Obesity and its surgical treatment d. Abdul Wahid Nasr Al-Mushaikhs, Consultant of Surgery - Department of General and Laparoscopic Surgery, King Fahd Specialist Hospital, Dammam, Dammam - Saudi Arabia Introduction: There is a general consensus that obesity (Morbid Obesity) is a disease that needs treatment like chronic and fatal diseases such as tumors. In addition, obesity is one of the most common diseases in the world, and it is a precursor to many other serious diseases such as:

• Hypertension, cardiovascular disease, high cholesterol, and lung clots.

• Asthma and obstructive sleep aponea syndrome.

• Diabetes.

• Back pain and herniated disc, as well as rheumatism of the knee, pelvis, and ankle.

• Gallstones, Gastro-esophageal Reflux Disease, and cirrhosis of the liver (Fatty Liver) and its cirrhosis.

• The high incidence of some cancers such as liver, colon and rectal cancer, as well as breast, pancreas, uterus and prostate cancer.

• Psychiatric illnesses such as depression and eating disorders.

During the past fifteen years, the incidence of obesity increased dramatically in the entire world, including the Arab Gulf region and the Kingdom of Saudi Arabia in particular. It has also been evident by conclusive evidence that being underweight, even by a rate not ranging between 5-10%, may help a lot in reducing the incidence of obesity-related diseases such as pressure, diabetes and high cholesterol. Excess weight loss also helps banish premature death from these diseases. Based on this information and conclusive scientific evidence, it has become imperative to establish specialized governmental medical centers for treating obese patients medically, psychologically and surgically. Inevitably, this will be of general benefit to injured patients, society and the state, as this will enable obese patients who cannot afford the costly expenses of the private sector to receive the necessary treatment without overburdening their financial budgets. This will also ultimately lead to a reduction in the percentage of chronic diseases associated with obesity in the community.

Currently, obesity surgery is concentrated, in most regions of the Kingdom, in the private sector and teaching hospitals only, which makes this surgery unavailable to everyone, as the vast majority of injured patients cannot afford the costly expenses of the private sector. Also, university hospitals have limited capabilities that cannot keep up with the increasing momentum of cases. Add to that the lack of infrastructure in these hospitals to be specialized centers capable of treating the serious complications of obesity operations, which may sometimes cost the life of the patient if they occur.

Obesity in the Kingdom of Saudi Arabia

According to the 2007 Forbes report, the ranking of the Kingdom of Saudi Arabia is the twenty-seventh among the countries in the world where obesity is prevalent, with the obesity rate among the Kingdom’s population higher than 68%. Richness and prosperity have contributed to a radical change in our daily lifestyle, so movement and physical exercises have decreased, and our dietary pattern has changed, so we have relied on eating fast food and have become accustomed to a monotonous lifestyle. And based on a national food survey in 2007, it became clear that the obesity rate for Saudi women is 25% and for men 15%. As for the percentage of overweight, it was for women and men: 28% and 30%, respectively.

And in another study conducted in 2005 AD, it was found that the rate of obesity in Saudi Arabia exceeds 35%, meaning that there is one obese person out of every three Saudi individuals. These figures seem very worrying and reflect well the seriousness of the situation that has exacerbated greatly over the past ten years since this research was conducted. This frightening spread of obesity in the Kingdom may lead to a great disaster if the Saudi Ministry of Health does not notice and exposes this disease to the attention it deserves. What gives this topic a great dimension is the scientific fact that does not accept any doubt, which is that obesity is a disease that leads to diabetes, hypertension, and high cholesterol, and these are all of the most prevalent diseases in the Kingdom and they exhaust the ministry’s budget every year to treat patients with these diseases Chronic complications and the dispensing of expensive medicines to treat them and treat their complications. By treating obesity, the incidence of these deadly diseases and their complications will be eliminated, and it will save the Ministry of Health a lot of money and effort and will reduce patients'' visits to health centers and hospitals. Add to that - and most importantly - keeping the specter of premature death due to heart and lung diseases away from these infected patients.

In a survey conducted in 1991 in the Khobar region of the Eastern Province on 1072 Saudis referring to primary care centers (477 men and 595 women) aged between 18-74 years, it was found that, using body mass index, the prevalence of obesity is higher when Women than men (men 52%, women 65%).

Causes of obesity

Obesity occurs in anyone if the energy consumed (Input Energy) is much higher than the energy produced (Output Energy). If the individual eats a large amount of food rich in calories, and makes no effort to get rid of them, this excess energy accumulates in the body and is stored as fat. But obesity is very complex, as multiple factors interact with each other, resulting in a complex mixture that causes some of us to become obese while we are not affected at all. Among these factors:

The genetic makeup of each of us. There, as is the case with many other diseases, genetic factors in our genetic makeup that make some people more susceptible to obesity than others.

• Factors related to endocrine diseases such as the thyroid gland, as well as metabolic factors (Metabolic Factors).

