Surgical treatment of morbid obesity

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Surgical treatment of morbid obesity

M. Tanyi, Z. Kanyári, B. Juhász, L. Damjanovich
Referate generale, no. 2, 2007
* University of Debrecen, Medical and Health Science Centre, Institute of Surgery
* University of Debrecen, Medical and Health Science Centre, Institute of Surgery

Appearance of the evils of civilization irreversibly accompanies the development of humankind. As generations have longer expected life time, as medical science can solve more diseases and as people live under better conditions, humankind faces new and other problems. In developed countries obesity is a new health problem growing to epidemic size. Unfortunately we do not have exact data on the Hungarian situation, but many developed industrial countries have been fighting against morbid obesity for decades. Between 1960 and 1990 the per cent of overweighed individuals in the American adult population have risen from 16% to 35% (1). In 1980 on the basis of data of the Australian Diabetes, Obesity and Lifestyle Study 7.1% of the 25-64 year age population had been morbidly obese, which rose up to 18.4% by the year of 2000 (2). Morbid obesity means not only health, esthetical and social problems for the individual, but the related co-morbidities mean heavy burden for the health service providers as well. In 1993 in the United States of America treatment costs of co-morbidities clearly in relation with obesity came to 5.5% of the annual health budget. Thus, extent of obesity amongst people living in the welfare states would become national health crisis. According to an other study made in 1999, in the United States 12.5 million morbidly obese people lived, from amongst about 4 million suffered from such co-morbidities that seriously threatened their health. Morbidity and mortality of this patients' group highly outnumber the average of the population, and their expected lifetime is shorter with 20-25 years than of the population having normal body weight. So it must be emphasized that treatment of morbid obesity is more than a treatment of an individual, esthetical or social problem. Due to restoration of the normal or nearly normal body weight, treatment of several life-threatening co-morbidities could become possible. As a result, not only the patient but also the health service provider who finances the treatments could get rid of a huge problem. Considering the wide-ranging ethiology of obesity, its treatment requires multidisciplinary co-operation and often means high professional challenge for the internalist-obesitologist as well as the surgeon having experience in this field.
Classification of morbid obesity
Obesity is a well-known but very subjective idea. Many accesses and methods of measurements had been applied for reaching an objective judgement of obesity, such as the measurement of thickness of subcutaneous fat layers of different body parts or the so-called anthropometric measurement methods, which apply other parameters. The hydrodensitometric method gave more exact data that - using the Archimedes principle - counted the density of the body with the help of the measured body weight and the expelled volume, and concluded to the fat content of the body. More reliable method was the so-called bioelectric impedancy analysis that - using with the Ohm Law - knowing the volume and length (height) of the conductor (the human body) could measure the resistance of the conductor, and could make consequences on the volume of the fat and the fat free tissues. Of course these methods rather had scientific value but being the tools of everyday practice. The most widespread and applied parameter to judge obesity is the so-called Body Mass Index (BMI) that can be counted from the quotient of the body weight in kilograms and of the square of the height in meters. According to this the extent of obesity can be classified into six categories that are shown in Table 1.
Ethiology of morbid obesity
Ethiology of morbid obesity is multicausal. We face a real multicausal disease, in which formation exogen and endogen factors participate as well. Standard of living, social and eating habits, sedentary lifestyle and other environmental features can be considered as exogen factors. Endocrinologic and metabolic alterations as well as genetic and ethnic characteristics can be considered as endogen factors. Their combination often can be found that makes the elaboration of an adequate therapy more difficult. The increase of standard of living, the sedentary lifestyle and the consumption of high calorie food are the reasons for the spreading of obesity at population's level. But it is not negligible that the background of the disease often emerges from endocrinologic alterations, such as hypothyreoidism i.e. adrenocortical hyperfunction. Social and psychiatric diseases like depression or bulimia nervosa can often be reasons for the continuous increase of the body weight. Different work groups considered several different gene mutations as background of morbid obesity, as reasonal factors. In 1994 Zhang et al. during the genetic study of a mouse family suffering from hereditary obesity verified the mutation of the ob (obesity) gene, and experienced that the expressed protein, called leptin turned to be unfunctional (6). Later the mutation of the gene responsible for the expression of the leptin receptor was also verified in other obese mouse families as well as in human trials (7). Leptin was considered to have multiple roles both in the regulation of insulin mediated sugar intake in sceletal muscles and in the triggering of satiety after eating through the decrease of neuropeptid Y production in the hypothalamus (8). Unfortunately hopes for leptin in the treatment of obesity during human trials were not realized and the use of synthetic leptin has not brought the expected results. Human obesity gene and leptin receptor gene were cloned and some families were published where the mutation of the gene was found responsible for the hereditable obesity (9). But in the case of obese patients treated with synthetic leptin the expected success failed to occur. Then the mutation of many other genes were verified, which were considered to have pathogenic role in the background of obesity or of the inclination to it (glucocorticoid receptor genes, sulfonylurea receptor genes etc). But if the tendency is considered that in the welfare societies the population average of obese people continuously grow, we have to establish that in its background not only genetic but socio-economic reasons must be looked for.
