Uncategorized · December 22, 2020

Obesity/ Bariatric / Weight Loss surgery – What , How & When?

Dr. Tarun Mittal

MBBS, MS, FACS, FNB, FMAS, FIAGES, FAIS, FALS, FCLS.

Dr. Tarun has a total of 13 years of experience and he is currently practicing as a laparoscopic, bariatric, robotic surgeon at Sir Ganga Ram Hospital, New Delhi. His areas of interest include Laparoscopic- Bariatric, Hernia, and Hepatobiliary surgeries.

 

Obesity is a medical condition in which excess body fat has accumulated to the extent that it may have an adverse effect on health, leading to reduced life expectancy and/or increased health problems. Obesity is defined when the body mass index of an individual is >30.

Trends of Obesity & DM in India
• In India, currently more than 62 million individuals are diabetic.
• It is predicted that by 2030, diabetes mellitus may affect up to 79.4 million individuals in India.
• 12.1% of males and 16% of females are obese in India.

Body Mass Index (BMI) is a measurement that compares weight and height, defines people as normal weight, overweight or obese. The BMI is a statistical measurement derived from height and weight.

BMI = Weight (in Kg) / (Height) 2(in Meters)

BMIClassification
<18.5Under Weight
18.5 – 22.9Normal Weight
23.0 – 29.9Over Weight
30 – 34.9Class I Obesity
35 – 39.9Class II Obesity
More than 40Morbid Obesity

Being overweight dramatically increases the chances of suffering a serious health problem in the near future (sometimes referred to as an obesity-related disease). Obese people are more likely to develop heartburn and reflux disorders, high blood pressure, diabetes, arthritis, snore, and suffer sleep disorders, fatty liver disease, menstrual irregularities, and infertility. Some cancers including prostate, breast, cervix, and ovarian cancer are commoner in obese individuals. Also, they are more likely to suffer depression and adjustment problems in society. Due to the constant discrimination, they face at their workplace, among friends, and snide remarks within the family and even from strangers. Treatment of obesity would confer improved quality of life and improvement in self-confidence, self-esteem, and positive body image that would have a tremendous impact on one’s lifestyle. The life expectancy of an obese individual is much shorter than that of a normal weight person – the more obese you are, the more risk you have of dying at an earlier age.

The important thing to realize is that obesity, beyond a certain BMI, results in an innate inability to be controlled by drugs, diet, and exercise. Efforts to treat morbid obesity through controlled diet, behavior modification, and exercise program are only temporarily successful with patients invariably regaining the weight even more than the amount lost. Obesity surgery is the only method by which long term weight loss can be achieved in these patients. Currently, a number of clinical trials are being conducted worldwide to reduce the lower limit of the current indications, particularly for the Asian population. This is because it is seen that the Asian population is susceptible to the cluster of abnormalities called ‘metabolic syndrome’ in a relatively lower BMI group than their western counterparts.

Obesity is a potent risk factor for the development and progression of type II diabetes, and weight loss is a key component of diabetes management. Obesity surgery results in significant weight loss and remission of diabetes in most patients. After surgery, glycemic control is restored by a combination of enforced caloric restriction, enhanced insulin sensitivity, and increased insulin secretion.

Medical Conditions that may be greatly improved after surgery includes:

High blood pressure: At least 70% of patients who have high blood pressure, and who are taking medications to control it, are able to stop all medications and have normal blood pressure, usually within two to three months after surgery. When medications are still required, their dosage can be lowered, with a reduction of the annoying side effects.

High cholesterol: More than 80% of patients will develop normal cholesterol levels within two to three months after the operation.
Heart disease: Although we can’t say definitively that the incidence of heart disease is reduced, however, the improvement in problems such as high blood pressure, high cholesterol, and diabetes certainly suggests that improvement in heart disease risk is very likely. In one recent study, the risk of death from cardiovascular disease was profoundly reduced in diabetic patients who are particularly susceptible to this problem. It may be many years before further proof exists since there is no easy and safe test for heart disease.

Diabetes Mellitus: more than 90% of Type II diabetics obtain excellent results, usually within a few weeks after surgery: normal blood sugar levels, normal hemoglobin (HbA1c) values, and freedom from all their medications, including insulin injections. Based on numerous studies of diabetes and the control of its complications, it is likely that the problems associated with diabetes will slow in their progression when blood sugar is maintained at normal values. There is no medical treatment for diabetes that can achieve as complete and profound an effect as obesity surgery – which has led some physicians to suggest that surgery may be the best treatment for diabetes. In the seriously obese patients, abnormal glucose tolerance, or “borderline diabetes”, is even more reliably reversed by gastric bypass. Since this condition becomes diabetes in many cases, the operation can frequently prevent diabetes as well.

