Obesity and Bariatric (Weight Loss) Surgery

Overview : There are 2.1 billion obese people in the world. We in India have 97 million people with obesity,out of which 25 million(6% of our total population ) are morbidly obese. Urbanisation has been implicated as the strongest risk factor for obesity in India.

The incidence of obesity in children is also on the rise as shown by school surveys in Indian cities, where nearly 30% of adolescents from India’s higher socioeconomic groups are overweight.

Technology and globalization has gifted a new kind of disease to mankind i.e. obesity and diabetes.This new disease is called “DIABESITY”. This is a great challenge to all agencies including the government, NGO’s & public at large.

Obesity : According to the National Institute of health(NIH) an increase of 20% or more of your ideal body weight is the point at which excess weight becomes a health risk. Obesity can be calculated by a parameter called BMI (body mass index). This is calculated by weight(kg) /height(m2).

Classification of Obesity:

Obesity does not come alone. It is just not a matter of looking ugly or asymmetrical, infact it is associated with number of life threatening co-morbid conditions.
Some of the common co-morbid conditions associated with obesity are:

Diabetes type2	Hypertension and heart disease
Osteoarthritis of weight bearing joints	Gastroesophageal reflux disease and heart burns
Sleep apnea and respiratory problems	Depression
Infertility	Fatty liver and hepatic lipidosis
Skin breakdown	Swollen legs and skin ulcers
Urinary stress syndrome	Menstrual irregularities
Lower extremity venous stasis	Dyslipidemia
Pulmonary embolus;	Cancer

MEDICAL TREATMENT

Most nonsurgical weight loss programs are based on combination of diet , behaviour modification and regular exercise . Unfortunately, medical treatment has proven to be effective for only a small percentage of individuals. It is estimated that less than 5%, of individuals who participate in nonsurgical weight loss program will lose a significant amount of weight and maintain that loss for a long period of time. According to NIH most people in these programs regain their weight within one year called the “yo-yo effect”.

BARIATRIC(WEIGHT LOSS) SURGERY :

Bariatric surgery has provided the longest period of sustained weight loss in patients for whom all other therapies have failed. It should be viewed first and foremost as a method for alleviating a debilitating disease. A meta-analysis of more than 22,000 patients who underwent bariatric surgical procedure showed a complete resolution or improvement of their co-morbid conditions along with weight loss .The indications for bariatric surgery are:

BMI >32.5 with atleast two co-morbid conditions
BMI > 37.5 with or without co-morbid conditions.

There are two basic approaches to bariatric surgery according to the mechanism of action.

Restrictive Procedures: It works on the principle of restricting the diet intake of the patient. The procedures are:
Gastric Banding
Sleeve Gastrectomy.

Malabsorptive Procedures: Malabsorptive procedures alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in stool. In addition to restriction , these techniques involve a bypass of the small intestine, limiting the absorption of calories. The commonly done malabsorptive procedure is Roux en Y Gastric Bypass.

All the above mentioned procedures are being done routinely by LAPAROSCOPY (key hole surgery). The advantage of laparoscopy is:
• Faster recovery with reduced post-op pain
• Minimal blood loss ,
• Short hospital stay( 3-4 days)
• Better cosmetic results
• Early return to work.( within 7-10 days)

PROCEDURES:

LAGB (Laparoscopic Adjustable Gastric Banding): Purely restrictive procedure. In this a silicone band is placed around the uppermost part of the stomach. This band is adjustable by an access port kept under the skin. The band divides the stomach into two portions: one small and one large. The small pouch gives early satiety hence patient eats very small amount of food, gets satisfied with it, and ultimately gains its goal of dieting voluntarily. This is a reversible procedure but it requires follow up in OPD for band adjustment.

Laparoscopic Sleeve Gastrectomy: Essentially a restrictive procedure. It involves cutting and stapling 75% of the stomach and leaving in place 25%(100ml) of gastric tube along the lesser curvature of the stomach. It also decreases appetite as with the removal of fundus of stomach ,the appetite stimulating Ghrelin hormone is also removed. This is an irreversible procedure but it does not require frequent followup in the OPD.

Laparoscopic Gastric By-Pass : This is a combination of restrictive and malabsorptive procedure. In this procedure a small stomach pouch(30cc) is created by stapling and then a large length of small intestine is bypassed to join with the stomach pouch. It therefore restricts the intake of food and also produces higher levels of malabsorption . Compared to the other two procedures long term weight loss is more in this procedure. It is a major surgery and therefore has more complication rate along with certain nutritional deficiencies eg. Iron deficiency, Vitamin B12 deficiency and Calcium deficiency.

Metabolic Surgery : Today bariatric surgery is also known as metabolic surgery as it treats ”DIABESITY”.i.e. diabetes and obesity. Recent evidence suggests that a small amount of weight loss reduces the effects of Type 2 diabetes, infact many patients have completely eliminated their blood sugar problems after losing a significant amount of body weight.

LIFE AFTER SURGERY:

Diet: Some of the generally accepted post surgical guidelines are:
• Chew thoroughly
• Not to drink fluids while eating.
• Omit desserts.
• Omit carbonated drinks.
• Avoid alcohol.
• Limit snacking between meals.

Going back to work: Most patients return to full presurgery levels of activity within two weeks. In conclusion surgery combined with behavioural modification, is currently the only proven method of achieving long-term weight loss for the obese.