Frequently Asked Questions

It is useful to look at the bright side first. First of all, almost all patients lose weight significantly. Most of them will definitely regress or go into complete remission if their diabetes is not based on very long years, hypertension and high cholesterol levels may improve. In addition, since the knees are relieved of a considerable load, they recover and conditions requiring orthopedic surgery may disappear. Sleep apnea improves and sleep makes sense. Fat in the internal organs, especially in the liver, disappears. Fertility increases in women who have infertility problems and cannot have children, and sexual functions improve in men. Psychologically, it is almost like a vaccine of happiness. Almost all of the patients who undergo these surgeries become more self-confident, more hopeful and much healthier people. Most importantly, due to all these improvements, the life span of our patients is extended by 10-15 years in a scientifically significant way. On the other hand, it would not be correct to say that bariatric surgery has zero problems in the long term. Very rarely (1 - 4%), stenosis may develop in the joining and cutting suture lines after both sleeve gastrectomy and gastric by-pass (gastric by-pass or duodenal switch) surgeries. The clinical signs of “stenosis” are excessive weight loss, increased reflux complaints and decreased tolerance to solid foods, especially “lump meats”. Recognition of these conditions is not difficult and these strictures can be dilated with endoscopic balloon applications. Very rarely, re-surgical intervention may be required for strictures and these are not easy procedures.

In obesity, body fat increases. Where this fat is distributed is also important. Increased fat tissue around the abdomen and waist increases the risk of diabetes more. There is a very close relationship between Type 2 Diabetes and obesity and 80% of individuals with Type 2 Diabetes are obese. Obesity causes insulin resistance, which facilitates the development of diabetes. Obesity also makes diabetes treatment and blood sugar control difficult. With weight loss and exercise, blood sugar control is much easier and oral antidiabetic drug doses are significantly reduced compared to obese patients.

Insulin is a hormone secreted from the pancreas that regulates sugar metabolism. Insulin binds to insulin receptors and is activated. If these receptors do not allow insulin to bind for various reasons; insulin cannot show its effects even though it is in sufficient amounts in the blood. Insulin resistance can be defined as the difficulty in showing the effect of insulin secreted to control sugar in the body. As insulin resistance increases, insulin is also increased to control sugar. This means that more insulin is secreted in the body than necessary. Increased body fat leads to insulin resistance, and insulin resistance leads to increased body fat, i.e. obesity. In addition, this resistance can lead to pancreatic insufficiency and diabetes over time.

Gastric Bypass is an older type of surgery compared to other obesity surgery methods. First, a small stomach with a volume of 30 mlt is created. For this, stomach tissue close to the esophagus-stomach junction is used. The small intestines are connected to this newly created small stomach at a certain distance. There are two types of bypass. In one type, the small intestines are brought in a ring shape and connected to the stomach without being separated at all. This is called “Mini Gastric Bypass”. In the other type, the small intestine is separated and one end is connected to the stomach and the other end is connected to the small intestine only after a certain distance. This is called Roux en Y gastric bypass. As with the gastric sleeve, the mechanism here is both restrictive, i.e. the patient can consume a more limited amount of food, and the food meets the bile and pancreatic enzymes poured into the duodenum in small intestine sections much further away from where it should be. Thus, the breakdown and absorption of food becomes more difficult and a related malabsorption mechanism is added. In short, the patient eats less and benefits less from what he or she eats. Here, the change in the hormones of the gastrointestinal system is more pronounced than in the gastric sleeve. Accordingly, the feeling of hunger decreases, the feeling of satiety increases and blood sugar is stable. Among its advantages, the patient can lose 60-80% of the excess weight. It is a method that restricts food intake.

A diet rich in saturated fats (red meat, fried foods, etc.) can cause obesity, as well as an increase in the level of low-density (ldl) cholesterol in the blood, which is called malignant. In obesity, high-density (hdl) cholesterol, which is defined as benign, decreases and triglycerides increase. Most of the fat in the body is stored as triglycerides. Increased fat levels in the long term cause it to accumulate in the artery wall and cause arteriosclerosis. Arteriosclerosis is the most important risk factor in the development of cardiovascular disease. Arteriosclerosis also increases the risk of stroke. Chest pain (angina) occurs when the heart muscle is not adequately nourished, especially during increased exertion (e.g. climbing stairs, fast walking, during sports). Severe blockage of blood vessels can lead to a heart attack. Since obesity triggers atherosclerosis, narrowing of the arteries supplying brain tissue can also occur. This triggers the formation of an intravascular clot and the clot that forms causes a lack of blood supply to the part of the brain that the artery feeds. This condition clinically constitutes a stroke. The brain tissue, which is not nourished, loses its function and often there is loss of movement or function in one or more organs in the body. The risk of stroke is significantly increased in morbid obesity.

