EUROBESITY

1. Introduction

Obesity surgery has tremendously developed over the last fifteen years or so. Despite significant media coverage, most patients still don’t know much about the different types of surgical procedures and sometimes tend to mistake possible effects and complications of one technique for another.

The purpose of this website is to inform future patients in an unbiased way about what is currently done, and help them make the best choice for themselves. We will review the different surgical techniques, their indications, and their pros and cons. Each procedure will be given a “Eurobesity assessment” to inform the patient about our personal approach to obesity.

The final decision always belongs to the patient. But, as health advisors, it is our duty to help patients make the best decision possible, and give them clear and objective advice about the therapeutic possibilities.

 

2. Why surgery ?

Surgery does not treat obesity! It is important to remind individuals that obesity is neither a disease nor an abdominal disorder. Cutting here and bypassing there will not be enough to return things to normal.
Surgery must help the patient better stick to a nutritional programme.
Losing weight equates to burning one’s reserve calories. No surgical procedure will make the patient burn more calories. Surgical procedures try to induce an early feeling of fullness or reduce the intestinal absorption of ingested calories. A surgical procedure without a concurrent long-term treatment is doomed to failure in most cases. Surgery must be seen as a way to permanently help the patient better stick to a nutritional plan.

That permanent, uncontrollable, and even unbearable, feeling of hunger dooms most diet plans. Of course we can hide behind psychological, metabolic or even genetic explanations. Some patients have a constant feeling of hunger that urges them to eat excessive quantities of food. This urge cannot be fought forever. Other patients feel the constant need to snack on sweet or savoury food. These are powerful and recurrent urges. Of course, they must be channelled. But if they are repressed too strongly they may cause serious psychological imbalance.

The ideal purpose of surgery must be to try and control this inappropriate urge to eat. Patients will then be able to curb their excessive eating more easily and will better stick to a nutritional plan. Obviously things are not always this easy. Lots of external factors such as professional concerns, marital situation, family, heredity and stress, etc. will play a part.

We will never emphasize enough how surgery is only part of a comprehensive treatment. Surgery does not increase a patient’s income, does not change the relationship of a couple and cannot erase a family history of obesity. It is essential to remind all of this to a potential patient who might put too much hope in the “surgical solution”.

3. Surgery for whom ?

The data generally used to determine whether a patient is suitable for surgery is as follows:

BMI (Body Mass Index)

BMI = Weight in kilograms / Height in square meters
BMI = kg/m²

Classification

BMI (kg/m²)

Level of health risk

Indication for surgery

Underweight

< 18,5

Increased

-

Normal Weight

18,5 - 24,9

Normal

-

Overweight or pre-obesity

25,0 - 29,9

Moderate

-

Obesity

     
Class 1
(obese)
30,0 - 34,9 High
-
Class 2
(severely obese)
35,0 - 39,9

Very High

In case of comorbidities (diabetes, hypertension, asthma)

Class 3
(morbidly obese)
40 and over Extremely High Definite indication

 

Waist circumference :

The waist measurement should be taken at the narrowest part of the torso – i.e. mid-way between the lowest point of the ribcage and the iliac crest – with the person standing up and at the point of maximum exhalation.

Waist circumference threshold

Health risk

Indication for surgery

Men: >= 102 cm  

Increased risk

definite

Women: >= 88cm  

definite



Combination of BMI and waist circumference :

 

Body Mass Index

 

Normal

 

Overweight

 

Class 1 obesity

 

Waist circumference
 

< 102 cm (men)
< 88 cm (women)

Lower risk

Increased risk

High risk

>= 102 cm (men)
>= 88cm (women)

Increased risk

High risk

Very high risk

 

These different classification systems are somehow limited. These measurement criteria do not take into account how the patient feels. Each individual has a different experience of his or her extra kilos. Some individuals, especially men, are fine with a BMI of over 40kg/m² thanks to a heavy muscle and skeletal structure. Women, on the other hand, suffer a lot from a BMI of 30 kg/m². They experience back pain, knee pain and shortness of breath on effort.
We think that each case is different and deserves to be discussed.
Beside the usual morphological measurements, Eurobesity adds other criteria to its indications for surgery, i.e.:

  • Weight evolution over time
  • The consequences of overweight on the patient’s quality of life and occupation.
  • The client’s requests and wishes.
  • Heredity
  • A desire for future pregnancy

Deciding in favour of surgery will always be the result of a conversation with the patient and his or her relatives after they received clear, accurate and honest information.

