Gastric Botox is generally used for overweight individuals rather than obese patients. The procedure involves injecting Botulinum toxin into muscle layer of the stomach with endoscopic technique in order to hinder full contraction of gastric muscles. The gastric emptying will be prolonged, as the stomach will contract at less frequent intervals. This ensures the food contents stay longer inside the stomach, resulting in fullness for a longer period of time. Thus, daily amount of consumed food is decreased.
The procedure is completed in approximately 30 minutes and patients may return to their daily routines without any pain or ache afterwards.
Since the lifetime of Botox is approximately 6 months in body, its effects on the stomach are limited to this period of time. Individuals who get habit of eating in reasonable amounts may continue losing weight afterwards. It is possible to lose 10-15 kg of body weight. Another key point should not be disregarded; a diet program is necessary after a Botox procedure. Success rate is lower for patients who do not comply with a diet program.
Intragastric balloon is not actually a surgical procedure. Intragastric balloon is based on the principle of placing a balloon into lumen of stomach with endoscopic technique and inflating the balloon with air or fluid. This method aims to decrease the amount of food consumption by creating a feeling of fullness in the stomach.
Intragastric balloon is a short term procedure which generally does not require hospitalization and patients may be sedated only for a very short time. The procedure lasts for 15 to 30 minutes and patients are discharged to home following a few hours of observation.
This is a very appropriate method for patients who do not consider surgical treatment. Patients may continue losing weight after the extraction of the balloon, if they can change their eating habits. Intragastric balloon may help losing 10-30% of the excessive body weight.
Sleeve gastrectomy is the procedure where the left lateral part of the stomach is dissected and removed with a special surgical device, called stapler. A stomach is created, which measures 150-200 ml in volume, and thus, the amount of food influx is decreased. Moreover, it is possible to suppress the appetite, as the fundus of the stomach – the gastric dome – is removed, where certain hormones are secreted that stimulate the appetite.
Patients are generally observed for 2 days after the operation and they are discharged thereafter. And patients face no problem in engagement to daily routines after discharge. Patients should start eating liquid foods in early postoperative period. This liquid diet lasts approximately for 1 month and the patient is gradually switched to solid foods. Food servings and contents require strict attention following transition to solid foods. This also ensures the lost weight is not regained. One should always remember that regaining the lost weight after the surgery is a patient factor rather than a surgery-related problem. Weight gain is likely for the patients who do not comply with diet.
A proper diet should be combined with regular exercise to quicken the weight loss and minimize the sagging. Therefore, we recommend our patients to start exercising immediately after the end of convalescence.
Sleeve gastrectomy is a very safe surgery if it is performed by experienced surgeons and it is the most effective technique for loosing excessive weight.
Type 2 diabetes mellitus and obesity generally coexist and they lead to serious problems, such as kidney failure and blindness secondary to generalized damage to blood vessels and heart attack, stroke and loss of limbs secondary to vascular occlusions. “Metabolic surgery” is a novel rescue and treatment option for patients, if diet and medications do not help the condition. Metabolic surgery techniques are surgical procedures that aim permanent and appropriate regulation of glucose metabolism by influencing the physiological processes in addition to restrictive anatomic changes and balance the blood glucose levels in intestines rather than reducing volume of stomach and ensures more efficient and effective functioning of neuropeptides and hormones, which trigger feeling of fullness, in patients who are obliged to undergo revision surgeries due to frequent failures. These surgeries not only control diabetes mellitus, but they also prevent complications of diabetes; patients get rid of obesity, while hypertension is regulated and cholesterol and lipid metabolisms improve.
METABOLIC SURGERY METHODS
In addition to sleeve gastrectomy, terminal part of the small intestine is connected to stomach through a new route. Thus, absorption of nutrients in the small intestine is reduced. There are different techniques, such as (SASI) bypass and SADI-s, which are selected by the surgeon according to the needs of patients. Basically, a second outflow tract is created in addition to the native outflow tract of the stomach and thus, a part of foods does not pass through the entire small intestine and bypassed the last 250-cm segment of the small intestine. The last 250- to 270-cm segment of the small intestine from the colointestinal junction is cut and the remaining part is anastomosed to the stomach, while the proximal end of the cut intestine is anastomosed to the terminal part of the intestine at 100- or 120-cm. Now, there are two gates and routes for passage of foods (transit bipartition). Measurements revealed out that two thirds of foods pass through the new route created in the stomach and one third passes through the native route, namely duodenum.
