Bariatric & Metabolic Surgery
What is BARIATRIC Surgery?
Bariatric (weight loss) Surgery:
Obesity in the Indian context is defined as body mass index [BMI: Weight (kg)/ Height (m)2] more than 27.5 kg/m2 (normal BMI is between 18 to 23 kg/m2) and people with a BMI more than 32.5 kg/m2 and 37.5 kg/m2 are defined as “severely obese” and “morbidly obese” respectively. Obesity poses risks for all organs and can eventually lead to a number of symptoms called “Metabolic Syndrome of Obesity”. Obesity is a chronic disease wherein excess body fat builds up and subsequently poses real risk of developing medical conditions like diabetes mellitus (DM), hypertension (HT), obstructive sleep apnoea (OSA), degenerative joint disease, hyperlipidemia (HPL), hyperuricemia, fatty liver, depression, polycystic ovarian disease (PCOD) and asthma to name a few. People with morbid obesity (BMI > 37.5 kg/m2) face around 50% to 100% higher mortality rates. There is also the emotional aspect of obesity where obese patients suffer from poor self image, social ostracism and are more likely to develop issues like depression, anxiety and eating disorders. Bariatric surgery or weight loss surgery or metabolic surgery is a lifestyle modifying surgery which not only helps people lose weight but because of its hormonal effects; it cures and controls medical conditions that come along with it. Its positive effects on glucose levels and other metabolic problems is immense, and can be seen soon after the procedure is completed, in fact before significant reduction in weight occur.
Bariatric surgery is recommended if a patient is morbidly obese (BMI > 37.5 kg/m2) or severely obese (BMI > 32.5 kg/m2) with serious co-related diseases like DM, HT, OSA and others mentioned above. It is very safe for patients aged 18 to 65, particularly those who can’t manage to lose weight through alternatives like dieting, exercise, modification programs or a generally healthy lifestyle. Patients not only lose extra fat but many obesity related conditions like Diabetes, high blood pressure, sleep apnea, heart diseases are resolved or are at least significantly improved. PCOD and resulting infertility can also be dealt with through weight loss. Patients have gotten pregnant after 18 months to 2 years post surgery, the overall quality of life has also been found to improve in 95% of our patients, with mortality risk reduced by 89%.
Today, due to new stapling devices, the risks associated with home procedure are extremely negligible like any common laparoscopic surgery. Patients go within 2 to3 days post surgery and can begin with their normal routines after 1 week and can return to strenuous activity after 6 weeks. The diet after surgery is phased, beginning from an all liquid diet to semisolid to a complete diet in around 6 to 8 weeks. The overall diet is smaller in amount and is split into smaller meals, food has to be chewed properly and the patient has to avoid consuming water, or liquids 30 minutes before and after meals. It is striking how diabetes is brought under control after surgery. Theories suggest that dietary control after surgery along with hormonal changes (Ghrelin and Integrins) which produce satiety: have similar effects like insulin. Also, when a person loses weight they are naturally more mobile which will make whatever insulin their bodies produce work better as there will be lesser insulin resistance. The weight lost through surgery is sustainable and studies have shown improved motivation desire and dedication towards a healthier and better life. Apart from changes in appearance, surgery brings new hope, improves self-confidence and positivity in people’s lives and thinking.
Why BARIATRIC Surgery?
People often confuse bariatric surgery with liposuction and when they hear that their dietary intake will be reduced after surgery; they believe all they need to do is change their diet but bariatric surgery offers fast and sustainable weight loss because of the hormonal changes associated with it. After bariatric surgery, binge eaters stop eating extra, there is vast improvement in the occurrence of diseases associated with obesity like Type 2 Diabetes Mellitus, Hypertension, Obstructive sleep apnea, PCOD (infertility); so much so that some patients don’t even need to continue medicines for their diseases, so bariatric surgery can even get you off medication.
Liposuction isn’t really a weight loss procedure but rather it’s used for losing inches: a cosmetic procedure basically, not meant for morbidly obese cases, no disease control afterwards, and hunger cravings remain the same.
