About 311,850 bariatric surgery have been carried out in Brazil for the past five years. Data from the National Health Agency (REPLY) show that 252,929 were performed by healthcare companies, 14,850 privately and 44,093 by the SUS. From this year, if approved by the Federal Council of Medicine (CFM extension), the rules for indicating bariatric and metabolic surgery are expected to change in the country. If the new guidelines are changed, the minimum BMI (Body Mass Index) must be 35 kg/m², if there are no comorbidities; patients with pathologies associated with obesity could undergo bariatric surgery with a BMI as low as 30 kg/m².
Marco Aurélio Santos, associate professor at the USP Faculty of Medicine and director of the Bariatric and Metabolic Surgery Unit of the Hospital das Clínicas, explains these new changes. “Given the great impact that bariatric surgery has on diabetes control, a resolution was recently approved in Brazil by the Federal Council of Medicine, which authorizes the surgical indication in doses between 30 kg/m² and 35 kg/m² , in the presence of diabetes with more severe characteristics that would benefit from surgical treatment,” he says. These are resolutions that have yet to be evaluated in the national context.
The procedure is not aesthetic
Once the criteria for the surgical indication have been contemplated, a preoperative evaluation is required, which involves what is defined as a multidisciplinary evaluation and which covers the nutritional, psychological, endocrinological fields, all condensed with the critical evaluation of the surgical indication by the by the bariatric surgeon himself. Popularly, bariatric surgery is known as stomach reduction surgery, and in fact, technically, there is a reduction in the volume and size of the gastric chamber. It should be noted, however, that bariatric surgery is not aesthetic and that there are a large number of private consultations, demonstrating a very serious situation, emphasizes Wilson Salgado Júnior, professor in the Department of Surgery and Anatomy of the USP School of Medicine in Ribeirao Black. “He Has a very clear and very precise indication for accepted body mass indexes who have already tried a previous clinical treatment. This depends on the discretion of the surgeon, who must be ethical enough to follow the law. If he doesn’t follow the existing legislation, he is outside the law and can be prosecuted for it. Now, these ANS data show another concern. Only there are very few SUS (Unified Health System) who do bariatric surgery and that’s the big problem. We have a huge queue at SUS,” adds Salgado.
On the other hand, it should be taken into account that private practices are more attractive for doctors due to the economic return. “It’s really not attractive for hospitals, for doctors, to perform surgery in the SUS, despite the fact that the Ministry of Health also has adequate coverage. A doctor out there, in a private health plan, makes a lot more.” The challenge is just that, to demonstrate that more SUS services should be opened. “We need to have more public services to be able to operate on these bariatric surgery patients who do not have health insurance. We have noticed the increase more and more. In addition to the Covid pandemic which has increased obesity in our population, many patients who had a pact have lost it for economic reasons. So where did they all go? For SUS. We are having a large influx of obese patients and we are not able to operate in the quantity that would be necessary”.
Surgery doesn’t work miracles
Salgado notes that the surgery isn’t miraculous and requires a large amount of pre-op testing. “We make the patient lose weight before operating, because this reduces the possibility of having surgical complications”. On the other hand, weight loss implies a decrease in harmful effects such as diabetes, hypertension and also reduces the risk of pneumonia, which makes things easier for the surgeon, although there are always risks of complications. “The possibility of dying in bariatric surgery today is very low, less than 1%, but it is certainly not zero, no surgery has a zero risk. If you’re going to tear off a toenail, it can get tricky and you can die.
Furthermore, it is a “major” surgery, in a large patient, who has associated pathologies, such as diabetes and hypertension, which means a procedure that must be performed with care to avoid risks such as bleeding or pulmonary embolism, for instance. . “These are both surgical and clinical complications”, underlines the specialist, who also addresses the treatments that must be provided in the postoperative period. “Early complications are usually surgical complications. In the long run, it comes to malnutrition and the patient can gain weight again. It can happen, yes. Provided that the patient leaves the multidisciplinary team that takes care of him”. Malnutrition, he underlines, is a problem that cannot be overlooked: “We are always attentive. This is why we don’t discharge our patient, we continue to follow him for the rest of his life to do tests. We transmit the drugs that the patient should take in the postoperative period, we transmit nutritional guidelines to give priority to the foods that are most important to him. This is fundamental”. On top of that, some patients have binge eating and anxiety issues and get angry with food, but because the stomach is so small and food can no longer be swallowed in the amount it was used to, the patient can no longer use it as an outlet and it can turn to other things, such as alcohol and drugs, facilitating the onset of depression and even suicide.
Patients can regain weight
Weight gain may occur in the postoperative period, as, according to Salgado, patients tend to use tactics to deceive the surgery. “They start snacking on small amounts of food throughout the day, eating high-calorie foods, alcoholic beverages. The alcoholic drink is extremely caloric, more caloric than sugar. Stop exercising. The weight regain we call obesity relapse is something that happens, yes. We think it happens in up to 35% of patients. And we know that the patient can gain weight again, even remaining at the same weight or even greater than it was before surgery. If the person does not take care of himself, if he disappears from consultations, if he is not psychologically well, if he does not have a sequel, this is the great concern we have ». Again according to the doctor, after the operation there is a change in the way one eats. Those who previously ate about 1 kg of food in 5 minutes will now take half an hour to eat 100 grams. In fact, in the first 15 days the food is exclusively liquid.
Salgado recommends that anyone considering bariatric surgery seek out a service that has an established team, preferably from the Brazilian Society of Bariatric Surgery. “He Runs away from the surgeon who, on the first appointment, is already talking about operating next week. That doesn’t exist. There is a time for preparation, for evaluations to be made. You can’t think about surgery happening the following week. If he decides to operate on you, he’s outlawed. He has to give you the opportunity to lose weight in other ways, with a team. If the surgeon follows the rules correctly, backed by a team that has all this follow-up, without a doubt, the possibility of positive results is much greater”. (With information from the Journal of USP)
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