Bariatric, Obesity and Metabolic Surgery

What is Obesity?

Obesity is the excessive accumulation of fat that exceeds the body's skeletal and physical standards.The National Institute of Health (NIH) states that excessive weight becomes a health hazard when it is 20 percent or more above ideal body weight. Patient with serious health risk are susceptible to serious diseases like heart disease, respiratory diseases or even infertility.It can result in either significant physical disability or even death.

Causes of Obesity:

Obesity can be caused due to various reasons like changed lifestyles, energy dense diets, low level of physical activity, environmental factors, heredity, psychological and cultural influences and many others

• Heredity : Genes may increase vulnerability to obesity
• Metabolic Factors : Obesity is directly linked to a slow metabolism or reduced metabolic activity
• Endocrinological factors : This is a rare occurrence and contributes to less than 1% of all weight gain in the world.
• Hypothyroidism : Hypogonadism in men and Polycystic Ovarian Syndrome in women are closely associated with obesity
• Medication :
  Certain drugs may contribute to weight gain, such as corticosteroids, sulfonylureas for diabetes, steroidal contraceptives and anticonvulsants such as valproate used in epileptic therapy. Antipsychotics, antidepressants, mood stabilizers like lithium are medicines that have weight gain as a side effect.
• Psychological Factors :
  Though psychological factors play a minor role in the development of obesity, they are important in relation to responses to treatment. For example, many patients reduce depressive symptoms by eating. These people may gain weight with one episode of depression and increase it with the next. Further, concepts of dietary restraints, body image dissatisfaction and binge eating disorders have been intimately linked to the increase in obesity
• Dietary Factors :
  An increase in caloric intake, changes in lifestyle, food systems and increased portion sizes, eating out frequently also leads to increased calorie intakes as one meal served in restaurants and fast food outlets exceeds a person's caloric needs for the entire day.

Health Risk

Mortality :

Research shows that excessive body weight is linked to overall health and susceptibility to chronic ailments. It has been proven that a BMI beyond 30 kg/m2, increases the risk of cardiovascular death, heart attack and diabetes, even after adjusting for age, smoking, social class, alcohol consumption and physical activity. Studies show that non smoking overweight men and women lose 3.1 and 3.3 years of life respectively, as compared to normal weight non smokers. These studies have also established that weight fluctuations increase the risk of death.

Coronary heart disease is the major cause of weight-related death followed by diabetes mellitus, Liver diseases and cancer. Evidence suggests that women can reduce mortality rate by 25% in diabetic, cardiovascular and cancer conditions by achieving a weight loss of 9 kgs. However if an obese person has already developed an associated co-morbidity, then planned weight loss of any amount has been reported to reduce mortality by 20%. It has also been established the risk of mortality is greater in younger patients suffering from obesity as compared to older ones.

Morbidity :

Obesity is associated with chronic diseases such as heart disease, Type 2 diabetes, hypertension, stroke, gallbladder disease, sleep apnoea, certain cancers and osteoarthritis. These chronic ailments tend to worsen with increasing degree of obesity. Non alcoholic fatty liver disease which may progress to end-stage liver disease is now also being recognized as a consequence of obesity. Obesity may also lead to poor wound healing and poor antibody response.

Regional Distribution of fat & Health Risk :

There are two type of Obesity

1. Android or apple-shape obesity
2. Gynoid or pear-shape obesity

This fat distribution is determined genetically and varies among men and women. Android obesity is more common among males whereas females are more susceptible to gynoid obesity. While in case of gynoid obesity it is more difficult to shed weight, the android obesity is linked to chronic ailments such as glucose intolerance, insulin resistance, hyperlipidemia and hypertension. This type of obesity is also closely associated with the development of metabolic syndrome (a complex of unified conditions like glucose intolerance, high blood pressure and alterations in serum lipids).

Assessing the Risk Factor :

BMI

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

Grade 1 to Grade 3 Obesity is applicable to all age groups (Source: World Health Organizations)

WAIST

NORMAL WAIST / HIP RATIO < 1.0 in Males < 0.8 in Females

Is Surgery for me?

