MORBID OBESITY, METABOLIC & BARIATRIC SURGERY - INDIA

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Laparoscopic Gastric Bypass Surgery, Laparoscopic Sleeve Gastrectomy and Laparoscopic Gastric Banding ( lap band ) are increasingly getting popular in New Delhi, India. There is an increase in the Indian population opting for these procedures and also amongst patients coming for Medical Tourism from USA, Europe, Australia etc. looking for a low cost option at International Standards.

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·  With Minimal Access Surgery ( also known as Minimally Invasive Surgery or Laparoscopic Surgery ) reaching all parts of the body for various diseases, it was only a matter of time that this would be applied for the treatment of obesity in India as has been the case in the western countries. World obesity status

·   India has now the world's third largest number of obese individuals following USA and China. We have 20% of our population classified as obese, 40% as malnourished and 40% normal weight. Our diabetic population is world's highest and there is correlation between diabetes, metabolic syndrome and obesity. India has already been labelled as the Diabetes capital of the world with nearly 80 million diabetics. Diabetes statistics

While a third of India’s population still falls below the poverty line, there has been a steady growth of the relatively affluent urban middle class, now estimated to number over 200 million. Those who have achieved affluence within a lifetime constitute a good proportion of this middle class.

The Nutrition Foundation of India has just completed a study of the prevalence of obesity in urban New Delhi. It would appear from the results of this study that nearly a third of the males and more than half of females belonging to what may be termed the ‘upper middle class’ in India are currently overweight using the WHO criteria of BMI>25, but the figure will be higher if the AIIMS recommendations for Indians is followed (see below). The prevalence of abdominal obesity in this group is even higher. Assuming that the ‘upper middle class’ in India number around 100 million (half the number of middle class), it may be computed that there are roughly 40 to 50 million overweight subjects belonging to the upper middle class in the country today. If present trends continue, the situation can get worse within a decade, and overweight could emerge as the single most important public health problem in adults. Overweight/obesity may not be considered as a specific disease but it is certainly the mother of important degenerative diseases in adult life.

Affluence is now taking its toll of children's health, with a new study in Delhi indicating that every 15th school going child in the high or high-middle income group is obese. The study conducted in a public school cautions that all these children are prone to hypertension, diabetes, coronary artery disease and overall morbidity and mortality during adult life.

 

 

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DEFINITIONS AND RISK FACTORS

·   Body mass index (BMI) is used to define obesity. This is the figure obtained by dividing body weight by the square of height in meters. If your weight for instance is 80 kg and height is 5 feet 7 inches (1.70 m ), then your BMI would be 80/2.89 = 27.68 kg per m2

CALCULATE YOUR BMI HERE

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 ·  People are classified as:

 WHO CRITERIA  RECOMMENDATION FOR INDIANS
 Normal  less than 25 kg per m2  less than 23
 Overweight  more than 25 kg per m2  more than 23
 Obese  more than 30 kg per m2  more than 27.5
 Severe obesity  more than 35 kg per m2  more than 32.5
 Morbid obesity  more than 40 kg per m2  more than 37.5

Metabolic syndromeOther risk factors that are very specific to India and neighboring countries is what is known as Metabolic Syndrome. Three or more of the following criteria This puts individual at tremendous risk for systemic diseases involving the heart, brain, liver and kidneys. When combined with obesity, the problem gets compounded.

  A waist-to-hip ratio of 1.0 or higher in men and 0.8 or higher in women defines upper body obesity and is an independent predictor of disease risk. This is also known as syndrome X and is a common problem seen in India.

 The most significant observation is that morbidly obese patients may experience a 12-fold reduction in life expectancy compared with age-matched control subjects.

  Once classified, patients who are obese or severely obese are treated medically diet, life style modifications and exercise; bariatric surgery is reserved for patients who are morbidly obese or severely obese with concomitant obesity-related diseases.

