OBESITY SURGERY

What is obesity?
Obesity is a condition where there is excess fat accumulation which has adverse effect on the health and may reduce the life expectancy or increase health problems.

What are the health risks of obesity?
There are numerous risks associated with obesity which are listed below:

 
Adult Type 2 diabetes Ischemic heart disease
Hypertension (↑ BP) Obstructive sleep apnea (persistant snoring)
Osteoarthritis (chronic knee pain) Non-alcoholic steatohepatitis (NASH), NAFLD
GERD (heart burns, acidity) Metabolic syndrome (↑ cholesterol)
Social embarrassment, depression Infertility
PCOS Stress incontinence
Lower limb venous stasis Intertrigo
lymphedema Some cancers

What are the causes of obesity?
Basically there is calorie accumulation. If one start accumulating 100 Kcal extra every day in 10 years I will be 40 Kgs overweight! It is about lifestyle; as someone would say 'everyone in my family is overweight' as they all have similar dietary habits. One important cause is a sedentary daily routine which is due to a lifestyle of convenience. When we work a lot I 'exhaust' not 'exercise'. Abundance of high calorie, cheap ready to eat food (fast foods) in today's world is one significant factor. SEVERE OBESITY: The causes of morbid obesity are multiple and complex. Research has indicated that underlying cause of morbid obesity may be genetic.

How to know if one is obese?
BMI is calculated by the formula Wt (in Kgs)/Height (in mt) 2 (BMI chart, BMI calculator). Obesity is measured in several ways. ‘Body Mass Index’ is the most popular way of doing so though waist circumference is also a good measure of obesity to risk ratio. The significance of increasing weight or waist circumference is that it is directly proportional to the risk of developing diabetes, hypertension, ischemic heart disease and cerebrovascular accidents. Given below is an overview of the categories of obesity

BMI (Caucasian) Classification BMI (asian)
25 – 29.9 over weight 23 – 24.9
30 – 39.9 Obese 25 – 32.4
> 40 morbid obesity >37.5
> 35 – 39.9 + 2 Co-M morbid obesity 32.5 – 37.4 + Co-morbidities

Waist circumference too is an important indicator of risks due to obesity. Given below are the waist circumferences limits for males and females above which they are at increased risk of obesity related diseases.

Global Cms / inches Waist circumference limit Indian  Cms / inches
102 / 40 Males 90 / 35.5
88 / 35 Females 80 / 31.5

What is morbid obesity?
Obesity is termed as 'Morbid' if the BMI is >40 of if there are multiple co-morbid conditions at the BMI of 35. Morbid obesity is classified as a disease by the 'World Health Organization' which requires proper expert medical treatment.

What is the treatment of obesity?
The main stay of obesity control or weight reduction is to reduce calorie intake. Exercise helps in maintaining the weight reduction over long term. This can be achieved through control of dietary intake. It is a good idea to meet a qualified expert in nutritional sciences and follow their advice. Carefully note your daily food consumption and calculate the calories you consume. Try to reduce the calories consumed but at the same time maintain adequate intake of proteins, carbohydrates, fats, vitamins and micronutrients. The important thing to remember is that while on diet and exercise regimen one has to achieve a change in lifestyle for a long time so as to have a good sustained weight loss. Several drugs have been used to achieve weight loss but many of them were found to have side effects and are now banned. There are several drugs in experimental phase the long term outcome of which needs to be studied.

What is 'intra-gastric balloon' treatment?

What is the treatment of morbid obesity?
In extreme obesity it has been found that diet and exercise do not yield satisfactory and sustained weight loss. Morbidly obese people are unable to exercise enough due to the weight and commonly associated knee and back problems. They need assistance to achieve a diet modification and reduce calorie intake. 'Bariatric surgery' has been found to be an extremely effective technique of achieving persistent sustained weight loss in morbidly obese patients.

BARIATRIC SURGERY

What is the principle of laparoscopic 'Bariatric surgery'?
Laparoscopic Bariatric surgery is done on the stomach and small intestine. It achieves three primary goals
• ↓ food intake (restriction)
• ↑ satiety (↓hunger)
• ↓absorption of calories

What are the types of bariatric surgeries available?
The most popular and effective bariatric surgeries done are:
• Laparoscopic adjustable gastric banding
• Laparoscopic sleeve gastrectomy
• Laparoscopic gastric bypass

What is Laparoscopic adjustable gastric banding how does it work?
Laparoscopic adjustable gastric banding involves surgical placement of an inflatable silicon band on the upper part of the stomach and create a small pouch. As a person eats the food accumulates in this small pouch and gives a feeling of fullness (satiety). Due to the band below the pouch the food enters the larger part of the stomach very slowly hence giving a prolonged satiety. As a result of this mechanism the person eats very small quantity of solid food and feels full. The feeling of fullness stays for a long time till the person feels hungry again. The limitation of this technique is that the patient needs to comply very well with the doctor's advice. It is possible to 'cheat' the band by consuming high calorie liquids like ice-creams and colas. There is also the fact that a foreign body is implanted around the stomach which can sometimes create complications. It is a technically reversible procedure.

