Yeditepe University Hospitals General Surgery & Gastroenterology Specialist answered the questions about Obesity Surgery.

• What methods are most commonly used in obesity surgery?

Today, there are three methods of obesity surgery. The most common of these is sleeve gastrectomy surgery. Normal bypass (Roux-en-Y) comes in second place and mini-bypass surgery comes in third place. In fact, it can be divided into two: sleeve gastrectomy surgery and bypass surgery. Sleeve gastrectomy surgery is performed only on the stomach, while bypass surgeries are performed on the stomach and small intestine. Sleeve gastrectomy surgery is an operation that restricts the foods we eat. It is done by shrinking the stomach. In bypass surgeries, in addition to shrinking the stomach, the route of the food is shortened by bypassing it. Thus, less absorption of food is ensured. In the mini-bypass, an intestinal length of 2 meters is skipped. In a normal bypass, a 1-1.5 meter length is deactivated. Although mini-bypass is perceived as an easier operation compared to normal bypass due to its name, it is a more severe operation as it deactivates more length compared to normal bypass. If we rank the surgeries according to their severity, sleeve gastrectomy is the lightest. Then comes the normal bypass. The heaviest and therefore the most effective is the mini-bypass. As the effectiveness of these surgeries increases, their side effects may also increase. For this reason, sleeve gastrectomy surgery is the lightest in terms of side effects. Then comes the normal bypass. The heaviest is the mini-bypass.

• Can any overweight person undergo obesity surgery?

Certain criteria are required for a person to have obesity surgery. The first criterion is calculated by the ratio of height and weight, called body mass index. Ideally, this ratio should be between 20-25. If the ratio is between 35-40 and there are chronic patients with diseases related to the heart, fatty liver, diabetes, hypertension, etc. or if the ratio is above 40, obesity surgery can be performed. Otherwise, obesity surgery is not performed for those who have 3-5 kilograms of excess weight.

• My father is 60 years old and over 120 kg. Can he undergo obesity surgery? Is there an age limit for surgery?

There is no clear upper age limit for surgery, but as age progresses, the surgeries are riskier. There is no age limit for patients with good physical performance. Patients can undergo surgery up to the age of 65. It can be performed in people over 65 if their physical performance is good, but it is still rarer.

• How is the method to be used in obesity surgery decided?

Which method will be used in obesity surgery is decided by looking at the age of the patient, chronic diseases, and body mass index. For example, a mini-bypass may be a good option for patients with diabetes that is difficult to control. Sleeve gastrectomy surgery may be preferred more in younger patients. Sleeve gastrectomy can also be preferred in people whose body mass index is not very high. If the patient has reflux, normal bypass may be preferred, since reflux problems may increase after sleeve gastrectomy or mini bypass. Which surgery is suitable for which patient can only be decided during the examination, not according to a single criterion, but according to many criteria. 

• I had obesity surgery before, but after a while, I rapidly gained weight. Can I have the surgery again?

This is a common question and can be a problem. This may be caused by two problems. Firstly, there may be a technical problem with the surgery. The small stomach may have been enlarged. Some of the regions that need to be removed may have been left inside, or a fistula (food may be escaping into the stomach which is closed by a second way) may have developed in patients who have been bypassed. These are very easy to understand. If there is a technical problem inside, it is very easy to understand with methods such as tomography, passage imaging, and endoscopy performed after the surgery. Correcting these will help the patient lose weight again. However, most of the patients can gain weight without any technical problems. This is the second reason. The most important reason here is that the patients return to the bad eating habits they acquired before the surgery. Bad eating habits often stem from their desire to comfort themselves by eating while struggling with stress. It is more important to provide psychological support to patients before performing a second surgery.

• How much weight is lost after obesity surgery?

The most important factor that determines how much weight the patient will lose is the weight before the surgery. The more weight the patient has, the more weight he/she will lose. For example, it is a success for a person who was 200 kg before the surgery to drop to 120 kg after the surgery. However, a 120 kg patient losing 40 kg after surgery can be counted as a success.

• When can one go back to a normal eating routine after sleeve gastrectomy surgery?