• Environmental, social and cultural factors.

• and behavioral and psychological factors.

How is obesity measured?

There is general acceptance and consensus on using the Body Mass Index (BMI) as a measure of obesity, due to its simplicity and ease of use. The mass index of any given body can be calculated by dividing the body weight in kilograms by the square of the body''s height in meters. That is,:

Mass index = weight (kilograms) ÷ (height in meters) 2

Based on the calculation of BMI, a person is classified as follows

Rating BMI (kg / m2)

Thin or Under Weight Less than 18.5

Normal weight 18.5 - 24.9

Weight gain 25.0 - 29.9

Obese 30.0 - 39.9

Very fat 40 and over

Although BMI is considered a reliable method for classifying the degree of obesity in individuals, it has some limitations, especially when:

• People with bodybuilders and athletes, due to the high muscle mass they have, which may give a high indication despite the absence of overweight or obesity.

• pregnant woman.

• And children who are not yet fully developed.

Obesity Program Medical Team

Obesity surgeries require the cooperation of a number of medical specialists in several medical fields to achieve the best surgical results without serious complications. The treating team consists of a surgeon who specializes in this type of bariatric surgeon, a doctor specializing in endocrinology, a psychologist, a nutritionist and a coordinator of the treatment team. This team also needs continuous help and support from a specialist in gastroenetrologist and an interventional radiologist, as they have an effective role in treating surgical complications without surgical intervention. Any treatment program also requires an intensive care unit.

Obesity treatment

1) Medical treatment

Obese patients are referred to a nutritional clinic first to put the patient on a regular and strict diet that limits calories and the amount of food consumed, which helps the patient to lose weight. And the role of health education is important to motivate the patient to regularize his nutritional program and to keep on exercising, especially walking, for an hour a day on a regular basis. And it may be necessary to put the patient on a diet consisting of liquids only, which helps to shrink the size of the liver from cirrhosis and does not harm the planned surgery in the future, in the event that conservative treatment fails. Putting the patient on a harsh diet helps to predict whether the patient will really abide by the necessary nutritional instructions that will be given to him after the obesity surgery or not.

Despite the popularity of weight-loss drugs among the public, it is not recommended to use them due to the serious side effects that may result from them. In addition to being ineffective in the long term.

2) Surgical treatment

Surgery is considered the last resort for treating obesity, after all other therapies such as diet, exercise, psychotherapy, and medication have failed. And surgical treatment may be the best solution to get rid of chronic diseases associated with obesity. Most medical centers depend on what was agreed upon by the National Institute of Health Consensus, which states that surgical intervention for obesity is a must in the following cases:

1. The body mass index is higher than 40 kg / m2, even if there are no other diseases related to obesity such as diabetes, pressure, obstructive sleep apnea, and others.

2. Body mass index is higher than 35 kg / m2, with the presence of other obesity-related diseases such as diabetes, hypertension, and others.

And obesity operations are not suitable for those who have chronic diseases such as kidney failure, liver failure and metastatic tumors, or those who have behavioral diseases such as schizophrenia and addiction.

Obesity surgeries

There are three types of surgeries that are performed for obesity

1. Restrictive Surgery

For example, gastric banding, sleeve gastrectomy, or sleeve gastrectomy.

2. Restrictive Surgery with some Malabsorption

An example is gastric bypass surgery.

3. Malabsorptive Procedures with some Restriction

An example is the bile-intestinal switch with duodenal switch (Bilio-enteric Bypass & Duodenal Switch).

4. Non-surgical methods: such as the stomach balloon.

1) Restrictive Surgery

(i) Lap Band

This process is very easy as it is performed by the laparoscope, where a ring lined with a balloon (balloon belt) is placed around the top of the stomach to a small stomach that does not exceed 15-20 milliliters. This ring is connected to a hose that connects it to a metal device that is placed under the skin. The belt can be narrowed and expanded as needed by entering this device with a needle through the skin. And the patient needs constant revisions to tighten or expand the belt as needed. And the belt and its accessories can be removed surgically if the patient so requests. With this operation, the patient can lose 60% of the extra weight.

And the procedure of this operation has decreased in recent times after studies have proven ineffective in reducing excess weight sufficiently, when compared to other surgeries such as stapling, bypassing or reducing the stomach. Another reason is the many surgical complications resulting from it, such as gastric perforation, band migration, and stomach wall erosion. It may result in gastric juice leakage into a collection of purulent and septicemia (Septicaemia) that may lead to death.

(ii) Sleeve gastrectomy

In this operation, the stomach shrinks to 20% of its original size by cutting a large part of the stomach lengthwise by using special surgical consumables that staple and cut the stomach at the same time. And this operation was performed as a first part of preparing the patient for another obesity surgery, such as bypassing and others. However, after this operation has been proven to be a good and effective one, it has now become a primary operation in the treatment of obesity. This laparoscopic procedure i