Co-morbidities of morbid obesity
Co-morbidities of morbid obesity are in whose formation the increase of body weight plays a role of reason and correlation can be found between the increase of body weight and the worsening of the disease. These deviations later can reach the level that threatens the life of the patient. By restoring of the normal BMI the co-morbidities can be successfully treated or can often be totally eliminated. We can mention - without the sake of completeness - the II-type diabetes, the hypertension, the dislipidemy and the later forming ischemic heart disease, the non-alcoholic steatohepatitis and the gall stone disease. Hypertension is one of the most often co-morbidities of morbid obesity and this reacts best to the decrease of body weight. In its formation probably the decreased cardial outflow - that decreases the perfusion of the kidney - plays a role that emerges from the increased intra-abdominal and intra-thoracal pressure. But this elicits a blood pressure increasing effect by the activation of the renin-angiotensine system. 75% of the patients suffering from II-type diabetes is overweight. Many studies had dealt with the connection between II-type diabetes and the body weight, and it was stated that in case of women the risk of diabetes showed a continuously increasing tendency above BMI = 22. In the case of a BMI = 30 it was 28-fold, while above the BMI = 35 it was 93-fold higher the risk of the development of the disease (11). Due to the degenerative deviations of the bearer joints (hip- and knee joints) they must be got prosthesis in the early age. Very serious problem for obese people is the sleep apnoe syndrome and the so-called obesity hypoventilation syndrome. Sleep apnoe is called when the apnoe episodes last at least 10 seconds during sleep and they occur more than 5 times per hour. Patients suffering from sleep apnoe syndrome can suffer even 400-500 such episodes during one night that leads not only to cardial failure during sleep but on the other day sudden fallings asleep during work or driving. In the case of obesity hypoventilation syndrome the chronic hypoxia and hypercapnia occur together and lead to pulmonary hypertension and consecutive cardial damage.
Treatment possibilities of morbid obesity
Treatment of morbid obesity is at least as multilateral as its ethiology.
Proper prevention, education for healthy lifestyle and nutrition at the early school age should be the first and most important step. Prevention of further body weight gain in the childhood and teenager years and thus the avoidance of co-morbidities cannot be rather emphasized.
Change in the lifestyle and low-calorie diet
The next step is keeping the obese patient on a low-calorie diet by the help of an obezitologist, dietetic expert as well as daily routine motion therapy under the supervision of a physiotherapist. It can be heard as complicated as simply since in case of many patients significant change in lifestyle is needed. These, so-called conservative diet tries require huge will power and endurance from both patient and physician. Unfortunately a significant part of the patients are not able to keep their diet permanently, thus the success is only temporarily.
Detection of endocrinological and psychiatric diseases causing obesity
Detection and adequate therapy are important steps of the treatment of those endocrinologic and psychiatric diseases that are often in the background of obesity. The proper hormone substitution or the application of proper psychiatric pharmaceuticals can prevent many unsuccessful surgical operations that can have many complications. We must call attention to the obesity which is formed as a side effect, and is particularly frequent in the case of taking high-dose steroid or antidepressant medicines.
Other important area in the treatment of obesity is the application of different pharmaceutical therapies. They can be classified into two main groups on the basis of their mechanism of clinical effects: the appetite supressants and the lipid absorption inhibitory pharmaceuticals.
Significant part of appetite supressant drugs after the temporary enthusiasm was withdrawn from circulation because of their serious cardiovascular side effects. The nowadays still applied sibutramine that is agonist of the Beta 1 and 5-HT 2/A 2/c receptor, triggers satiety and inhibits hunger pains by hindering the serotonin and noradrenalin binding. Its application must be avoided in the case of obese patients suffering from high-risk cardiovascular disease, hypertension or angina pectoris.
