• Metabolic Surgery

Bariatric surgery is the only scientifically proven method for permanent and effective weight loss. Weight loss Surgery or Bariatric Surgery means modification or alteration of the gastrointestinal tract to induce weight loss. It includes a range of procedures from simple restriction to combined restrictive and malabsorptive. Excess fat is not removed in this method.  Sleeve gastrectomy and diversion procedures re-set the fat set point to a lower level. This new low fat set point in turn reduce fat burden and maintain low body fat stores. Majority of the obese individuals fail to reduce weight by diet restriction and regular exercise. Even if they lose initially, weight is regained due to the effect of fat set point. Depending upon the age, BMI, food habits, dietary pattern, co-morbidity status and patient compliance, an appropriate weight loss procedure is chosen by the Bariatric surgeon after thorough psychological evaluation of the patient. It is a painless, minimally invasive  procedure with the patient being in the hospital for 3 days. Eligibility Criteria

  • Patients with Body Mass Index:

◦≥ 30 kg/m2 with co-morbid conditions ◦≥ 35 kg/m2 with or without co-morbid conditions It is considered as a non primary alternative if the BMI is ≥ 27.5 kg/m2 but < 30 kg/m2 with uncontrolled diabetes. In western countries these cut off limits are 32.5kg/m2 and 37.5 kg/m2 respectively.

  • Age of 18 to 65 (assessed on individual basis)
  • Documented failed attempts at weight loss for at least 6 months
  • No significant, untreated psychiatric illnesses
  • Sufficient ability and cognition to understand surgery, potential complications and subsequent associated changes
  • Acceptable medical/operative risks
  • Willingness to participate in treatment and long-term follow-up

Obese individuals should understand various surgical options, their mechanism of weight loss and the need for lifestyle and behavior modifications after surgery

  • TYPES OF LAPAROSCOPIC BARIATRIC SURGERIES

 

  • These are two main categories.

(1) Operations that restrict food intake (Restrictive Procedures) Laparoscopic greater curve plication (LGCP) Laproscopic Adjustable gastric banded plication (LAGBP) Laparoscopic sleeve gastrectomy (LSG) Laparoscopic Mini Sleeve (Fundectomy with Plication) (2) Mixed restrictive and malabsorptive procedures) Laparoscopic Roux–en–y Gastric Bypass (LRYGB) Laparoscopic Mini Gastric Bypass (LMGB) Loop duodenojejunal bypass with sleeve gastrectomy  (LDJBSG) Laparoscopic Proximal jejunal bypass with sleeve gastrectomy (LPJBSG)

  • SLEEVE GASTRECTOMY & DIVERSION PROCEDURES RE-SET THE SET POINT FOR FOOD STORAGE

In purely restrictive operations like gastric greater curve plication and adjustable gastric banded plication, stomach size is restricted to receive only small amount of food. As a result food intake is restricted at any given point of time. Postoperative food selection plays a major role in success of these restrictive operations. Patients should be willing to change their food habits after these operations. As a result appetite doesn’t come down. Patient wants to eat more but can’t eat much as a result of restriction of the stomach size. So these operations are effective in patients who are young and can modify their eating habits. Sleeve gastrectomyand Mini Sleeve gastrectomy are physiological operations that alter several hormone levels in the body resulting in resetting of the set point of food storage to a lower level. These hormonal changes include reduced Ghrelin, increased GLP 1, Peptide YY, Amylin etc., resulting in reduced appetite and increased energy expenditure. In SG, as stomach size is reduced there is restricted food intake. In diversion procedures, additionally proximal part of the small intestine is bypassed leading to mal-absorption. Studies showed that 95% people who follow diet restriction without undergoing bariatric surgery regain lost weight, while 95% of people who undergo sleeve gastrectomy or diversion procedures maintain successful weight loss. The difference is that these operations reduce fat set point while diet restriction doesn’t. After these operations weight is lost gradually towards ideal body weight set by the new reduced fat set point. In addition out look towards food is changed and individuals like healthy food. And aversion develops towards most of the unhealthy foods. Diversion procedures are complex surgeries and technically demanding. Vitamin and mineral deficiencies are more after diversion operations.