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EFFECTS OF MORBID OBESITY

     People who are obese, are more likely to develop a number of potentially serious health problems, like:

Obesity complications Blood abnormalities - hypercholesterolemia
Cancer, including cancer of the uterus, cervix, ovaries, breast, colon, rectum and prostate

Depression
Gallbladder disease and stones
Gynecological problems, such as infertility and irregular periods
Heart disease ( Coronary artery disease )
High blood pressure
Metabolic syndrome
Nonalcoholic fatty liver disease
Osteoarthritis of knees, back ache etc.
Skin problems, such as intertrigo and impaired wound healing
Sleep apnea, snoring
Stroke
Diabetes and its complications

When you're obese, your overall quality of life may be lower, too. You may not be able to get around or to perform normal daily activities as well as you'd like. You may have trouble participating in family activities. You may avoid public places. You may even encounter discrimination. Traveling by public transport can be a problem. Other issues that may affect your quality of life include:

Depression
Disability
Physical discomfort
Sexual problems
Shame
Social isolation

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NON-SURGICAL TREATMENT OF MORBID OBESITY

  Nonsurgical treatments include caloric restriction, exercise, behaviour modification, and drug therapy. Please note : This is the preferred method for people with BMI less than 32.5

  The long-term results of caloric restriction programs are good for the overweight but have been poor for those who are over a BMI of 32.5 and are morbidly obese. A regular balanced diet that is sustainable in the long term is what works best. Most diets concentrate on high proteins and low carbohydrates. Crash diets cause nutritional imbalance and usually ends with weight regain that may be higher than the start point.

  Exercise programs again are good for the overweight with some type of caloric restriction but are generally ineffective beyond the loss of 6 to 10 pounds in the morbidly obese. Also it is difficult and extremely tiring for them. In the overweight category it succeeds if combined with a good diet program. Also it is important to keep a balance of both aerobic and anerobic exercises to ensure fat loss without loss of muscle mass.

   Long-term success with behaviour modification programs is also lacking in people above BMI of 32.

   Pharmacologic programs are popular, but they are equally ineffective as a treatment for morbid obesity; they use appetite-suppressing medications that act by increasing the central nervous system concentration of serotonin, a mood-elevating neurotransmitter believed to be involved in eating disorders. Amphetamines and newer potentially addictive sympathomimetic medications are also used without significant long-term success.10% weight loss is seen but is regained once the medicine is stopped. Xenical and Reductil are the most popular drugs prescribed.

Research is on to identify the genes responsible and hopefully one day gene therapy may solve this 'growing' problem.

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 CURRENT SURGICAL THERAPIES FOR MORBID OBESITY

Surgical approach can be by 3 methods : Open surgery ( not done any more ), Laparoscopic Surgery ( most centres ) and by Robotic Surgery ( selected centres )

(click on video below to get an idea of what the 3 commonest operations mean)                       

1. Restrictive ( surgical reduction of the stomach size to reduce amount of food intake)

Vertical Banded Gastroplasty -- NOT DONE NOW
✔✔ Adjustable Gastric Banding - POPULAR FOR SELECTED CASES
✔✔ Sleeve Resection -- POPULAR       

2. Malbsorptive ( surgical re-routing of the consumed food leading to reduced absorption )

 

Jejunoileal Bypass -- NOT DONE NOW

Biliopancreatic Bypass -- EXTREME CASES

3. Combined restrictive and malabsorbtive ( size reduction with bypass )

✔✔ Roux en Y Gastric Bypass (RYGB) -- POPULAR
Single Anastomosis Bypass ( MGB - 'mini' gastric bypass )-- POPULAR
Duodenal Switch -- EXTREME CASES / RE-DO SURGERY

4. Other Procedures

Endo luminal sleeve -- UNDER EVALUATION
Gastric Pacemakers -- UNDER EVALUATION
Gastric Balloon -- TEMPORARY MEASURE


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PATIENT SELECTION

       Patients with a BMI more than 40 kg per m2 ( 37.5 in India and Asia )

and those with BMI more than 35 ( 32.5 in India and Asia ) with medical comorbidities

are potential candidates for surgical treatment of morbid obesity after failure of conservative treatment.

   Surgery should be offered only to patients who are well informed and motivated and who are acceptable surgical risks; the patients should be evaluated preoperatively by a multidisciplinary team of nutritionists, nurse clinicians, internists, psychologists or psychiatrists, and surgeons.

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RESTRICTIVE PROCEDURES

 The stomach size is reduced by applying staplers across it and thereby reducing the amount of food a person can eat at a given time.

