Postgraduate Medical Education, Warsaw
Head of Department: prof. Wiesław Tarnowski, MD, PhD
Leczenie chirurgiczne w chwili obecnej wydaje się najbardziej skuteczną metodą trwałej redukcji masy ciała. W przeciwieństwie do metod zachowawczych pozwala uzyskać, w dużej części przypadków, całkowite ustąpienie większości schorzeń towarzyszących otyłości. W ostatnich dekadach można zauważyć stale zwiększającą się ilość osób wymagających leczenia z powodu otyłości oraz gwałtowny wzrost liczby wykonywanych operacji na całym świecie. W 2011 roku liczba operacji bariatrycznych na świecie przekroczyła 340 tysięcy. W Polsce w tym samym czasie wykonano 1250 tego typu operacji. Najczęściej wykonywaną operacją jest ominięcie żołądkowo-jelitowe na pętli Roux. Wśród uznanych metod leczenia operacyjnego pojawiają się stale nowe procedury. Ich efektywność, w zakresie trwałej redukcji masy ciała wymaga dalszych obserwacji. Nadal do najbardziej skutecznych metod należy wyłączenie żółciowo-trzustkowe z przełączeniem dwunastnicy. W leczeniu otyłości, poza chirurgiem wyspecjalizowanym w operacjach bariatrycznych ważną rolę odgrywa wielospecjalistyczny zespół w skład którego powinni wchodzić: doświadczony internista, endokrynolog, psycholog oraz dietetyk. W celu zwiększenia skuteczności leczenia konieczna jest modyfikacja nawyków żywieniowych oraz codziennej aktywności fizycznej. Rodzaj operacji powinien być dobierany indywidualnie dla każdego pacjenta. Metodyka raportowania wyników leczenia powinna być ściśle określona. Dotyczy to zarówno kryteriów kalkulacji utraty masy ciała jak i ustępowania chorób towarzyszących. W pracy przedstawiono ogólne uwagi na temat chirurgicznego leczenia otyłości z uwzględnieniem najczęściej stosowanych i nowych metod operacyjnych.
Bariatric surgery currently seems to be the most effective method for durable weight loss. In contrast to conservative treatment it allows for complete resolution of the majority of co-morbidities in a large number of cases. In recent decades an increasing number of patients requiring treatment for obesity and the rapid increase in the number of procedures around the world can be seen. In 2011, the number of bariatric surgery in the world exceeded 340,000. In Poland, at the same time, 1,250 operations of this type were performed. The most commonly performed surgery is Roux-en-Y gastric bypass. Among the recognized methods of surgical treatment of obesity there are new procedures. Their effectiveness in terms of durable weight loss requires further investigations. Still one of the most effective methods is biliopancreatic diversion with duodenal switch. In the treatment of obesity, in addition to bariatric surgeon, a multidisciplinary team plays an important role. It should consist of an experienced general practitioner, endocrinologist, psychologist and dietician. In order to increase the effectiveness of treatment is necessary to modify eating habits and daily physical activity. The type of operation should be selected individually for each patient. Treatment outcomes reporting methodology should be clearly defined. This concerns both the criteria for the calculation of weight loss and resolution of co-morbidities. This paper presents a general comment on the surgical treatment of obesity taking into account the most commonly and novel surgical methods.
Over the past few decades obesity has become an important health problem. This problem mainly relates to well developed countries. To a greater extent, it is also becoming crucial in Poland. Obesity is accompanied by disturbances associated with overweight such as type 2 diabetes mellitus, dyslipidemia, hypertension, circulatory system diseases, obesity hypoventilation syndrome and degenerative lesions of the osteoarticular system. Conservative treatment, which mainly includes modification of existing eating habits and daily physical activity, usually does not provide any permanent effect. In the majority of patients in the long-term prospective, maintaining a beneficial relationship between the amount of energy intake and expenditure fails. In addition, implementation of fully effective pharmacological measures, which allow effective treatment of pathological obesity, has not been successful so far. After body mass reduction achieved by conservative treatment, patients manifest increased appetite, disturbed evaluation of the amount of consumed food and a tendency to consume high calorie foods (1, 2). After body mass reduction in obese patients, consuming large amount of food does not affect hunger and it does not provide feeling of fullness to such extent as it does in case of persons with normal body mass (3). Surgical treatment is an attractive alternative mainly because of the degree of body mass reduction and the permanency of obtained effects (4). It was also shown that surgical treatment is more beneficial compared to conservative treatment in terms of remission in comorbidities (5, 6). Over the past decade, the number of performed bariatric surgeries significantly increased. This phenomenon was undoubtedly affected by development of laparoscopic techniques and continuously increasing awareness of this problem, not only among patients, but also among physicians (7). In 2011 – 340,768 bariatric procedures were performed all over the world. This is a significant increase compared to 2003, when there was only 146,301 surgeries performed. The most frequently performed surgery was Roux-en-Y gastric bypass (RYGB) – 46.6%, sleeve gastrectomy – 27.8% (SG), adjustable gastric banding (AGB) – 17.8% and biliopancreatic diversion with duodenal switch (BPD – DS) – 2.2%. In the same paper, tendencies regarding a change in the percent share of the respective types of surgeries in the general number of bariatric procedures were evaluated. Data collected in 2003, 2008 and 2011 were compared. A downward tendency was noted in the case of Roun-en-Y gastric bypass, 65.1, 49.0 and 46.6%, respectively, and in the case of biliopancreatic diversion, 6.1, 4.9 and 2.1%, respectively. In 2011, there was a significant increase in the percent share of sleeve gastrectomy in the general number of conducted surgeries, from 0.0 through 5.3 to 27.89%, respectively. In the case of adjustable gastric banding, after an initial increase from 24.4% in 2003 to 42.3% in 2008, a decrease took place in 2011 to 17.8%. The most surgeries were performed in the U.S. and in Canada – 101,645, in Brazil – 65,000, in France – 27,648 and in Mexico – 19,000. In 2011, 1,250 surgeries were performed in Poland. The number of the respective types of surgeries performed in our country were as follows: adjustable gastric banding – 256, sleeve gastrectomy – 516, Roun-en-Y gastric bypass – 381, mini gastric bypass – 65, biliopancreatic diversion – 5, biliopancreatic diversion with duodenal switch – 3, banded gastroplasty – 10, other – 14. The proportion of the number of surgical procedures to the number of citizens in Poland was 0.0033 and the same proportion in the U.S. and in Canada – 0.0326 and in Belgium – 0.7722 (8).
