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Today, obesity is one of the most important diseases threatening public health. Despite obesity was predicted to be the most important problem of this century by the World Health Organization (WHO) in 1998 and many precautions were taken, obesity continues to be a rapidly growing problem by causing preventable deaths. Therefore, getting rid of obesity is very important for human health. Even a minor weight loss of 5–10% seems to be sufficient to provide a clinically significant health benefit in terms of risk factors for cardiovascular disease and diabetes.

Obesity surgery, also known as bariatric surgery, is a surgical procedure performed to help individuals who are severely obese achieve significant weight loss. After bariatric surgery, major regressions and even, complete recovery is seen in many chronic diseases. Moreover, the vast majority of the patients, who have undergone bariatric and metabolic surgery, discontinue taking their medications. After long years of being obese, the person can make a fresh start to life with bariatric surgery.

The common procedures for bariatric surgery are listed and explained below. Each surgical procedure has its own advantages and potential disadvantages. Your bariatric surgeon will review your health history and work with you to determine which surgery is best for you.

The most commonly performed surgery is the “Sleeve Gastrectomy” surgery, known as the “Laparoscopic Sleeve” surgery. This is followed by “Gastric Bypass” surgery. Apart from these, there are also other surgery methods such as “Mini Gastric Bypass”, “Duodenal Switch”, and “Transit Bipartition”

The sleeve gastrectomy is one of the most frequently performed surgeries. The first and most important reason for that there is no major change in the digestive system with this surgery. The sleeve gastrectomy is performed by removing approximately 80% of the stomach. The remaining stomach is the size and shape of a banana. The new stomach holds less food and liquid which helps people consume less food and that reduces calorie intake. Patients who have had gastric sleeve surgery normally lose between 50% and 60% of their excess body weight in 12-18 months. If patients follow their dietary restrictions and exercise programs diligently, they may possibly lose more. The simple nature of the operation makes it very safe without the potential complications from surgery on the small intestine.

The reason for this surgery being more advantageous than all other bariatric and metabolic surgery operations is that no anastomosis is performed in this surgery. Anastomosis is the combination of two digestive system organs with each other. This is the combination process conducted between the stomach and the small intestine or between two parts of the small intestine via the support of sutures or staples. After such anastomosis procedures are conducted, there may be leakage between the sutures, and this poses a great risk. Thus, “Laparoscopic Sleeve Gastrectomy” poses fewer risks than all the other bariatric and metabolic surgeries.

The Gastric bypass is another type of weight loss surgery. It is one of the restrictive + absorption-reducing procedures and the second most frequently performed bariatric surgery in the world, is accepted as the “gold standard” method by many centres in bariatric surgery. The purpose of gastric bypass surgery is to limit the amount of food you can eat and the number of calories your body can absorb. In such surgeries, besides reducing the stomach volume, it is also provided to have the food pass through a part of the small intestines. Thus, food that passes through a small part of the intestine is less absorbed. In other words, all the calories taken by the patient cannot be absorbed and the unabsorbed calories are excreted via faeces. Thus, besides eating less, fewer calories are absorbed. Via these methods weight loss is achieved faster than laparoscopic sleeve gastrectomy.

Gastric bypass is quite less effective than metabolic surgery methods, which are especially outstanding in the treatment of diabetes. While the probability of recovery of diabetes mellitus via “Duodenal Switch” and “Transit Bipartition” is more than 95%, this ratio is between 85% and 87% in “Gastric Bypass”. However, operations similar to this surgery have been performed for many years, especially in patients with gastric cancer. Therefore, our knowledge about the risks that may arise due to this surgery in the long term is more when compared to other methods.

Duodenal Switch and Transit Bipartition
Methods such as “Duodenal Switch” and “Transit Bipartition” are more complex surgeries including more anastomosis when compared to these two methods. However, they give better results in the treatment of metabolic disorders, especially in people with additional diseases such as diabetes mellitus and high blood pressure.

The other type of weight loss surgery is gastric banding in which a silicon band is placed around the top region of the stomach, which helps people lose weight by reducing the size of the stomach and reducing the amount of food they eat. The degree of constriction around the stomach can be altered with adjustments. The band forms a small stomach pouch above it. A smaller stomach pouch limits the amount of food the stomach can hold at any given time. As a result, after eating less food, you will have a greater sense of fullness. This, in turn, reduces hunger and aids in the reduction of overall food intake. This type of bariatric procedure has the advantage of allowing the body to digest normally without malabsorption.