·        Gastric Banding is a popular restrictive procedure currently. A band is placed around the upper most part of the stomach. This band divides the stomach into two portions, one small and one larger portion. Because food is regulated, most patients feel full faster. Food digestion occurs through the normal digestive process. Other advantage is that it is EXTERNALLY adjustable ( the band can be tightened or loosened to regulate the amount of food passing ). RISKS: There are foreign bodies under the skin and also around the stomach that has a rare potential of eroding or slipping and that would mean a second surgery for its removal. 

·        The Gastric Sleeve Resection removes a great part of the stomach and leads to 'considerable' loss of weight. This is useful in those with a BMI between 35 and 40. Also, this procedure is being done in BMI over 60 to downgrade the obesity to a more manageable level of about 50, after which a gastric bypass / duodenal switch can be done. RISKS The pouch may stretch and long term results of weight loss is awaited.

 

 

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COMBINED RESTRICTIVE AND MALABSORBTIVE

In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile andpancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat. According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y  gastric bypass is the most frequently performed weight loss surgery in the United States. 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. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end 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 increased to produce lower or higher levels of malabsorption.

mgbThe Single Anastomosis Gastric Bypass ( popularly known as 'mini' gastric bypass or MGB ) uses a long stomach sleeve tube that is connected to small intestine at a length between 180 and 300 cm based on original weight, eating patterns, presence of diabetes, metabolic disorders etc. The Mini-Gastric Bypass, which uses the loop reconstruction, has been suggested as an alternative to the Roux en-Y procedure, due to the simplicity of its construction, which reduced the challenge of laparascopic surgery. It is claimed that construction of a long tubular gastric pouch reduces the risk of inflammatory complications, and renders it as safe as the RNY technique. Many bariatric surgeons shun the procedure, while those doing the procedure claim to have many satisfied patients.

The other procedure in this group is of Duodenal switch. With this procedure, the surgeon removes approximately 60 percent of the stomach so that it takes the shape of a tube. The small intestine is then divided much further downstream than with gastric bypass so that more intestine is bypassed and two intestinal pathways are created: one for food, and one for the digestive juices, both of which meet to form a common channel. Duodenal switch preserves the pylorus and the outlet muscle that controls emptying of the stomach. It also offers the ability to eat near normal portion sizes and produces reliable weight loss. Since this operation induces a state of decreased absorption, patients typically experience more bowel movements and need to be monitored for vitamin, mineral, and protein levels.

 

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PURE MALABSORBTIVE PROCEDURES

JIBBPDThe stomach is joined to the intestine at a point further down to cause malabsorbtion of the consumed food. Jejunoileal bypass (left picture) and bilio-pancreatic bypass (right picture) had serious nutritional complications and are not done commonly.

·        These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard gastric bypass. procedure. These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.

 

RISKS : For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but VERY RARELY may be a permanent lifelong occurrence. Abdominal bloating and malodorous stool or gas are common. Lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. Nutritional deficiencies of iron, vitamin B12, folate, calcium, and the fat soluble vitamins A, D, and E can occur. Lifelong vitamin supplementing may be required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment. Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder and re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers. Revision of the gastric bypass is required in 2% to 15% of cases as a result of staple line dehiscence, marginal ulcer, outlet stenosis, or inadequate weight loss.

 

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RE-DO BARIATRIC SURGERY

 

·        Patients who require revisionary surgery can be categorized into two groups.

  1. 1. Those with insufficient weight loss

  2. 2. Those with metabolic or surgical complications

·        Gastric band cases would need removal of the band and either a sleeve gastrectomy or a gastric bypass. Sleeve gastrectomy patients would need a duodenal switch or gastric bypass. Gastric bypass patients may need lengthening of bypassed intestine or a re-do of the procedure. Stomaphyx and some other endoscopic devices have been tried in this group but long term results are not known.

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WHICH IS THE BEST LAPAROSCOPIC BARIATRIC SURGERY ( MINIMAL ACCESS / ROBOTIC SURGERY FOR OBESITY ) ??

    There is no best surgery. Had there been a best surgery, the others would not have existed.

So how do we decide ?