• Presence of serious sequelae of morbid obesity
• 30 kg overweight or a BMI> 33 kg/m2 for more than 5 years with at least one co-morbidity (ASIA PACIFIC GUIDELINES)
• BMI > 37 with or without co-morbidities
• Failure of sustained weight loss on supervised dietary and conservative approaches (OR Multiple unsuccessful attempts at Weight loss with non-surgical methods)
• Absence of an endocrine cause
• Acceptable operative risk
• Compulsive eaters
• Educated, compliant patient. Demonstrate willingness to maintaining dietary guidelines and other follow-up care.
• Have support from family, spouse, or close friends.
• Surgery is not recommended for the mentally ill or impaired, patients known to abuse alcohol or drugs, or those with an eating disorder such as bulimia.

If the answer to the above is yes, then you should be seeking the opinion of our Bariatric expert.

Obesity Surgery

A. Restrictive Procedures: The Lap Gastric band

Restrictive weight loss surgery works by reducing the amount of food consumed at one time. The theory is simple; due to the restriction created, you feel satiated with small amounts of food and because of a smaller outlet, food stays in the stomach for a longer time. The net result is - a reduction in daily caloric intake without a feeling of deprivation.

The Procedure
Entails laparoscopic implantation of a Silastic band around the stomach just below the gastro-esophageal junction to section off a small portion called as stomach pouch creating an hour-glass effect. A small outlet, about the size of a pencil eraser, is left at the bottom of the stomach pouch.

B. Combined procedures: Roux -En- Y Gastric Bypass

Procedures that alter digestion are known as malabsorptive procedures. Malabsorptive techniques reduce the length of intestine that comes in contact with food so that the body absorbs fewer calories. In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is completely stapled shut and divided from the stomach pouch. It is not completely removed. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, called the Roux limb, thus eliminating the duodenum and a small portion of the jejunum from the absorptive circuit. The omitted segment is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be adjusted to produce lower or higher levels of malabsorption.

Risks

• The duodenum being bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia.
• A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
• A condition known as "dumping syndrome" can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
• Metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones.
• All the above listed deficiencies can be easily managed through a proper diet and vitamin and calcium supplements. It is mandatory for patients undergoing gastric bypass to consume a multivitamin and calcium supplement daily.

Why Choose Our Center?

Our Bariatric Surgeon, Dr Jayasshree Todkar, is a highly skilled and world renowned surgeon. She is a speaker and faculty member for live demonstrations of the advanced laparoscopic and bariatric operations, at multiple International and national conferences. She performs minimally invasive or key hole surgery techniques, with very high success rates and low complication and mortality rates.
Our centre is easily accessible in the metro city of Mumbai with availability of experienced team of doctors round the clock. Our center is the first in India and the Indian subcontinent to start training surgeons and multidisciplinary members in the field of Obesity surgery.

Importance of Support

Obesity and it treatment requires tremendous support. Unlike what most people think, obesity is not caused by over-eating or eating disorders. It is a chronic disease, the causes of which may vary. People suffering from obesity may suffer from severe depression as well and need tremendous support from their loved ones. What one needs to understand is that the first step towards any kind of remedy is fraught with many unexpressed fears and tensions – the support of friends and family is of incalculable help at such times.

Diseases Related to Morbid Obesity

Cardiovascular

• Essential hypertension
• Myocardial infarction, hypertension and congestive heart failure
• Fatal or non-fatal myocardial infarction
• Risk of coronary heart disease

With every 1 kg of weight loss, there is a corresponding reduction by about 1% in total cholesterol and LDL and a rise by 1% in HDL and a 3% decrease in triglycerides.

Metabolic Syndrome

• Central adiposity is also more closely associated with the development of metabolic syndrome than the absolute degree of fatness.
• Prevalence of diabetes mellitus and cardiovascular disease.

Pulmonary

• Obesity hypoventilation syndrome (OHS)
• Obstructive sleep apnoea syndrome (SAS)

Liver Diseases

• Fatty liver
• GERD - Gastroesophageal reflux disease

Cancer

• Colorectal cancer
• Endometrial cancer

Childhood Obesity

Since well before the COVID-19 pandemic started, the world has been facing the global epidemic of obesity since the decade of 1990. This owes to highly sedentary lifestyle, and easy availability of high calorie foods.

