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Op. Dr. Murat Üstün

Not long, only ten years ago, most people did not know the meaning of word obesity and the first thing to come to mind about obesity surgery was gastric band and related deaths. However, it is possible to see tens of news about obesity surgeries on both printed and mass media today. Public consciousness is surely a positive thing but there has been also an infollution on this.

Obesity Surgery

We have conducted a long and sincere interview with Dr. Murat Üstün, who is interested only in this area for about 15 years and who is one of the leading obesity and metabolism surgery specialists of our country to enlighten confusing details and to ask key questions about both obesity and the obesity surgery. We hope this will be helpful for those who plans to have surgery or who have already had it and in need of information about the post operation period.

Sir, nowadays we always see obesity and obesity surgery related news in press. Some of them are success stories, whereas some are about the post operation problems and losses of life. We encounter with contradicting and confusing articles very often. What is going on, is there a boom in obesity in our country or something else?

First, yes, it is true that there is an increase in obesity, almost an epidemic, in Turkey as in the whole world. Nearly two of every three people has become obese. The increase in childhood obesity makes us think that the rates will be even higher in near future. In the last ten years, there has been a 44% rise in obesity and 90% in diabetes. The rise in the obesity and metabolism surgery, which is the only method to offer a long-term solution to both problems, is just natural. As we do not have decent statistics, while surgery numbers were approximately 1000 five years ago, it is said to have reached 6000 even 10000 presumably. Even with these figures, that means only 1% of the patients in need of surgery can get it. So to say, the rise in surgery is a result of the rise in obesity.

obezite-cerrahisi-hakkinda-detayli-bilgiler

First, yes, it is true that there is an increase in obesity, almost an epidemic, in Turkey as in the whole world. Nearly two of every three people has become obese. The increase in childhood obesity makes us think that the rates will be even higher in near future. In the last ten years, there has been a 44% rise in obesity and 90% in diabetes. The rise in the obesity and metabolism surgery, which is the only method to offer a long-term solution to both problems, is just natural. As we do not have decent statistics, while surgery numbers were approximately 1000 five years ago, it is said to have reached 6000 even 10000 presumably. Even with these figures, that means only 1% of the patients in need of surgery can get it. So to say, the rise in surgery is a result of the rise in obesity.

So, what may be the economic consequences of intense practice of these surgeries and the rise in them? How does Ministry of Health approach this?

Obezite Cerrahisi Röportaj

No country in the world can finance health system constantly with these rates of obesity and diabetes. Because most of the budget for health is spent on the treatment of obesity and its succeeding chronical diseases such as diabetes, hypertension, hypercholesteremia and consequent complications of these such as kidney damage, arteriosclerosis, heart attack and stroke. Studies indicate that obesity surgery redeems itself in 3 years of time. So, the amount that these patients should spend for their health decreases seriously after the surgery.

Therefore, obesity surgery would affect health budget in a positive way in the long-term. However, unfortunately, the struggle with obesity in Turkey mostly consists of flashy openings and good intentions. It is possible to see the “decisive struggle with obesity” headline every day in the last five years. That resembles our taken or not-so-taken precautions to earthquake. But we really don’t have time to waste. However it is good to express positive behaviors like jogging, healthy nutrition and protective treatments, these have no effect on patients with the heaviest form of obesity, which we call morbid obeses. Believing that these would work is just like believing that if a patient with lung cancer would be well if s/he stops smoking.

We have been hearing about obesity surgery a lot recently, are these new techniques?

In fact, the first obesity surgeries were conducted 50-60 years ago. Sleeve gastrectomy, the youngest obesity surgery, has already been 16 years old. So, there is no scientific base of objections defending the unknown long-term effects of these.

murat-ustun-2

Another reason of these being so popular these days is our young colleagues’, wo have just started these procedures, triumph to have personal advertisement by writing some striking articles. Although we have two occupational organizations in this area, unfortunately, because of the in sufficient inspections, some potentially dangerous information is spread by means of press and the internet. “End of obesity with sleeve gastrectomy”, 100% success in sleeve gastrectomy”, losing weight is piece of cake” are some of the headlines I’ve run across in the last few days. These are not suitable to the seriousness of obesity surgery, also they give a wrong impression to the patients. These surgery types should definitely be preferred by those who are over a certain weight, who has tried diet, exercise and other medical treatments and been unsuccessful in losing weight or started to gain back.