Well this is done on the following basis 

  • BMI of patient, current weight and target weight

  • Presence of other problems like Diabetes, Gastroesophageal reflux etc
  • Dietary habits of the person

  • Physical activity and motivation for exercise on a long term basis

  • Experience of the surgeon for a particular procedure

  • Persons choice after knowing the benefits and side effects of each procedure ( see below )  

BandSleeveBypass

Now that was a very confusing list but I am sorry that is the best that we know at present. So that is why it is important that the surgeon is experienced in all three procedures so that he can offer the most suitable one to the patient. It is somewhat like a camera shop that keeps Sony, Nikon and Cannon digital cameras !!

ROBOTIC vs LAPAROSCOPIC BARIATRIC SURGERY

Laparoscopic bariatric surgery has replaced open surgery in most abdominal operations including bariatric surgery. Of late, Robotic surgery has gained popularity due to the added advantages of 3D vision, precise and accurate tremor free instrument movements and lack of surgeon fatigue while suturing and dealing with heavy abdominal wall in patients of morbid obesity. This technology is however available in limited hospitals across the world due to the capital expense in setting it up. Many laparoscopic surgeons however are dismissive about this procedure saying that nothing extra is gained by it. Click on video link on right to see how a robotic gastric bypass surgery is done.

 

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OTHER PROCEDURES ( new !! long term results awaited )

Intragastric Balloon is a soft, silicone balloon that is inserted into th stomach and filled with sterile saline. with the balloon you will have a feeling of satiety, or lack of hunger. The balloon will be removed after six months. Short term results are not good as a lot of patients complain of bloating and vomiting leading to early removal of balloon. Weight regain is also common after removal of the balloon.

The Gastric Stimulation System is designed to provide electrical stimulation to the stomach for the treatment of obesity. The system is comprised of an implantable pulse generator, an external programmer, and a gastric stimulation lead. The implanted pulse generator delivers electrical pulses to the stimulation lead. The lead conducts the pulses to the smooth muscle of the stomach. The external programmer can noninvasively communicate with the implanted pulse generator and allows the electrical parameters to be adjusted. The lead is implanted in a laparoscopic procedure with 2 - 4 trocars used during the implantation: one for the camera, two for operating ports and one (optional) for liver retraction. It is placed in a subcutaneous pocket in the abdomen. The regular surgery time is less than one hour. Gastric stimulation is designed to help patients lose weight in combination with standard behavior and dietary modifications. It is normally indicated for patients with a body mass index (BMI) of greater than 40 or 35-40 with one of more comorbidities. The programmer consists of a computer connected to a small programming wand. It is used to check and, if necessary, change electrical values of the IGS before and after implantation. Communication is accomplished noninvasively via radio frequency signals.

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LIPOSUCTION AND ABDOMINOPLASTY SURGERY

Plastic surgery in the form of suction of fat deposits from back of thighs, sides of abdomen and back of arm are advocated for those who have a BMI less than 35 but are troubled by the fat deposits. This procedure involves sucking of fat using special syringes. Abdominoplasty is a form of plastic surgery also known as apronectomy or tummy tuck and is done for loose overhanging skin in people with normal BMI. This is also done in people who have undergone bariatric surgery and then have loose skin after the weight has stabilized.

COST OF BARIATRIC SURGERY

Table below should give an idea of costing by the hospitals. The charges vary depending on the size of the hospital and the city they are located. These are starting charges with basic accomodation. With stay in special rooms and suites, cost would go up.

No. HEADING BAND / SLEEVE BYPASS
1 Operation charges ( surgery and anesthesia ) 500 800
2 Operation room charges ( OR, Consumables, Medicines ) 1000 1200
3 Staplers / Lap Band (Expensive imported from Europe / USA) 2500 3000
4 Room charges @   100/day 100/day
5 Doctors visits 500 500
6 Investigations 400 400
TOTAL ( APPX ) 5000 6000

TOTAL COST SHOULD BE AROUND $6000 IN MOST CASES OF GASTRIC BYPASS AND AROUND $5000 FOR GASTRIC BANDING / SLEEVE RESECTION
There could be an addtional charge for Robotic Surgery - so please check that when planning.

(COULD FLUCTUATE AS PER DOLLAR RATES )

Hospitals may be offering the treatment for lesser cost by squeezing the expenses, but it should be kept in mind that cost squeezing at times binds the hands of the treating doctors and may not be always in the best interest of the patient. Doctors usually would like to have the liberty of keeping the patient in the ICU for a day, extra day stay in the hospital, extra tests or medicines to be on the safer side etc.

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Dr Arun Prasad