During the pandemic of COVID-19 it has been globally noticed that morbidity and mortality was significantly higher in patients suffering from obesity and diabetes. Lockdowns restricted movement, social distancing and work/learn from home seem to worsen obesity indices across the middle class and higher socio-economic groups.

The children and adolescents have suffered the most: We are observing minimum 10% to maximum 80% rise in the weight of children and adolescents in the last 2 years. This partly owes to non-availability of playground/sports complex/opportunity to mingle with friends and thereby decrease in physical activity combined with increased screen time and junk food intake. This has unveiled genetically predisposed diabesity. (combination of obesity and diabetes) in children and adolescents.

Patients present with

1. Weight gain
2. Central obesity
3. PCOD and Hirsutism in girls
4. Gynecomastia and less facial hair in boys
5. Hypertensive tendencies

It is important to monitor weight, waist circumference, signs of fatigue and signs of hypogonadism in this age group before they land up in long lasting impact of obesity on various organs of the body. Up to the BMI of 30 kg/m2, dietary modifications and physical activity can reverse the disease of obesity. A Rising BMI shifts the control from the voluntary factors to involuntary factors and creates impairment of various organ functions like heart lung, liver, kidney, skeletal and endocrine system during these age groups.

After the BMI of 35 kg/m2 many of the organs get a near permanent function damage. In this situation bariatric surgery can save the patient from severe diseases with long-term impact.

Severe obesity affects the health and well-being of millions of children and adolescents in the India and is widely considered to be an "epidemic within an epidemic" that poses a major public health crisis.

The outcome of bariatric surgery in type 2 diabetes

Efficacy: The benefits of surgery are compelling, and its recipients are among the most grateful patients you will encounter. Weight - reducing surgery does more than reduce weight. It offers psychological benefits and reduces blood pressure, lipids and blood glucose, and the need for these to be treated. Deaths from cardiovascular disease and cancer are reduced, and many of the secondary consequences of obesity, such as fatty liver, musculoskeletal disorders. Intracranialhypertension, sleep apnea and infertility are ameliorated. Not surprisingly, long - term health costs are also likely to fall, including those associated with diabetes. A study of more than 22,000 patients showed that obesity surgery leads to the disappearance or improvement of medical problems such as type 2 diabetes, high cholesterol, high blood pressure and obstructive sleep apnea.

Safety: Bariatric surgery is safe in the hands of experienced surgeons. One meta - analysis revealed a 30 - day mortality of 0.1 % after gastric banding. 0.5 % after gastric bypass and 1.1 % after bilio pancreatic diversion. The short term operative mortality for low risk patients attending centers with experienced surgical teams is around 1 / 2,000 . Short term complications after surgery are venous thrombo - embolism and cardiovascular events. Venous thromboembolism affected 0.3 % of banding patients and 0.4 % of laparoscopic gastric bypass patients in a large survey from US .

Healthcare cost savings: The evidence for cost effectiveness of surgically induced weight loss is compelling. During the last five years papers have been published from all over the world where the conclusions are that bariatric surgery saves money spent on health care. Keating et al conducted a within trial where they compared the cost - effectiveness of surgical therapy with conventional therapy in obese patients with Type II Diabetes. They found strictly from a cost perspective (Disregarding quality of life and life expectancy benefits of Diabetes remission) that after 10 yrs. the return of investment of surgical therapy is fully recovered through savings in health care costs to treat Type II Diabetes.

Improvement in Quality of life : Weight reduction in the severely obese is accompanied by improvements in health - related quality of life ( HRQL ) and some studies indicate that a dose - response relationship exist between the magnitude of weight loss and HRQL benefits . In the Swedish obese subjects (SOS) intervention study they followed 655 surgically treated patients for 10 years and compared them with a group of conventionally treated obese patients. They concluded that the change in HRQL followed the phases of weight loss, weight gain and weight stability. But they also found that a maintained weight loss of 10 % is sufficient for positive long term effects on HRQL. The surgically treated patients who completed 10 years of the study easily achieve this.

