Obesity is not only an aesthetic problem and acceptance of an imperfect body, but above all a health problem, because as the kilograms keep adding up, other problems appear in the body. Beyond the surface effects, such as those on the skin, obesity can be associated with deep and complex problems such as type-II diabetes, high blood pressure or various forms of cancer.

Many times, persons dealing with obesity don’t consider other possible conditions. Or, if they suspect some, others are a total surprise. This is what happened in the case of Andra, from Bucharest, who came to the decision to undergo surgical treatment after a long history of fighting with kilograms, initially motivated only by aesthetic and psychological considerations.

"My struggle with weight started as a child - I remember my first diet when I was 8 years old. Because of the flawed relationship I developed with food, my life was a constant balance between having and not having a weight problem. And after I got pregnant and after I gave birth, the balance tipped towards obesity and I couldn't get rid of the excessive kilograms. I felt terrible, I was always indisposed and slowly slipping into depression. On my birthday, on December 10, 2021, I had the idea to have a stomach surgery. I read a lot about the surgery, but what followed was, from a certain point of view, totally unexpected", confesses Andra. 

After careful documentation and on the recommendation of a friend who had undergone bariatric surgery, she decided to approach the surgeons at the Center of Excellence in Obesity Surgery at Ponderas Academic Hospital. The discussion with Dr. Bogdan Smeu, one of the most experienced surgeons in the team coordinated by Prof. Dr. Catalin Copaescu, gave her the confidence to make the final decision, that of shrinking her stomach through the longitudinal gastrectomy surgery (Gastric Sleeve).

Pre-operative investigations and the shock of a harsh diagnosis

The patient, 31 years old and with a height of 1.73 m, weighed 95 kilograms in February 2022, when she approached Dr. Bogdan Smeu. After the decision to undergo surgery, she entered the special circuit dedicated to bariatric patients.

Preparation for a bariatric surgery at the Center of Excellence in Bariatric Surgery at Ponderas Academic Hospital is thorough and includes a series of mandatory analyses and investigations, as well as a psychological assessment. In this stage of multidisciplinary assessment, various pathologies associated with obesity can be identified, which in turn need medical or surgical treatment, and the possible risks associated with the context are also estimated and analyzed.

Being young and with a weight that didn’t fall under the scope of morbid obesity, Andra didn’t expect major health problems. However, the results of pre-operative investigations came with two surprising diagnoses: a hiatal hernia and a kidney tumor. Hiatal hernia associated with obesity isn’t uncommon and it is explained by the effect produced by excessive kilograms on the diaphragmatic hiatus. But the identification, during the abdominal ultrasound, of a tumor formation at the level of a kidney, totally asymptomatic, was a shocking discovery. 

A cancer diagnosis is hard to digest at any age, even more so at 31. "I would say that she received the news with fear, naturally, as I think each of us would react to finding out such a diagnosis. Especially when you don't consider yourself sick, you don't have any particular pain and you don't worry that you might have something serious", says Dr. Bogdan Smeu, surgeon of Excellence in Bariatric Surgery. 

Moreover, life often surprises us, because practice shows that "not infrequently it happens to identify, on the occasion of a pre-operative checkup with a view to a bariatric surgery, numerous health problems, not necessarily of an oncological nature, but which may need surgical treatment at the same time as the Gastric Sleeve surgery", as confirmed by the surgeon.

Case assessment in the Tumor Board multidisciplinary committee

As happens with all oncological cases, Andra's case was also analyzed by members of the Tumor Board multidisciplinary committee, in order to offer the young woman a customized solution, the best therapeutic solution for her medical situation. The surgery for weight loss was thus secondary, the priority becoming, in the light of the latest discoveries, the removal of the discovered kidney tumor. 

„The two weeks after finding out the kidney tumor diagnosis were a nightmare, I went through all kinds of bad moods. I regained my courage and zest for life after Dr. Andrei Nadu explained to me that the discovered tumor, which was less than 4 cm, had no oncological implications and that he would perform the surgery to remove it at the same time as the Gastric Sleeve”, says Andra.

"A 3 cm kidney tumor means that the disease is at an early stage and that the patient will be completely cured of the cancer. I would say she was lucky to have discovered it that way because these tumors are often asymptomatic at this stage, and as they grow in size, they metastasize and become difficult to cure. Most patients come to the doctor when they already have symptoms and sometimes they cannot be cured, unfortunately", says Dr. Andrei Nadu, specialist urologist at Ponderas Academic Hospital.

Kidney tumors generally grow by about 1 cm per year, and once they reach sizes exceeding 4-5 cm, metastases begin to appear. In addition, the larger the tumor, the lower the chances of being able to save the kidney after surgery. 

"As with any form of cancer, early detection is the key. Unfortunately, in kidney cancer, we can’t talk about a set of screening tests, because it is a rather rare cancer. For this reason, it is discovered by chance most of the time, during investigations recommended for another health problem", explains Dr. Andrei Nadu.

The solution of the multidisciplinary team: three surgeries performed simultaneously 

Following the assessment of the case in the Tumor Board multidisciplinary committee, an optimal surgical approach was decided for the patient, by minimally invasive treatment of three health problems in a single surgery.