Vitamin D and B1 deficiency and iron deficiency that are commonly detected in patients with diabetes mellitus become less likely.
A very few patients require vitamin and iron supplementation (approximately 5 percent).
Since a new outflow tract is created in the stomach and therefore, intragastric pressure is low, the short-term postoperative risk of leakage and the long-term risk of weight regain secondary to enlargement of stomach reduce.
Since gastrointestinal anatomy is protected, it does not complicate future endoscopic procedures and examinations.
In a multi-center trial participated by investigators from many countries:
Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI)
Bypass for Patients with Morbid Obesity: a Multicenter Study
Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI)
Bypass for Patients with Morbid Obesity: a Multicenter Study
(Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients with Morbid Obesity: a Multicenter Study Obesity Surgery · November 2019)
Ileal interposition implies interposing the terminal 200-cm segment of the small intestine to the initial part of the intestine at the junction of stomach and the small intestine in addition to reduction of gastric volume. In this technique, reducing secretion of ghrelin, also known as “appetite hormone that is secreted by stomach aims to reduce endogenous synthesis of glucose and fatty acids by suppressing secretion of glucagon that is secreted from terminal segment of the small intestine and increases insulin sensitivity and to increase secretion of hormone-like GLP-1 peptides that improves synthesis of insulin in the pancreas. Since this surgery reduces concentration of the appetite hormone secreted from the stomach, appetite is postoperatively suppressed and feeling of hunger decreases. Feeling of fullness is boosted.
These surgeries not only restrict consumed amount of foods, but it also helps early feeling of fullness.
Since surgeries that restrict food intake lead to serious vitamin and protein deficiencies and resultant diseases, this surgery does not affect the absorption and nutritional disorders that are associated with vitamin and protein deficiency are rare in the long term.
This technique allows successful results also in non-obese diabetic patients with low body mass index.
To the best of our knowledge, diabetes mellitus is eliminated and approximately 90% of patients do not need medications and diet for at least 10 years.
FOR PATIENTS WITH WEIGHT REGAIN AFTER OBESITY SURGERY
Obesity is a chronic disease and weight lose surgery may be a lifesaving option, but it is not a treatment. Its success depends on modification of lifestyle and eating habits by modifying eating-related mental processes.
Weight regain after a surgery carried out to correct obesity does not arise out of a problem in patients’ stomach; it is more common after mental alterations secondary to changes in life conditions that lead to long-term stress, such as bankruptcy, divorce and diseases, and also due to psychological trauma. For patients who cannot lose weight with diet and exercise, revision surgery may, sometimes, be decided to eliminate extra burden placed by the obesity. It is reported that one out of every 20 patients with past history of obesity surgery undergoes revision surgery (5%).
Revision surgery is a tough test for surgeons due to increased risks, challenging technique due to redo operation and its adverse outcomes such as potential complications. However, potential risks that patients with weight regain will face, if the condition is left untreated, encourage surgeons decide this surgery and these are lifesaving operations also after a successful process. Prerequisite of success is professional devotedness of surgeons beyond their consent to this challenging technique. Experienced surgeons can minimize the complication rate through correct techniques carried out at correct time for correct patient.
(Revisional Bariatric Surgery for Unsuccessful Weight Loss and Complications, Hideharu Shimizu Obesity Surgery volume 23, pages1766–1773, 2013)
Studies demonstrated that volume of stomach may increase two folds two years after sleeve gastrectomy; it is an expected condition and it is not a failure of anybody. As the stomach enlarges, some patients start eating more. Revision surgery may help this group of patients. Possible options include conversion into bypass, duodenal switch or redo sleeve gastrectomy.
Conversion into gastric bypass is effective especially for patients with reflux complaints, as bypass not only treats the reflux, but it also helps the weight loss. Vitamin absorption disorders emerge especially after bypass surgeries.
Technique of the previous surgery is the first factor that influences selection of surgical technique in revision surgery. If the technique of previous surgery is not known, endoscopy and/or double contrast barium enema may help.
If vertical band gastroplasty was carried out, mini gastric bypass with modification of transit bipartition should be preferred.
If the previous surgery was Roux-en-Y mini gastric bypass, it is observed that gastro-gastric reflux occurs in ¾ of patients with weight regain. Combination of transit bipartition and Roux-en-Y bypass and repair of fistula should be considered for these patients.
In conclusion, selection of surgical technique in patients with weight regain depends on the previous surgery and preference of surgeon.
