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.

Bilio-pancreatic diversion with pancreatic switch (malabsorbtive procedure)

MS, DNB, FALS (IAGES)

Sr. Consultant GI, Laparoscopic, and Bariatric Surgery 

Chairman, Institute of Gastrointestinal Sciences,

Alchemist Hospital, Panchkula, Chandigarh Tricity 

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

Mini-Gastric Bypass

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 pain is minimized and recovery is much faster.

Laparoscopic gastric bypass roux en Y

Bariatric Surgery 

Obesity is the new pandemic. The world-over experiments are on to fight it through various forms of exercise, diets and food fads, herbs and even drugs. Bariatric surgery steps in when morbid obesity compromises lifestyle as well as health and not with the aim of just enabling you to wear a smaller size of fashion clothing.

What is Bariatric surgery?

Bariatric surgery, or weight loss surgery, is a type of procedure performed on people who are morbidly (dangerously) obese, for the purpose of losing weight. This weight loss is usually achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or bilio-pancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).

Long-term studies show the procedures cause significant long-term loss of weight, recovery from diabetes, improvement in cardiovascular risk factors, and a reduction in mortality of 23% from 40%.

Obesity is measured objectively by calculating your body mass index (BMI) using a formula

BMI = Wt in Kg / Ht in M2

To know your BMI, use the BMI calculator. 

Due to genetic tendency of Indians towards abdominal obesity and its associated risk of related lifestyle diseases the Ministry of Health & Family Welfare along with the Indian Council of Medical Research (ICMR) updated guidelines (2012) Indians   with     BMI    

      > 23 kg/m2 is considered over weight;
      > 25 is considered obese and
      > 32.5 is an indication for bariatric surgery.


What causes Obesity ?

• Energy Balance:  You gain weight when you consume more calories from food than your body uses through its normal functions (basal metabolic rate-BMR) and physical activity. The unused calories are stored as fat. You become obese if you consistently consume excess calories over a long period of time.
• Genetic or Hereditary Factors: In many cases underlying cause of morbid obesity is genetic you inherit the tendency to gain weight. Genes 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 like fast food (high in fat and low in fruits and vegetables), long sitting at desk, and suburban neighborhoods that require cars 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: We used to think of weight gain or loss as only a function of calories ingested and then burnt. But the equation isn't that simple. Obesity 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 ?

Severe 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 obese and the earlier a person become obese; the more years of life are lost.
• 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.
• High Blood Cholesterol.
• 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.
• 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 and high blood pressure and respiratory insufficiency.
• Heartburn due to gastro esophageal reflux disease (GERD) and nocturnal reflux aspiration of stomach contents into the throat and lungs, giving rise to Recurrent Bronchitis and Bronchial Asthma.
• Gallbladder Disease:  Gallbladder disease occurs several times as frequently in the obese, in part due to repeated efforts at dieting, which predispose to this problem.
• Urinary stress incontinence.
• Degenerative disease of lumbo-sacral spine (Backbone).
• Degenerative arthritis of weight bearing joints like knee and hip.
• Venous stasis in the lower extremities.
• Emotional / psychological illness:  Seriously overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends and remarks from strangers. They often experience discrimination at work. Stereotypes of the obese, such that they are assumed to be lazy, 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.

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.

You have to seriously consider the surgical option for reducing weight to avoid its ill effects:

• If your BMI is over 35.
• If 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
• If you have been unable to reduce weight or maintain weight under medically supervised program
• You have been obese for at least 5 years
• Have no history of alcohol abuse
• Do not suffer from depression or other major psychological / emotional disorder

The surgical options for obesity

Laparoscopic gastric sleeve resection (restrictive procedure)