When we diet, we feel hungry yet eat less, it’s not sustainable for very long and once the discipline breaks all the weight lost can come back.
Types of Bariatric Surgery:
LSG (Sleeve Gastrectomy)
Sleeve Gastrectomy (Fig. 1) includes removing the sleeve of the stomach so that it can hold up to 50 to 150 ml of fluid depending on use of bougie size.
Sleeve gastrectomy is an irreversible procedure; it removes that part of the stomach that produces hunger stimulating hormones (Ghrelin). Dumping syndrome is less likely due to the preservation of the pylorus. By avoiding the intestinal bypass, the chances of intestinal obstruction (blockage), anemia, osteoporosis, protein deficiency and vitamin deficiency are significantly reduced. Very effective as a first stage procedure for high BMI patients (BMI >55 kg/m2) and results have shown promising as a single stage procedure for low BMI patients (BMI 35–45 kg/m2).
Laparoscopic Mini Gastric bypass (LMGB)
Laparoscopic Mini Gastric bypass consists of forming a long gastric tube and attaching it 180 - 200 cm down to small bowel with single anastomosis. Unlike conventional gastric bypass it has fewer early and long term complications and can achieve weight loss similarly. The disadvantage is bile reflux but practically very few patients suffer from it.
LRYGB (Gastric bypass)
Laparoscopic Roux-en-Y gastric bypass (Figure 3) has mixed restrictive and malabsorptive component. It consists of forming a 25 to 30 cc pouch and bypass of 70 to 100 cm biliopancreatic limb and 100 to 130 cm of alimentary limb.
The benefit of gastric bypass is greater weight loss and control of diabetes but it is also associated with dumping syndrome, nutritional deficiencies among others. Patients will need to multivitamins and mineral supplements for life.
If we compare the three procedures, the sleeve gastrectomy has advantages and disadvantages. It carries lesser risk than the bypasses, and has a faster weight loss.
As it does not involve any diverting or bypassing of the intestine, there are less chances that patients will require long term vitamin, mineral or protein supplements. Unlike the gastric bypasses, you’ll have normal gut anatomy and can therefore have standard diagnostic procedures such as Gastroscopy can be carried out after operation. There is no such “dumping” with sleeve gastrectomy; as observed with gastric bypasses and no considerable dietary change is required; compared to the gastric band. However, unlike the gastric bypasses, the stomach is permanently removed. It is also possible to convert the sleeve gastrectomy into another weight loss procedure, usually a gastric bypass, in case future problems occur. Once a patient gets over the initial peri-operative period, the likelihood of further problems with a gastric sleeve is low.
People should carefully weigh the pros and cons of each of the available bariatric procedures before deciding which is best. If I believe a particular procedure is most advantageous for you, I will recommend that during consultation.
Banded Bariatric Surgeries
These days a band is put over the gastric pouch to prevent dilatation and weight gain later on.
Revisional Bariatric Surgeries
SILS (Scarless) Bariatric surgery
Now, single incision surgeries are gaining popularity and bariatric is no exception to this. Single incision bariatric surgeries are performed in selected subgroups of patients, young females with height less than 180 cm and no previous umbilical surgery.
Indications for Bariatric Surgery
The following are the indications of Bariatric Surgery according to 2005 APBSG consensus meeting for Asian people to:
- Obese patients with BMI >37.5 kg/m2 (Morbid Obesity),
- Obese patients with BMI >32.5 kg/m2 (Severe Obesity) in presence of diabetes or two significant obesity related co-morbidities,
- Patients unable to lose or maintain weight loss by dietary or medical measures and
- Patients > 18 years and < 65 years of age.