After sleeve gastrectomy surgery, normal eating habits can be resumed in a few weeks. In the first weeks, liquid foods are taken, followed by soft foods. Afterward, solid foods can be taken. The most advantageous period after surgery in terms of weight loss is the first 3 months. The first 3 months are the golden period. For this reason, patients are recommended to consume liquid and soft food for the first 3 months.

• My son is 15 years old and has a weight problem. He is currently in the obese class. Can surgery be done? Does it affect him negatively afterward?

With the consent of the parents, surgery can be performed for people under the age of 18 who are defined as obese. Young people under the age of 18 who are obese are a special group as it has psychological side effects. The youngest patient I have ever operated on was 14 years old. The boy was 13 when he first came to me with his mother. It is very difficult to make a surgery decision for a child of this age. I consulted pediatricians. We followed a diet program for a while. After a while, he did not lose any more weight, so we performed surgery in the summer when the schools were on vacation. It has been 10 years since this surgery. He's even graduated from university now and has never been overweight again. It is necessary to be very careful and elaborate when deciding on obesity surgery for the age group in question. The patient and his/her family need to be very motivated about this surgery and weight loss.

• Are obesity surgeries risky?

As with any surgery, there is a risk. The risk is less if the preoperative preparations and what needs to be done are done, the patient adapts to the surgical team, fulfills the instructions, the surgeon is experienced, and the infrastructure of the hospital is suitable. Simply put, the patient needs to stand up early after the surgery. He/she needs to take deep breaths and cough. These are the essential conditions that the patient must fulfill.

• What is the process after obesity surgery? Is it painful?

Every surgery is painful. It is not possible to say that there is no pain after the surgery. However, we try to reduce the severity of pain as much as possible with the pain relief protocols used in the hospital. A little movement and exercise after the surgery will reduce the risks such as constipation and water accumulation in the lungs, which may be caused by constant lying down. 

• Will there be an incision scar after obesity surgery?

Since these surgeries are performed with a closed method, the incision scars are quite small. These surgeries are usually performed through three or four holes. Since these holes are 0.5 to 1.5 cm in size, the problem of scarring is very low.

• Is the weight lost with obesity surgery regained? What should be done to avoid weight gain after surgery?

After Obesity Surgery, the patient may gain weight again as a result of technical difficulties or the patient's return to his/her old eating habits. In order not to gain weight after surgery, it is necessary to find other ways other than eating to combat stress. If we do not put aside the habit of constantly snacking and eating in order to relieve the tension and stress during the day, we can always experience this problem. Instead of this habit, stress-reducing things such as reading a book, watching TV, walking, etc. that will not harm the body can be done.

• How soon can one get pregnant after obesity surgery? 

In the first 3 months after the surgery, weight is lost quickly, but after this period, the weight loss process takes up to 1 year, although it decreases slightly. Therefore, we do not recommend pregnancy for 1 year after surgery for women who are considering pregnancy. Obesity is also a problem that prevents pregnancy. For this reason, many overweight women first want to have obesity surgery in order to become pregnant. Some of our patients who come with this motivation can get pregnant within one year after the surgery because they are not protected. This is something we do not want as physicians. Because the patient loses weight rapidly during this period, and when she becomes pregnant, she tries to raise a new life in her belly. For this reason, we do not recommend pregnancy within the year after the surgery so that the child does not experience nutritional and developmental problems.

• Can obesity surgery be repeated? When can the second surgery be performed?

In obesity surgeries, it is preferred to perform this once, but it can be repeated if necessary. If there is a technical problem arising from the first surgery or if the patient has returned to his/her eating habits before the surgery, he/she can undergo surgery again 1 to 1.5 years after the first surgery, provided that he/she changes his/her eating habits with psychological support.

• Can chronic diseases be taken under control with obesity surgery?

After the obesity surgeries started, some beneficial side effects were seen in the patients. It was observed that fatty liver decreased, sleep apnea and snoring disappeared, diabetes, blood pressure, and cholesterol levels decreased, and menstrual irregularities in women improved. It is a known fact that obesity also causes susceptibility to many cancer diseases. In this sense, it was seen that obesity surgery alone is not a weight loss surgery. It is also not an aesthetic surgery. We aim to solve the negative effects of weight on human health and quality of life at the end of the day.

• I am a cardiac patient receiving treatment. But my excess weight also complicates my treatment. Can I undergo surgery?