More often used drug that hinders lipid absorption in the small intestine is the orlistat. By inhibitoring the pancreas lipase it is able to decrease fat absorption with 30%. In combination with low-calorie diet and motion therapy even in a year it provides an opportunity to the decrease of the body weight with 10%, but later small regain of weight is possible. As its side effect steatorrhoea and diarrhoea can occur several times a day.
Application of intra-gastric balloon
This procedure is being applied by several experienced endoscopic laboratory in Hungary, that can be applied in the case of super and super-super obese patients as preparatory treatment for operation. Making use of this method 10-15% decrease in body weight can be achieved. Its main point is that by the help of a gastrofiberoscope a balloon is get into the stomach, then it is filled with 200-300 ml liquid. It gives a continuous satiety, thus lets the patient consume less food. The balloon contains painted (e.g. with methylene blue) physiologic salt solution, so in the case of its damage the patient can see the decolouration in its urine and can call for the physician. In such a case the balloon can be removable by endoscopic way and the ileus caused by the balloon can be avoidable. The intra-gastric balloon can be kept in the stomach for about six months, then it must be changed or removed. Its most useful function is the preparatory treatment of high-risk patients with BMI more then 50, since it lets the patient to loose about 10 % of his body weight.
But the permanent result of the above mentioned methods can be questioned. The co-operation of patients gets worse in time, and after the initial successes they put on weight again. This "jo-jo effect" is characteristic to most patients that lead to newer and newer weight regains. Many studies analyzed the long-term results of the treatments that concluded exasperating experiences. Therefore not only the achievement of temporary body weight loss is the goal but its long-term maintenance. Its most successful method up to now is the surgical treatment of morbid obesity.
Surgical treatment of morbid obesity
Surgical treatment of morbidly obese people is called bariatric surgery that originates from the Greek words "baros" (means weight) and "iatricos" (the art of curing"). It is the most efficient method in the treatment of obesity and provides excellent long-term results. Surgery of morbid obesity has been looked back upon for a past of several decades and in spite of several unsuccessful procedures and failures it went through significant development. More than 30 different operational procedures have been elaborated during the past decades, from among several have only historic significance for the time being. We must emphasize that surgery is not the first choice of treatment, it must be preceeded by very thorough previous medical investigation, conservative treatment methods and patient selection. According to the recommendation of the American National Institutes of Health Consensus Conference (1991) surgical treatment of morbidly obese people can be indicated in the case of those patients whose BMI is higher than 40 or having a BMI between 35 and 40 and suffering from several relevant co-morbidities. The different procedures address different mechanism of action, and on its base they can be classified into different groups. Without the need of completeness the classification of bariatric surgery methods are shown in Table 2.
The main point of malabsorptive methods is, that due to the significant decrease of the absorptive surface of the gastrointestinal tract, it reaches a huge loss in body weight without changing the eating habits of the patient. Disadvantage of this method is the possibility of formation of malabsorptive syndromes in different extent and in different times in the case of the different methods.
The main point of restrictive methods to reach their effect is the decrease of the amount of food intake and the speed of consumption, independently from the patient. They provide slower and smaller body weight loss than the malabsorptive methods but their results are satisfactorily long-term. Their advantage is the lack of malabsorptive syndromes.
The combined malabsorptive and restrictive methods mix the advantages and disadvantages of both groups. Several operational methods have been elaborated in this group, whose greater part is out of use by now. Scopinario et al. reached the consequence after the analysis of the results of several thousands of operations that the combined operational procedures have not brought the expected advantages.