The patient will be required to participate to a protocol of nutritional follow-up adapted to his or her morphotype, metabolism, and, most of all, his or her living and working environment.  There is no point in rushing patients and drastically changing their everyday lives. A subtle correction of some bad habits and access to a line of better-adapted food products will guarantee long-term results.

 

4. What type of surgery ?

Obesity surgery offers two different approaches based on:

Malabsorption: the purpose is to reduce the time it takes for food to mix with bile and pancreatic juice in order to reduce food resorption by the body.
To do so, these types of surgery require partial gastric resections and the creation of intestinal bypasses.

Restriction: the purpose is to create a small gastric pouch. The expansion of the pouch by small food intakes causes an early feeling of fullness.

Restriction-malabsorption combination: the purpose is to combine a gastric restriction with an intestinal bypass.

Gastric Stapling (a.k.a. Vertical Banded Gastroplasty or Mason Surgery or SVRG (Silicone Ring Vertical Gastroplasty))

Vertical gastric stapling creates a small gastric pouch with a non-adjustable exit. Food must therefore go through this narrowed non-adjustable opening. The expansion of the gastric pouch causes an early feeling of fullness. It can be performed by laparoscopy and requires a 3-to-5-day hospitalization.

Pros:

  • Easy-to-perform procedure
  • Oldest bariatric surgery procedure
  • No nutritional deficiencies
  • Low morbidity rate
  • Low cost

These gastric stapling techniques did not meet our approval for several reasons:

  • Gastric stapling is not reversible: The placement of four rows of staples will create significant adhesion to the pancreas (towards the back) and to the liver (towards the front). Any type of subsequent gastric or pancreatic surgery will therefore be all the more difficult. In case of oesophageal cancer, gastric stapling can jeopardize the use of the stomach in a tubular plastic operation, if this should become necessary. We believe that a surgical procedure designed to fight obesity is likely to help the patient today. However, it should definitely not reduce the patient’s treatment options in the future. If such should be the case, the patient must be clearly informed about this permanent and irreversible disability.

  • Stapling is not adjustable: Whatever the type of obesity the sizing of the pouch performed during the stapling procedure will be the same and will be irreversible. Also, during the first few weeks following surgery, the oedema created by the stapling will press on the gastric pouch exit and cause sometimes serious vomiting. People know about this but vomiting is sometimes generalized to all types of obesity surgery. This unfortunately brings into disrepute several procedures that are much more respectful of the patient. Weight loss is difficult to control and the stapling is impossible to adjust.

  • Stapling can cause leaks: There is a risk that the staples might come apart, which will cause leaks and peritoneal infections. Moreover, long-term studies clearly show that about 30 per cent of patients will have their staples come apart after about three years. This will allow food to go through a large opening and into the stomach under the small pouch and will inevitably lead to weight gain.

  • Endoscopic stapling: this technique is still tentative and is only an incomplete form of the classic stapling procedure. By endoscopy, stapling actually only applies to the mucosa and not to the entire stomach wall. There is no ring device under the stapling.

  • Low cost: Of course the low cost of this technique is a major advantage. This argument must be considered but must not hide the well-known side-effects of stapling and gastric resection. The patient will be the one to choose his or her procedure in full knowledge of everything involved. The practitioner’s role is to inform the patient about all the available therapeutic options, and to give him or her competent and impartial advice.

 

“Laparoscopic Adjustable Silicone Gastric Banding”

This technique consists of the laparoscopic placement of an adjustable silicon band around the uppermost part of the stomach. This technique allows the creation of a small proximal pouch (10 to 15 cc). The dilation of the pouch through small food intakes is perceived by our brain as a total dilation of the stomach and therefore induces an early feeling of fullness. The device is equipped with a small reservoir that allows adjustments of the band opening.

This technique has been adopted by the Eurobesity surgical staff.

The pros of this technique are as follows:

  • Laparoscopic approach: Performed by an experienced surgeon this procedure only requires a 30-to-40-minute general anaesthesia.  Five small trocar orifices are required for this procedure. There is no need for drainage or the use of a stomach or vesicular tube. The patient will start drinking fluids within a few hours of the procedure and will be allowed to go home the day after the procedure at the latest. Since very little parietal stress is caused during the procedure, the patient will only need to take few painkillers in the days that follow surgery.

Laparoscopy in obese patients avoids major surgical incisions and reduces the risk of incisional hernia to nothing. Since the patient can move after surgery, lung complications such as atelectasis and phlebitis with embolism risk will be avoided.

  • Adjustable device: When placed, the device is empty and therefore barely restricts the passage of food.  Still, to be on the safe side, ground food is recommended for ten days after surgery. These ten days are more than enough for a possible postoperative oedema to resorb naturally.