In order for a person with heart disease to undergo obesity surgery, the cardiologist and anesthesiologist must first approve that the patient can undergo surgery. This is a team effort, and the decision to operate must be made with a multidisciplinary approach.

• What are the risks that can be experienced after obesity surgery?

There are risks of infection, bleeding, and leakage that can be seen after every surgery. With the developing technology and the increase in the experience of surgeons, the risk of leakage has decreased as much as possible. Although the risk of bleeding has decreased compared to the past, it can still be seen. The most important reason why this cannot be completely reduced to zero is the risk of embolism from the legs to the lungs in some patients after obesity surgery. This is a life-threatening condition for the patient. Especially if the patient remains immobile after the surgery and does not stand up, the risk of clotting increases even more. For this reason, it is necessary to take some precautions, the patient should stand up as soon as possible after the surgery, use blood thinners for the first month, and wear special anticoagulant pressure socks.

• I want to have surgery, but I am worried about the post-operative process. What should I change about my lifestyle after obesity surgery?

Eating habits before obesity surgery should be changed. Other ways should be found to deal with stress other than eating. Therefore, we can say that the whole lifestyle should be changed after the surgery.

• Is the weight lost after obesity surgery permanent?

Compared to diet, sports, and other methods, weight loss in obesity surgery is more permanent. The weight loss with diet and sports is regained after a short time when attention is not paid to it and it is not adopted as a lifestyle. A healthy person is not expected to constantly gain and lose weight, but to maintain it for many years after losing weight. Compared to diet and sports, obesity surgery is the method that can provide this stable situation the most.

• What kind of diet should be adopted after obesity surgery?

It is necessary to adopt a protein-rich diet in order to prevent muscle loss in the early period. In addition, fluid intake is very important during this period. It is recommended to consume both liquid and protein foods such as milk, yogurt, and chicken broth soup. High-calorie and carbonated drinks should be abandoned.

•  How much time is needed before and after surgery? When can I return to work?

It depends on your job. If you are doing a physically heavy and active job, a recovery period of 1-1.5 months may be needed. However, if you are a housewife or a white-collar worker working at a desk, you can usually start within 15 days. The most important reason for this short time is that closed surgeries are performed. Patients can be nervous because they cannot eat as much as they want after the surgery, as in their old routine. This may take several months. However, this tension resulting from surgery is not permanent. The patient's family should be understanding and solution-oriented towards this tension.

• Is there any harm in undergoing stomach surgery?

It has some long-term side effects. After obesity surgery, some functions of the stomach may be deficient. There may be deficiencies in the absorption of iron in the stomach. Vitamin B12 deficiencies can be seen. These need to be followed for a lifetime and definitely supported.

• Is there a difference between men and women in obesity surgery?

Technically, these surgeries are more difficult for men. There are 2 types of obesity. The first is apple-type obesity. This is mostly male-type obesity. The upper body is rounder, the legs are thinner. Since the upper part is more rounded like a barrel in apple type, surgical intervention can be more difficult. The second type is the pear type. The upper part is thinner, and the hips and legs are thicker. This is more common in women. Surgical techniques are easier with this body type. For this reason, obesity surgery in men is a little more difficult than in women.

• How soon after the surgery can I exercise?

Heavy exercises should not be done in the first 2 months. Light exercises and walks can be done.

• I have liver disease, and I also have an obesity problem. Can I undergo surgery?

Since I am also a liver transplant surgeon, I can easily answer this question. There are 3 stages of liver disease. You cannot undergo surgery in stage C because, for example, if you perform obesity surgery on a patient with cirrhosis who has accumulated water in his/her abdomen, it will have a bad outcome. While some patients in stage B can undergo surgery, it can be dangerous for others like stage C. However, obesity surgery can be performed for liver patients in stage A.

• Can patients with reflux and gastritis undergo surgery?

Yes, they can. Sleeve gastrectomy surgery was controversial in patients with reflux. After sleeve gastrectomy surgery, an increase in reflux may occur, but sometimes it may not be seen. For this reason, I inform patients with reflux in advance. I want them to know that reflux complaints may increase after sleeve gastrectomy. Bypass surgeries are more suitable for patients with reflux and gastritis.