A Surgeon Tells You Everything You Should Know About Bariatric Surgery
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"India saw a significant rise in obesity from its 19th position, for both men and women, in 1975 to 5th and 3rd positions respectively." Dr. Vikrant Sharma from CK Birla Hospital for Women talks about morbid obesity and the controversial bariatric surgery.
Morbid obesity is a serious health condition that results from lifestyle changes, unhealthy eating habits, a lack of physical exercise, medical conditions like hypothyroid, and even certain genetic conditions. It can interfere with basic physical functions such as breathing or walking. Those who are morbidly obese are at a greater risk of illnesses, including diabetes, high blood pressure, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, osteoarthritis, heart diseases, and cancer.
India saw a significant rise in obesity from its 19th position, for both men and women, in 1975 to 5th and 3rd positions respectively in 2014, reflecting increasing obesity rates among women worldwide. Indian women are more likely to be obese than their male counterparts—there were 20 million obese women in India in 2014 compared to 9.8 million obese men.
While Indians have been using different methods to get rid of their excess weight like exercise, yoga, dieting and so on, bariatric surgery has increasingly emerged as a popular option.
What is bariatric surgery?
Bariatric surgeries include a variety of procedures performed on people suffering from obesity. Many a times physical exercise and dieting fail due to different medical or non-medical reasons. Sometimes, patients are very overweight which makes it difficult to get into shape, and a bariatric surgery becomes the ideal solution for such people. Evidence suggests that bariatric surgery may lower death rates for patients with severe obesity.
The basic principle of bariatric surgery is to restrict food intake and decrease the absorption of food in the stomach and intestines. Bariatric surgery is designed to alter or interrupt this digestion process so that food is not broken down and absorbed in the usual way. A reduction in the number of nutrients and calories absorbed enables patients to lose weight and decrease their risk for obesity-related health risks or disorders.
When does one need a bariatric surgery?
The BMI, which stands for ‘body mass index’, is a measure of a person’s height in relation to his/her weight. It is used to define levels of obesity and help determine if surgery is required. In case your BMI is 40 or higher, and you have serious weight-related problems, or your BMI is 35 or more and you suffer from at least one or more obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea, and other respiratory disorders or even heart diseases, you may be a candidate for a bariatric surgery. However, you must discuss your condition with your physician.
Types of bariatric surgeries
Gastric Sleeve Resection
It was originally performed as a modification to another bariatric procedure. The weight loss procedure is very effective which removes approximately 50 per cent of your stomach and reduces the level of the hormone ghrelin. This hormone is responsible for hunger. The surgery permanently alters the size of your stomach by removing the lower portion of the stomach.
- It does not require any ongoing adjustments.It’s a purely restrictive procedure.
- Regular follow-ups are necessary to ensure weight loss is appropriate and intake is nutritionally adequate.
- It is the most physiological procedure with minimum nutritional deficiencies.
- The stomach may dilate and lead to weight regain after 2 years.
A Gastric Bypass is an irreversible procedure which involves dividing the stomach into a smaller upper section, or ‘pouch’, and connecting the small intestine directly to that pouch. The result is that the ‘stomach volume’ is reduced, as is the length of the effective small intestinal tract.
In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed but is completely stapled shut and divided from the stomach pouch. This is connected to the side of the Roux limb of the intestine, creating the ‘Y’ shape that gives the technique its name.
- It’s mainly restrictive with slight malabsorption.
- After a year, weight loss can average 77 per cent of excess body weight.
- Up to 90 per cent resolution in DM, HTN OSA at one-year post surgery.
- Poor absorption of iron and calcium can result in the lowering of total body iron.
- Chances of nutritional deficiency and marginal ulcers.
Mini Gastric Bypass
It is quicker, technically easier, and the risk mortality is very low—about 0.5 per cent according to most studies. The newly constructed stomach is smaller and tubular in shape. Around 2 to 7 feet of intestines are bypassed, and the surgeon attaches the remainder of the intestines to the new stomach.
- The surgery has promising results around the globe in terms of excess body weight loss and co-morbidities resolution.
- People can eat all types of food.
- There is no mortality concern associated with the surgery.
- This is a reversible operation.
- Type II diabetes, infertility, HTN, and OSA resolution rates are higher as compared to Gastric Sleeve Resection and Roux-en-y Bypass.
- Lower complication rates when compared to Gastric Sleeve Resection and Roux-en-y Bypass.
- It is a purely malabsorptive procedure.
- The risk of nutritional deficiency is greater than Roux-en-y Bypass.
How does bariatric surgery work?
Bariatric surgeries work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiological changes in your body that change your energy balance and fat metabolism. Weight loss is achieved by reducing the size of the stomach with a gastric band or through the removal of a portion of the stomach or by re-routing the small intestine to a small stomach pouch. The Gastric Bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less digestion and less digestion of food due to the smaller stomach pouch. Further, the small intestine is bypassed, and therefore food calories are ineffectively absorbed into the body and are instead passed out of the body as stool.
- Produces significant long-term weight Loss, which is almost 60 to 80 per cent excess weight loss
- Restricts the amount of food that can be consumed
- Produces favourable changes in gut hormones that reduce appetite and enhance satiety
- Increases the energy expenditure on top of decreasing medications and losing weight
- Reduces the risk of cancer in morbidly obese patients
- Improves self-esteem and the quality of life
- Improves fertility and reduces complications during pregnancy
- Affords a longer span of life
- Technically more of a complex operation than the Adjustable Gastric Banding (AGB) surgery—usually has a longer hospital stay than the ABG
- Potentially may result in greater complication rates
- Requires adherence to dietary recommendations, lifelong vitamin/mineral supplementation, and a follow-up compliance
- May lead to long-term vitamin/mineral deficiencies, particularly deficits in Vitamin B12, iron, and calcium
Bariatric surgery in India
There are many hospitals in India which are doing their best to provide necessary care and treatment to obese patients. These hospitals are performing different types of weight-loss surgeries, including revision surgeries with success rates comparable to international standards.
High-volume centres have successfully provided better outcomes and an improved quality of life for hundreds of obese patients with the help of committed consultants, allied specialists, and dieticians. The additions of second-generation single incision laparoscopy surgeries and robotic surgical operations are amongst the latest procedures for patients who have morbid obesity.
Surgery for weight loss in India is substantially lower than in developed countries or available in only tertiary care hospitals. Despite low costs, hospitals in India have a reputation for providing excellent facilities and highly trained doctors to do it. Hospitals for weight-loss surgery in India are also reputed to have the most modern operating theatres, ICUs, equipment, and infrastructure to deliver the best care to their patients.
Here are some key factors one should consider while researching hospitals for the surgery:
- All major equipment and facilities at all weight-loss centres
- A big line-up of experienced and skilled doctors
- Highly qualified paramedical staffs
- Easy accessibility
Cost of bariatric surgeries
Bariatric surgery is an expensive surgery. Iern India, a bariatric surgery costs anywhere between Rs. 2.5 lakhs to Rs. 5 lakhs, and the equipment and technology alone cost around Rs 1.75 lakhs. Surgeons with the Obesity and Metabolic Surgery Society of India (OMSSI) have stated that they have written to the union government to ensure that bariatric surgery procedures are insured as they have been now established as metabolic surgeries, rather than cosmetic ones.
Dr. Vikrant Sharma
Consultant, Advanced Surgical Sciences
CK Birla Hospital for Women