Blood pressure is equal to the product of cardiac output and peripheral vascular resistance (PVR). Both are increased in obese hypertensives. In the obese, cardiac output is regulated to meet metabolic demand. An increase in body weight leads to an increase in cardiac output. This increase is achieved by an increase in stroke volume. Heart rate remains the same for unknown reasons. Muscle mass increases to prevent an increase in left ventricular wall muscle tension; muscle tension remains normal. In obesity, there is normal or increased ventricular volume with increased muscle mass. Obesity, salt and high calorie diet cause left ventricular hypertrophy (LVH) independently of blood pressure. Sometimes it can also lead to right ventricular hypertrophy (RVH). Increased body weight is often associated with increased blood pressure. Obesity and hypertension are increasing rapidly worldwide, especially in industrialized societies. At least 1/3-2/3 of hypertensive patients are obese. The probability of hypertension is 3 times higher in obese people. Blood pressure is correlated with skinfold thickness measurement.

Since the weight on the joint surfaces in obesity is much higher than normal, it causes wear and tear in the articular cartilages, especially in the waist, hip and knee joints. This situation causes joint pain at first and swelling, difficulty in movement and limitation of movement in later cases. The increase in joint diseases seen in the hands of obese people also suggests a metabolic mechanism. While the risk of knee joint problems in a person with a BMI of 20 and below is 0.1, this risk increases to 13.6 with a BMI above 36. In other words, it increases approximately 130 times.

Obesity causes wear and tear in the articular cartilage, especially in the waist, hip and knee joints, as the weight on the joint surfaces exceeds the normal. This situation causes joint pain at first and swelling, difficulty in movement and limitation of movement in later cases. The increase in joint diseases seen in the hands of obese people also suggests a metabolic mechanism. While the risk of knee joint problems in a person with a BMI of 20 and below is 0.1, this risk increases to 13.6 with a BMI above 36. In other words, it increases approximately 130 times.

Dieting before surgery is a practice we recommend. This both reduces the risk of complications related to surgery and facilitates the surgical procedure as it reduces the size of the liver. For surgical preparation, all routine surgical tests are performed. Respiratory functions are evaluated. In addition, the stomach is evaluated by endoscopy before surgery for possible stomach pathologies. Apart from the relevant tests, the opinions of cardiology, endocrinology, thoracic, psychiatry and anesthesiology doctors are obtained for consent for surgery. The patient is fasted the night before. The patient is told what to do to prevent the formation of a blood clot and blood thinners are started.

First of all, let us remind you that all obesity surgeries are laparoscopic (closed) interventions, that is, they are performed without cutting the abdomen. Since there is no large abdominal incision; postoperative pain is very minimal. Shoulder pains that can be observed after all laparoscopic surgeries disappear spontaneously in 1-2 days and can be easily controlled with simple painkillers. Nausea and retching may be observed in approximately 20% of patients in the first 1-2 days after surgery, but this is a self-limiting condition that passes in 36 hours at most. In the first days after surgery, especially when fluid intake starts, our patients may feel a compressive chest pain, but this is controlled when they learn to take fluids slowly. All patients are up and walking after 3-4 hours. Thanks to early walking and special mechanical compression stockings applied to the legs, the risk of clot formation in the legs is extremely low. In addition to early walking and mechanical compression stockings, blood thinners are started in the preoperative hours to prevent clot formation in the legs. These injections are administered once a day while in the hospital. Mechanical compression stockings are used for 7-10 days. A simple “leakage” control film is taken in our radiology unit on the 1st day after surgery. If no problem is detected, methylene blue is given as the 2nd test. If this test is also normal, they are immediately started to be fed with clear fluids by mouth. Almost all of our patients are discharged on the 3rd day. During the 3 days of hospitalization, our dieticians meet with the patients and their relatives every morning and inform them about what kind of diet they will follow, especially in the first 1 week. All patients will receive intravenous fluids continuously during the 3 days in the hospital. This is because it is not possible to get enough fluid by mouth in the first days. In fact, this is the most important reason why we keep all our patients in the hospital for 3 days. On the 3rd day, the patient who meets with our team is discharged by being called for a follow-up visit one week later and fully informed about what to do at home. After going home, the most important priorities should be to be as active as possible and drink at least 1.5 liters of “water” a day. The primary reason for re-hospitalization after discharge is fluid deficiency caused by not drinking enough water at home.

