Treatment of Obesity by Bariatric Surgery

 

WHO views obesity as the most serious public health problem of the 21st century and has labelled it as the leading preventable cause of death worldwide. Obesity is a disease in which excess body fat has accumulated to the extent that it is having a negative effect on your health, which if untreated will lead to significant morbidity and reduction in life expectancy. The problem has reached epidemic proportions in India as morbid obesity is affecting 5% of the population, which is surprising in a country where over 250 million people live below the poverty line. In a study - titled 'Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: A systematic analysis for the Global Burden of Disease Study 2013' published in the “The Lancet” in August 2014,  India is very closely following USA and China in the prevalence of obesity - a trend in most developing countries. Rising income is increasing the average caloric intake per individual among the middle class. Unhealthy processed “junk” food, alcohol and sedentary lifestyles is making one in every five Indian overweight.

The prevalence of obesity is highest in Punjabis and a recent survey by PGIMER found Chandigarh to be the obesity capital of the country with 36 % population having a BMI over 25. It is commonly caused by a combination of excessive food intake, lack of physical activity and genetic susceptibility, although a few cases are caused primarily by genetic disposition, endocrine disorders, medications or psychiatric illness.

In western countries a Body Mass Index (BMI), which is the ratio of the individual’s weight divided by the body surface area in metre² more than 25 kg/M² is considered overweight. Due to a genetic tendency of Indians towards abdominal obesity and an increased risk of lifestyle diseases like diabetes, high blood pressure, obstructive sleep apnoea, infertility, arthritis and depression, the Ministry of Health & Family Welfare along with the Indian Council of Medical Research (ICMR) updated its guidelines in 2012 and considers Indians with a BMI over 23 kg/M² as overweight; BMI over 25 is considered obese and more than 32.5 an indication for Bariatric surgery, in those with a co-morbidity such as Diabetes or high blood pressure, and in all who have a BMI more than 35. (Table 1)

Table 1.

Ministry of Health & Family Welfare along & Indian Council of Medical Research (ICMR) updated guidelines for obesity in Indians (2012)

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BMI     > 23 kg/m2 is considered over weight;

            > 25 is considered obese

            > 32.5 with a co-morbidity is an indication for bariatric surgery.

            > 35 is an indication for bariatric surgery even without any co-morbidity.

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What causes Obesity ?

    Energy Imbalance:  An individual gains weight when he / she consumes more calories than the body can use through its normal functions (basal metabolic rate or BMR) and physical activity. The unused calories are then stored as fat and the person becomes obese if he / she consistently consumes excess calories over a length of time.

    Genetic or Hereditary Factors: A very few patients inherit the tendency to gain weight. Genes may play an important role in tendency to gain excess weight. Just as some genes determine eye color or height, others affect our appetite, our ability to feel full or satisfied, our metabolism, our fat-storing ability, and even our natural activity levels.

    Environmental Factors: Environmental and genetic factors are obviously closely intertwined. Modern lifestyle and environment such as fast foods which are high in fat and low in fruits and vegetables, sedentary work and lack of regular excercise all magnify hereditary factors such as metabolism and efficient fat storage. For those suffering from morbid obesity, anything less than a total change in environment usually results in failure to reach and maintain a healthy body weight by non-operative measures.

    Metabolism: It used to be thought that weight gain or loss as only a function of calories ingested and then not burnt. But the equation isn't that simple. Researchers now talk about a theory called the "set point" - a sort of thermostat in the brain that makes people resistant to either weight gain or loss. If you try to override the set point by drastically cutting your calorie intake, your brain responds by lowering metabolism and slowing activity. You then gain back any weight you lost.

Why should morbid obesity be treated ?

Obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal bodily function. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life-threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life and can seriously shorten life, as well. The risk of developing these medical problems is proportional to the degree of obesity. People who are obese do not live as long as those who are not, and the earlier a person become obese; the shorter his life span becomes.

Common complications of obesity

·         Heart disease:  Severely obese persons are approximately 6 times as likely to develop heart disease as compared to those with a normal weight. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life which it shortens their lives.

·         High Blood Pressure (Hypertension) is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes and kidney damage.

·         Diabetes Mellitus: Overweight persons are 40 times as likely to develop type-2, (adult onset) diabetes. Once diabetes occurs, it becomes even harder to lose weight because of hormonal changes which cause the body to store fat even more than before.

·         Deranged lipid profile adds to the damage to blood vessels caused by diabetes and high blood pressure ads to the incidence of heart disease and brain stroke.

·         Obstructive Sleep Apnea (OSA):  Apnea, which means repeated failure of breathing during sleep, is common in the obese because of compression of the air passage by fat, gives rise to headaches, feeling of dullness, repeatedly dozing off during the day, high blood pressure and respiratory insufficiency.

·         Gastro esophageal reflux disease (GERD) and nocturnal reflux aspiration of stomach contents into the throat cause heartburn due and recurrent bronchitis and bronchial asthma.

·         Non-alcoholic steato-hepatitis (NASH) due to fatty infiltration of the liver is a precursor of liver failure.

·         Gallstone Disease occurs several times frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem.

·         Sub - fertility due to polycystic ovarian disease (PCOD) and low sperm count are commonly seen in the morbidly obese

·         Degenerative disease of lumbo-sacral spine (backbone) leads to persistent back ache and sciatica.

·         Degenerative arthritis of weight bearing joints like knee and hip occur in the early age, leading to inability to exercise and thus starts a vicious downward spiral of progressive weight gain.