Afterwards, adjustments will be performed at determined intervals by puncturing the port and injecting saline. These adjustments give control over the patient’s weight loss, and allow interrupting the restriction when desired. A very common example is pregnancy. We are absolutely convinced that pregnancy is a favoured and sacred moment in a patient’s life. A complete opening of the device will allow the child to develop naturally without barriers or traps. The same does not apply to malabsorptive procedures, which cause the mother's and the child's malnutrition, or stapling, which aggravates the vomiting. A surgical procedure must help a patient and never endanger the patient’s or her foetus’s life.

  • A fully-reversible procedure: We believe that, first and foremost, obesity surgery must be fully reversible. The patient must have the possibility, at any time, to choose his or her destiny. That means he or she must be able to choose between continuing the treatment and stopping everything. The patient cannot end up being trapped and a victim of a device for the rest of his or her life. Making the decision to undergo surgery in order to lose weight is often difficult. This decision must not be seen as a trip – to hell sometimes – from which there is no going back. Of course, the purpose of any procedure is to help the patient for the rest of his or her life. But life is sometimes made up of unexpected events. Going back without suffering from any consequences has to be an option. The adjustable gastric band is reversible in two ways. Emptying it by draining its content immediately allows food to go through the band. If deemed necessary the band can be laparoscopically removed without any after-effects. Carrying or having carried a gastric band at some point does not prevent a patient from having any type of subsequent surgery, whether functional or oncological. Gastric banding has no interference whatsoever with a patient's surgical future. Nevertheless, we hope the patient will resort to surgery as little as possible!
  • Complication rate: Since abdominal and stomach wall integrity is guaranteed, risks of incisional hernia, fistulas or leaks are avoided. In the hands of an experienced surgeon, the death rate for this type of surgery must tend towards zero per cent. To us, suggesting functional surgery with high death and morbidity rates to a young mother seems hard to conceive.

Still we need to emphasize time and again that gastric banding is not a miracle cure. It does not burn calories. It has no effect on the mind, does not solve family problems, and does not improve the socio-economic situation. It may seem ridiculous but too many patients think that this procedure - often regarded as harmless - will fix everything. The band helps patients better stick to a nutritional plan. It forces the patient to eat more slowly and induces an early feeling of fullness after small food intakes. If the patient scrupulously follows indications he or she will lose weight regularly, in a controlled and lasting way.
 But if the patient strays from course by, for instance:

  • Ingesting high-calorie liquids and only eating sweets or chips, then he or she will taste bitter failure.
  • Eating too fast or too much despite the feeling of fullness, he or she will vomit repeatedly and might cause a dilation of the gastric pouch. This is one of the most significant complications and will require the repositioning or removal of the band.
This means that the band forces the patient to modify his or her eating behaviour, and learn to have a balanced diet and chew properly. It forces us to follow patients closely so that they do not go back to their bad eating habits. We must also help them deal with their snacking habits and binging episodes by offering them a line of food products specifically designed to this end.

 

Sleeve Gastrectomy or Longitudinal Gastrectomy :

In this operation, in order to induce an early feeling of fullness, a large part of the stomach is removed and the remaining part takes the shape of a tube. This procedure can be performed laparoscopically.

Pros:

  • Easy to perform
  • Laparoscopically feasible
  • Low cost

This is an irreversible removal of a large part of the stomach. Adjustments or reversibility are impossible.

 

Biliopancreatic diversion” (also known as Scopinaro Procedure)

With this technique, a pouch is created by removing a large part of the stomach. The pouch is then connected to the final segment of the small intestine, thus bypassing almost the whole intestine. Ingested food is therefore barely digested.

Pros:

  • Low cost
  • Extreme (but uncontrollable!) weight loss

Eurobesity does not perform this type of surgery because of the following drawbacks:

  • Heavy procedure, mutilating and irreversible
  • Still difficult to perform laparoscopically
  • Adjustments are impossible
  • Significant risk of complications: leak, stenosis, internal hernia, fistula, …
  • Risk of death if the suture line comes apart
  • The bypass causes iron, calcium, vitamin A, B, E, B12, and protein deficiencies.
  • “Dumping syndrome” with feeling of discomfort, nausea, vomiting, and diarrhoea as soon as large quantities of food reach the intestine.
  • Hepatic insufficiency

 

Gastric bypass

With this technique, the stomach is cut vertically in order to create a small proximal pouch (restriction). This pouch is directly connected to the jejunum, thereby causing food to bypass a large part of the stomach, the duodenum and proximal jejunum. The functional part of the intestine is thus reduced to 40-50 cm. This causes malabsorption resulting in weight loss.