Historic review
Malabsorptive procedures
Jejunoileal bypass
This procedure was first published by Varco and Kremen in 1953 and 1954. Their first experiences were received from trials made with dogs. First results in the case of human application came quickly since Payne and DeWind published their first clinical results in 1956. Their method was the end-to-side anastomosis of the 35-40 cm of the proximal jejunum to the transvers colon, that besides the excellent body weight loss led to dramatic early complications. Besides the collapse of the electrolyte-water balance they experienced the occurrence of liver cirrhosis and hepatic failure as well, thus later the above-mentioned authors took a clear stand against the jejunocolic bypass (1967) (13) Changing their method the 35 cm of the proximal jejunum was end-to-side anastomized to the terminal ileum approximately 10 cm far from the ileocoecal junction. Indeed the occurrence of later complications significantly decreased, but due to the food mixed with digestive enzymes that got back to the blind loop the efficiency of this method worsened. Later Scott and Buchwald modified the procedure and they made an end-to-end anastomosis between the proximal jeunum and the terminal ileum, whose length was not more than 50 cm. The blind loop of small intestine was anastomised into the colon (Fig. 1) (14). In the case of the two later mentioned procedures bacterial colonization formed in the blind loop often resulted in toxic syndromes such as "bypass enteritis" or pneumatosis intestinalis. In the approximately 20% of the patients serious, life threatening metabolic alterations such as hypocalcaemia, hypokalaemia, lacks of iron, vitamin B12, folic acid and protein and calorie malnutritions have formed. The developed diarrhoea further aggravated the malfunction of water and electrolyte balance. Later stones in the urinary tract, liver cirrhosis and hepatic failure, arthritis and serious osteoporosis have developed. Later in the case of high percent of the patients the anatomical conditions had to be restored with other operations. Nowadays this method has only historic significance, it is already out of use.
Combined restrictive-malabsorptive procedures
Roux - Y Gastric bypass
After the early unsuccessful results of the jejunoileal bypass new changes were needed, thus newer and newer procedures have developed. Mason and Ito have published a new procedure in 1966, in which the upper part of the stomach was closed under the cardia by a linear stapler. Into this newly formed gastric reservoir a jejunum loop was anastomized in side-to-side way(15). They started from the experience that patients underwent subtotal ventricular resection, due to gastric ulceration suffer significant body weight loss. Restrictive component of the operation was a small stomach "pouch" (approx. 200 ml), while the malabsorptive component was the shortening of the small intestine. Although the procedure had seemed effective, due to the many early complications it had to be modified. In 1977 Griffen et al. - for the prevention of the marginal ulceration forming because of the biliar reflux - had offered the achievement of the Roux-Y loop completing the gastro-jejunostomy which later took over the leading role (Fig. 2) (16). From the early 1980s other modifications were developed for improving the efficiency of the procedure and decreasing the rate of complications. In this way the so-called "Greenville Gastric bypass" was developed, that formed only a 20-30 ml small upper stomach pouch. Separation of the two parts of the stomach was made by linear stapler (i.e. six staple line) decreasing the former quite like 20% insufficiency rate of instrumental anastomosis to a few per cent. As an other modification the junction of gastrojejunostomy couldn't be bigger than 8-10 mm in order to emptying of the small stomach pouch would occur as slow as possible. Proximal loop of Roux-Y was done for about 60 cm long (17). With these modifications a highly efficient method with less earlier complications have been elaborated. But they experienced that a great part of the patients although at first lost significant weight, finally were not able to reach the required ideal body weight. Even for the treatment of co-morbidities this body weight loss was sufficient, mainly in the super obese category (BMI >60) the patients still remained overweight (BMI: 30-35). This is why in 1987 Torres and Oca elaborated and published the so called "gastric bypass operation with long proximal loop" (150 cm proximal loop), where the efficiency of the malabsorptive component was improved. (18). In 1992 Brolin et al. considered that the gastric bypass operation with long proximal loop was the first selectable procedure in cases of the super obese patients, thus they highly participated in the wider spreading of the method (19). Because of the malabsorptive characteristic of the Roux-Y gastric bypass late malabsorptive complications could be expected. These problems could be the protein malabsorption, the lack of B12 vitamin due to the lack of the intrinsic factor as well as the folic acid deficiency because of the decrease of the absorptive surface. Iron malabsorption and consecutive anaemia occurred in 42% of the patients.
Of course later the spreading of the minimal invasive surgery the performance of the laparoscopic bariatric operations occurred as well. In 1994 Wittgrove et al. published at first the performance of a laparoscopic Gastric bypass operation, then in 2000 about their experiences on 500 patients (20,21). Their most important complication was the insufficiency of the gastro-jejunostomy that occurred in 2.5% (21). In 2001 Nguyen et al. during the comparison of the open and laparoscopic technologies (76 open and 79 laparoscopic) arrived at the conclusion that neither between the operational time nor the early and the late complications had significant alterations between the two methods. All but one that in the case of minimal invasive technique late stenosis occurred more often in the anastomosis of gastrojejunostomy (11.4%) than after open operations (2.6%). But as an advantage of laparoscopy the risk of purulent complication of abdominal wounds and post-incisional hernias decreased significantly. Nowadays in the US this is the most used bariatric operation.

