Obesity is one of the most significant health problems of the modern world.
According to the World Health Organization (WHO), obesity is now considered a disease and not an aesthetic issue.
It is associated with numerous complications, such as type 2 diabetes, hypertension, cardiovascular diseases and sleep apnoea.
When conservative treatment (diet, medication, etc.) fails, bariatric procedures offer effective solutions for substantial weight loss and improvement of health.
When should patients with obesity undergo surgery?
Surgery is indicated when BMI (Body Mass Index), expressed in kg/m², is:
- Greater than 34 kg/m², accompanied by comorbidities such as type 2 diabetes, hypertension, cardiovascular diseases or sleep apnoea.
- Greater than 40 kg/m² (an absolute indication for surgery). In this case, obesity is classified as morbid obesity, as the patient will soon develop complications due to excess weight.
- Greater than 28 kg/m² with the presence of type 2 diabetes (metabolic surgery). In this case, laparoscopic gastric bypass has absolute indication. There is currently extensive discussion about this procedure as a surgical treatment for type 2 diabetes that is inadequately controlled with medication.
ONLY then is there an indication for patients to undergo surgery for obesity.
One of the best-known surgical methods since 2000 is the laparoscopic gastric bypass.
The first laparoscopic gastric bypass in Greece was performed in November 2002 by the author.
Today, however, with the availability of robotic systems, the operation can be performed robotically.
Robotic gastric bypass, when a robotic platform is available in the hospital, offers the following:
Advantages
• Exceptional stability of surgical movements, allowing the surgeon to operate even from a distance.
Disadvantage
• The increased cost of the procedure compared with the laparoscopic approach.
The operation is described as follows:
a. Restriction of food intake: the volume of the stomach is significantly reduced by being surgically separated from the rest of the stomach.
b. Bypass of the distal / separated stomach with the proximal segment of the small intestine.
The procedure functions as follows:
A. The patient consumes smaller amounts of food and therefore gradually reduces body weight. Early satiety is achieved, reducing hunger and preventing overeating.
B. Malabsorption occurs due to bypassing a large segment of the small intestine, the length of which is determined by the surgeon. Thus, only part of the small amount of ingested food is absorbed.
C. Incretins are stimulated.
As a result, the patient achieves substantial weight loss.
The operation is preferred:
A. In patients who consume large quantities of food (“big eaters”), eat many sweet-tasting foods (sweets, chocolates, ice creams), or drink large amounts of sweetened beverages (“sweet eaters”).
B. In patients with diabetes.
Before surgery, patients undergo a series of examinations, including gastroscopy, to investigate known and unknown conditions.
A multidisciplinary team evaluates and assesses patients preoperatively (pulmonologist, cardiologist, gastroenterologist, the operating surgeon, etc.).
The procedure is performed under general anaesthesia.
Special laparoscopic instruments are used, and the operation is carried out through 4–5 small abdominal incisions.
Length of hospital stay: typically 3 and up to 4 days (noting that this is a form of gastrectomy with an entero-enteric anastomosis).
From the day of surgery, the patient is mobilised immediately and encouraged to walk. Pain is generally minimal.
The patient does not drink or eat for 2–3 days but receives appropriate intravenous hydration.
Subsequently, the patient begins drinking liquids and then gradually progresses to food intake, according to the surgeon’s written instructions.
These instructions MUST be followed STRICTLY to prevent complications.
Postoperative course
Patients:
• Begin to lose body weight gradually so that within 2 years they approach and maintain their ideal body weight (the goal of the procedure).
• Are monitored until weight stabilises, with blood tests ensuring timely correction of vitamin deficiencies, anaemia, etc.
• May require modification of preoperative medication (antihypertensives, antidiabetics, lipid-lowering drugs). In some patients, discontinuation of these medications is recommended by the specialist — a therapeutic advantage of surgery.
• May no longer require CPAP for sleep apnoea — another advantage of surgical treatment.
• Receive enteral nutritional supplements for a short period only (1–2 months) to ensure adequate nutritional support. During this time patients are trained in proper eating (chewing well, swallowing small quantities until satiety).
• Are encouraged to begin physical activity — mild at first, gradually increasing — contributing both to faster weight loss and improved muscle tone.
Patients must receive lifelong injectable vitamin B12, as it cannot be absorbed effectively postoperatively.
Postoperatively, all patients MUST be reviewed by their physician according to the follow-up protocol provided.