The most dangerous trend is that hospitals see this type of surgery as a new income channel and this becomes a subcontractor job. Have you ever seen an ad of laparoscopic cholecystectomy? But we see obesity surgery ads of hospitals on billboards and magazines. Every day, another bariatric surgeon mentions bariatric surgery on TV as if it was something found new. Some even challenge their colleagues, blame others with mistreatment, claim that the only one applying the rightest method was themselves. A surgeon, who we have never seen in an obesity surgery congress, has reports in news claiming to have applied 1000 surgeries with only one year of experience in obesity. Or, they add the number of the previous experienced surgeons’ surgeries into theirs. That’s why we should be careful to evaluate the number of the surgeries. It is all forbidden according to the regulations, but money does not have the ears to hear that.

So, sir, isn’t it really easy to lose weight by means of sleeve gastrectomy or gastric bypass?

The biggest and most undesirable mistake about this is to believe that the surgery is an easy, quick and warranted solution. Obesity surgery can only be applied after all the methods like diet, exercise, psychotherapy and when the patient is obese in a certain serious level. Even with this group, we should make the patients pursue healthy eating habits, add regular exercise and get support psychologically to eliminate eating disorders. Or else, the surgery cannot guarantee success all alone. However, when the rules are followed, it is possible to lose almost all of the surplus weight and maintaining it. But nowadays we encounter news of celebrities, who are not even eligible for the surgery, to lose 15-20 kilos with sleeve gastrectomy, which is clearly a medical and ethical crime.

Then, in general obesity surgery, specifically sleeve gastrectomy should be taken neither too dangerous nor too easy?

Obezite Cerrahı Uzmanı Murat Üstün

Exactly. Ten years ago, just a few obesity surgeons, we, were trying to tell public that these were not things to be afraid of and that obesity is a disease with a long-term solution by surgery. And now, contrary to newbies of these surgeries, we are trying to explain that these procedures are not that easy and the success is dependant on the post operation follow-ups and adaptation that these operations cannot be done just for 15-20 kilos of overweight. Obesity surgery is not a miraculous solution, it is the step to a big change. The key to success is the adaptation of the patient to this process.

Well, how are these operations performed and how do they work? Namely, why would a patient need this if they were to be on diet after the operation?

We can perform all operations in laparoscopic way, without incisions, with the help of the advanced technology. That means we do not cut the stomach, we do the process by going in with camera and 4-5 special devices, biggest being 1cm. we can put surgeries into two general categories. First group is the volume restricting ones, second group is anti-sorption ones. That is actually a wrong distinction. If you ask me why, I will give you the example of the metabolic impact of Ghrelin, which is responsible for the biggest part of the restrictive surgeries’ effect. Ghrelin is in the part of the stomach taken in the operation and when the hunger hormone goes down, it gives you a metabolic effect. This meant sleeve gastrectomy is not only a restrictive operation, but it is a procedure with hormonal and metabolic consequences. On the other hand, some of the effect in gastric bypass, too, stems from the diminution of the stomach. Therefore, there are not clear distinctions between surgeries. What is for sure is that they don’t only reduce the lust to eat, namely volume restriction, but also they reset the disfunctioning metabolic balance and take the weight down to the set the body defines as a goal itself.

Then which surgery is better or more effective? This seems to be a complicated issue..

There is only one answer to the question of the best operation, the one most suitable for the patient. Surgeries cannot have the same success in every case. We evaluate a number of factors when we try to decide on the operation. For example, it has been understood in the new studies that sleeve gastrectomy is not maintainable more than 5 years in treatment of type 2 diabetes. So, it is unfair to tell a patient with diabetes for 20 years that you can solve diabetes by sleeve gastrectomy.

Another danger is the persistence of some surgeons on a specific type of operation. There are some names among us like sleeve gastrectomist, bypassist. This is a wrong way. If a surgeon claims to be a bariatric an metabolic surgeon, he has to know the logic of all the methods, be able to perform them laparoscopically and when needed he has to interfere in complications again laparoscopically and perform the revisions the same way again. Of course these all need advanced laparoscopy experience and high talent of surgical skills. There is not a rule for everyone t be a bariatric surgeon. In order to achieve this level, it is necessary to perform at least 300 bariatric operation with a complication rate in world standards.

And there is the claim that in Turkey the rate of complications is high, what do you think about this?

Right and wrong. That colleague of us claims that 6000 obesity surgeries to be performed and the death rate is 10%. This means 600 people in our country die of obesity operation. There is not such a thing. But it is for sure our rate is above the world standards. Why is clear, there is no inspection on this and some general surgeons are performing these operations just to try. Obesity surgery is not something like that.