Figure 1
Figure 2
Figure 3
Figure 4

Mainly malabsorptive procedures with restrictive component
Biliopancreatic diversion, Duodenal Switch
As a result of the experienced failures in the case of super obese patients Nicola Scopinario modified the above-mentioned procedure and elaborated the bilipancreatic diversion (1979) (23). To improve the efficiency of the procedure he increased the proximal loop of the Roux loop, that the common loop was only the last 50 cm of the terminal ileum. With this, the malabsorptive component was significantly improved and thus the efficiency of the procedure as well, but multiplied the possibilities of late malabsorptions. Later this method was offered as first eligible method only in the case of super obese patients. It turned to an explicit point of view that in the case of the unsuccessful outcome of other restrictive or malabsorptive procedures as second procedure, the transfer of the former operation into biliopancreatic diversion is the procedure to be followed. The procedure is very similar to the Roux-Y gastric bypass, but in this case the subtotal resection of the stomach is to be done. Then to the remained small stomach pouch the last 250 cm of the small intestine is to be anastomized, while the proximal loop bringing the digestive enzymes is to be anastomized end-to-side to the terminal ileum 50 cm far from the ileocoecal junction. Therefore the food and the digestive juices mix only in the last 50 cm of the terminal ileum, in the so-called common loop (Fig. 3). The procedure turned to be very effective, but led to several serious malabsorptive complications. Malabsorptions of protein, B12, folic acid and iron were developed stronger than in the case of Gastric bypass. Thus consecutive anaemia, hypoproteinae-mia and crural oedema occurred. The fat malabsorption manifests itself in putrescent steatorhoea 4-6 times a day and malabsorption of fat-soluble vitamins (A, D, E, K). Therefore these patients frequently suffer from night-blindness, demineralization failures of the bones and latterly developed alopecy.
Because of the frequently occurred dumping syndrome Marceau made another change in the operational procedure (1993), developing the so-called "Duodenal Switch" method, in which sleeve gastrectomy was made instead of subtotal stomach resection with the removal of about two-third of the stomach (restrictive component)(24). By preservation of the pylorus he reached the termination of the dumping syndrome, then after the dissection of the proximal duodenum the Roux distal loop was end-to-end anastomized to the duodenum (Fig. 4). Later the introduction of its laparoscopic variety has also been occurred. Having regard to its many late malabsorptive complications this method is now used only in the case of thorough indication.
Restrictive methods
Vertical banded gastroplasty
First author of this method was Mason in 1991, who offered this method as an alternative one besides the Gastric Bypass. The method is clearly restrictive, i.e. it reaches its effect by the decrease of the volume of the consumed food and by the delaying of the speed of eating. The initial method divided the stomach into an upper smaller and a lower larger compertment by a horizontal staple line. Between the two parts a narrow drainage was let by removing several staples from the cartridge at the end of the staple line or in its middle. Later Mason switched over to the vertical gastroplasty, in which he lengthened the oesophagus along the lesser curve by a linear stapler (1980) (25). On the lower side of the suture line he had adjusted the diameter of the outlet of the ventricular pouch by a circular stapler, then it was reinforced by a Marlex (non-absorbable) mesh. Thereafter Laws and Piatadosi tried to provide the outlet of the small stomach compartment by a non-expandable silicone band preventing the further dispansion (26) (fig. 5). In 1994 Hess and Hess, then in 1995 Chua and Mendiola published the laparoscopic version of Vertical banded gastroplasty (27, 28). The efficiency of this method falls with 10-12% behind the malabsorptive methods, but as its unambiguous advantage can be mentioned that after operation development of vitamin deficiency, or other malabsorptive condition, or dumping syndrome cannot be expectable. Of course this method has its own typical complications, that contains of the dehistency of the instrumental staple line (2-7%), stenosis of the outlet (2.5-8%) and erosion of the gastric band into the stomach (1-2%). Later it was observed that in the case of a part of the patients after a temporary body weight loss their weight remained stable or was able to regain some weight. In its background the frequent or almost continuous consumption of high-calorie liquids was observed. These liquid nutrients could quickly get from the small stomach pouch, therefore the triggered feeling of repletion did not happen. These so-called "sweet eaters" were not be treated effectively by this method (29). In the case of these patients Mason et al. recommended "Gastric bypass" procedure, where the consumption of high-calorie, i.e. hyperosmotic liquids led to the formation of dumping syndrome. As a consequence the patients were willing to change their sweet eating habits. Therefore the vertical banded gastroplasty has less earlier and late complications as of the malabsorptive operations, but has less efficiency as well, i.e. meant a good alternative solution for the treatment of morbid obese people. As an other disadvantage we can mention that the implanted band is not adjustable, only with the help of an other operation. The introduction of the adjustable gastric band meant the end of the spreading of this method.