Pros:

  • Low cost
  • Faster (but still uncontrollable!) weight loss in the beginning

According to Eurobesity, the drawbacks of the gastric bypass are too serious for this procedure to be suggested to a patient:

    • Irreversible surgery, difficult to perform laparoscopically
    • Gastric stapling and gastric section with several intestinal suture lines: risks of leaks, stenosis and internal hernia
    • Higher complication rate
    • Risk of death if the suture lines come apart
    • Ion (such as iron for instance), protein and vitamin deficiencies caused by the bypass
    • Difficult metabolic control in case of pregnancy
    • “dumping syndrome” (discomfort, nausea, vomiting, diarrhoea, etc.)
    • Permanent impossibility to examine the stomach below the staples if screening for cancer or ulcers is necessary.
    • Permanent impossibility to endoscopically examine the liver and bile ducts in case of lithiasis, cancer, etc.

 

5. "Eurobesity Warning”: 

Because the gastric bypass and the biliopancreatic diversion have been sotrendy recently we must warn patients against the immediate and long-term danger of these procedures.
If evolution over millennia has provided our species with about six metres of small intestine and three metres of colon it is not only for food digestion but also for detoxification. Our intestine is designed to break down food into very small absorbable particles by mixing enzymes with intestinal bacteria. At the end of this long journey the waste products enter the colon where they are dried and discarded. To us, changing the natural digestion process equates to playing God. The bypasses performed during those procedures do not only eliminate calories. They also eliminate proteins, vitamins and ions and this will cause sometimes significant metabolic deficiencies.
Also, some medications will not be absorbed the way they should be. In case of pregnancy, this type of surgery can cause deficiencies harmful to both the mother and the foetus.

Non-digested food entering the colon – for which it is not designed – will cause frequent and extremely foul-smelling diarrhoea. Won’t repeated contact of non-digested and non-detoxified food with colic mucosa – whose fragility and instability has been well-documented – unacceptably increase the risk of colon cancer? No one is currently able to answer this question.

Nonetheless it is out of the question for us to put patients at risk.
Most patients who come to see us are young and healthy despite their overweight. Very often they are women still young enough to have children. Other reasons why Eurobesity does not offer this type or surgery are:

    • heavy surgery: these procedures are sometimes still difficult to perform laparoscopically and large abdominal incisions may be required. Such incisions in obese patients automatically increase the risk of incisional hernia. Prolonged immobilization due to pain dramatically increases the risk of deep phlebitis and pulmonary embolism. Gastric and intestinal resections require suture lines that increase the risk of complications such as leaks, fistula or total breakdown. These complications very often involve additional surgery and, unfortunately, can sometimes be fatal.
    • Irreversible surgery: Patients must be clearly informed before undergoing resections of the stomach or small intestine – which are by the way perfectly healthy organs. Too many patients do not know about this and end up having to live the rest of their lives with the consequences of their surgical history. Eurobesity surgical staff refuses to irreparably and permanently mutilate a patient’s healthy organs and put the patient at significant surgical risk simply because of being overweight.
    • Patient fragilization: Patients who have been disappointed by the inefficiency of long-term diets might almost see gastric bypass as a miracle cure. Patients indeed often think that they can keep their bad eating habits and still lose weight. Therefore they consider the procedure as a “repair” of their metabolism, and, in their euphoria, may forget about the consequences. The second element is medical. A patient with a gastric bypass may be nutritionally weakened. Metabolic disorders due to vitamin deficiencies as well as extremely fast and difficult-to-control weight loss will require regular blood tests and, sometimes, hospitalizations to re-establish hydro-electrolyte equilibrium.
    • Numerous surgical variants: Medical literature describes more and more variants of malabsorptive surgeries, and, sometimes, the combination of several different techniques. It is therefore difficult, even when taking some distance, to determine the true efficiency of one technique compared to another.

Eurobesity must clearly inform people about this drift.

Eurobesity must remain honest and will not sell dreams. Successful weight loss must rely on a comprehensive and lasting nutritional diet, helped or not by medication or surgery.

Eurobesity therefore considers that banishing all types of malabsorptive and mutilating surgery (i.e. gastric bypass, sleeve gastrectomy and biliopancreatic diversion) from its therapeutic options in order to give absolute priority to a comprehensive and respectful approach to patients, their living environment and eating habits is evidence of common sense, ethics and reason.

The only type of surgery Eurobesity will agree to resort to is the fully reversible laparoscopic placement of an adjustable gastric band.

Dr. Vertruyen Marc
General Coordinator Eurobesity
Responsible for “Surgery”
0475/87.11.60

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