Morbid obesity

The problem of obesity is one of the most pressing issues in medicine, since the number of people with excess body weight is rapidly increasing every year, which gives reason to speak of a true “epidemic.” Obesity is defined as an increase in body weight due to adipose tissue, which leads not only to aesthetic problems but also to a sharp increase in the risk of developing a large number of diseases and a significant deterioration in a person’s quality of life. In severe forms, obesity may lead to disability and even premature death.

According to WHO data, there are 1.7 billion adults (over 20 years old) living in the world who suffer from this problem. The increase in the number of people with excess body weight naturally leads to an increase in the number of individuals with severe forms of obesity.

One of the main indicators used to determine the presence of this pathology is the body mass index (BMI), which is a number obtained by dividing a person’s body weight (in kilograms) by height (in square meters). It should be noted that the obtained data are not an absolute indicator of the presence or absence of obesity, since each individual case has its own nuances, and only a physician, taking into account all individual characteristics, can most accurately establish the diagnosis.

If BMI is within 25–30, it indicates overweight; if it increases and reaches 30–40, it is obesity. In cases where BMI is more than 40 or more than 35 in the presence of severe complications, morbid obesity is diagnosed.

Morbid obesity is an extremely dangerous pathology, as it leads to the development of such severe complications as:

• type 2 diabetes mellitus;
• pathology of the cardiovascular system (arterial hypertension, ischemic heart disease, circulatory insufficiency, etc.);
• gallstone disease;
• disorders of the reproductive system (menstrual irregularities in women, erectile dysfunction in men);
• development of musculoskeletal pathology (osteoarthritis);
• fatty liver disease;
• increased risk of developing oncological diseases.

In addition to the listed diseases, it is extremely important to note psychological and social problems that arise in obesity and lead to a significant deterioration in patients’ quality of life. Therefore, ignoring this problem is unacceptable. Only proper and adequate treatment of morbid obesity allows a person suffering from this pathology to return to a normal and active life.

Causes of obesity

The causes of obesity are quite diverse; however, the following factors should be highlighted:

• sex (women are more prone to obesity than men);
• age (the risk of developing this pathology increases with age, which is associated with physiological characteristics of metabolism);
• a number of diseases, especially endocrine ones;
• нарушения характера и режима питания → disturbances in dietary pattern and eating habits. Excessive consumption of high-calorie, fatty, and carbohydrate-rich foods is the most common cause of obesity;
• harmful habits (alcohol consumption, smoking);
• decreased physical activity;
• нарушение режима сна → sleep disturbances (lack of sleep);
• stress;
• use of certain medications.

Treatment of morbid obesity

Treatment of obesity can be carried out using conservative and surgical methods. Conservative therapy includes lifestyle modification, which consists of following a diet, engaging in dosed physical activity, and taking medications (only when indicated and prescribed by a physician!). This method is widely used and effective in overweight and mild forms of obesity; however, in the presence of morbid obesity, it is often not possible to achieve a positive effect due to a number of factors (presence of comorbidities, psychological aspects, etc.).

At present, the most effective method of combating morbid obesity is bariatric surgery — a surgical intervention on the organs of the gastrointestinal tract aimed at correcting obesity.

Types of bariatric surgery

Bariatric surgery can be performed either via laparotomic (open) access or using minimally invasive techniques, i.e., laparoscopically. The latter option is more common in modern surgery, since laparoscopy has a number of advantages: rapid recovery, less pronounced postoperative pain syndrome, and a lower risk of postoperative infectious complications. Due to the fact that the operation is performed through several small incisions on the abdominal wall, a better cosmetic effect is achieved.

All bariatric operations can be divided into the following groups:

1. Restrictive (gastro-restrictive), the purpose of which is reduction of stomach volume. Decrease of body weight in this case occurs due to reduction of the volume of consumed food, as well as due to rapid satiety arising during eating. Types of restrictive operations:

• Adjustable gastric banding, in which the stomach is divided into two parts by means of installation of special cuffs (according to the principle of an “hourglass”). The diameter of the opening between the parts of the stomach can be regulated by means of injection filling or emptying of the cuffs.
• Vertical (sleeve, longitudinal) gastric resection — consists in removal of the greater part of the stomach, while sphincters (cardiac and pyloric) are preserved and a narrow gastric tube is formed along the lesser curvature of the stomach, with a volume of approximately 60–150 ml.

2. Malabsorptive (bypass) — involve bypassing parts of the small intestine, reducing absorption. Currently not performed as isolated procedures.

3. Combined — which combine a gastro-limiting and malabsorptive component. These include:

• Gastric bypass (gastroshunting). The essence of the operation consists in isolation of a small part of the stomach with a volume of 20–30 ml in the subcardial region by means of staplers and connection directly with the small intestine. In this operation, most of the stomach, the duodenum and part of the jejunum are excluded from the passage of food through the gastrointestinal tract, which leads to acceleration of transit of gastric contents.
• Biliopancreatic bypass, in which longitudinal gastric resection is performed, after which it is directly connected with the ileum. There is also a modification of this operation, in which longitudinal gastric resection is performed, but the ileum is connected with the duodenum.

Indications and contraindications

The surgical method of treatment of obesity is not indicated for all patients. The indication for surgery is the presence in a patient aged from 18 to 60 years of morbid obesity not amenable to conservative treatment, with BMI above 40 (or above 35 in the presence of severe complications). However, since 2014, according to European recommendations, it is possible to perform operations in patients with BMI below the specified level in the presence of a history of morbid obesity, as well as a number of psychosocial factors. It is also possible to perform bariatric intervention in children, however, only in the presence of strict indications.

Contraindications for bariatric intervention are:

• pregnancy;
• oncological diseases;
• mental disorders;
• peptic ulcer disease in the period of exacerbation;
• presence of severe lesions of vital organs (renal, hepatic, cardiovascular insufficiency, etc.).

The decision on performing this operative intervention is made by a team of physicians together with the patient, taking into account all the pros and cons of such an operation.

Recovery

In the early postoperative period, patients who have undergone bariatric surgical intervention are обязательно (обов’язково → necessarily) under observation of a group of specialists with the aim of early detection of possible complications. Then the patient is prescribed staged diet therapy, which предусматривает (provides for) gradual introduction in small volume at first of liquid products with limited caloric content, and then gradual change and expansion of the diet.

In the presence of indications, patients are prescribed vitamin therapy. Psychological assistance may also be provided.

It should be noted that all recommendations given by the physician regarding diet and lifestyle are mandatory for execution, since the speed and quality of recovery, as well as the effect of the performed intervention, depend on them.