Laparoscopic Bariatric (Anti-Obesity) Surgery

          Before

Obesity essentially means an abnormal accumulation of fat in the body associated with increased risk of illness, disability and death.

Due to changes in socioeconomic conditions, changes in diet and increasing sedentary lifestyle, obesity has reached epidemic proportions in developed countries like USA. In India too obesity has increased exponentially; specially in urban areas.

Morbid obesity is an advanced state of obesity which is associated with life threatening and serious disorders like diabetes, high blood pressure, heart disease, sleep apnoea etc. It is associated with an increase in body weight which is at least two times the ideal body weight.

Studies have shown that sustained weight loss is very difficult to maintain with diet or exercise alone. The most successful method for achieving weight loss and maintaining it long term has been shown to be special surgery called bariatric surgery or surgery for obesity.

Anti obesity surgery not only results in consistent weight loss but also has additional benefits of either reducing the medication needed for associated diseases like diabetes, high blood pressure, reflux disease, sleep apnoea etc or improving them to such an extent that there is no need for further medication.

Obesity is also defined and graded in more mathematical terms by an index called Body Mass Index or BMI.

BMI of a person = Weight in kilograms (KG) /(Height in meters)2

Due to the differences in the distribution of fat and muscle mass; the definitions of obesity and indications for surgery as per BMI differ in Asians (including Indians) and Caucasians.

Definitions in Indians (Asians)
Overweight: BMI > 23
Obese: BMI > 28
Indications for Bariatric ( Weight Loss) Surgery in Indians (Asians):
BMI > 37 without any co-morbidity like diabetes, hypertension, reflux disease etc
BMI > 32.5 with presence of a co-morbidity like diabetes, hypertension, reflux disease etc

Definitions in Caucasians
Overweight: BMI > 25
Obese: BMI > 30
Indications for Bariatric (Weight Loss) Surgery in Caucasians:
BMI > 40 without any co-morbidity like diabetes, hypertension, reflux disease etc
BMI > 35 with presence of a co-morbidity like diabetes, hypertension, reflux disease etc

Types of Surgical Procedures for treating Obesity

There have been many procedures devised for treating obesity.

In India the two most common procedures used for treating obesity are;

Laparoscopic Sleeve Gastrectomy:

This involves the removal of almost 75% of the stomach and leaving behind 25% of the stomach as a tube. The procedure is carried out Laparoscopically ie. using very small incisions and minimally invasive techniques. This results in small incisions and early recovery from surgery.

The small capacity of the residual stomach results in early satiety and low food intake.

In addition the portion of stomach that has been removed contains Gherlin secreting cells.

Gherlin is a hormone that stimulates appetite. Its removal leads to decrease in appetite and thus less intake of food and weight loss.

Initially, this procedure was used as a first step in treatment for super-obese patients. However, studies have shown it to be very effective as a stand alone procedure.

Almost 40% to 60 % of excess weight is lost by this method in one year.

Laparoscopic gastric bypass

This involves division of stomach to form a small pouch and bypassing this from the rest of the stomach and a long portion of small intestine before rejoining it to small intestine.

It is a restrictive and malabsorptive procedure.It is more used in superobese patients with very high BMI of 55 – 60 or greater.

This procedure too is carried out by the Laparoscopic method.

As mentioned , Bariatric surgery results in beneficial side effects like improvement / eradication of chronic diseases like Diabetes, Hypertension, Reflux disease Ischaemic heart disease, Hypelipidaemia, Sleep apnoea. This has resulted in surgery being considered for the treatment of these diseases and the development of a new branch called Metabolic Surgery.

In the future, it may be possible to use this type of surgery for cure of such chronic diseases even in patients with normal weight. Results from research studies are awaited.

STEPS IN UNDERGOING BARIATRIC SURGERY

You will first meet with the Surgeon who will be conducting the surgery and will be taking overall care. During this consultation, the indications for surgery, the appropriate surgery for you and the pros and cons will be discussed.

Blood tests like, Complete blood count, Liver function tests, Kidney fuction tests, Blood sugar (Fasting/Post meal),Thyroid function test, Serum Cortisol,Coagulation Profile, Serum Calcium are done.

ECG and Ultrasound scan of the abdomen is done If needed, CT scan of abdomen ,Doppler scan of leg veins is carried out.

You will then be seen by the Anaesthetist who will assess the risk for anaesthesia. If needed further tests like an Echocardiogram, Pulmonary Function Tests and consultations from Cardiologist, Physician and Endocrinologist are arranged.

Once fitness for surgery /anaesthesia has been assessed, a date for surgery is decided upon.

You are then seen by a Dietician who advises you on a low calorie, high protein diet. The more weight you lose before surgery, the better the outcome. At least 1 week prior to surgery, the dietician will start you on a complete liquid diet low on calories. This results in decrease in size of liver which reduces surgical risk.

A consultation with a Clinical Psychologist is carried out to assess your understanding, readiness and commitment for the operation and also to give you psychological support during and after surgery. An upper GI endoscopy is carried out prior to surgery to look for reflux disease, gastritis

Once surgery is successfully over, patient is discharged between 2 to 5 days.

Post-operative diet: Clear liquids are taken for 6-10 days, followed by liquid diet for 6-10 days and then soft diet for further 10 days .Normal diet therefore starts about a month after surgery. Small meals, avoiding fried and high calorie food helps achieve the targets.

Approximately 40 % to 60 % of excess weight is lost in a year’s time.

For those patients keen for pregnancy; it is advisable to wait for one year after surgery.

Regular follow up with the Surgeon and other specialists is arranged to monitor special dietary and medication requirements.

It is a team effort and the patient himself/herself is part of the team which ensures a successful and satisfying outcome for all concerned.

Obesity essentially means an abnormal accumulation of fat in the body associated with increased risk of illness, disability and death.

Due to changes in socioeconomic conditions, changes in diet and increasing sedentary lifestyle, obesity has reached epidemic proportions in developed countries like USA. In India too obesity has increased exponentially; specially in urban areas.

Morbid obesity is an advanced state of obesity which is associated with life threatening and serious disorders like diabetes, high blood pressure, heart disease, sleep apnoea etc. It is associated with an increase in body weight which is at least two times the ideal body weight.

Studies have shown that sustained weight loss is very difficult to maintain with diet or exercise alone. The most successful method for achieving weight loss and maintaining it long term has been shown to be special surgery called bariatric surgery or surgery for obesity.

Anti obesity surgery not only results in consistent weight loss but also has additional benefits of either reducing the medication needed for associated diseases like diabetes, high blood pressure, reflux disease, sleep apnoea etc or actually curing them completely without need for further medication.