Metabolic syndrome is a serious health problem, increasing especially in the developed countries. With the increase of the socio-economic level, the increase in the proportion of ready-to-eat food has led to consumption of prepared foods and more sedentary life. Thus, the incidence of a combination of metabolic problems has begun to increase. These problems are defined as the “Metabolic Syndrome” in the form of glucose metabolism, fat metabolism disorders, and elevation of blood pressure, along with an increase in waist circumference. In the US, the incidence of metabolic syndrome is generally 21.8%, reaching up to 43.5% with the increasing age. According to the World Health Organization data, in 2005, 30% of the total 58 million deaths (approximately 17,500,000 deaths) were caused by cardiovascular system and accompanying diseases. It is predicted that this ratio will reach to 36% by 2020. Although there are differences according to regions in our society, the frequency of the metabolic syndrome is particularly high in women.
People with metabolic syndrome have a 5 times greater risk of developing type 2 diabetes in the future than those without metabolic syndrome, and a 2 times greater risk of developing atherosclerotic cardiovascular disease. Alcohol-independent liver fattening, polycystic over syndrome, sleep apnea syndrome, gallstones, gastroesophageal reflux, depression and asthma are also considered to be related to metabolic syndrome. In addition to classical findings such as blood sugar elevation, hypertriglyceridemia, low HDL cholesterol, elevated hepatic transaminase, hyperuricemia, microalbuminuria, elevation of CRP and plasminogen activator inhibitor-1 may also be seen.
Early-stage patients may benefit from exercise and diet programs. Surgical treatments should be considered in patients who are overweight or who are not successful with diet and exercise.
Metabolic surgery, also known as diabetes mellitus surgery, is performed in obese patients with metabolic syndrome or diabetic patients with type 2 diabetes even if they are not obese. In these processes, the hormonal changes provided by the removal of a part of the small intestine are utilized together with reduction in food intake of the stomach. In some patients, only obesity surgery is sufficient. However, metabolic surgery is more appropriate, especially if there is type 2 diabetes. For this purpose, there are 3 basic metabolic surgery applications that are being applied in clinical practice. All surgical techniques can be safely performed with laparoscopy (closed method) by experienced staff. Thus, the patient recovers quickly, and length of hospital stay is minimized.
It was used commonly for a while. However, the relatively high rates of complications led the surgical world to new pursuits. Although newly defined surgical methods such as SADI-S, Transit bipartition are at least as effective as duodenal switch, the duodenal switch is now rarely applied due to lower complication rates of the first procedures.
8. Sleeve gastrectomy + Duodenal Switch:
The duodenal switch is unquestionably the most effective anti-obesity laparoscopic surgery that can be an important option in patients with advanced morbid obesity, that is, in patients with a BMI greater than 60 and who had sleeve gastrectomy before but lost their success over the years.
This operation is a very complicated “closed” procedure that is performed together with the “sleeve gastrectomy” and “by-pass” (usually at the same time or occasionally in two consecutive stages). “Sleeve gastrectomy” restrains food intake and reduces appetite. Since the by-pass part involves deactivation of a longer part compared to stomach by-pass of upper digestive system, the malabsorptive effect of surgery (i.e. disruptive effect for the absorption of food) is at the forefront. Thanks to the by-passed small intestine segment containing long and almost 2 – 2.5 meters of small intestine, the confrontation of the food intake with pancreas and bile secretions is also reduced, which will further reduce the absorption of lipids in particular. For this reason, it is imperative that protein support and vitamin and mineral supplements should be maintained carefully and under the supervision of a dietitian after this operation.
There are three processes performed with this operation. The first step is the removal of the gall bladder, “cholecystectomy”. This is a routine and all “duodenal switch” surgery is first started with cholecystectomy. The second stage involves the “sleeve gastrectomy” and is almost identical to the standard “sleeve gastrectomy”. The stomach tube created will only be made slightly wider than the standard “sleeve gastrectomy”. Third and lastly, there will be “by-pass” changes on the small intestines. For this purpose, firstly “duodenum” is completely cross cut from the first part immediately adjacent to the stomach; two ends are completely closed and separated. Thereafter, the cutting and joining operations associated with the small intestines in the lower levels follow. At lower levels and at a certain distance, the small intestine is cross cut once again, closed by separating the two ends and prepared for by-pass. The bottom end of these two ends is pulled up, thus duodenum is cut and closed, and first part on the stomach side is combined. The integrity of the digestive system is restructured through enteroanastomosis of the upper part of small intestine again with small intestine at very low levels, and “duodenal switch” are terminated. The newly developed “single anastomosis duodenal switch” is a somewhat simplified version of this surgery, and this new alternative is shared in animation.
It is one of the most commonly performed metabolic surgeries. It is a very effective method. It is commonly known as diabetes surgery. First, the patient undergoes sleeve gastrectomy surgery. In this way, the amount of Ghrelin, which is an appetizing substance secreted from the removed part of the stomach, decrease and the amount of food taken is reduced. Then the stomach is separated from the duodenum, and the last 250 cm of the small intestines is connected to the exit of the stomach. It can also be applied to the patients who have previously undergone sleeve gastrectomy surgery.
The hormonal changes which occur both by the inhibition of the touch of the food to the duodenum and shut down of a greater part of the intestines and touching of the food directly to the end of the intestine can seriously control the blood sugar level. The whole procedure can be performed safely with laparoscopic method (closed method).
It is a popular method today. It is commonly known as diabetes surgery. The most important advantage is that it is easily tolerated, and since it does not interfere with the passage to the duodenum, the chance of endoscopy intervention is not prevented in other diseases such as stone in the bile duct.
Transit bipartition is an operation technique that has been proven to be safe and effective, even in patients with type 2 diabetes with lower Body Mass Index (BMI) values.
First, the patient undergoes sleeve gastrectomy surgery. In this way, it is possible to reduce the amount of Ghrelin, which is an appetizing substance and secreted from removed part of the stomach, and to decrease the amount of food intake. Then most of the intestine is by-passed and the rest is sutured to the stomach. It can also be applied to the patients who have previously undergone sleeve gastrectomy surgery.
As an ultimate effect, tubing of the stomach and thus reducing calorie intake, increase in positive hormone levels resulting in contact of the food with the last part of the small intestine in the early phase of digestion, and reduction of the activity of the negative hormones obtained with the by-pass of duodenum are provided. The increase in positive hormones does not only increase insulin activity, it also causes an early satiety feeling and change the eating preferences due to increased appetite suppressant and regulatory hormones. The entire procedure can be safely performed laparoscopically (closed method).