·         Venous stasis in the lower extremities leads to deep vein thrombosis, swelling and discoloration of the ankles and feet

·         Emotional / psychological illness:  Seriously overweight persons face constant challenges to their emotions due to repeated failure with dieting, disapproval from family and friends and remarks from strangers. They often experience discrimination at work, such that they are assumed to be lazy which results in low self - esteem and poor body image. Anxiety and depression might accompany years of suffering from the effects of a genetic condition, which skinny people believe could be controlled easily by will power.

Bariatric (weight-loss) Surgery

The world-over experiments are on to fight obesity by various forms of exercise, diets and food fads, herbs and even drugs. Bariatric surgery is advised when morbid obesity compromises lifestyle as well as health. Patients usually come for surgery having tried all kinds of weight loss regimens, packages and diets and having experienced a number of rebound weight gains after some weight loss, also known as the “yo-yo” phenomenon, due to the extreme difficulty experienced in sticking to a rigid diet for any length of time.

Bariatric surgery alters the digestive system to help people lose weight at an average rate of one to three Kg per week (depending upon the procedure performed) thus significantly reducing all the related health issues. This weight loss is achieved by reducing the size of the stomach by removal of a portion of the stomach (sleeve gastrectomy or bilio-pancreatic diversion with duodenal switch) or by re-routing the small intestines to a small stomach pouch (gastric bypass surgery).This surgery is very different from liposuction, as no fat is removed during the operation. The fat is lost by the patient by adhering to a diet and undertaking regular exercise. The alteration made in the digestive tract makes it easier for the individual to follow the dietary advice, as appetite is reduced and a small amount of food gives the patient a sensation of satiety and fullness, besides which, after a bypass surgery even if the individual defaults on his prescribed diets a significant amount of nutrients are not absorbed preventing weight regain. Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes and high blood pressure, alleviation of obstructive sleep apnoea, reduction in cardiovascular risk factors and a very significant overall reduction in morbidity and mortality.

Who should get the surgery done?

Limited success has been achieved with a variety of non-surgical approaches including medically supervised dieting. Diet alone cannot be considered a reasonable option for permanent weight loss surgery. Drug therapy for clinically severe obesity has been disappointing.

It is recommended to seriously consider the surgical option for reducing weight to avoid its ill effects if :-

·         Your BMI is over 35.

·         Your BMI is 32.5 or higher and you have a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity

·         You have been unable to reduce weight or maintain weight under medically supervised program

·         You have been obese for at least 5 years

       However, you should not have a history of alcohol abuse or suffer from depression or other major psychological / emotional disorder

Surgical options

Laparoscopic gastric sleeve resection which is purely a restrictive procedure is a very popular operation in which the size of the stomach is reduced from a bag to a tube leaving a small pouch near its lower end, where only about 50 ml of food or drink can be held. There is no change in the way that food passes through the intestine. However it is not reversible as the resected portion of the stomach is removed from the body.

​​​​The other commonly done procedure is the Gastric Bypass (Roux-en-Y / Mini) where a small pouch or tube is separated from the stomach and anastomosed to the small intestine after bypassing a certain variable length of bowel. It is thus a restrictive cum malabsorbtive procedure. The advantage in this procedure is that the weight loss is faster and more sustained and it is theoretically reversible, however a closer watch needs to be kept on dietary supplements because of the malabsorbtive element lest the patient develop serious deficiencies of proteins, vitamins and minerals.

Roux en Y Gastric Bypass

Bilio-pancreatic diversion with pancreatic switch (a predominantly malabsorbtive procedure)

Prehabilitation

The patient goes through a protocol based preoperative preparation, which includes a detailed evaluation by an endocrinologist, psychological counsellor, getting clearances from the Cardiologist and Respiratory physician during the pre-anaesthetic assessment. He / she is also counselled by the dietician to follow a very low carbohydrate high protein diet to be used for two weeks prior to the operation to reduce the size of the liver and get used to the kind of diet to be followed after the procedure. The individual’s cardio-respiratory condition and diabetic status is optimised to minimise the chances of complications after surgery. Injectable anti-coagulants (blood thinners) are started 4 hours prior to the operation.

Minimal access surgery

All the above shown operations are done by laparoscopic technique, in which 5 small incisions are given and specially designed ports used to insert a telescope behind which a camera is attached. The camera sends the real time image to a high resolution monitor. Using this magnified vision the surgery is done using specialized delicate instruments and staplers. Thus the post-operative discomfort is minimized and recovery much faster. The patient is ambulant by the evening of surgery and can start oral fluids after 48 hours, go home in three to four days, resume work in 10 days and consume normal home cooked food in 3 – 4 weeks.

 

Ports used for Laparoscopic Bariatric Surgery - (12 mm x 3/4 ports & 5mm x 1/2 ports)

Summary

Weight reduction surgery is not for all over-weight people. It offers an alternative to those who are unable to maintain weight loss through dieting. But it is very important to know that to maintain weight loss after surgery, you still have to eat less food, change the type of food you eat and increase physical activity. Weight reduction surgery helps you in changing your food behavior by giving early satiety after a small meal and providing prolonged feeling of fullness so that you can adhere to the dietary control. Three to five days admission to the hospital is all that is required before you can embark upon an exciting journey of progressive and sustained weight loss at the rate of one to three Kg per week for the next two years, to regain your health and self-confidence after reaching your ideal weight. Some dietary supplements like proteins, calcium, iron and vitamins are required to be taken life long, a small price to pay when you consider the benefits of being off insulin and blood pressure medicines and being able to slip into your favourite old pair of jeans!

 

Some very satisfied patients after bariatric surgery at Alchemist Hospital, Panchkula.