Obesity surgery is the best and only therapeutic option that achieves weight loss and improves the comorbidities of morbidly obese patients. With the introduction of minimally invasive surgery, postoperative results have improved and, consequently, satisfaction and the degree of acceptance in the population. All this motivates that in Spain each year more interventions are made with the incorporation of new surgical equipment.
The most accepted techniques, with their variants, are the gastric bypass, the adjustable gastric band, the vertical gastroplasty type Masson and the biliopancreatic derivation. Any technique must be reversible and reproducible and provide a long-term (5 years) good quality of life and a weight loss of 50% of overweight in 70% of patients operated on.
The success of the gastric bypass depends on the surgeon, since it consists in creating a small volume gastric reservoir to promote restriction and early satiety. As a complex procedure, you can have serious complications such as postoperative bleeding and digestive fistula. Total mortality is 1-2% and weight loss is very important, 70-80% of overweight is reached in just 9 months. The bypass is indicated in any type of obesity and provides very good results in patients who eat sweets due to the dumping effect that the technique induces. It is the technique of choice for many surgeons and represents 2 out of 3 interventions performed in Spain .
The adjustable gastric band is a rare restrictive procedure in Spain, but it is the number one surgery in Central Europe, Australia and South America. Unlike bypass, it is a simple technique, which consists of placing a subcardial inflatable band to create a virtual gastric reservoir. The incidence of serious immediate complications is low, with a mortality of 0.1%. With this band, the weight loss is slow because it depends on the gradual modification of the patient's eating habits, but it can exceed 50-60% of the excess weight in the long term. It is the least invasive technique and should probably be the treatment of choice for young patients who are willing to modify their habits without altering the digestive tract. The band works better in patients with a low BMI than in superobesos and poorly controls diabetics.
The biliopancreatic diversion is a hypoabsorptive technique that involves 15-20% of the surgeries performed in Spain. It drastically reduces the intestinal absorption capacity and is the procedure that offers better quality of life, since the patient eats a hyperprotein free diet. Long-term weight loss reaches 80-90% of overweight, although the malabsorption syndrome predisposes to severe nutritional deficits of fat-soluble proteins, minerals and vitamins.
The tubular gastroplasty works as a pure restrictive technique because it creates a gastric tube from cardia to pylorus less than 2 cm in diameter. It is indicated as the first surgical gesture in patients with supersuperobesity (BMI> 60) or with important risk factors so that, after losing weight and correcting comorbidities, a derivative procedure is programmed, be it a duodenal switch or a bypass. The weight loss at 2 years after the tubular gastric is 50-60% of overweight. It should be carefully evaluated before offering it to a morbidly obese patient because it is not a simple procedure nor is it free of serious complications such as subcardial fistulas.
The immediate challenges that surgeons must face are obesity surgery in those over 65 and, above all, in adolescents with extreme obesity. It is increasingly important to organize expert teams of surgeons, anesthetists, endocrinologists and specialists in nutrition and eating disorders to study and select patients and offer them individually the least aggressive and safest treatment.. As surgeons we can not forget that obesity is an incurable chronic disease, that surgery is only a tool for the patient and that the final success will depend on how well you use it.