Key Medical Procedure/Services
Eating Habits and Exercise
Imp: Please follow the diet chart given to you at the time of first appointment. It is vital you consume the appropriate amount of calories, protein and vitamins in order to avoid feeling ill, weak and possible losing some hair during the initial recovery period. Always remember they the goal is to burn fat, not muscle, so protein is necessary for maintaining muscle bulk. Remember to take full advantage of the early lack of appetite to get into the right eating and exercising habits. Patients who don’t adopt healthy diet habits early on are more likely to regain weight in the long term. If you return to high calorie junk food and don’t remain active, then even the best bypass will fail eventually. Your bariatric procedure should be considered a means to aid your overall weight loss. The paramount importance of behavioural factors cannot be overstated . It is therefore extremely beneficial and important that you participate in our Patient Support Group as much as possible and seek dietary and psychological assistance whenever it is recommended or whenever you feel that you are struggling to achieve your goals. Studies have shown that patients who participate in patient support groups, and have their surgery carried out in a multidisciplinary environment, achieve better results.
Though it is unusual to have significant bleeding (< 1%) but blood transfusions and very rarely relaparoscopy may be needed in case of significant bleeding.
Every surgery carries risk of infection. The most common are wound infections, urinary infections and chest infections. More serious are blood infections, abscess and peritonitis. Fortunately they are rare, and in extremely rare cases some of these infections can lead to death, even if the source of infection treated in advance.
Blood clots in the veins in the legs or pelvis (DVT) can migrate to the lung (pulmonary embolism – PE), which can prove fatal (Cause Death). This can happen after any surgery, and it continues to pose a risk for about three weeks, but chances of such a complication is less than 1%, but because it is a serious complication, we follow all protocols and take all measures to minimise the risks. Blood thinning medication may be given to patients, stockings to compress the legs and while a patient is sound asleep in the operating theatre, machines will be used to squeeze the blood out from the legs. These machines continue to be used in the ward when you are in bed and we encourage you to get up and walk about the ward as soon as possible. The risk of DVT is about 1:200 and the risk of pulmonary embolism about 1:1000. If you are identified as a high-risk candidate, we may have to put you on blood thinning injections for longer to minimise the risk.
Incisional hernias are more common after open bariatric surgery but rather rare after laparoscopic bariatric surgery. The risk is about 1% and if hernias do occur they will most likely be small and easily treatable.
Small Bowel Obstruction
The small intestine may get blocked by twists around the scar tissue (adhesion) inside the abdomen after surgery. The other (but less common) cause of bowel obstruction is an internal hernia. These types of obstructions can arise at any time and even years after surgery. The chances of bowel obstruction after a laparoscopic sleeve are negligible. Most obstructions after laparoscopic surgery can be successfully repaired laparoscopically.
This can happen occur with any surgery and even in completely clean surgeries they happen in upto 5% of all cases. They may require antibiotics, or opening and draining of the wound. These wounds are then allowed to heal over a longer period of time with dressings.. Patients who smoke are at higher risk of getting wound infection.
Damage To Spleen Or Other Organs
The spleen is located close to the upper portion of the stomach and can be injured during surgery, but this is extremely rare during laparoscopic surgery within the rate of less than 1%. In case this happens, it may require conversion to an open procedure and removal of the spleen. This is naturally avoided as far as possible. Pancreatitis is rare but has been a reported complication along with liver injury. These don’t need surgical intervention.
Very seldom, the intestines or stomach get injured during surgery. If this happens, it will be repaired laparoscopically and the operation might be halted at that point and rescheduled at a later time and date. In case the bowel injury is not recognised; then there is risk of developing life-threatening peritonitis requiring more surgery and probably Intensive Care.
The odds of death because of gastric sleeve is 1:500: laparoscopic gastric bypasses carry more risk. Patients must recognise that risk, be it any kind; cannot be reduced to zero. By going for bariatric surgery you trade your risk of decreased life expectancy from related illnesses, to a temporary and short term increase in the risk of dying during and immediately after operation. Even though the procedure is carried out with keyhole surgery it is still a major surgery; you should consider speaking with your family before making any decisions.
Staple Line Leak
The stomach is divided with a stapling device in sleeve gastrectomy leaving three rows of steel staples behind. If this staple line breaks down and leaks, there is a risk of peritonitis, infection or abscess. The risk of this happening is less than 3% but in case it occurs, further surgery and the placement of drains will be needed, along with some time in intensive care, this can potentially become a risk to your life in very rare cases.
