Obesity today is recognized as a health problem of epidemic proportions. Obesity refers to a spectrum of problems of excess weight ranging from mild overweight to the morbidly obese. Patients with morbid obesity do not respond to medical means of weight loss. Efforts to treat morbid obesity through controlled diets, behavior modification and exercise programs are only temporarily successful with the patient invariably regaining even more weight than the amount lost. Obesity surgery is the only method by which long-term weight loss can be achieved in these patients. Seven to nine percent (7-9%) people in India are overweight, of which 20 - 25% are morbidly obese, which amounts to a staggering 2 - 2.5 million people. Incidence of childhood obesity is on the rise due to changing lifestyles. These people are more likely to develop obesity related complications at an earlier age. If not addressed today this problem is likely to compound imposing heavily on medical resources.
Surgical procedures for obesity can now be safely performed by endoscopic or laparoscopic approach. These morbid patients stand to benefit tremendously by laparoscopic surgery decreasing the hospital stay, minimizing pain and an early return to activity. Laparoscopic gastric banding has emerged as a highly popular and successful surgery for morbid obesity. A biocompatible, silicon band is placed around the stomach just below the food pipe creating a 30ml pouch (~ 2 table spoonful). The patient feels full after just two bites of food thus decreasing the intake and resulting in the weight loss. The procedure is safe, simple and reversible. It can be done as a short stay procedure (hospitalization for 24 to 48 hours). It is a very patient friendly procedure and has no cut on the abdominal wall hence an excellent cosmetic result (only few tiny puncture marks), very little pain is caused by the surgery and patient can resume his or her work within few days after surgery.
AILS Mumbai has been gearing upto this challenge since two years.
WEIGHT LOSS SURGERY
Obesity and Morbid Obesity
OBESE Body Mass Index (BM!) of 30 or greater.
MORBIDLYOBESE Body Mass Index (BMI) of 40 or greater (Rough equivalent to 45 kg. over your ideal body weight).
The clinical guidelines for consideration are:
- 45 kg. or more above ideal body weight or a BMI OF 40 or greater
- BMI of 35 or greater with one or more obesity related health conditions.
- History or documented dietary weight loss attempts Lifelong commitment to follow-up care and extensive dietary, exercise and medical guidelines.
- Psychological evaluation.
Obesity related health conditions that may be improved or resolved with weight loss surgery :
- Type II Diabetes
- High Blood pressure / heart disease
- Osteoarthritis of weight bearing joints
- Sleep apnea / respiratory problems
- Gastro esophageal reflux / Heartburn
- Infertility / menstrual irregularities
- Skin breakdown
- Swollen legs / skin ulcers
- Urinary stress incontinence
- Extremity Venous stasis
- Dyslipidemia (lipid metabolism abnormalities)
- Pulmonary embolus
Understanding the Gastrointestinal Tract:
- The Esophagus
- The Stomach
- The Pylorus
- The Duodenum
- The Jejunum
- The Ileum
- The Large Intestine
WEIGHT LOSS SURGERY PROCEDURES
Restrictive and Malabsorptive Procedures
There are two basic mechanisms of weight loss surgery.
- Restrictive procedures decrease food intake by creating a small upper stomach pouch to limit food intake
- Malabsorptive procedures alter digestion, thus causing the food to be properly digested and completely absorbed.
- There are several procedures that combine the restrictive and malabsorptive mechanisms of weight loss surgery.
LAP ADJUSTABLE GASTRIC BANDING
Procedure Type Restrictive
- The gastric banding is the least invasive of all procedures
- An adjustable silicon band is placed around the stomach which induces weight loss by restricting food intake
- The band can be adjusted by injecting saline in a small container placed under the skin during surgery
- Surgery can be reversed
- Digestion and absorption is normal
- When eating less the body draws the required energy from its own fat
- In a U.S. study, the mean weight loss at three years after surgery was 36.2% of excess weight
In case of high-risk patients, the sleeve is used as a first stage to induce weight reduction allowing for the more demanding intestinal dissection to be performed under better conditions.
In the sleeve gastrectomy, trocars are placed as for a gastric bypass.
The stomach is lifted and the surgeon starts the devascularisation of the greater curvature with the help of the Ultracision device. Once the lesser sac has been entered, dissection is continued in a cephalad direction and the lower pole of the spleen is quickly reached.
At the level of the spleen’s lower pole, the peritoneal sheets are farther apart and the tissue in between is thicker and harbours tortuous vessels (the short gastric), which must be coagulated separately, by using small bites of the Ultracision.
Eventually the dissection reaches the root of the left pillar of the hiatus. When the upper pole of the fundus has been mobilised, the surgeon can lift the stomach anteriorly and to the right, much like turning a page of a book.
Care should be taken not to damage the left gastric vessels, which in an obese patient are closer (lower) than one would anticipate. Once the stomach has been freed, the division can be performed.
What is a "Sleeve Gastrectomy"?
The sleeve gastrectomy is an operation in which the left side of the stomach is surgically removed. This results in a new stomach, which is roughly the size and shape of a banana. Since this operation does not involve any "rerouting" or reconnecting of the intestines, it is a simpler operation than the gastric bypass or the duodenal switch. Unlike the Lap-Band procedure, the sleeve gastrectomy does not require the implantation of an artificial device inside the abdomen. For certain patients, in particular those with a body mass index greater than 60, the sleeve gastrectomy may be the first part of a 2-stage operation. The 2-stage operation may have substantial advantages for specific individuals.
