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24 Prophylactic Surgery inTrauma
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Surgical Prophylaxis ofObesity
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25
ErdincKamer andFevziCengiz
25.1 Introduction
Obesity is a condition where body fat mass
exceeds normal acceptable levels and it is a
chronic metabolic disease with high mortality
and morbidity rate due to metabolic complications. The World Health Organization (WHO)
has dened the term “obesity” as excessive fat
accumulation that is harmful to health. Obesity,
considered as the twenty-rst century’s epidemic,
is the primary health problem in developed countries, reducing life expectancy and creating a
challenge for the global economy. WHO has
dened obesity as a disease in ICD-10 [1, 2].
Obesity is usually dened by the Body Mass
Index (BMI) criteria, which is obtained by dividing body weight in kilograms by the square meter
in meters. According to the BMI, individuals are
divided into ve different categories: (1) 18.5–
24.9kg/m
25.0–29.9kg/m2 as overweight, (3) 30–34.9kg/
m2 as class 1 obesity, (4) 35.0–39.9kg/m2 as class
2 obesity, (5) ≥40 kg/m2 as class 3 obesity
(Table25.1) [3]. Those with the highest risk in
terms of obesity-related consequences are the
individuals with BMI ≥40 kg/m2 in the group
dened as morbid obese. More than 35% of
E. Kamer (*) · F. Cengiz
Department of General Surgery, Izmir Katip Celebi
University Ataturk Training and Research Hospital,
Izmir, Turkey
e-mail: kemalerdinc.kamer@saglik.gov.tr;
fevzi.cengiz@saglik.gov.tr
2
is classied as healthy or normal, (2)
Table 25.1 Indications for bariatric surgery [3]
1.
If BMI is ≥40kg/m
comorbidity requirement related to obesity;
surgical treatment should not cause increased risk.
2.
If BMI is ≥35kg/m
associated with obesity should be accompanied.
These associated situations are as follows:
(a) Type 2 diabetes mellitus
(b) Hypertension
(c) Dyslipidemia
(d) Sleep-apnea syndrome
(e) Obesity-hypoventilation syndrome
Pickwick syndrome (coexistence of sleep-
(f)
apnea syndrome and obesity-hypoventilation
syndrome)
(g) Non-alcoholic fatty liver disease or “non-
alcoholic steatohepatitis (NASH)”
(h) Pseudotumor cerebri
(i) Gastro-esophageal reux disease
(j) Asthma
(k) Venous stasis disease
(l) Advanced urinary incontinence
(m) Arthritis affecting daily life
adults are obese in the United States and Turkey
[4]. According to the “Turkey Nutrition and
Health Survey-2010” preliminary studies report
issued by the Ministry of Health of the Republic
of Turkey, the prevalence of obesity is 30.3% [5].
Increased prevalence of obesity causes an
increase in various comorbidities especially in
type 2 diabetes, cardiovascular and cerebrovascular diseases, digestion, leukomotor and respiratory disorders, cancers (such as colon, breast and
uterus), and psychosocial complications [6]. If
overweight and obesity continue with this rate, it
2
, there is no additional
2
, at least one comorbidity
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021
O. N. Dilek et al. (eds.), Prophylactic Surgery, https://doi.org/10.1007/978-3-030-66853-2_25
273
274
E. Kamer and F. Cengiz
is reported that it will affect 60% of the world
population in 2030 (2.2 billion overweight, 1.1
billion obese, 89% male, 85% female) and result
in an increase by 97% in obesity-related heart
disease prevalence, by 61% in cancer prevalence
and by 21% in Type 2 diabetes prevalence [7, 8].
On the other hand, the prevalence of overweight
and obesity among children and adolescents has
started to increase worldwide. WHO European
Childhood Obesity Surveillance Initiative (COSI)
routinely measures the overweight and obesity
prevalence of children aged 6–9 years, and
according to these data, the prevalence of obesity
was found to be between 6.0–26.6% in boys and
4.6–17.3% in girls. Overweight among children
of 6–9years is dened as a serious public health
problem [9].
While obesity causes serious health problems
on the one hand, it causes signicant economic
impact on the other. The cost of obesity complications and treatments in the United States is
approximately $200 billion, accounting for over
20% of all US healthcare spending in 2005. The
global economic impact of obesity was estimated
at $2.0 trillion in 2014 [10].