  • COMPLICATIONS OF BARIATRIC SURGERIES

Bariatric surgeries are very safe when performed on suitable candidates after obtaining fitness. Described complications are bleeding, leak from staple lines, vomitings due to narrowing of stomach, intestinal obstruction (block to the flow of intestinal contents), wound infections, hernias at port sites, lung infections, clots in the legs etc. However, at our center complication rate is <0.5%. Full HD technology and advanced vessel sealing systems (Force Triad, Harmonic, Enseal) are used to prevent bleeding. As gastric tube or pouch is fashioned over a calibration tube passed into the stomach, narrowing of the stomach is rare. Methylene blue solution or air is used to check for leak at the end of surgery. To prevent internal herniation and intestinal obstruction all the gaps in the mesenteric layers are closed. To prevent clots in legs prophylactic low molecular weight heparin and pneumatic compression stockings are used. Prophylactic broad spectrum antibiotics are used to prevent wound infections. Fascial defects at ports larger than 1 cm are closed to prevent port site hernias.

  • ADVANTAGES OF LAPAROSCOPIC METHOD

After laparoscopic bariatric surgery patient can walk on the same day, go home within 3 days and resume normal activities in 1 to 2 weeks. Cosmetically it is excellent as only small holes are created to perform surgery.

  • EXPECTED WEIGHT LOSS AFTER BARIATRIC SURGERY

Depending upon the type of bariatric surgery, weight loss varies between 4 to 7 kg/ month. Patient behavior after bariatric surgery doesn’t decide the amount of weight loss after surgery. Patients are advised to do regular exercise to be fit and healthy. Weight loss varies from individual to individual and procedure to procedure. There can be 50 to 90 % excess weight loss over a period of 1 to 2 years.

  • EFFECT OF BARIATRIC SURGERY ON CO-MORBID MEDICAL CONDITIONS

In addition to weight loss, bariatric surgery results in resolution of medical problems like type 2 diabetes, hypertension, obstructive sleep apnea, hyperlipidemias in significant number of patients. This resolution is more after sleeve gastrectomy and diversion procedures compared to purely restrictive operations. Reason behind this resolution is thought to be due to the alteration of gut hormones like GLP 1, that control insulin production and action, Ghrelin, Anti Incretins in addition to weight loss and calorie restriction. Due to these positive effects laparoscopic metabolic surgery is developed to cure type 2 diabetes. Sleeve gastrectomy and diversion procedures are also metabolic surgeries. If surgery is performed in an individual with BMI ≥ 30 kg/m2 then it is bariatric surgery. If the same surgery is performed with the intention of curing type 2 diabetes in an individual with a BMI < 30 kg/m2 then it is called metabolic surgery. Sleeve gastrectomy with duodeno-ileal interposition (SG-DII) is the most effective metabolic surgery. I even performed this surgery on my brother-in-law who is suffering from uncontrolled type 2 diabetes. Now he is cured of diabetes. All my patients who underwent this metabolic surgery got their type 2 diabetes cured. Sleeve gastrectomy with jejuno-ileal interposition (SG-JII) and sleeve gastrectomy with duodenojejunal bypass (SG-DJB) are other metabolic surgeries in addition to SG, RYGB, BPD – DS. These operations result in resolution of type 2 diabetes in majority of the patients regardless of their weight.

  • COST OF BARIATRIC SURGERIES

Bariatric surgeries are expensive. Main cost is due to usage of high definition technology, staplers and advanced vessel sealers. Given the excellent results of bariatric and metabolic surgeries, these costs should be considered as an investment for future healthy life. If obesity is left untreated, then overall cost to treat associated medical problems and their complications is lot more than the cost of bariatric surgery. This expenditure is saved, as bariatric surgery in addition to weight loss results in resolution of medical problems in significant number of patients.

  • CONCLUSION

Diet control & exercise can prevent obesity. But these are not enough to produce permanent weight loss in obese individuals. Effect of diet control, exercise, very low calorie diet products, naturopathy, liposuction on weight loss is temporary. Bariatric surgery is the only scientifically proven safe and effective method for permanent weight loss. Obese individuals with a BMI ≥ 30 kg/m2 are eligible for bariatric surgery. Among all the existing methods for achieving weight loss only bariatric surgeries like sleeve gastrectomy and diversion procedures are effective in giving long term sustained weight loss. Laparoscopic sleeve gastrectomy is the most popular bariatric surgery in recent times as it reduces fat set point to near normal level without adding mal-absorption. Diversion procedures like SG – DJB or BPD – DS can be added on this in future in case need arise. Laparoscopic gastric bypass has certain disadvantages like dumping syndrome, mal-absorption of iron, calcium & magnesium, at risk gastric remnant etc. These can be avoided with SG or SG – DJB. SG – DJB is equally effective in producing long term weight loss as RYGB. Counseling is needed for the eligible patients who wish to undergo bariatric surgery. Patient needs to be on lifelong vitamin and mineral supplements after diversion procedures. They need to be compliant with the instructions and need long term follow up.

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