Obezite Röportaj Murat Üstün

That is the most surprising thing for the newcomers in the area. Normally general surgery is a radical branch. You take out the ill tissue and make the patient better. But obesity surgery is not like that. Even when you take out the whole stomach, it may not be the solution. Because the ill thing is not the stomach but the whole body, the whole metabolism. We only try to find a place to reset it. But this is not always possible. And like all the other surgeries, our job does not finish with the operation, it just starts. If the doctor does not have the power, will and patience to follow the case for years and to support 7/24, being unsuccessful is inevitable. You can’t perform all operations and once in a while the obesity surgery. Commitment is the sine qua non of this surgical area.

You said the decision of the suitable operation is also important for success, so how do you give that decision?

Personally, first I listen to my patient and I create a clear picture in my head with all details from eating habits to obesity story, from diet history to associated diseases. Then, I tell the procedures without leading them with all the surgical advantages and disadvantages. And then I reveal which method I prefer and find suitable with my reasons. We decide on the type of surgery with the patient at last. Of course, we don’t always decide on what I find OK. Sometimes patients abstain from serious procedures or vice versa they choose an up-level operation. If there is not a big handicap, we tend to choose the one in which the patient would feel more comfortable. But we warn the patient with 100 surplus kilos and using 140 units when they choose the sleeve gastrectomy that it may not be enough for them.

There is a belief that these operations are fairly dangerous. What do you say?

Frankly, it is just a misconception from the first years of obesity surgery in Turkey, which started with the stomach stapling, but done is done. There has been technological developments, held new consensus meetings on methods since then. Techniques has been defined clearly and now we have a broader knowledge of obesity and management of obese patients. And of course the surgical experience has increased. We perform the obesity surgeries today with the risk of laparoscopic cholecystectomy only. The risk goes up in cases with severe diabetes, heart attack history or atherosclerosis, coroner problems. On the other hand, these patients are under great risk because of their level of obesity. For example, Mustafa Koç had the sleeve gastrectomy 4 months ago and he died of heart attack later. Though Koç had a coroner bypass years ago, meaning his heart had the damage from obesity long before. The risks of obesity is on a higher scale compared to operation, that’s for real. It has been proved that the obesity surgery improves the heart health, decreases coronary failure, eliminates migraine attacks, solves sleep apnea, and even reduces risks of cancer. Yes, you can think unrelated but it has been found out that the 3% of the cancer cases have obesity origins.

What is the age criteria in this? Can these operations be performed on children or adolescents now that obesity is also common among them?

In the past, it was written as 18-60 years everywhere. As our knowledge was all translation, the same thing was repeated exactly. However, as the life expectancy is longer now limit superior is being put according to the health condition of the patient. In a congress in Hamburg, a male 73 year-old patient was operated live on gastric bypass because of diabetes. Lower limit record is on a 4 year old Indian patient and it is controversial. But personally I think we should go down as far to 14-15 years old. My lower limit is 15. We seek for the approval from a child endocrinologist and a pedagog below 18.

Is there a type of patient that these surgeries cannot be performed on?

Firstly, the patients who are not in the criteria of obesity surgery as to weight- height balance and the associated diseases, meaningly the patients beyond the border of obesity. Then alcoholics and drug addicts, patients with severe psychiatric conditions, and most importantly unwilling ones to change their life style after the operation.

 Is there a special diet to follow after the operation? What are the changes and weight loss they will experience?

As in most international clinics, we, too, apply a diet of pure liquids in the first week, liquids the other week and mashed food next two weeks. This is a compulsory diet for the healing in the stapler line, or stitches, and avoiding complications. Because the will to eat is almost zero in this process, following the diet is fairly easy for most of the patients. There are some operation specific notes, too. Not mixing the solid and the liquid is important to take the necessary nutrients and avoid enlargening in stomach as it gets smaller. Moreover, sodas should be avoided for the same reason. Later on, developing an eating strategy we call eating wisely, namely avoiding junk food and filling the stomach with necessary food, is generally enough. Also eating slow and chewing a lot, being careful with the sleeping and exercising 4-5 days a week 30 minutes a day in a regular way enhances the chance of success.

After the first 8-12 months of the surgery, almost all our patients lose their overweight completely. After two years, we aim to stabilize the habits to maintain the weight achieved. In this process, money should not be spent on clothes because weight loss happens very quickly and everything just gets large for them. Our patients develop self-confidence and have a better self-image. Their social, family and sexual lives get normal. Mst patients don’t need the antidepressants anymore.

The most irritating problems after the operation are skin prolapse and hair loss. Contrary to general belief of the patients, the cause of hair loss is not insufficient vitamins and minerals. Generally, it is connected to a metabolic change, as in all methods of losing weight, and it is temporary. It starts in the 3rd month and goes until the 8th. Skin prolapse depends on the amount of lost weight, the quality of skin and the genetic, and the place of the fat accumulation. But if there is a disturbing level of prolapse, plastic surgery can help patients.

