Metabolic Surgery

The new frontier in the care of obesity and diabetes

In Italy, almost 10% of the population is affected by obesity, in particular in women. 4F7A8927

Among the children, 20% are overweight and 4% are obese, while in adolescents 25% are overweight and 5% are obese. The data is showing a disturbing picture, because obesity is a full-fledged disease, and as such, it involves numerous health risks.

The ideal candidates for surgery are patients aged between 18 and 65 with a BMI of 40 or more.


Bariatric surgery in the super-obese patient.

There is a weight limit beyond which surgery is risky and the doctor does not accept to operate because he does not want to take responsibility (life-threatening risk and postoperative complications), the patient is referred back to the dietician. When he has lost the necessary weight (for example, 50 kilos or more) to bring back his BMI and general clinical values to levels safe for surgery, the doctor reviews his records and verifies he is eligible for a safe surgery.


"Usually, the patient who has a BMI of more than 50, defined as super-obese, is considered more at risk, especially if male. There is no BMI limit beyond which the surgeon can refuse to operate. We must handle each case appropriately. A male patient with a BMI of 62 with diabetes, sleep apnea and arterial hypertension is different from a male with a BMI of 51 with no associated pathologies (comorbidity, etc). In the first case, a three-week hospitalization period in the nutritional rehabilitation Unit is recommended, or, as an alternative, before surgery: an intragastric balloon or at least a high-protein hypocaloric diet.

All this is with the aim of making the patient lose as much weight as possible in order to make the surgery less difficult for the surgeon and to reduce the incidence of potential perioperative complications. "

The World Health Organization (WHO) defines it as a real global epidemic because of its growing and alarming diffusion in all Western countries. Many still consider it as an aesthetic problem only. In fact, obesity is a real, multifactorial, chronic and recurrent disease that, if not addressed promptly and correctly, can lead to the onset of other diseases, such as diabetes, metabolic syndrome, cardiovascular diseases, respiratory diseases, sleep apnea and orthopedic and joint problems. Often diet alone is not enough, although it always represents the first approach to the problem.

Therefore, bariatric surgery can be a valid option to promote a path of change, a journey that is certainly not simple but possible. Yes, because obesity is treatable and so are the diseases related to it, and, in particular diabetes. "In recent years the term "metabolic surgery" has become increasingly popular in the medical-scientific world, which can be defined as an evolution of bariatric surgery or obesity surgery," observes Dr. Alessandro Giovanelli, head of the National Institute for the treatment of obesity (INCO) that, since November, has started its activity at Policlinico San Donato. The valuable scientific collaboration between researchers of Policlinico San Donato and the Vita-Salute San Raffaele University, will allow INCO to offer an important contribution in terms of scientific research on obesity and diabetes. "The principle that the surgical treatment was confined to the sole cure of obesity seemed too limited and limiting from the beginning. In fact, numerous randomized clinical trials have shown in recent years that a surgical procedure performed on an obese and diabetic person has beneficial effects not only on weight loss, but also on diabetes, so as to document a better control of it in the short and medium term with this new therapeutic approach, compared to conventional medical therapy.

This observation led us to consider diabetes as a specific indication of surgical treatment ", continues the head of INCO, the leading group in Italy for the number of patients with over 1 500 surgical procedures performed per year and a center of excellence SICOB (Italian Society of Obesity and Metabolic Diseases).

Professor Giovanelli, what is obesity?4F7A8906 1

"Obesity is a condition characterized by an excessive accumulation of body fat that causes serious damage to health. Obesity is a major public health problem worldwide, both because its prevalence is steadily increasing and worrisome - not only in Western countries, but also in those with low-middle income - and because it is an important risk factor for various chronic diseases such as type 2 diabetes, cardiovascular disease and cancer. It is estimated that 44 percent of type 2 diabetes cases, 23 percent of cases of ischemic heart disease and up to 41 percent of some cancers are attributable to obesity / overweight. In total, overweight and obesity are the fifth leading risk factor for global mortality and deaths attributable to obesity are at least 2.8 million per year in the world."

When is surgery indicated?

"According to the international guidelines, patients between 18 and 65 are eligible for intervention, with exceptions to be evaluated according to the clinical picture of the patient. Another condition is that the patient has already followed, without substantial and lasting results, a path to combat severe obesity with a controlled food program, with or without the support of drugs, and has carried out regular physical activity. Another parameter to consider is the BMI (Body Mass Index): the recourse of bariatric surgery is indicated when the BMI is equal to or greater than 40; between 35 and 40 it may be indicated if there are other associated diseases of some importance that could also benefit from weight loss such as diabetes, but also hypertension, high cholesterol and triglycerides, hepatic steatosis or fatty liver disease, nocturnal apneas, joint problems.

