The term morbid obesity is known to designate the excessive body fat, which has consequences for health. Are persons with body mass index (BMI = weight / height) greater than 35 kg / m² with associated diseases or above 40 kg / m² (normal BMI between 19 and 24.9 kg / m², overweight of 25, 1 to 29 9 kg / m²).

Bariatric surgery, also known as bariatric surgery or more popularly reduction stomach, meets techniques with scientific backing for the treatment of obesity and diseases associated with excess body fat or aggravated by him as type 2 diabetes mellitus (T2DM), hypertension , osteoarthritis, infertility, sleep apnea, etc. Bariatric operations has over 40 years of safe use in Brazil and are without doubt the most effective forms of treatment for long-term weight loss when clinical treatments fail.

But a new concept has drawn attention of physicians: a malignant obesity. Such individuals may have BMI from or around 30 kg / m², featuring mild obesity, but suffer from the disease aggravated by excess weight, especially diabetes and hypertension. Are cases where the severity of the diseases associated is not directly related to BMI. More than half of diabetics are not morbidly obese and are initially independent of disease control mechanisms of weight loss, bariatric surgery is equal to surgery for type 2 diabetes mellitus or metabolic? The answer is no!

From the identification in morbidly obese diabetics who had their blood sugar level normalized after bariatric surgery (for obesity) not directly related to weight loss, but through mechanisms that act directly on the T2DM, began a series of clinical studies to evaluate the feasibility of conducting this type of surgery in morbidly obese diabetic no.

The results showed that patients with clinical conditions of deficiency in the pancreatic function to produce insulin, tissues resistance to insulin action in difficulties in maintaining drug treatment, can benefit from surgical treatment, being created then the definition of metabolic surgery or surgery type 2 diabetes can be defined that interventions on the digestive tube that has control of T2DM almost immediately after surgery, through various direct mechanisms against the disease, initially unrelated to weight loss, are called metabolic operations where the weight loss that occurs in the long run is an excellent side effect. The bariatric surgeries are those indicated for those individuals who have complications due to the heavy weight, such as joint disease, disc herniation, stomach acid reflux into the esophagus, etc. Metabolic interventions or diabetes has as a primary objective the control of T2DM and its complications has nothing to do with the patient's BMI, but with gravity and inadequate control of T2DM, regardless of BMI, whether above or below 35 kg / m². metabolic surgery or diabetes primarily deals with T2DM and conditions coming together, such as hypertension, elevated cholesterol and triglycerides.

In cases of morbid obesity, important studies demonstrated the efficacy of bariatric surgery, which decreases significantly the risk of complications of diabetes and development over the years. Only 10% of the patients develop the disease during the 10 and 15 years after surgery, compared with 95% of non-operated following non-surgical programs to control the disease. And fundamentally, several epidemiological studies have shown decrease of up to 92% of deaths related to diabetes in the operated group, in a follow-up to 16 years.

In relation to surgery in morbidly obese diabetic not, the results are also promising. The mortality in diabetics is predominantly secondary to cardiovascular complications, and about a year after surgery there is evidence of control of the progression of vascular disease in the operated group, which suggests that correctly indicated surgery reduces mortality in type 2 diabetics submitted to surgical treatment. Our research group integrate the consensus that BMI preoperative does not reveal precisely the severity of diabetes, its power to cause complications and mechanisms of disease. Moreover, other factors such as age, gender, diabetes history and loss of postoperative weight have not been decisive in remission.

Many researches conducted and underway in Brazil and abroad reinforce the guidelines of the International Diabetes Federation (IDF, its acronym in English), which recommends surgery to patients with BMI from 30 kg / m², provided it is diabetic or has predisposition to disease and cardiovascular risk present. The guideline, published in March 2011, had the support of more than 200 medical organizations from 160 countries.

National and international standards restrict the indication of bariatric surgery and metabolic for patients with BMI from 35 kg / m² with associated diseases or above 40 kg / m², without the mandatory presence of other diseases. This criterion is maintained for 20 years, based on the consensus of the US agency National Institutes of Health (NIH) and Brazil is set by the Federal Council of Medicine (CFM) through Resolution 1974 of 2010.