INDICATIONS FOR SURGICAL TREATMENT
The generally adopted qualification criteria for surgical treatment include: BMI > 40 kg/m2 or BMI 35-40 kg/m2 and the coexistence of at least one obesity-dependant diseases such as: hypertension, type 2 diabetes mellitus, severe sleep apnea syndrome, dyslipidemia and motor organ diseases resulted in limiting mobile activity. In a majority of centers, patients in the age of 18-60 are qualified for surgical treatment. Additional conditions to be met if surgical methods are used include a patient’s complete understanding of the purposes and principles of surgical treatment, informed consent for treatment, approval for the type of proposed treatment, willingness to constantly cooperate during the postoperative period and a lack of general contraindications for surgical procedure and general anesthesia. In the case of body mass index 30-35 kg/m2, indications for surgical treatment should be individually determined depending on the type of comorbidities. It is also possible to qualify patients below 18 years of age for surgical treatment (9). In the case of patients over 60 years old, the qualification for the procedure takes place after evaluating the balance between the benefits and risk of complications. In these patients, surgical treatment may be used, but rather to achieve a better quality of life but not for the purpose to extend their lives. Currently, past attempts of using conservative treatment are not a necessary condition to qualify for surgical treatment. Sometimes it is questionable what weight should be assumed for the calculation of the body mass index, which would be the base to qualify for surgical treatment. In some centers, the highest weight reached by the patient is considered. The most frequently, however, qualification is made on the base of current body mass. It should be kept in mind that the reduction of body mass, which takes place during the preparation period before the surgical procedure, should not result in changing the qualification for treatment.
OVERVIEW OF SURGICAL METHODS
The main mechanisms leading to body mass reduction as a result of surgical treatment include limiting the volume of consumed food and limiting its absorption. The action of each of these factors leads to a decrease in energy value of absorbed food. Restrictive surgeries, i.e. limiting the volume of consumed food, include: gastric plication, vertical banded gastroplasty (currently performed less often), placement of adjustable gastric banding and sleeve gastrectomy. Recently, reports have been published regarding endoscopic methods using restrictive mechanisms. These methods include transoral vertical gastroplasty. Surgical procedures, which use both mentioned mechanisms, i.e. restrictive and malabsorptive procedures, include: Roux-en-Y gastric bypass, mini gastric bypass and biliopancreatic diversion with duodenal switch. Procedures with malabsorption as the main mechanism of action include biliopancreatic diversion. Presently, each of these surgeries may be performed using the laparoscopic method. A perfect bariatric surgery should be safe, easy to perform, and lead to significant body weight loss, a high level of patient’s satisfaction and minimum pain in the postoperative period. The level of early and late complications should be low. The duration of a procedure and hospitalization period should be short, and convalescence as well as return to professional activity should be fast. Achieved body mass reduction should be permanent and the achieved results should be easy to evaluate. A given method should not lead to nutritional deficiencies, and in case of their occurrence, treatment should be relatively easy. The surgery should be performed by an experienced surgeon involved in bariatric or metabolic surgery (10). An overview of the most frequently performed bariatric surgeries with consideration of some interesting methods introduced in recent years is presented below.
TRANSORAL VERTICAL GASTROPLASTY – TOGa®
In this procedure, a stomach cuff is created using a specially designed stapler, through the intraoral approach under endoscopic control. Suturing with titanium staples leads to bringing the abdominal walls closer to each other. By placing consecutive staples, a cuff of desired length and diameter is created. This procedure takes place under general anesthesia. In the study to compare the efficacy of transoral vertical gastroplasty with Roux-en-Y gastric bypass and biliopancreatic diversion, the following results were obtained in terms of %EBMIL: after 12 months: TOGa® – 43.1% (5.2-85.8), RYGB – 73% (48.4-105.4), BPD – 77.8% (53.6-92), and after 24 months: 37.7% (-11.4-87.9), 81.1% (51.7-119.7) and 79.1% (57.3-111.8), respectively. A better effect in a group with vertical gastroplasty was achieved in patients with lower baseline BMI (<45 kg/m2). No complications were reported in reference to this method (11).
ADJUSTABLE GASTRIC BANDING – AGB
In this surgery, a ring made of synthetic material is placed below the gastro-esophageal junction and small reservoir with a volume of 20-30 ml is made in the superior part of the stomach. By suturing the fundus of the stomach above the banding, a possible change of its position is limited. It is possible to control the degree of restriction with a subcutaneous port. This surgery is associated with a small number of perioperative complications and very low perioperative mortality rate. A relatively high rate of repeated surgeries, which results from the necessity to remove the band due to late complications or due to a change in its initial position, is a serious disadvantage of this method. The efficacy of this method was confirmed in terms of permanency in body mass reduction in longer periods of observation (12). The percent share of laparoscopic adjustable gastric banding in the general number of surgeries performed in Europe decreased from 63.7% in 2003 to 17.8% in 2011 (8).
LAPAROSCOPIC GASTRIC PLICATION – LGP
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