From all these and other evaluations, derives the choice of intervention that, in order to be successful over time, must be as suitable as possible to the specific case and take into account all aspects of the person, both physical, psychological and behavioral".

Psychological support is essential for the patient to learn how to change his eating habits and to recognize themselves in their new self-image.

What are the types of interventions?

«The types of intervention are divided mainly into three categories:

• gastric restriction interventions, which act by reducing the amount of food introduced, without changing the processes of absorption;

• interventions to reduce intestinal absorption, whose action is based on the processes of digestion and reducing the absorption of food;

• interventions with a metabolic / hormonal component that has the effect of appetite reduction

More specifically, the gastric restriction interventions are the intragastric balloon (positioning of a balloon in the stomach that swells with air or water to give a sense of fullness and early satiety), vertical gastroplasty and sleeve gastrectomy (vertical section of the stomach, removing the rest and creating a tube that reduces hunger, allows in parallel to satiate with a smaller amount of food), the adjustable gastric band (positioning of a silicone ring around the upper part of the stomach that creates a narrowing through which the food passes slowly).

On the other hand, the following are classified as measures to decrease intestinal absorption: biliopancreatic diversion (change of the stomach with deviation of the biliopancreatic digestive juices that meet food later than in nature, preventing its absorption) and the bilio-intestinal bypass (creation of a different path for food that, passing through a reduced section of intestine, is less absorbed in particular in its lipid share).

Finally, the metabolic / hormonal interventions refer to the gastric bypasses in which the restrictive component (linked to the division of the stomach with a bypass of the residual stomach and the first intestinal tract) is combined with reconstructions of the digestive canalization that induces an increase in hormones of the enteropancreatic axis with an appetite reducing action.

It is important to underline that today, in the centers of excellence, all these interventions are performed with a minimally invasive video laparoscopic technique with a camera introduced into the abdomen through small incisions".


The success of the intervention depends to a large extent on the commitment to the changes in long-term eating habits: after an intervention of this type, the patient must learn to follow a controlled and nutritionally balanced diet. The follow-up phase is also fundamental, i.e. periodic medical checks. Turning to specialized centers, the patient has the certainty of being followed with regular multi-specialistic controls. This will allow you to check the course of treatment with time and the absence of any complications, but above all the maintenance of the results by the patient. In the long journey that every obese patient faces to treat his illness, psychological support is very important before, during and after the operation. The operated person in fact, needs support to acquire the new image of oneself, to recognize oneself in spite of the radical change, to achieve and maintain a good inner balance.


There is a numerical value that helps to distinguish the two conditions, namely the Imc body mass index or BMI (Body Mass Index), which is obtained by dividing the weight (expressed in kg) by the square of the height (expressed in meters).

The World Health Organization's defines it as follows:

• overweight = BMI equal to or higher than 25 up to 29.99

• obesity = BMI equal to or greater than 30

What are the advantages of using a minimally invasive technique?

"This technique reduces pain, postoperative discomforts and complications over time and improves the whole process. Using small accesses, through which surgical and optical instruments are inserted, the intervention is less "tiring" for the patient and results in quicker recovery. At the exit of the operating room, in fact, the patient can already walk and the same day or the day after the patient is able to start eating. After a couple of days, the patient can also get discharged and return home. "

How does weight loss influence the improvement of diabetes?

“The various interventions act on the controlling of diabetes 2, which is the most common form of diabetes characterized by high levels of glucose in the blood and caused by an alteration in the quantity or functioning of insulin, and by weight loss (which can also reach 60-80% of the excess weight percentage) both through the recovery of the pancreatic reserve, i.e. that part of the silent endocrine pancreas which, when stimulated by enterohormone (a group of substances with hormonal activity, produced by the stomach, from the intestine and pancreas), can resume its function of glycemic control."

Bariatric surgery is decisive or you can run the risk of gaining weight again?

"Obesity has a pattern of chronic-relapsing: this means that for each procedure there is a variable percentage of failure and weight regaining over time. It is usually possible to intervene surgically with a revision procedure aimed at stopping weight recovery and inducing a new weight loss "


Date: 07/09/2018

By: Elena Buonanno

Translation and editing: Violetta Valeeva