What bariatric surgery is about and who it is for, as explained by St. Bernard’s Hospital resident specialist surgeon Alfonso Antequera.

In a world inhabited by more over-nourished than under-nourished people, obesity is a pandemic, and one hard to tackle with the medical tools currently at our disposal. Most governments and health authorities worldwide sat idly and watched the western world population growing fatter and fatter for three decades, blaming it on fast food but without officially promoting healthier lifestyle changes, and proactive solutions to prevent it to spiral.

This is partly because obesity has always been regarded mainly as an aesthetic no-no rather than a disease. Yes, it is now considered a disease, a chronic one, and a ‘contagious’ one (‘if either or both of your parents, or your partner, are obese, there is a notable chance you will steadily gain weight’ claims the sternest warnings issued by dieticians), but also because food is readily and abundantly available – in the western countries at least – and a rich diet often goes hand in hand with a  sedentary routine, so doubling or even trebling the disastrous effects of excess calorie intake.

Throughout history, being fat has been a sign of wealth and health, as rich people wouldn’t suffer malnutrition or starve to death, but always had food on their tables, three meals per day when the man in the street would consider himself lucky if he ate once every other day. In the late Twentieth Century, when obesity became a ‘commodity’ accessible to many, not just in elderly patients but also young adults and children, it was proven how one can be fat and malnourished concurrently, when following an ‘empty-calorie’ diet that doesn’t supply the energy and the necessary nutrients like protein and vitamin.

The five-a-day campaign soon started to get everyone eat more fruit and vegetables and the food pyramid was invented to educate consumers on how to split their nutritional intake in three or four nutritional groups. More recently, the traffic-light system was introduced to label percentage of fats, carbs and sodium in packaged food, but the stark reality remains the same: poorer people in richer countries cannot afford to eat healthy enough, because frozen TV dinners and processed food are cheaper than fresh produce and lean meat, notwithstanding that lower working class may have less time and resources to cook daily from scratch, so they turn to the frozen aisle and are grateful that the purported progress provides them with tasty and affordable hot meals.

And so, umpteen chocolate bars, packets of crisps and microwavable trays later, the pounds pile up around your midriff, and drastically changing your eating habits becomes a harder battle to fight, often pointless against the almost inevitable effects of yo-yo dieting. Unfortunately, quick to label obesity a chronic disease, doctors haven’t yet found a cure for it. Prevention plays an important role, but when the damage is done, the existing pharmacology doesn’t list prescription drugs which could burn away the flab already accumulated under your skin – and when strict dieting fails, the only option left is surgery. Gastric bypass is the most effective way to decrease one’s body mass index from 40 or over down to 30, the average for a healthy adult, and to keep the excess weight off for virtually the rest of one’s life, thus increasing of up to 30% one’s life expectancy fifteen years after the procedure, compared to a much lower rate of success with dieting alone.

Alfonso Antequera

Until last year, patients eligible for bariatric surgery were attended in the UK through the sponsored patients scheme, but given the alas increasing demand, the Gibraltar Health Authority eventually introduced a dedicated clinic at the local hospital, which is now harvesting the fruit of its investment, with thirty-five cases awaiting their operation under the supervision of consultant surgeon Mr Alfonso Antequera, one of the best specialists in the field, with great experience in running bariatric units in Madrid, Hull and Dublin. Bariatric medicine is still in its infancy, and there are many issues to explore and experiment on, like for example the role of hormones in inhibiting or triggering hunger and cravings, or the efficacy of gastric bypass in non-obese type II diabetes sufferers, which is still relegated to clinical trials only; and of course the most uncomfortable question of all: why do some patients struggle to lose weight under supervised dieting while others seems to metabolise everything they gulp down?

“Sometimes, two similar operations yield different results with different patients,” Alfonso says, “as bariatric surgery unfortunately fails in 20% of the cases.” This means that after two or three years from their operation, some patients start regaining weight and fall victim of their old eating habits, if they haven’t learnt how to control their impulse eating during the period of grace they enjoyed after surgery. However, surgical procedure is so far considered the only viable option in the long term, because only a mere 1% manages to stay lean for the rest of their lives with dieting only, as a comprehensive Swedish study begun in the Eighties has shown.

Surgery is considered the last resort when other treatments have failed at drastically reducing the patient’s body mass that is severely affecting his or her quality of life. The team includes dietician and psychologist who assess the feasibility of dieting alone as well as emotional implications, ruling out bulimia and other eating disorders, or schizophrenia and drug addiction. Hormonal imbalance is also investigated, but it is highly unusual that obesity would be caused by endocrine conditions alone, although there is hypothyroidism to consider, and also the newly discovered, but apparently rare, obesity gene, that re-opens the debate on the triggering factors being natural or social.

Prepping for the op takes about one year after the patient is referred to the bariatric clinic through primary care: after the initial assessment by the team, the patient is required to adhere to healthier lifestyle in order to downsize considerably before undergoing surgery, especially in the month prior to that, in order to shrink the liver. Despite the minimally invasive keyhole surgery, patients are admitted for up to five days in Gibraltar, contrary to the US where similar procedures are carried out in day hospital, and they are also expected to rest for a three-four week convalescence period. This being a public health service, the time off work is covered by social insurance, and costs to the tax payer are fully recovered within two years, thanks to the patient’s increased productivity at work and the slash in future medical costs, especially if the operation succeeds in reversing the effects of type II diabetes, a.k.a. ‘diabesity’ – thus the insulin insufficiency caused by excess sugar consumption is dubbed.

In fact, gastric bypasses not only make your stomach smaller and hence easier to fill, but they make the bowel to ‘mistrust’ any sugar ingested, causing you a sort of allergic reaction to it, with sudden sweats and general malaise that will warn you against consuming sugary snacks and eventually condition you to steer clear from them! And what happens if patients do their homework so diligently that they reach operation day with a body mass of 30 or just slightly over? That’s the surgeon’s dilemma, of course, but it is advisable to operate anyway, so that the yo-yo effect is averted. Afterwards, patients are advised to follow a fitness regime to tone their muscles and re-absorb the excess skin: if this is relatively easy in young people, older patients may have to be referred to the plastic surgeon after they have lost fifty-sixty kilos, one or two years later, most commonly for a tummy tuck.

“When I was first offered to start and direct a bariatric unit because of my specialisation in keyhole surgery,” Alfonso says, “I had my reservations, which were soon dispelled by witnessing the change in my patients’ lives: watching depressed, withdrawn, lonely, sick people feeling reborn, with a new body that allowed them to seek and find employment, have a social life, fall in love… that made me feel it was all worth it.” Alfonso Antequera graduated and trained in Madrid, where he specialised in organ transplant at Clinica Puerta de Hierro and went on working at a state-of-the-art Fuenlabrada University hospital where he started the bariatric unit before expanding his horizons in Hull and Dublin later. In early 2017, he was invited to Gibraltar to tackle the local obesity rate, which is higher than in Spain, but definitely lower than in the UK. He also calls for prevention and change in attitude towards an active lifestyle: “Gibraltar is the ideal city for walking or cycling everywhere: we could set an example to the rest of the world in that.”