Laparoscopic adjustable gastric banding
It is a clearly restrictive method. At first in 1976 Wilkinson and Peloso tried to form sand-glass shape of the stomach through a minor abdominal incision by the help of a non-absorbable mesh taking around the stomach (30). Later Molina and Oria (1983)(31) by the help of a Dacron band coated with nylon tried to reach the same result. But the long-term results were not good enough. In 1986 Kusmak published at first the band that had inflatable small balloon section, which was adjustable. It was in connection with a sub-cutane implantable so-called injection port by the help of a thin connecting tube (32). Later the narrowness of the band was adjustable through this port. This method was adapted to a laparoscopic method by Catona et al. in 1993 (33). Since then this method has been turned to very popular mainly in Europe and Australia. In the United States still the Roux-Y Gastric bypass is the most widespread method in spite of the fact that The Food and Drug administration approved the utilization of the gastric band in 2001. There was no other method than the implantation of the laparoscopic gastric band having so many articles and conflicting points of view about.
The main point of this method is that after the dissection of the pars flaccida a small tunnel is made behind the stomach towards the His angle, then the band let into the abdominal cave is pulled through here and is united in front of the stomach. Then in front of the band on the stomach seromuscular sutures are made, but about the necessity of these sutures the points of views are different. The connec-ting tube of the band is taken out of the abdominal cave and is united with the injection port joined to the praesternal fascia or to the fascia of the rectal abdominal muscle (Fig. 6). This fixed small port can be palpated during the further band calibrations without using an X-ray instrument. Unambiguous advantage of this method is its adjustability depending on the patient's body weight loss and that it contains of neither suture line nor anastomosis, therefore the possibility of complications from them doesn't exist. Further advantage is that its effect can be immediately terminated by the desuflation of the band, for example in the case of pregnancy. Of course the method bear the possibilities of early or late complications. Such complications can be for example the perforation of the oesophagus or the stomach caused and not recognized during the operation or the quite frequent purulent complication of the sub-cutane port that can spread into the abdominal cave along the connecting tube. Among the late complications we can find the stomach prolaps through the band, the late stomach erosion caused by the band and the likeage of the contrast material due to the deterioration of the system material.
O'Brian in his study containing more than 700 operations has experienced the complications with the frequency as follows: prolaps 12.5%, penetration of the gastric band into the stomach (erosion) 2.8%, likeage and port infection 3.6% (34) The multi-central Italian study in 2001 that contains of 1265 patients from 25 authors' five-year studies has reported on much better results. According to their data prolaps occurred in 5.2%, erosion in 1.9%, while leaking and port infection in 4.2% (35).
Many authors reported the formation of the so-called artifical achalasia after the implantation of the gastric band, that mainly occurs in the case of the malfunctions of the peristaltic movements of the oesophagus. This problem is of course curable with the desuflation of the gastric band, but thus the method loses its efficiency. Therefore emphasis must be on the prevention that can be done by the pre-operationally made oesophageal manometry. Other significant problem is the gastrointestinal bleeding along the implanted gastric band, whose endoscopic intervention is difficult to be done along the tightened gastric band. Up to now development of several different-type gastric bands were made, whose are shown without the demand of completeness in Table 3.