25.2 Obesity Comorbidities
The incidence of many chronic diseases has
increased in obese people. These risks are higher
for class 3 obese individuals, whose BMI is over
40kg/m
tality independent of concomitant diseases.
Diseases accompanying obesity and complications of obesity are: diseases related to the cardiovascular system (hypertension, atherosclerotic
heart and myocardial infarction and cerebral
vascular accidents and peripheral vascular disease, peripheral venous insufciency, thrombophlebitis, pulmonary embolism), respiratory
system related diseases (obesity-hypoventilation
syndrome, obstructive sleep apnea, dyspnea),
diseases related to the metabolic-endocrine system (Type 2 diabetes mellitus, dyslipidemia,
insulin resistance), diseases related to the gastrointestinal tract (Hiatus hernia and reux disease,
nonalcoholic fatty liver, hepatic cirrhosis,
2
. Obesity is the cause of increased mor-
hepatic carcinoma, gallstones, colectal cancer),
diseases related to neurological diseases (nerve
compression, carpal tunnel syndrome, sciatica,
pseudotumor cerebri), musculoskeletal system
(osteoarthritis, at foot, disc diseases), endocrine and genitourinary system related diseases
(stress incontinence, decreased fertility, mechanical difculty in sexual intercourse, pregnancy
complications, urinary stones, polycystic ovarian
syndrome, male hypogonadism, endometrium,
breast, ovarian, prostate and pancreatic cancers),
related to psychosocial conditions (self dissatisfaction, depression, anxiety, difculty in nding
work, high life insurance premiums, unhappiness
in marriages, eating disorders), dermatology
related diseases (intertriginous dermatitis).
Approximately 30% of overweight adolescents
in the United States (USA) meet metabolic syndrome criteria, which increases the risk of type 2
diabetes and coronary heart disease. Obesity
ranks second as a preventable cause of cancer in
the USA. Obesity causes 40% of the cancers
diagnosed to develop in the USA [11]. The
International Agency for Research on CancerOAC has identied 13 malignancies including
obesity-related post-menopausal breast, colorectal, kidney, endometrial, thyroid, pancreas, liver,
gastric cardia, meningioma, ovarian, esophageal
adenocarcinoma, gallbladder and myeloma
malignancies [12]. The effect of obesity on long
life is well documented. More than 2.5 million
deaths per year can be attributed to obesity worldwide [13].
25.3 Patient Selection andTargets
The aim of obesity treatment is to impose adequate and balanced eating habits and to improve
the quality of life by targeting the individual specic body weight loss in order to reduce obesityrelated morbidity and mortality risks. Treatment
options for obesity include surgical treatment and
non-surgical treatment. Non-surgical treatments
include dietary changes, use of various pharmacological agents, physical exercises, and behavioral therapy methods. The rst-line treatment of
obesity should be diet and lifestyle changes. If
25 Surgical Prophylaxis ofObesity
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275
these are not successful, drug treatments are
added. Unfortunately, in obese patients, most of
these can be ineffective in ensuring and maintaining weight loss. Therefore, the use of bariatric
surgery methods in morbid obesity is increasing
worldwide. Studies have shown that surgical
methods in obesity treatment lead to more effective and permanent weight loss in the long term
compared to non-surgical methods [14].
Therefore, the use of bariatric or metabolic surgical methods is increasing worldwide. In 2013,
468,609 cases were reported worldwide, with
154,276 cases in the USA/Canada and 3250 cases
in Turkey [15, 16]. It is seen that these numbers
have increased considerably today.
The principles of the National Institutes of
Health (NIH) adopted in 1991 are generally
accepted as the basis for patient selection for bariatric surgery. General indications are shown in
Table25.1. In addition to those, they can be listed
as failure in medical treatments applied prior to
surgical treatments, stability of the psychological
state, presence of family and environmental support, no alcohol and drug addiction, and fully
informing the patient about the application [17].
