In CMED we have created a unit specific for patients with obesity combining gastroenterology, endocrinology and nutrition, psychology and surgery of the digestive system to achieve the best results with the greatest possible safety for the patient.
Not all obese patients are candidates to this type of treatments and not all of them can undergo the same type of process. After a thorough study by CMED’s team, patients with obesity can become candidates for bariatric-metabolic surgery.
Morbid obesity and its associated diseases
Severe clinical obesity or morbid obesity is a chronic disease characterized by the excess of fat deposition in the body in a permanent and progressive way and to which other serious pathologies (called co-morbidities) are added, such as:
- Hypertension.
- Diabetes.
- High cholesterol (hypercholesterolemia).
- Heart and coronary diseases.
- Sleep apnea.
- Arthrosis.
- Varices.
- Fatty liver (hepatic steatosis).
People with severe obesity have between 1.5 and 2 times more possibilities to suffer one or more associated diseases. However, in the case of diabetes, risk is even higher: diabetes is between 10 and 40 times more frequent in people with obesity from moderate to morbid through serious.
Obesity is also associated to greater possibilities of suffering nearly any type of cancer but with special relevance breast cancer, ovary cancer, endometrium, colon, liver, pancreas, esophagus, stomach and kidney. Cancer mortality may increase over 50% in people with morbid obesity.
In addition to purely physical consequences there are also psychological. Negative skills tend to consider them clumsy, neglected and with little will. This damage is so intense that crosses age, religion, race and socio-economic barriers. Obese patients may suffer discrimination and social stress than can cause psychological alterations and anxiety.
Morbid obesity is a disease with a genetic component (between 25-50% of patients) as they have reduced proteins in fat cells which control satiety. It is not a disease caused by the absence of will. Obesity is multifunctional and influenced by genetic factors, family and social environment, culture, socioeconomic level and psychological situation.
How to calculate the level of obesity?
One of the ways to calculate the level of obesity of a patient is applying the formula of Body Mass Index.
The Body Mass Index (BMI) is a measure to associate weight and height of an individual.
Calculate your Body Mass Index
Result Your BMI is:
More related information
Obesity and Type II diabetes are closely related, and weight reduction in these patients is a very important milestone of treatment and a target to accomplish.
Over 80% of Type II diabetics have obesity, a circumstance that worsens the prognostic of diabetes and life quality because it normally comes with other alterations such as hypertension, increase of cholesterol and triglycerides, etc.
In fact, obesity is the main risk factor of Type II diabetes as it causes many metabolic alterations that normally stops the functioning of pancreas.
Food and physical exercise represent the basic cornerstones of treatment in these patients. Neither hypoglycemic drugs nor insulin are helpful if the patient does not tackle his weight excess first.
When a diabetic patient disregards these measures and reaches a BMI over 30 there are other measures that may be efficient.
Bariatric-metabolic surgery, combined with the modification of life routines, is the only efficient treatment to achieve a weight loss maintained in patients with morbid obesity attaining a remission of diabetes in over 75% of cases. (-less)
There is no efficient medical treatment of morbid obesity with diets, drugs or psychotherapy. There is not one single study published including an efficient medical treatment over 10% of the weight loss in 5 years.
Bad results with diets may cause anxiety and loss of confidence of patient as minimum weight losses are achieved followed by a rebound effect that makes patients gain all weight lost. It is known as the “yo-yo” effect. It is difficult to attain an effect sustained in the long-term, but weight fluctuations that in the end as they are not effective produce a loss of self-esteem, depression and great anxiety. Patients end up avoiding the scale and even looking themselves in the mirror.
For these reasons, surgery is necessary in all those cases in which different diets or drugs have failed as it is the last resource that has proven itself useful on the long-term for the weight control in morbid obesity. But obesity surgery is not a cosmetic treatment and does not consist on removing fat.
Bariatric surgery consists on the reduction of the size of the stomach either associated or not to a procedure avoiding the absorption of fat of the diet.
Eating habits change radically and therefore the intake of calories is reduced and guarantees a forced diet when changing eating habits obliging the patient to eat small amounts and having to chew very much.
Obesity surgery has been performed during the last 40 years, and now it has become standard and its results are very well known on the long-term..
In addition to avoiding the early death due to obesity, surgery avoids related complications.
The option of surgery has to be offered to well-informed patients, motivated and who strongly wish to change their weight and life style and that have an acceptable. post-operative risk. The patient has to accept that it is necessary to undergo controls and monitoring after the operation, practically all his life.
Under no circumstance, surgery is done for the patient all he wants without gaining weight. This is absolutely false. If no instructions regarding meals are followed and life habits are changed, on the long term (years) the lost weight will be gained and then the options of another surgery are null so life quality of the patient will worsen progressively.
Individuals with BMI over 35 are candidates for the surgery to improve their quality of life, avoid complications and early death.
In some exceptional cases surgery may be performed with lower BMI if the patient has high risk of accompanying co-morbidities such as sleep apnea syndrome, heart disease related to obesity, hypertension or diabetes
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There are two types of procedures:
A- Restrictive procedures are those limiting the capacity of the stomach and their purpose is to reduce the amount of food intake. In this category we have:
It is a relatively simple surgery that consists on the placement of a balloon in the stomach to reduce its capacity.
After an upper digestive endoscopy or gastroscopy which assesses whether there are contraindications, we proceed to the placement of the balloon in the stomach. During the whole process, the patient is sedated.