What is laparoscopic sleeve gastrectomy and how does it work?
The stomach is a large pouch with a capacity of over a litre. Laparoscopic sleeve gastrectomy (vertical sleeve gastrectomy) was first done by Marceau in 1993 involves trimming this pouch to a small tube with the capacity of about 100 ml or less. This surgery helps in restricting the food intake to less than 1/8th of the normal diet. The 'fundus' of the stomach which is responsible for the feeling of satiety and also secretes the hunger hormone 'ghrelin' is removed by this surgery, as a result there is early and prolonged satiety with delayed hunger. This surgery is done laparoscopically with endoscopic stapling device. The remnant pouch is permanently removed. It is technically irreversible procedure. Over last few years this procedure has gained tremendous popularity. It is recommended in young obese people without diabetes, hypertension or dyslipidemias and those patients who do not have severe longstanding co-morbidities associated with obesity.

What is Laparoscopic 'gastric bypass' and how does it work?
Laparoscopic gastric bypass is one of the oldest and most practiced bariatric surgeries. This surgery was developed in 1960 since then it has proven to have the best outcomes in terms of weight loss and also has shown good reversal of co-morbidities like resolution of diabetes (patient not requiring anti-diabetic medications anymore), resolution of hypertension, resolution of lipid disorders and significant reduction in risk of developing heart disease. Laparoscopic gastric bypass involves creating a small pouch of the stomach at the upper end, to this we attach a length of the intestine (intestinal bypass) so that the food and the digestive enzymes do not meet normally hence creating a partial 'mal-absorption'. The small pouch of stomach reduces the hunger and creates early satiety.

What is the nutritional effect of bariatric surgery?
After bariatric surgery a person eats a fraction of what one would normally eat. In such a case it is important to eat intelligently. The patient is counselled before the surgery and constantly monitored after surgery about what one eats. The right quantity of nutrients is needed to balance the diet after bariatric surgery. A good expert nutritional counselling and regular check up insures that the person eats the right kind of food. Also bad eating habits should be discouraged as it may give poor weight loss. Special care is taken to supplement iron, vitamins, calcium and proteins and prevent deficiencies. Care is also taken to avoid sudden rapid weight loss and prevent protein energy malnutrition.

What can be the cause for insufficient weight loss or sometimes weight regain after bariatric surgery?
If the person who has undergone bariatric does not follow the diet pattern advised by the bariatric nutritionist and resorts to consuming high calorie liquids like coke, ice creams, sweet liquid or semi-liquid food then this defeats the purpose of bariatric surgery.

What is ‘Metabolic Syndrome’?
• A large waistline.
• High triglyceride (or you’re on lipid lowering medications)
• Low level of HDL (or you’re on lipid lowering medications)
• High blood pressure (or you’re on medicine to treat high blood pressure).
• High fasting blood sugar (or you’re on medicine to treat high blood sugar).
When two or more of the above factors are present then the person is said to be suffering from ‘Metabolic Syndrome’. Obese people have a very high risk of developing metabolic syndrome. People suffering from metabolic syndrome have a significantly higher risk of developing heart diseases and Diabetes.

What is ‘Metabolic Surgery’?
Bariatric surgery which reverses diseases like Diabetes, Hypertension, Dyslipidemia (high cholesterol) is called metabolic surgery.

What are the surgeries that can reverse Metabolic Syndrome? Literally most of the bariatric surgeries have a potential to improve, cure or reverse metabolic syndrome. Some bariatric surgeries may work better than the other. In the order the surgery with least metabolic effects is the ‘Adjustable Gastric Band’ better than that is the Vertical Sleeve Gastrectomy. ‘Gastric Bypass & Mini Gastric Bypass are bariatric surgeries with excellent metabolic reversal, it means that these surgeries have extremely good cure rate for Type2 Diabetes Mellitus, Dyslipidemia, Hypertension & Ischemic heart disease. There are other surgeries like the Bilio-pancreatic diversion & Duodenal switch which work well too but have severe nutritional problems hence are not preferred as primary operations. Lately surgeries like the ‘Ileal interposition’ are being performed which are supposed to be ‘purely metabolic’ with less weight loss effect and are being done for diabetics who are not morbidly obese.

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