Since 2014, it has become the most frequently performed bariatric surgery in the world. It is considered by most bariatric surgeons to be the first surgery that should be performed in the treatment of obesity. It is a restrictive, that is, volume-limiting surgery. Approximately 75-80% of the stomach is removed by cutting it through a tube placed through the mouth. The remaining stomach becomes a long, thin tube. The patient is satisfied with small portions and weight loss is achieved. Weight loss rates are similar to other bariatric surgeries. In addition to its restrictive effect, it also contributes to the recovery of diabetes with the hormonal changes it causes. It is primarily preferred in patients with obesity. Since there is no malabsorption surgery, vitamin-mineral supplements are often not required in the long term.

It is a safe surgery that has been performed for more than 20 years and its long-term results are known. Weight loss and diabetes remission rates are quite good. Having a single anastomosis increases its reliability. The stomach is turned into a closed tube as a continuation of the esophagus, and the remaining stomach is left in the abdomen. A new path is created between the small intestine and the newly created stomach pouch. Food is prevented from touching the first 150-200cm of the small intestine. This causes weight loss by creating a controlled malabsorption; On the other hand, diabetes is taken under control with the hormonal changes that occur. It is preferred in patients with prominent metabolic problems. Since it is an malabsorption surgery, vitamin-mineral support may be required in the postoperative period. The disadvantage is that the remaining stomach cannot be accessed endoscopically.

It is a procedure performed endoscopically, without requiring general anesthesia or surgery.  The estimated application time is 10-15 minutes. It does not require hospitalization, a few hours of rest after the procedure is sufficient. The gastric balloon is inflated with air or liquid to 400-700ml. It creates a volume restrictive effect and restricts oral food intake. When combined with a low-calorie diet, it provides an average of 15% weight loss.  Nausea, vomiting and cramp-like pain may be observed in the first 48-72 hours after application. There are balloons that can stay in the stomach for 6-12 months, depending on how long they stay in the stomach. When the balloons expire, they are removed again endoscopically.

Botulinum toxin is a toxin created by the bacterium Clostridium botulinum that causes temporary relaxation in the muscles.  Gastric botox is the process of endoscopically injecting botulinum toxin into the stomach tissue. When injected endoscopically into the stomach tissue, it delays gastric emptying and reduces appetite. It has not been shown to have a weight loss effect on its own. It helps to lose weight in combination with a low-calorie diet.

The advantages of the procedure are that it is reversible, does not require surgery, and has a very low side effect rate. The weight loss achieved with Botox application in some studies seems to be low and dependent on the diet applied.

After obesity surgery, some patients may not achieve sufficient weight loss. This situation is often due to inadequate surgery, unless there is another underlying reason. For example, leaving a large stomach in sleeve gastrectomy or not properly adjusting the size of the bypassed intestine in bypass surgeries can lead to this issue. In an obesity patient who was inadequately evaluated before the surgery, an overlooked metabolic disease, such as undiagnosed Cushing’s syndrome, may also result in insufficient weight loss.

In some patients, there is also the issue of regaining weight after weight loss. Approximately 15-20% of patients experience weight regain after obesity surgery. This can be attributed to inadequate surgery, patient non-compliance, or an underlying metabolic disease.

Factors contributing to insufficient weight loss or weight regain after obesity surgery include:

Surgical/Anatomical Factors:

• Inadequate reduction of the stomach size
• Dilation of the remaining stomach pouch
• Distance of the stapler line from the pylorus
• Length of the bypassed intestine

Hormonal/Metabolic Imbalance:

• Changes in hormone levels such as ghrelin, serotonin, pancreatic polypeptide (PP), glucagon-like peptide (GLP-1), leptin, cholecystokinin, etc.
• Pregnancy
• Steroid treatment
• Newly developing Cushing’s syndrome

Postoperative Behavioral/Psychological Factors:

• Non-compliance with diet
• Inability to change eating habits
• Inability to make lifestyle changes (exercise, sports)
• Anxiety and depression

While surgical/anatomical factors are prominent in weight regain or insufficient weight loss, behavioral and psychosocial aspects should also be addressed. These are important because they are preventable and correctable causes.

Before making a surgical decision, the patient’s eating habits, diet compliance, current body mass index, and comorbidities should be thoroughly assessed. In patients who gain weight due to postoperative diet non-compliance, the success rate of revision surgeries will be low.

Revision surgeries are planned individually, taking into account the characteristics of the first surgery and the patient.

Metabolic surgery is often mentioned together with obesity surgery or bariatric surgery. What we understand from metabolic surgery is surgeries that cause metabolic changes by causing hormonal changes. For example, changes in GLP and neuropeptide Y levels cause changes in insulin resistance and, as a result, blood sugar returns to normal levels.

All obesity or bariatric surgeries also have metabolic effects. Obesity surgeries cannot be considered without their metabolic effects. For this reason, all obesity surgeries are also metabolic surgeries. The opposite is also true; all of the surgeries we perform to benefit from their metabolic effects have weight loss properties.

As a result, all obesity surgeries are also metabolic surgeries and all metabolic surgeries are obesity surgeries.