Asthma: Most asthmatics find that they have fewer and less severe attacks, or sometimes none at all. When asthma is associated with gastroesophageal reflux disease, it is particularly benefitted by gastric bypass.
Respiratory insufficiency: Improvement of exercise tolerance and breathing ability usually occurs within the first few months after surgery. Often patients who have barely been able to walk find that they are able to participate in family activities, and even sports.
Sleep apnea syndrome: Dramatic relief of sleep apnea occurs as our patients lose weight. Many reports that within a year of surgery, their symptoms were completely gone, and they had even stopped snoring completely and their spouses agree. Many patients who require an accessory breathing apparatus to treat sleep apnea no longer need it after surgically induced weight loss.

Gastroesophageal reflux disease: Relief of all symptoms of reflux usually occurs within a few days of surgery for nearly all patients. We are now beginning a study to determine if the changes in the esophageal lining membrane, called Barett’s esophagus, may be reversed by the surgery as well-thereby reducing the risk of esophageal cancer.

Gallbladder disease: When gallbladder disease is present at the time of surgery, it is “cured” by removing the gallbladder during the operation. If the gallbladder is not removed, there is some increase in the risk of developing gallstones after the surgery, and occasionally, removal of the gallbladder may be necessary at a later time.

Stress urinary incontinence: This condition responds dramatically to weight loss and usually becomes completely controlled. A person who is still troubled by incontinence can choose to have specific corrective surgery later, with a much greater chance of a successful outcome with reduced body weight.

Low back pain, degenerative disk disease, and degenerative joint disease: Patients usually experience considerable relief of pain and disability from degenerative arthritis and disk disease and from pain in the weight-bearing joints. This tends to occur early, with the first 15-25 kgs lost, usually within a few months after surgery. If there is nerve irritation or structural damage already present, it may not be reversed by weight loss, and some pain may persist.

Indications for bariatric surgery in patients with obesity

• In candidates with a BMI ≥35 kg/m2 in the presence of obesity-related co-morbidities (Hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea).
• Whereas in India, Obese patients with a BMI > 32kg/m2 and any of two significant obesity-related co-morbidities (Hypertension, impaired glucose tolerance, diabetes mellitus, hyperlipidemia, and obstructive sleep apnea).
• A BMI of 30 kg/m2 may be considered in the presence of T2DM that is not adequately responding to optimal medical treatment.

Obesity surgery works by helping to reduce the number of calories that are available in the body. There are three ways this can be achieved surgically:

 

 

Restrictive – by reducing the size of the stomach, only small meals can be eaten and the appetite is satisfied. The most commonly performed surgery is the Laparoscopic Sleeve Gastrectomy.

 

 

 

Majorly mal-absorptive, as well as restrictive – by bypassing part of the small intestine, fewer calories from food are absorbed by the body. An example is a Mini-gastric bypass.

 

 

 

 

 

Majorly restrictive, as well as mal-absorptive, is RYGB (Roux en Y gastric bypass surgery).

 

 

 

 

After bariatric surgery, patients lose more weight than with traditional weight-loss methods—up to 25% of their total body weight. Furthermore, of those with type II diabetes, 87% achieve at least better glucose control and need fewer anti-diabetic medications, 12 and an average of 78% achieve normal glycemic control without taking any anti-diabetic medications at all.

Benefits of Bariatric Surgery

What are the risks of bariatric surgery?

As with any surgical procedure, there are few risks and complications associated with bariatric surgery. The more extensive the bypass operation, the greater is the risk for complications and nutritional deficiencies. Patients with extensive bypasses of the normal digestive process require not only close monitoring but also may require the use of special foods and medications. Five to ten percent of patients who have weight-loss operations require follow-up operations to correct complications. Abdominal hernias are the most common complications requiring follow-up surgery.

Rare complications of gastric bypass surgery include leak through staples or sutures, ulcers in the stomach or small intestine, blood clots in the lungs or legs, (it is hence important for all our patients to strictly adhere to the compression stockings and LMWH therapy as advised postoperatively) stretching of the pouch or esophagus, persistent vomiting and abdominal pain, inflammation of the gallbladder, and failure to lose weight (very rare).

Up to 30 percent of patients who have weight-loss surgery may develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intakes are maintained – a close follow up with our nutritionist is thus emphasized. Women of childbearing age should avoid pregnancy for 12-15 months until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus.

Though gastric bypass procedures can be reversed, patients should carefully consider all of the risks and benefits before electing to have this surgery.

It is important to understand that after bariatric surgery it is important for the patients to maintain a healthy lifestyle and follow the advice of the bariatric surgeons religiously. This will lead to better outcomes and also avoid most of the complications.

This information is for general guidance and reflects the opinions and experience of the author. It is not intended to replace specialist consultation or provide treatment advice for specific cases.