• What is the youngest age for which weight loss surgery is recommended?
  Generally accepted guidelines from the American Society for Bariatric Surgery and the National Institutes of Health indicate surgery only for those 18 years of age and older. Surgery has been performed on patients in their teens. There is a real concern that young patients may not have reached full developmental or emotional maturity to make this type of decision. It is important that young weight loss surgery patients have a full understanding of the lifelong commitment to the altered eating and lifestyle changes necessary for success.
• What is the oldest patient for whom weight loss surgery is recommended?
  For Patients over 65 years of age need to evaluate the fitness of the patient to undergo surgery.
• Can Weight Loss Surgery prolong my life?
  Yes
• Can weight loss surgery help other physical conditions?
  At one year after successful bariatric surgery, 96% of obesity related medical conditions are either completely resolved or significantly improved.
• What are the routine tests before surgery?
  Certain basic tests are done prior to surgery: a Complete Blood Count (CBC), a complete profile in terms of liver functions, kidney functions and lipid profile will be done, Thyroid Function Test, Iron levels, B12 levels. All patients but the very young get a chest X-ray and an electrocardiogram. Due to the high incidence of obstructive sleep apnea, most patients will require a polysomnography study. Patients will get an abdominal ultrasound. Other tests, such as pulmonary function testing, echocardiogram, GI evaluation, cardiology evaluation, or psychiatric evaluation, will be requested when indicated.
• What is the purpose of all these tests?
  An accurate assessment of your health is needed before surgery. The best way to avoid complications is to never have them in the first place. If you are diabetic, special steps must be taken to control your blood sugar. Our objective is to maximize your likelihood of success.
• Why do I have to have a GI Evaluation?
  Patients, who have significant gastrointestinal symptoms such as upper abdominal pain, heartburn, belching sour fluid, etc., may have underlying problems such as a hiatas hernia, gastroesophageal reflux or peptic ulcer.
• Why do I have to have a Sleep Study?
  The sleep study detects a tendency for abnormal stopping of breathing, usually associated with airway blockage when the muscles relax during sleep. This condition is associated with a high mortality rate and can be present in nearly 70% of obese patients. It is important to have a clear picture of what to expect and how to handle it.
• Why do I have to have a Psychiatric Evaluation?
  Bariatric surgery will require significant changes in your lifestyle and will also change your life. A psychiatric evaluation will help prepare you for these changes by developing coping skills and encouraging behavior modification. Additionally, our psychiatrists will evaluate your understanding and knowledge of the risks and complications associated with weight loss surgery and your ability to follow the basic recovery plan.
• What can I do before the appointment to speed up the process of getting ready for surgery?
  • Make a list of all the diets you have tried (a diet history) and bring it to your doctor.
  • Bring any pertinent medical data to your appointment with the surgeon - this would include reports of special tests (echocardiogram, sleep study, etc.) or hospital discharge summary if you have been in the hospital.
  • Bring a list of your medications with dose and schedule.
  • Stop smoking. Surgical patients who use tobacco products are at a higher surgical risk.
• Does Laparoscopic Surgery decrease the risk?
  No. Laparoscopic operations carry the same risk as the procedure performed as an open operation. The benefits of laparoscopy are typically less discomfort, shorter hospital stay, decreased hernia and wound infection rates, earlier return to work and reduced scarring.
• Will I have a lot of pain?
  Every attempt is made to control pain after surgery to make it possible for you to move about quickly and become active. This helps avoid problems and speeds recovery. Often several drugs are used together to help manage your post-surgery pain. While you are still in the hospital, a Patient Controlled Analgesia (PCA), which allows you to give yourself an intravenous dose of pain medicine on demand, will be used to initially control your pain. When you are ready to go home, you will be given a prescription for pain medicine.
• How long do I have to stay in the hospital?
  As long as it takes to be self-sufficient. Although it can vary, the hospital stay (including the day of surgery) can be 1-2 days for a laparoscopic band, 3-4 days for a laparoscopic gastric bypass.
• How soon will I be able to walk?
  Almost immediately after, the doctor will require you to get up and move about. Patients are asked to walk or stand at the bedside on the night of surgery, take several walks down the halls the next day and thereafter. Walking is the most effective means to decrease your risk of having a pulmonary embolus. On leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation.
• How soon can I drive?

  For your own safety, you should not drive until you have stopped taking narcotic medications and can move quickly and alertly to stop your car, especially in an emergency. Usually this takes 3-5 days after surgery.