Indications for metabolic surgery, freed from the constraints of BMI as the only parameter for the indication has been expanded. The regulatory agency of the British medical practices (NICE) 6 months ago changed its surgical treatment criteria for patients with T2DM without adequate clinical control, reducing BMI to 30 kg / m2.

The CFM national guidelines are old, based on international consensus 1991, where there was no laparoscopic surgery, less invasive, and do not know the action of operations on the digestive tract to control T2DM.

absolute contraindications for metabolic surgery are uncommon. The main ones are patients with autoimmune diabetes (that which the organism itself produces antibodies against pancreatic beta cells which produce insulin), type 1 diabetes and type 2 diabetics with very advanced disease in which the pancreas does not beta-cell reserve that produce insulin.

psychiatric disorders, with the exception of psychotic patients with decompensated are not contraindications for surgery diabetes (even for bariatric) .Another is contraindicated for those with reduced sick reserves the cardiopulmonary functional impossible to support any operation under general anesthesia.

The general evaluation tests for any surgery such as coagulation, blood count, renal function, among others, are always requested. Regularly also requested blood tests to estimate the reserve of pancreatic beta cells that produce insulin. Also evaluates the cardiac reserve and research is through exercise testing or myocardial scintigraphy any sign of disease of the coronary arteries, common in diabetics. Diabetes is also responsible for diseases of the small vessels of the kidney, retina and peripheral nerves and all that should be checked preoperatively and compensated if necessary.

Other imaging tests such as ultrasound and abdomen should be asked and sometimes elastography of the liver, which can aid in the diagnosis of liver fibrosis resulting from diabetes. Always one routinely endoscopy is requested, since the stomach will be part of the surgery.

Diabetic patients severely decompensated with very high blood glucose and glycated hemoglobin (indirectly measures the glucose levels of the last 2 to 3 months) is also high, above 10%, they must be treated before being intensively operated. This aggressive intervention to control blood sugar greatly improves postoperative evolution.

In patients taking anticoagulant drugs (commonly and erroneously known as drugs "blood thinner") Must have them suspended 7 days before operations. It is routinely oriented preoperative fasting for 8 hours.

Most operations are performed metabolic-Y gastric bypass Roux (Roux-en-Y Bypass) and sleeve gastrectomy. The second has a medium / long term less effective for the control of type 2 diabetes bypass Roux-en-Y immediately have direct anti diabetic actions, independent of weight loss that is an excellent and expected side effect of operations. remember that the operations for diabetes, independent of the patient's BMI has the primary objective of disease control.

The operations are under general anesthesia by laparoscopy, having from 4 to 5 small incisions ranging from 0.5 to 1.2 cm. The mean duration of the surgery is 45 to 60 minutes. Obviously in the rare event of a complication intra operative, these procedures may take longer. The average length of stay is 48 hours.

General surgeons and digestive tract can now do the metabolic and bariatric operations, provided that they prove the technical training.

Ideally, always look for a surgeon member of the Brazilian Society of Metabolic and Bariatric Surgery (SBCBM), which has training and proof of being up to date on this issue that has constant new discoveries of its benefits.

The SBCBM, together with the Brazilian College of Surgeons and the Brazilian Digestive Surgery College, requested by the Joint Committee of the Federal Council of Medicine Specialties, that bariatric surgery and metabolic was raised to Practice Area, making it a sub specialty General Surgery and the Digestive System. In late 2014, this request was approved, leaving the final bureaucratic procedures. This will mean more trained and selected physicians and increased safety to patients.

Today, in high-volume surgical centers and have experienced surgeons, the operations are relatively quick, lasting 50-90 minutes. After the end, patients are referred agreed to the wing post anesthetic recovery, which are usually about an hour. The vast majority of patients will immediately into the room. Sometimes, depending on the severity of the associated disease, the first 24 hours are spent in the Intensive Care Unit (ICU). In our group, the average ICU admission is less than 0.5%. The hospital ranges from 36 to 48 hours.