The medical team formed by surgeon Bogdan Smeu and urologist Andrei Nadu decided to perform three surgeries at the same time: partial nephrectomy to remove the kidney tumor, longitudinal gastrectomy (Gastric Sleeve), and repair of hiatal hernia. 

"It is important to remember that we treat patients, not diseases, and therefore we offer each patient a solution adapted to their case. Therefore, the treatment proposed for our patient was a minimally invasive approach, in a multidisciplinary team, to solve all health problems in the shortest possible time, with maximum benefits for the patient", explained Dr. Bogdan Smeu.

Although the surgery was not without risks, it represented the best option for Andra. "The more surgical gestures are performed simultaneously, the patient assumes a series of greater risks during the surgery, but they also have a lot to gain. This was also the case with our patient. In the first phase, the kidney surgery was performed, during which we removed the tumor. Then we continued with the abdominal surgeries, the one for the hiatal hernia and the bariatric surgery. The patient went home peacefully, after three days of hospitalization, without the tumor and with the kidney preserved", explains urologist Andrei Nadu. 

All three surgeries were performed using a minimally invasive, laparoscopic approach to minimize the traumatic impact on the body. Thus, the post-operative evolution of the patient was very good, with a fast recovery, thus favoring the discharge after only three days.

After the surgical treatment, the histopathological result was reassessed by the Tumor Board multidisciplinary committee, which concluded that the patient didn’t require oncological treatment. However a short-, medium- and long-term post-operative monitoring plan was developed, with checkups at ten days, one month, three months, six months, and then annually, for both kidney pathology and bariatric surgery. These post-operative checkups are very important for timely monitoring by the medical team of the healing process and subsequently of the weight loss process so that everything proceeds normally.
 

"I feel like I’ve finally won the struggle with kilograms"

Beyond the aspects aiming at the safety of the medical act and subsequent favorable evolution of long-term health, no less important is the satisfaction of the treated person and the improvement of the perception regarding the quality of one's life. In fact, this was the engine that moved things in the beginning in the case of Andra who, without feeling sick, simply wanted to improve her life.

Nine months after the surgery, Andra weighed 56 kilograms. "It was a difficult journey after the surgeries - it wasn't easy for me to follow the diet for the first few weeks, I was hungry and I had all kinds of cravings that I fought hard. Also, for a while, I was getting tired very quickly and I couldn't do much, but I didn't have to stay in bed not even a day. I also experienced hair loss even though I was taking vitamins, which had some psychological impact. But I knew what to expect when I accepted the stomach surgery because I was informed, and I assumed those reactions. However, compared to the effects obtained with the surgery, these reactions were minor. After this first stage, I managed to get back to normal. Six weeks after the surgery, I was able to resume my physical activity normally: I started going to the gym two to three times a week. And now my mental state and the way I perceive myself have improved considerably. I feel, finally, that I am at peace with myself and that I have won the struggle with kilograms", confesses Andra.

Obesity and the risk of kidney cancer 

The incidence of obesity and obesity-related disorders, including cardiovascular diseases and type-2 diabetes, has steadily increased over the past decades in developed and developing countries, making it one of the most serious global health problems. An epidemiological link has also been established between obesity and the prevalence of several types of cancer, including breast, endometrial, esophageal, gastric, colorectal, pancreatic, liver, kidney, and gallbladder or urinary bladder cancers.

Kidney cancer is the third most common type of cancer associated with a high body mass index (BMI) and accounts for approximately 3% of cancers found in adults in Western countries. Several studies have demonstrated the bad influence of body mass index on the risk associated with kidney carcinogenesis. Statistics show that about 40% of kidney cancer cases in the US and 30% of cases diagnosed in Europe are associated with obesity. According to one of the most rigorous meta-analyses conducted to date, the risk of developing kidney cancer is directly associated with weight gain in a direct proportionality ratio of 24% for men and 34% for women for every five-fold increase in body mass index units. In other words, the risk of developing kidney cancer increases, on average, by 4% for every 20 kg more than the normal weight. (source: https://doi.org/10.4161/onci.27810)

Adipose tissue has the best representation in the human body: it is found both in the peripheral areas and around the organs, including the kidneys. It represents not only a form of long-term energy storage but also an endocrine gland that secretes hormones and cytokines, called adipokines, thus influencing hormonal balance. This partly explains the risk of developing obesity-related conditions.

Obesity hides multiple associated pathologies that, in their early stages, are not noticed based on symptoms or changes in the usual laboratory analyses. That is precisely why the pre-operative multidisciplinary assessment is of major importance in the economy of creating a customized, complete, and complex therapeutic plan. The doctors at the C Center of Excellence in Bariatric Surgery at Ponderas Academic Hospital Centrului de Excelență în Chirurgia Bariatrică din Ponderas Academic Hospital are prepared to offer surgical solutions perfectly adapted to the patient's needs and at the same time minimally invasive, through laparoscopic or robotic surgeries. The advantages deriving from this type of approach are multiple: from the accuracy and safety of the surgical act to the fast recovery, with minimal post-operative side effects, due to the small incisions, under two centimeters.

Scientific consultants: Dr. Bogdan Smeu, Surgeon of Excellence in Obesity Surgery and Dr. Andrei Nadu, urologist at Ponderas Academic Hospital