It is very important that all “possible” complications are well known and that the “risk” is fully understood by patients. Patients with obesity are already at a much higher life risk than the risk of surgery! So much so that; morbid obese patients die 10-15 years earlier than they should if they are not treated surgically. This is scientifically proven. Therefore, it is useful to re-emphasize that we are not only talking about obesity at a level that arouses aesthetic concerns. It should not be forgotten that obesity itself is a life-threatening fatal disease. The fatal risk of surgical methods varies between 0.1 - 0.4%. This 1-4 per thousand “fatal” surgical risk is an acceptable rate if we consider the issue in terms of profit/loss ratio. In order to prevent these, we as a team are thinking and working carefully on these issues with all our strength. Detailed preoperative preparation, fully equipped hospital conditions, high technology at hand, advanced surgical experience and 24/7 teamwork are our principles.

a. Anesthesia Modern anesthesia techniques have reduced the risks of anesthesia to an almost negligible level (1/20 000 - 1/30 000). b. Clot formation in the legs and pulmonary embolism: Clot formation, which is reported to occur in 0 - 1% of all large series, has never been observed in our series. Being overweight, especially if an operation is to be performed under general anesthesia, increases the susceptibility to a special condition known in medicine as “deep vein thrombosis”, which can be defined as the formation of clots in the deep veins of the legs (calf veins). In other words, obesity is a clearly proven risk factor for this type of clot formation. General anesthesia and prolonged operation time are additional risk factors for clot formation. There is also good news here. With the careful use of a low molecular weight “blood thinner” called “heparin” and special “pneumatic” pressure stockings applied directly to the legs, the risk of clot formation can be significantly reduced, if not completely eliminated. One of the most effective methods to reduce the risk of clot formation is the short duration of the operation and the immediate mobilization of patients in the first hours and days after surgery. In both gastric sleeve and gastric by-pass surgeries, the stomach, which are hollow organs, and in “by-pass” operations, the small intestine are cut at certain points, re-closed and some “reconstruction” (reconstructions) are performed. Therefore, the most feared complications in the early period after all three operations are bleeding or leakage from these incision and closure lines. Despite all care and precautions to prevent these from occurring, there is still a 1-2% risk. When these are seen in the early postoperative period, recognizing the situation quickly and controlling it with the right interventions makes these complications reversible. This is done by a center that performs bariatric surgery with experience and meticulousness. i) BLOOD - Bleeding may require immediate endoscopic intervention, and sometimes laparoscopic intervention again, although this is very rare. ii) LEAKAGE - As for leakage, this is also extremely rare, but if it occurs, it is vital that it is recognized immediately. Like many other centers around the world, we double check our patients on the first postoperative day by giving them an oral radio opaque liquid followed by a double test with methylene blue. Because “early” leaks occur in the first 1-2 days after surgery. Therefore, all our patients are followed very closely during the first 3 days after surgery while they are still hospitalized. After the 3rd day of discharge, patients are sharply warned so that “late” leaks can be recognized immediately. Unexplained fever and new onset of abdominal pain with no clear cause are alarming signs for us and may require immediate intervention. Therefore, all patients with fever or abdominal pain are repeatedly warned to contact us immediately if they are within the first 3 weeks after surgery. If a leak is detected, we may sometimes need to work together with experienced interventional radiologists. Interventional radiologists are an indispensable part of our team to drain intra-abdominal fluid collections due to leakage without surgery. Leakage of the contents of the digestive system from the suture line into the abdominal cavity can sometimes be resolved by endoscopic clipping, special “stent” applications, CT-guided “percutaneous” drainage, or sometimes by reoperation in cases where these fail. The important thing is to recognize the leakage immediately and to treat it immediately.