Implantable gastric pacemaker
The idea of electrical irritation of the stomach at first emerged in cases of the gastro paresis which were noncurable by pharmacotherapy. It works on a similar way than the peacemaker used in case of the arrythmia of the heart. Cigaina et al. had made their first research in swine and experienced that by changing the frequency of stimulation appetizing and non-appetizing effects appeared as well (36). It was planned for the cure of gastro-paretic and anorexic patients, but because of the nonappetizing and repletion triggering effect, its application in the case of morbidly obese patients arose as well. The electrodes are implanted by laparoscope into the seromuscular layer of the stomach (2-4 electrodes). These join through a cable to the electric "power pack" implanted into the abdominal wall. The switching on and off as well as the changing of the frequency is done by radio control. Its mechanism of action could not have yet verified, several theories have emerged. It is thought that at a certain frequency the pacemaker keeps the stomach in a relaxed condition, so triggers a continuous satiety. According to other ideas the stimulation makes such neuro-hormonal changes that produce the feeling of satiety in the central nervous system. Anyhow the patients consume less food and their hunger pains also significantly decrease. We must however emphasize that the procedure still in its experimental stage. In Europe studies containing more than a hundred cases were already published, but instead of this it is still not an accepted procedure in the United States. At present the conditions of its application are under multi-central studies. Its efficiency fall largely behind the surgical interventions and its cost probably sets limits to its spreading.

Figure 5
Figure 6
Figure 7

Treatment of morbid obesity has gone through a significant development during the last decades. The disappointing experiences of the early malabsorptive methods required continuous changes, thus kept the constraint for development. Later the spreading of restrictive methods was observable and even nowadays these more physiologic methods dominate the bariatric surgery. But we have to mention that in the case of a certain per cent of the patients only with the help of malabsorptive methods can be reached effective results. The introduction of the minimal invasive techniques seemed to revolutionize the surgery of morbid obesity and within several years laparoscopic introduction of all methods have been occurred.
The winner of minimal invasive technics are especially the morbid obese patients because of the early postoperative mobilisation and they are able to get rid of the possibilities of the development of early (deep vein thrombosis, wound infection) and late (incisional hernias) complications.
But it means a great challenge even for the most experienced laparoscopic surgent as well due to the need for specific tools and the extreme body volume of the patients. Several co-morbidities and the needed co-operation of different subspecialities further make the job of the specialists more difficult. Instead of all these things, those people are not right who belittle this problem to the question "to eat or not to eat". Surgery of morbid obesity is not only for the elimination of the body weight surplus but to cure the co-morbidities as well. Many studies deal with the observable changes in the seriousness of co-morbidities after the different bariatric operations, in parallel the body weight loss. These changes can also be well observed even after the application of the presently dominating laparoscopic gastric banding. Paul et. al examined the improvement of co-morbidities one year after the implantation of the gastric band. In the case of patients suffering from II-type diabetes they experienced the total stoppage of medication in 64% and in further 26% they experienced the reducibility of the doses of the drugs. In the case of patients suffering from hypertension they could stop the application of antihypertensive drugs in 59% while in further 33% the dose of the drugs was reducible. The fastest recovery after the operation could be observable in the case of patients suffering from manifest gastro-oesophageal reflux disease. It can be understandable due to the nature of the procedure. After the operation 89% of the patients needed no more antacid drugs. They experienced significant improvement in 33% of their patients suffering from asthma (38). Results of Spivak are a bit different. They made a survey on the changes of condition in the co-morbidities 18 months after the implantation of the gastric band. In the case of patients suffering from II-type diabetes they experienced the total stoppage of medication or improvement in 66% and in the case of patients suffering from hypertension they could stop the application of antihypertensive drugs in 42.5%. They published total recovery in 72.9% of their patients suffering from GERD, while in 81.8% (!) in the case of their patients suffering from asthma (39). We mustn't forget the decrease of the social and adaptational problems of the patients who lost weight and even the improvement of their quality of life. On the basis of all these facts we are sure that laparoscopic adjustable gastric banding in the hand of a well-experienced specialist can be a more widespread and secure method in the treatment of morbid obesity (7).
The present situation of the surgical treatment of morbid obesity in Hungary cannot be considered satisfactory. Operations are made in three centres (Budapest, Pécs and Debrecen); they are mainly laparoscopic adjustable gastric banding. On the application of other surgical methods we do not have significant experiences. The first domestic results that have already been published are excellent (40). However the greatest problem is the financial aspect of the operations. With the improvement of the co-morbidities of the patients who lost weight, their hospital and medicine costs significantly decrease in long-term as well, that means savings for the health service provider. This saving is much more than of the personal and material costs of the operations. Instead of all these facts the operations can be made only in limited number on the basis of individual request with partial financing. Therefore significant part of the patients must choose the so-called self-financing way, which cannot be afforded by a great part of them, thus remain without surgical treatment. We hope that the close future brings solution for this problem.

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