Staple Line Bleed
There is a risk of bleeding from the staple line with the chances of it happening less than 1%, and in case it happens it can be managed without the need for further operation (a Blood transfusion) and settles down itself. In some very rare instances patients were taken back to the operation theatre for another laparoscopic procedure to drain out any blood from the abdominal cavity.
IT IS MY POLICY THAT IF I AM UNHAPPY WITH YOUR POST OPERATIVE RECOVERY, I WILL TAKE YOU BACK TO THE OPERATION THEATRE FOR A LAPAROSCOPY. THIS MAY MEAN THAT YOU HAVE A 2nd PROCEDURE, WHICH SHOWS NO ABNORMALITY. HOWEVER STUDIES HAVE SHOWN THAT EARLY INTERVENTION FOR COMPLICATIONS PRODUCES THE BEST OUTCOMES.
Vitamin Mineral Deficiencies
Laparoscopic sleeve gastrectomy does not alter the normal gut anatomy, so there is no real risk of vitamin or mineral deficiency as seen in gastric bypasses. Vitamin D deficiency is commonly present in overweight patients and they are prescribed multivitamins for this. For patients who undergo Gastric Bypasses; multivitamin, calcium and Vitamin D supplementation will be needed for life.
Some thinning or loss of hair in the first few months after bariatric surgery have been reported but this is mainly temporary related to inadequate protein intake.
A hiatus hernia occurs when part of the stomach slips up through the diaphragm into the chest. It is common in obese patients and will probably have been noted during Gastroscopy. At the time of bariatric surgery your hiatus hernia may be repaired with simple sutures to the hiatus. Generally the symptoms associated with a hiatus hernia like heartburn and reflux respond best to weight loss rather than anti-reflux surgery.
Failure To Lose Weight
It is possible to defeat the purpose of the operation and not lose weight. The idea behind bariatric surgery is to adopt a healthy lifestyle along with a diet and exercise regime; not to replace them. If patients start indulging themselves with high energy liquids, alcohol and junk food they will regain weight.
Large Folds of Skin
This is always a possibility when significant weight loss takes place . There is no reliable way to determine whether this will happen or not before surgery, or how much will occur; it varies from case to case. Age, fitness, speed of weight loss, elasticity of skin all play a role. Patients need to wait for about a year to see if they need additional body contouring surgery. Plastic surgery procedures are available to treat excess skin problems.
Although it is always the intention to complete these operations laparoscopically, on some rare occasions it could become necessary to change into an open operation for safety purposes. If this happens; patients will need to stay while longer in hospital, along with some increased risks of complications like wound infections and incisional hernias.
Smoking is a major issue for bariatric surgery patients. It definitely increases the risk of pulmonary complications and blood clot formations regardless of the procedure performed. I strongly recommend that if you are a smoker, try and stop smoking prior to surgery. Even stopping smoking a week prior to surgery can be beneficial.
Women should avoid pregnancy for the first year post operation. Periods of rapid weight loss are not ideal to get pregnant or trying to maintain an existing pregnancy. Also bear in mind that as we lose weight our fertility will increase and women will be more likely to become pregnant.
Initial weight loss with the laparoscopic gastric sleeve can be very fast and apparent. This weight loss can be psychologically addictive but ultimately it will slow down after six to nine months so it is best that you are prepared for this event like it’s a process. The most rapid period of weight loss is the first few months, so this is the period when we recommend you begin your exercise regime with the assistance of our physiotherapy protocol. As you lose weight your exercise capacity will increase, making you feel better and fitter. The best average result from a laparoscopic gastric sleeve is losing 65% excess body weight over an 18-month period. Bear in mind that the goal of surgery is to make you healthier and improve your life expectancy and decrease the risk of obesity related diseases, it is not to get you down to your ideal weight. The more weight you have to start with, the more weight you will probably lose with surgery and our recommended dietary and exercise regime. Try not to get caught in the trap of comparing your weight loss with others.