Under general anaesthesia, a gastric band is placed. It is usually performed in an outpatient clinic, and the patient generally goes later that day. The operation is minimally invasive. It is carried out through keyhole incisions. In the abdomen, the surgeon makes one to five small minimally invasive cuts. A laparoscope, a long, narrow tube with a camera, is used for surgery. The procedure usually takes between 30 and 60 minutes.

The intragastric balloon is another type of weight-loss procedure that is an alternative to bariatric surgery. Generally, overweight people with no surgical indications choose that procedure. An intragastric balloon implantation technique helps you to lose weight by inserting a silicone balloon filled with saline into your stomach. This procedure reduces your appetite and makes you feel full, which aids in weight loss. It is expected to see a 10-30% loss of the total body weight initially, usually depending on the patient’s weight.

This non-surgical procedure is performed after the patient has fallen asleep after the anaesthetic. After that balloon is placed with the help of the endoscope. The placement is followed by the inflation of the specific amount of air or liquid depending on the balloon’s characteristics.

Approximately gastric balloon procedure takes 20 minutes. After the procedure, you will be observed for certain hours, generally 1-2 hours. After the observation and the health control, you will be able to return home. It should be known that this procedure is very effective in weight loss but compared to surgical methods it is not that much effective.

These surgeries are performed with robotic surgery in our hospital because it is safer. These systems, requiring serious investments and training costs, have been revolutionary in terms of bariatric surgery. In robotic surgery, clearer and sharper vision can be obtained via 3D imaging, and it imitates the arm and wrist movements of the surgeon and enables surgeons to perform extremely sensitive surgical interventions.

As the indications of bariatric surgery vary according to countries, the criteria accepted by our Ministry of Health are as follows:

1. Body mass index (BMI) ≥ 40 kg/m2.
2. n case BMI is ≥ 35 kg/m2, at least 1 obesity related comorbidity should accompany. Among these situations:

• Type 2 Diabetes Mellitus.
• Hypertension (High tension).
• Dyslipidaemia (Disorder in fat levels).
• Sleep-Apnoea Syndrome (Respiratory disorder during sleep).
• Obesity-Hypoventilation Syndrome.
• Pickwick Syndrome (Sleep-apnoea syndrome and obesity-hypoventilation syndrome are seen together).
• Non-alcoholic steatohepatitis.
• Pseudotumor Cerebri (Despite all the findings being normal; “Increased Intracranial Pressure”).
• Gastro-Esophageal Reflux Disease (Escape of Food and Gastric Fluids into the Pharynx).
• Asthma.
• Venous Stasis Disease (Stability in the Collecting Circulatory System).
• Severe Urinary Incontinence (Enuresis).
• Arthritis Disease affecting daily life (Joint Inflammation).

Despite bariatric surgery or metabolic surgery having many benefits, it is not suitable for some patient groups. Due to the reason that it may cause some major problems if implemented, the situations in which bariatric surgery should not be performed as stated by our Ministry of Health are as follows:

• Being younger than 18 or older than 65; however, it can still be considered.
• if a serious comorbidity accompanies (such as Type 2 DM, HT).
• Presence of an untreated endocrine disease that also causes obesity (such as Cushing’s syndrome, hypothyroidism, insulinoma).
• Having an untreated eating disorder (Bulimia nervosa – eating uncontrollably and trying to lose weight in any way that is harmful to health).
• The presence of untreated major depression or psychosis (Severe mental health disorders).
• The presence of severe bleeding-clotting disorders.
• The presence of severe heart diseases that will prevent receiving anaesthesia.
• Alcohol or substance use.
• Inability to comply with dietary recommendations, such as lifelong vitamin replacement or a calorie restrictive diet.
• Currently being pregnant or having a pregnancy plan within 12-18 months.
• Having a known cancer disease.
• Severe gastroesophageal reflux disease (GERD) (especially for laparoscopic sleeve gastrectomy).
• Portal hypertension (increased pressure in the intraabdominal venous system).
• Gastric bypass surgery in patients with Crohn’s disease.