25.4 Surgical Techniques
The bariatric surgery methods used includes
“Absorption Degrading Methods” such as biliopancreatic diversion (BPD), jejunoileal bypass
(JIB), which cause weight loss by shortening the
length of the small intestine where absorption
takes place, by bypassing the area where absorption takes place and preventing the encounter
with biliopancreatic secretions that play a role in
absorption, “Intake Restriction Methods” such as
Sleeve gastrectomy (SG), adjustable gastric band
(AGB), vertical band gastroplasty (VBG) that
provides weight loss by reducing food intake by
reducing gastric volume and Roux-en-Y gastric
bypass (RYGB) performed by combining these
two methods, biopancreatic diversion ± duadonal
Switch (DS) and mini-gastric bypass. Among
many different (over 50) effective surgical methods used for treating obesity, most of the popular
bariatric procedures such as Roux-en-Y gastric
bypass (RYGB), sleeve gastrectomy (SG), minigastric bypass, and biopancreatic diversion
(BPD) are considered as the safest effective procedures in terms of obesity-associated comorbidities and weight loss [2, 18].
25.5 Prophylactic Surgery
andOutcomes
Prophylactic surgery is not a very new concept.
The purpose of prophylactic surgery is to prevent
the development of the disease. Patients usually
leave therapeutic surgery because it is asymptomatic and surgery is not required immediately.
Prophylactic surgery can be performed in individuals who are prone to develop cancer from the
hereditary mutations most frequently diagnosed
by genetic testing, as well as for all organs foreseen to develop the disease. Although bariatric
surgery operations are procedures to protect the
patient from possible diseases and complications
in the future, it has not been dened as a prophylactic surgery procedure. There are very few articles in the literature that describe this as a
prophylactic procedure [19].
Bariatric surgery operations are applied to
patients for metabolic surgery as well as surgeries that result of weight loss. In the foreword part
of the Metabolic Surgery book dated 1978, the
discipline of bariatric surgery has dened metabolic surgery as “operational manipulation of a
normal organ or organ system to achieve a potential health gain and get a biological result.” In
Genesis, metabolic surgery has been described as
an “operative manipulation” under general anesthesia on “normal organ” to achieve a “biological
result” [20].
Various surgical procedures, generally used in
bariatric surgery, result in approximately
34–85.3% partial or total T2D remission depending on criteria applied to dene Type2 DM (T2D)
remission and 95% global success in glycemic
control [21]. RYGB is also a very effective option
for T2D remission. Most patients who were
applied RYGB did not require drug use 1year
after surgery and T2D remissions of 84–90% and
29–50% were reported respectively 1 and 5years
276
E. Kamer and F. Cengiz
after RYGB [2]. However, T2D remission rates
vary in the literature. Yan et al. had reported
56.81% (36.8–90.3%) T2S remission, while
Chang etal. reported 95.15% (88.38–98.8%) [22,
23]. Sleeve gastrectomy has gained popularity in
recent years due to glycemic control rates similar
to RYBG and lower complication rates related to
surgery. In the study of the Swiss Multicenter
Bypass or Sleeve Study (SMBOSS), which was a
randomized controlled study, T2D remission
rates were shown as 60% in SG and 77% in
RYGB 3years after the surgery [24]. It has been
reported that laparoscopic mini-gastric bypass
provides successful remission in patients with
BM2>35 and 77% in patients with BMI <35in
T2D/impaired fasting glucose patients [25].
Surgical Treatment and Medications Potentially
Eradicate Diabetes Efciently (STAMPEDE)
Trial in a study comparing 150 patients with T2D
in terms of bariatric surgery (SG and RYGB) and
medical treatment, more weight loss, normalization of glycine hemoglobin, decreased triglyceride levels, reduction in high density lipoprotein
levels, and decrease in the use of insulin and
other antidiabetic agents were seen more compared to the medical group. In addition, a reduction was observed in the use of lipid lowering or
antihypertensive in bariatric patients [26]. Brolin
etal. reported in their study that, considering that
presence of at least one concomitant disease
related to obesity is known in 95% of the patients
over 45 and who had undergone bariatric surgery,
it was obvious that the future development of diseases such as T2D (very likely in case of family
history), hypertension, and hyperlipidemia could
be prevented by the bariatric surgery to be applied
to these patients who do not have any additional
disease other than obesity [27].