What are the Advantages of the "Sleeve Gastrectomy"?
The sleeve gastrectomy has a number of advantages over other bariatric procedures:
It may be used as the first stage of a 2-stage operation. (See below)
- It does not require disconnecting or reconnecting the intestines
- It is a technically simpler operation than the gastric bypass or the duodenal switch
- It may be a safer operation for patients with a body mass index (BMI) more than 60.
What is a 2-Stage Operation?
Certain patients may have a body shape that makes their surgery technically difficult. For example, patients with a BMI over 60, particularly those who carry their weight around their belly area, may be at increased risk for bariatric surgery. If you fall into this category, you may benefit from a 2-Stage bariatric surgery.
In the staged approach, a multi-step operation like the gastric bypass or the duodenal switch is broken down into 2 simpler and safer operations. In the first stage, a sleeve gastrectomy is performed. This allows weight loss of 80 to 100 pounds or more, which will make the second part of the operation substantially safer.
The second stage operation is usually performed 8 to 12 months after the first. The "sleeve" stomach is converted into a formal gastric bypass or duodenal switch. This will permit additional weight loss and will provide a permanent result as opposed to sleeve gastrectomy alone. Both stages of the surgery can be performed laparoscopically, giving the advantage of shorter recovery, shorter incisions, and fewer incision-related problems and less pain.
Are There Any Disadvantages?
The sleeve may be an excellent option for you if your BMI is over 60, or if you have medical problems that would put you at excessive risk for a gastric bypass or duodenal switch (BPD-DS). However, the sleeve is usually considered to be a temporary treatment for obesity, until the second stage of the surgery is performed. Some people perceive the need for 2 separate operations as a disadvantage, despite the health benefits.
GASTRIC BYPASS ROUX-EN-Y
Procedure Type Combined Restrictive / Malabsorptive
- Stapling is used to create a small, upper stomach pouch, which restricts the amount of food able to be consumed
- A portion of small bowel is bypassed thus delaying food from mixing with digestive juices to avoid complete calorie absorption
- Average of 77% of excess body weight loss one year after surgery
- Studies show that after 10 to 14 years, patients have maintained 60% of excess body weight loss
- Study of 500 patients showed that 96% of certain associated health conditions studied were improved or resolved, including back pain, sleep apnea, high blood pressure, Type II diabetes and depression.
- In most cases patients report an early sense of fullness, combined with a sense of satisfaction, that reduces the desire the eat.
BILIOPANCREATIC DIVERSION (BPD)
Procedure Type Malabsorptive
- Approximately 3/4 of the stomach is removed
- Restricts food intake and reduced acid output
- Small intestine is divided
- One end is attached to the stomach pouch to create an alimentary limb
- Food moves through alimentary limb with little absorption of food
- Studies patients have achieved excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years and 91% at five years
- Provides highest levels of malabsorption
- Patients are able to eat larger meals than with restrictive procedures
LAPAROSCOPIC AND OPEN: TWO APPROACHES TO WEIGHT LOSS SURGERY
An open procedure involves one long incision that opens the abdomen to provide the surgeon access. Open procedures for weight loss surgery employ the same principles as their laparoscopic counterparts and produce similar excess weight loss
When a Laparoscopic operation is performed, a small video camera inserted into the abdomen allows the surgeon to conduct and view the surgery on a video monitor.
The camera and surgical instruments are usually inserted through small incisions made in the abdominal wall
Laparoscopic procedures for weight loss surgery employ the same principles as their 'open' counterparts and produce similar weight loss
Compared to open surgery, some benefits of laparoscopic surgery include:
- Negligible post operative pain
- Fewer wound infections
- Fewer incisional hernias
- Faster recovery and return to pre-surgical level of activity
All major surgery involves a certain level of risk. Risks involved with weight loss surgery vary according to procedure performed.
- Re-operation rate 30%
- Anastomotic leak 20%
- Anastomotic stricture 30%
- Wound infection 10%
- Obstruction 50%
- Deep vein thrombosis 10%
- Restriction of eating small meal indefinitely
- Occasional Vomiting / Regurgitations
- Minor hair loss
- Loose / Boggy skin
- Deficiency of Protein /Vitamins
IMPORTANT CONSIDERATIONS FOR ALL WEIGHT LOSS SURGERY
Surgery should not be considered until all other options have been evaluated:
- Weight loss surgery is not only a cosmetic surgery
- The decision to elect surgical treatment requires an assessment of the risk and benefit to you and the meticulous performance of the appropriate surgical procedure
- The success of weight loss surgery is dependent on your long term lifestyle changes in diet, exercise and behaviour modifications.
- In a survey of over 10,000 patients, the mortality rate for weight loss surgery was 0.30%
What defines successful weight loss surgery?
A recent study established the following criteria: the ability to achieve and maintain loss of at least 50% of excess body weight without having substantial adverse effects.
What is morbid obesity?
- Morbid Obesity is a disease, which is chronic and lifelong
- The disease is of excessive fat storage
What is BMI?
- BMI or Body Mass Index is a measure of calculating a person's excess weight.
- It is calculated by the following formula: