Bariatric surgery

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Obesity

Obesity is a metabolic condition due to accumulation of excess fat in the body. It is a chronic, progressive disease which can impair the functioning of various organ systems in the body and significantly reduce life expectancy. In medical terms, a patient having BMI > 30kg/m2 is considered obese.

Body mass index (BMI) is one of the simplest ways to quantify obesity. It is calculated by dividing the weight in kilograms by the (height in meters)2.

 

       BMI=    Body weight in kg

                   (Height in meters)2

According to western data, persons with BMI> 25 kg/m2 are considered overweight and those with BMI > 30 kg/m2 are considered obese. Due to certain genetic peculiarities, Indian people show increased tendency for abdominal obesity and visceral fat deposition which makes them prone for metabolic diseases like diabetes, hypertension and dyslipidemia at lower BMI levels as compared to Western people. Hence, BMI > 23 kg/m2 is the cutoff for normal in Indian scenario and those with BMI>27kg/m2 are considered obesity

                                                                                               BMI Table

Category

       BMI

Treatment

Underweight

< 18

Supplements

Normal

18-23

----------------

Overweight

23 – 27

Diet and exercise

Obese Class 1

27-32

Obese Class 2

 

Morbid Obesity

32- 37

 

Bariatric Surgery

Obese Class 3

>37

 

Obesity is on the rise in India with approximately 5 % of the population falling in the morbidly obese category. Taking into account the total population, this figure is very high in absolute numbers amounting to more than 30 million people making India the third most obese country in the world after USA and China. This situation is much worse in the metropolitan cities with almost two thirds of the population being overweight or obese. The north Indian cities of Delhi and Chandigarh are amongst the top ranked cities in terms of obesity prevalence.

 Bariatric Surgery

These are a group of surgical procedures which help in weight loss. It is a laparoscopic surgery which involves reducing the size of the stomach or bypassing part of the intestine to decrease the intake and/or absorption of food. The surgical procedure is carried out under general anesthesia and hence it is painless. The small incisions make it cosmetically appealing and the hospital stay is usually not more than three days.

 It is different from liposuction in that there is no fat taken out from the body at the time of surgery. Rather, the restriction of food intake and metabolic changes after the surgery result in caloric deficit which causes a gradual and sustained weight loss.

It has been proved in numerous studies and meta analysis that bariatric surgery is the most effective treatment for morbid obesity and associated diseases. Though some of the procedures are surgically reversible, the weight loss incurred after the surgery is generally permanent.

Candidates

Bariatric surgery is the most effective treatment for morbid obesity and associated diseases. The persons who have BMI > 32kg/m2 with significant associated diseases or those with BMI> 37kg/m2 with or without associated problems are the ones who would greatly benefit for such a procedure.

The choice of the appropriate surgical procedure is determined by many factors including age, gender, comorbidity, diet, lifestyle choices, etc. and is finalized after detailed discussion with your bariatric surgeon.

A simple questionnaire has been prepared to help you decide whether you are a proper candidate to undergo bariatric surgery. If the answers to most/all of the questions are yes, then you qualify for bariatric surgery and can expect to significantly benefit from the procedure.

1.      Are you morbidly obese (BMI>37 kg/m2) or obese (>32 kg/m2) with significant obesity associated diseases like diabetes, heart disease, osteoarthritis, etc.?

2.      Have you tried conventional weight loss methods like diet and exercise or other alternative methods and not able to maintain your weight?

3.      Is your weight static/constantly increasing?

4.      Is your age between 18 years and 65 years?

5.      Do you understand the details of the surgical procedure proposed for you?

6.      Are you committed to lifelong changes in diet and lifestyle which are mandatory after bariatric surgery?

7.      If you suffering from stress/depression, has it been treated by a psychologist/psychiatrist?

8.      Do you have realistic expectations from your bariatric surgery and committed to long term follow up

Procedures

The different bariatric surgical procedures have undergone tremendous evolution with time. New procedures are constantly being developed and older procedures are being discarded. There are three different types of procedures – Restrictive, malabsorptive and combined

Restrictive procedures decrease the capacity of the stomach and consequently reduce the amount of food which can be taken at one time by the patient. The common procedures include sleeve gastrectomy, gastric banding and gastric plication.

Malabsorptive procedures decrease the amount of food which is absorbed through the intestine like jejunoileal bypass. These procedures are usually not performed nowadays.

Combined procedures both reduce the stomach capacity as well decrease the absorption of food by the intestine and hence result in greater weight loss. The examples of such procedures are gastric bypass and bilio pancreatic diversion with duodenal switch.

The choice of the appropriate surgical procedure is determined by many factors including age, gender, comorbidity, diet, lifestyle choices, etc and is finalized after detailed discussion with your bariatric surg

Sleeve gastrectomy

 

Sleeve gastrectomy is basically a restrictive bariatric surgery which decreases the size of the stomach. Earlier this surgery was regarded as the first stage procedure of the more complicated operation known as bilio pancreatic diversion. However, the excellent weight loss seen after this surgery together with the technical simplicity has made it the most popular bariatric operation of recent times.

The operation removes around 80% of the stomach using a specialized laparoscopic stapling gun. This staples the stomach on both sides and cuts in between which makes the procedure fast and bloodless. The volume of the stomach is reduced from initial 2000 cc to only 150 -200 cc. This markedly reduces the amount of food that can be consumed at one sitting.

 Also, removal of the stomach reduces the level of hunger hormone (ghrelin). This makes the person satiated early and helps in weight loss. The food which is consumed also passes to the intestine faster which releases hormones which increase the metabolic rate and burn the stored fat.This not only augments the weight loss but also helps in remission of metabolic diseases like diabetes.

The 5 year expected excess weight loss for this procedure is up to 70%. Although long term data beyond this period is still lacking, the results so far look prom

Laparoscopic Adjustable Gastric Banding

In this procedure, an adjustable silicon band is placed around the upper end of the stomach which helps to regulate food intake and provide a sense of satiety to the patient. There is no cutting of stomach or bypass of the intestine which makes it one of the fastest and safest bariatric procedures to perform. The amount of fluid which is present within the band can adjusted from an access port placed under the skin. Through this, the band can loosened or tightened as per the requirement of the patient and this regulates the weight loss. This also means that the patient has to periodically follow up with the bariatric surgeon which often creates difficulties for people from far off places.

Gastric plication

This is a novel bariatric procedure wherein a part of the stomach is sewn with non-absorbable sutures to reduce its size. The shape and volume of the stomach becomes similar to that seen after sleeve gastrectomy.  Although the long term data with this procedure are still not available, the short term results are quite promising. The possibility of dilation of the stomach in the long term is a concern which has curtailed the popularity of this procedure amongst surgeons. However, this is an economical option for patients who cannot afford the previously mentioned procedures since stapling guns and cartridges which increase the cost of a procedure are not used in this procedure.

Roux En Y Gastric Bypass

Gastric bypass surgery is a combined procedure which causes both restrictions of food intake as well as malabsorption. It is regarded as the gold standard bariatric procedure and was the most commonly performed bariatric surgery until recently sleeve gastrectomy took this place.   Long term data of 15 years has shown excess weight loss more than 80% along with excellent remission of comorbities.

  In this procedure, the upper part of the stomach is converted into a small pouch which decreases the amount of food which can be taken at one time. This pouch is then connected directly to the mid part of the small intestine. This new anatomy bypasses the lower part of stomach and the first part of the small intestine which delays the mixing of food with the digestive enzymes and hence results in malabsorption.

The combined effect of restriction and malabsorption results in rapid and sustained weight loss. The direct contact of food with the small intestine results in release of hormones which increase the metabolic rate and burn fat. This not only decreases body weight but also helps in remission of metabolic diseases like diabetes and hyperlipidemia.

 Mini Gastric Bypass

It is primarily a malabsorptive procedure in which a long narrow gastric tube is created and joined directly to the mid portion of the small intestine. It differs from the classical RYGB in the size of the gastric pouch which is considerably larger and the diameter of the anastomosis between the pouch and the intestine which is also wider. As a result, the patient is able to eat larger portions of food than that possible after a RYGB. The main mechanism by which this procedure works is malabsorption due to delay in the mixing of food and digestive enzymes. It also results in effective excess weight loss of up to 80% with remission of comorbid diseases

Biliopancreatic diversion with duodenal switch (BPD-DS)

This is one of the most effective weight loss procedures currently available though its popularity has declined recently. It is a combined procedure which involves creating a tube of the stomach like that for a sleeve gastrectomy and bypassing around two thirds of the total length of the intestine for malabsorption. Although still being done widely in the western world, it has not gained popularity in Asia because of the malabsorptive side effects leading to diarrhea and protein malnutrition particularly when diet is deficient in protein. It leads to 80-90% of excess weight loss with excellent resolution of comorbid illnesses.