Usually the patient is fed on the first day after surgery with liquid diet, divided so that there is an adaptation to the new life. With the multidisciplinary orientation, with surgeon, and clinical nutritionist, ways will be explained and types of foods released for this first phase. The duration of the liquid phase is 7 to 10 days, and is then allowed to progress more diet creamy / pasty and around the 25/30 days after surgery, the transition occurs to ordinary food.

In this first month, an unprecedented event for the obese often does, which is to stimulate intake, since there is a feeling of fullness and there is also an obligation to stay hydrated and consuming a minimum of calories (about 600 to 1000 per day). Since the first week, patients in the postoperative period should begin vitamin supplementation, which is necessary for there eating less food, since in gastroplasty Roux-en-Y there is poor absorption of nutrients important. Also in the first 3 weeks is prescribed antacids such as ranitidine, in liquid form, to effectively decrease the formation rate of ulcers in the stomach again. The use of such drugs, small changes associated with the surgical technique has this ratio to about 1%. Painkillers are prescribed if necessary and not hours and are usually simple drugs like paracetamol and dipyrone. The average return to work with laparoscopic (7 to 10 days after operation) is much less than in conventional operation. Exercises, whatever are released from 21 to 30 days after surgery, since the operation has been laparoscopic.

A particularity of operations for diabetes is that due to the already mentioned direct antidiabetic action, especially the bypass Roux-Y, the resistance of tissues to insulin action decreases immediately after the operation for a number of physiological causes inherent to the procedure. Thus, there is rapid adjustment of the doses of the anti drigas diabetic and insulin doses. In our Obesity and Diabetes Center of the Oswaldo Cruz German Hospital, the average usage and insulin suspension, regardless of preoperative patient's BMI is 22 days. It is noteworthy that surgery for diabetes does not have as a primary objective the suspension of any medication for type 2 diabetes, but quickly control this chronic disease, progressive and devastating.

Finally, metabolic operations, when correctly indicated, bring with them many advantages and with rapid recovery and early return to normal life. In short, little suffering for immeasurable clinical benefits and quality of life.

The mortality after surgery or metabolic T2DM is very small. Since the operations are carried out by experienced teams in good-sized hospitals, the mortality rate is 0.315% number comparable to mortality after removal of a gall bladder, a trivial operation.

There are complications such operations greatest concern in postoperative gastric bypass Roux-Y. It is the leakage of the suture with the stapler in the stomach junction of the small intestine, so-called fistulas, which occur at a very low frequency, between 0.09% and 0.1%. To identify this complication, the surgical team routinely evaluates 2:03 times a day the patient while hospitalized. These complications can possibly deserve to reoperation for their treatment.

Other complications include venous thrombosis of the legs and pulmonary embolism whose risk falls close to zero using anti-thrombosis measures, with stockings and compression systems.

Obstructions can occur early in the gut however are very rare about 0.08% to 0.1% after metabolic operations and finally bleeds into the abdominal cavity, which are inherent to any operation also occurs in very small levels close to 0, 05%.

As late complications, there are few descriptions of malnutrition occurring in 1 to 1000 gastrojejunal derivations performed. Fundamentally these patients should be followed for tests of control of your diabetes, even in complete remission.

The higher the blood glucose of patients, less insulin is produced by your pancreas. This situation is called glucotoxicity. As mentioned above that control of blood glucose must be done carefully before surgery to have greater benefit, the same reasoning applies in the postoperative phase. The medical team, with surgeons and endocrinologists form a cohesive team. Both work together to glycemic strict control postoperative for a better result in the long term, aimed at complete remission of diabetes.

Who regulates medical practice in Brazil is the Federal Council of Medicine (CFM). The CFM national guidelines are old, based on international consensus 1991, where there was no laparoscopic surgery, less invasive, and do not know the action of operations on the digestive tract to control T2DM.

There is currently a joint effort of the National Society of Metabolic and Bariatric Surgery and Endocrinology to seek a new guideline that can benefit patients with T2DM inadequately controlled with medicines so that they have access to surgical treatment.

Text prepared by Dr. Ricardo Cohen, general surgeon and member of the Brazilian Society for Bariatric and Metabolic Surgery.