Obesity is known to have risk and negative
consequences for increased cardiovascular diseases (CVD). A signicant improvement was
observed in cardiovascular risk factors such as
hypertension, dyslipidemia, and T2D after bariatric surgery with the ratios of 63%, 65%, and
72%, respectively [28]. This wide improvement
in cardiovascular risk factors led to a signicant
reduction in the risk of stroke, myocardial infarction, and death [29]. Many studies clearly show
that obesity is an independent risk factor for early
CVD morbidity and mortality in childhood and
adolescence [30]. Also, the steady increase in
obesity prevalence causes an increase in CVD
risks in young people with obesity. On the other
hand, it is useful to examine the economic damage caused by long-term CVD risk with obesity
treatment. Ryder etal. showed in their study that
adolescents with severe obesity were at high risk
for CVD within 30years, the postoperative MBIs
of adolescents who had undergone bariatric surgery signicantly reduced the risk of CVD
despite having a plateau after a while, and that
bariatric surgery was cost-effective as it prevented CVDs and CVD related early mortality in
adolescents with obesity [23]. Therefore, prophylactic bariatric surgery can be considered in adolescents without CVD to reduce both the risk of
developing CVD and mortality from CVD at a
later age.
Given the multiple mechanisms by which obesity increases the risk of cancer, it is possible to
see that some types of cancer decrease with bariatric surgery [31]. In general, bariatric surgery
reduces the risk of cancer in women by 42%,
while cancer risk in men has not been reduced
[32]. For example, it is known that breast and
endometrium cancers are very sensitive to estrogen levels and patients have a history of exposure
to estrogen in their etiology and a decrease in the
incidence of these two cancers after menopause
[32]. Since it has been shown that weight loss
reduces the circulating estrogen level and reduces
the risk of breast and endometrum cancer, it is
obvious that bariatric surgical interventions that
will be performed before seeing cancer in obesity
patients will provide a prophylaxis for this cancer
due to weight loss that takes place with bariatric
surgery [33]. In addition, in a study in which bariatric surgery was performed with gastric bypass
and sleeve gastrectomy, it was reported that there
was a decrease in the risk of esophageal adenocarcinoma in the group that had undergone bariatric surgery [33]. A decrease in the risk of colon
cancer was also detected in the group treated with
bariatric surgery in the same study [33]. As a
result, since bariatric surgery decreases the risk
of breast, endometrium, esophagus and colon
25 Surgical Prophylaxis ofObesity
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277
cancer, application of bariatric surgery to obese
patients may create a prophylaxis.
There is a relationship between BMI and
physical limitation and fatigue. In other words,
obesity is closely related to the decrease in a person’s health-related quality of life. At the same
time, psychosocial problems such as dissatisfaction with their body appearance, unhappiness in
their marriages, and difculty in their sexual lives
are more common in these individuals compared
to the normal population [34]. In studies conducted in our country, it has been revealed that
psychiatric disorders are also common in obesity
patients. Eren and Erdi reported in their study
that 81.3% of obese patients who applied to the
endocrinology department for treatment purposes
had major depressive disorder, 71.7% had major
depressive episodes in the last month, and other
psychiatric distribution distributions were
reported to be 22.6% social phobia, 17% nicotine
addiction, 5.8% alcohol dependence 5.7% anxiety disorder, and 3.8% obsessive compulsive disorder, respectively [34]. Considering that 81.3%
of obese patients had major depressive disorder
and 71.7% of them had a major depressive attack
in the last month, the rate of encountering psychosocial problems in their future life is quite
high for an obese patient. Prophylactic bariatric
surgery to be performed has important psychosocial effects on individuals. Approximately 40%
of patients who request bariatric surgery present
with at least one mental health condition such as
depression, anxiety, overeating disorder, and
alcohol use disorder or impulse control disorders
[35]. There is a lot of evidence that bariatric surgery has a positive effect on psychopathology,
quality of life, body appearance, socio-economic
status, and social relationships [36–38].
Therefore, in order to prevent this, prophylactic
BS may be considered for obese patients.
25.6 Conclusion
Considering that bariatric surgery increases the
quality of life in obese patients and reduces or
eliminates comorbid medical problems and given
the advantages and disadvantages gained, it is
seen that operations performed for obesity are
prophylactic applications, even if they are not
dened as prophylactic surgery. Nevertheless, as
a concept that has not been widely used in the
literature, we believe that surgical practices in
obesity are performed for prophylactic purposes
and it will be useful to examine the issue in terms
of ethics, medicine, and cost.
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