The intragastric balloon is normally filled with 500ml of physiologic serum plus 2-4ml of methylene blue for the early diagnosis of an eventual rupture.
Patient stays in hospital in general no more than 24-48 hours. Tolerance during the first days is poor, with nauseas and frequent vomits that disappear progressively until the situation normalizes. It is not recommended to leave the intragastric balloon more than 6 months and therefore it is considered a transitory treatment towards other medical treatment options or as a first stage of the bariatric surgery. Therefore, the intragastric balloon is recommended for patients with overweight and mild to moderate disease.
It consists on the placement by laparoscopic surgery of a band as a belt around the upper part of the stomach which is narrowed or opened depending on the needs of the patient (the stomach remains as a “sand-timer”).
As the stomach narrows the gastric capacity is much reduced and when eating satiety is soon felt, but if forced vomits may appear. With this type, an average of 30% of initial weight is lost.
It is not necessary to remove it unless there is any complication so in theory it may be maintained throughout the life of the patient.
3- Tubular or vertical gastrectomy
It is a surgical procedure which consists on the vertical section of 80% of the stomach leaving in use only 20% of its, keeping the pylorus. This 20% is more than enough to perform the normal actions of the digestion and food storage.
The stomach is stapled lengthwise in order to form a thin tube and the rest of the stomach is resected. This is an important aspect because in the excluded area is where ghrelin, hormone responsible for appetite, i.e. hormone that makes us eat more than we physically need is produced. As it is among the restrictive techniques, the person undergoing this process is going to take less amount of food as its new stomach is smaller and its appetite is lower because the hormone in charge of hunger has been reduced.
Al estar dentro de las técnicas restrictivas, la persona sometida a esta intervención va a ingerir una menor cantidad de alimento debido a que su nuevo estomago es más pequeño, además de que su apetito es menor ya que la hormona encargada de generar hambre se encuentra disminuida.
B.- Malabsorptive procedures are those limiting the intestinal absorption of the nutrients taken. In this category we find:
1- Gastric By-pass
The gastric by-pass is the most frequent bariatric procedure and is both restrictive and malabsorptive. This surgery may cause a loss of two thirds of additional weight in two years.
The procedure involves the division of the stomach with staples to create a small bag with less space for food and then connect it to a part of the small intestine.
This way food passes on to the smaller new stomach directly to a part farther from the intestine through this By-pass or shortcut, without moving through the rest of the stomach, duodenum and the first part of the jejunum. Approximately food does not start the digestion until it has not passed approximately 1.5 meters of intestine. The weight loss mechanism is double: less food is taken because the stomach is smaller and a part of the nutrients are not absorbed throughout this path until it mixes with digestive juices later on.
This surgery may be performed by laparoscopy or by open surgery. It is the surgeon the one in charge of making this decision.
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Bariatric surgery is a functional surgery and the same surgery does not have the same effects with respect to weight loss in all individuals.
Weight loss depends on the surgical technique used, the level of initial obesity of the patient, the age and sex (men and youngsters loose more) but specially the level of adherence to the guidelines established regarding changes of life after surgery. With standard surgical techniques the weight loss expected is in average, 30-40% of the initial weight.
An ideal surgery is that where:
- The patient is able to lose at least 30% of the ideal weight.
- Weight loss is maintained over 5 years afterwards.
- A significant improvement of remission of comorbidities is achieved (50% remission of hypertension and over 75% in Type II diabetes, sleep apneas and lipid alterations).
- Improvement of the quality of life both physical and psychological.
- Little or none side effects (nauseas, vomits, diarrhea, anemia, etc.).
- Low risk for the patient (less than 1% mortality and less than 10% complications).
- No need for another intervention in a percentage of over 2%.
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Patients who have undergone bariatric-metabolic surgery have to learn new eating habits for the process started with surgery to be a success.
It only consists on getting used to eating small portions to adjust them to the size of the new stomach:
- They start with a progressive diet: liquid, grinded, soft and finally solids. The process normally lasts one month.
- More and better chewing of food.
- Intake will be slow with no rush.
- They will eat several times a day and in small amounts.
All these measures will help the patient to feel comfortable (nauseas and vomits) and to progressively adapt to the new size of the stomach.
At the end of the process most meals of a healthy and natural diet will be taken recalling that surgery has not changed the genetic component of “saving” or “gaining” when disregarding the recommendations established on a continuous basis. This is, consuming preferably cold drinks, pastries, nuts, ice creams, mayonnaise, snacks, fast food or appetizers in general may favor the gain of the weight lost. There is no treatment (diets or drugs) and no surgery allowing all type of diets and transgressions without gaining weight on the long-term or side effects.
In fact, with surgery life routines are more easily changed. Now patients will have the chance to do things that they couldn’t: eat less without being hungry and lose weight or do sports –more than expected- because the patient will be more agile and with physical capacity to face nearly any sport.
Frequent monitoring by the endocrinologist-nutritionist has this educational value of changing its life routines throughout several months of monitoring. In addition its will necessary to run periodic tests in case due to the type of surgery or inappropriate food it is necessary to give some kind of vitamin. Normally during the first year of quick weight loss and eating little it will be normal to complement the patient’s diet with vitamins and minerals; when weight is stabilized they will only be required depending of the results of the lab tests.
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Just as important as physical health is metal health and we know that emotions, stress and personal or professional conflicts may be reflected in negative food conducts and fallout of healthy habits. Preventing this alterations and their treatment has to rely on the appropriate psychological assistance as many times as necessary.
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