Controls and life-long nutrition training is crucial in long term. We offer 1 year of control and nutrition support as a package. We check for any deficiencies in the 1st, 3rd, 6th,12th,18th and 24th months with blood tests. If needed, we may add iron, calcium, B12 or D vitamin supplies. These deficiencies are rare in sleeve gastrectomy.

While these operations provide good outcomes, sometimes divorces can be seen as a side effect of the boosted self-confidence. Reversely, when they lose weight, singles get married, married ones have children more.

 

Sir, I want to have your opinion on the diabetes operation or diabetes lastly.

Obesity surgery has roughly 60 years of history. Most obese patients have type 2 diabetes, hypertension, high cholesterol, coroner artery diseases, which we call associated diseases. As the person slims down with the surgery, these conditions get better. Upon this comes the metabolic surgery. Metabolic surgery, indeed, is performing a procedure on a healthy organ to treat an illness. The sick part is not the stomach or bowl. We try to reset them with interfere. After these operations, there are sharp changes in hormone levels, such as Ghrelin, leptin and PYY. So, obesity and obesity surgery is a solution depending on very complex mechanisms.

It is always wondered, what happened and obesity boomed? A simple answer: people get too many calories and they can’t burn them because of the sedentary lifestyle. But if it was so easy, diets would work. But we know that the chance of losing weight with diet and exercise is 2-3%. The base of the problem is we consume processed food more. To activate the bowel hormones, one should eat unprocessed food to reach the deep of the small bowel and to use the calories in the right way. As we consume the processed floor, then, digestion ends in the beginning of the bowel, leaving only unnecessary things behind. Obesity surgery helps the food to go deeper in small bowel by breaking this mechanism. In that way, the hormones released from the deep of the bowels help to reset disrupting hormonal and metabolic balance. Any way you achieve this helps you lose weight and makes insulin levels better. Gastric bypass has been doing this for 60 years, anyway.

Then, what made “diabetes surgery” so popular?

90% of type 2 diabetes patients are obese in all European countries, including Turkey. That means they can get rid of diabetes by means of classical malabsorbent obesity surgery methods. However, things are opposite in India. That means 90% type 2 diabetes patients are fit. One result of malabsorbent surgeries is weight loss. Fit patients need a way to touch the food to deeper small bowel without losing weight. And then there came a specialist from Brazil and cut the last part of the small bowel, put it somewhere near the end of stomach, ileal transposition. Indians loved it, t was just the thing for them. Another surgeon from our country (later his newbies) brought one of these Indian specialists and they managed to market this procedure as the “diabetes operation”. However, traditional textbooks tell that this is an experimental operation and can only be performed with an approval from the ethical board.

In short, this is the reason of the fight between endocrinologists and surgeons in our country. Other than that, we were working with our endocrinologists in harmony with uncontrolled diabetic patients to have metabolic surgeries. So “there is a cur of diabetes, this is a liar” or “putting more on medication is not the treatment” attacks are nonsense. We know that it is impossible to solve obesity or diabetes100% whatever you do. Unless the patients develop healthy eating habits, pick the food meticulously, add exercise into their lives, there is no method to guarantee treatment.

As we understand from the talk, the key to success of these operations in obesity treatment lies in the patient harmony, surgeon experience, suitable technique and a firm communication. As we know you work both in Istanbul and London. Does it create a problem? What is the role of social media and the internet here?

 

Not at all. New surgeons in this are generally enthusiastic and they give their personal phone numbers to the patients, try to answer their questions. As the number of the patients and applications rises, they have to step back. Then, there are coordinators in between and it gets harder to reach the doctor. I have been using the internet as a communication channel since the first years that I started obesity surgery. We were informing our patients on our own forum sites before the social media agents like Facebook, making them share some with each other. We now pursue this tradition with our obesity support group, which is one of the biggest obesity sharing platform in Turkey. In addition, I personally communicate with my patients on the phone or Skype if they ask for an online interview. That way, a 54 year old patient who can reach me from Afyon, Emirdağ, knows that I am available in London at any time whereas no one in his city is not. I believe this strong communication is crucial to success. I suggest my patients and surgery researchers to use social media. Social media and internet creates a democratic platform to choose doctor if the ads are taken out and if it is used wisely. If you do well, you look good on it, same is applicable for the opposite. Also channels like Youtube, Vimeo gives us the opportunity to evaluate the competence in laparoscopic techniques. Shortly, patients are luckier than past both in research and follow up.

Interview: Nihat İpekçi

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