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Bariatric & Obesity Surgery

How is OBESITY measured?

It is calculated from a simple formula of wt/ht2 or (kgs)/ (m)2 which results in a term called the BMI or Body Mass Index. This allows us to appropriately classify the severity of the weight problem.

What are the indications for OBESITY Surgery?

  • A BMI of 37 or greater, with or without any obesity-related illnesses, or a BMI less than 37 with the associated illnesses (co-morbidities) listed below or as per the clinician if med fails
  • Most of which are known to reduce the life expectancy of the patient.

Some of the more common Co morbidities are:

  • Type 2 Diabetes : People who are obese become resistant to insulin (which regulates a period of blood sugar levels). Over time the constant elevation of the blood sugars affects many organ systems in the body. Resultant damage can include kidney failure, heart disease, blindness, and susceptibility to severe infections. Type 2 Diabetes can be cured in majority of these pts after obesity surgery.

  • High blood pressure / Heart disease : Obesity leads to elevated cholesterol/triglycerides and causes the heart to work under extreme conditions. These can result in inadequate pumping mechanisms or poor oxygen flow leading to heart failure, heart attacks, strokes, kidney failure & poor circulation in lower legs.

  • Arthritis : Additional weight is placed on multiple joints and their support structures. These include the knees, hips, and back causing rapid degeneration leading to pain ,inflammation, and lack of mobility.

  • Sleep apnea / Respiratory problems : Fat deposits in the tongue and neck which can block the airway causing a person to temporarily stop breathing during their sleep, especially when sleeping on their back. This causes them to lose sleep and results in daytime drowsiness, fatigue and headaches.

  • Gastroesophageal Reflux Disease nia and heartburn): Increased intrabdominal pressure weakens and overloads the valve at the top of the stomach, which then allows stomach acid to escape and irritate the esophagus. Approximately 10-15% of patients with even mild heartburn can develop Barrett's esophagus, which is a pre-malignant change that can progress into esophageal cancer.

  • Depression : People who are obese must deal with constant emotional challenges such as lack of self-confidence, poor self-image due in part to social discrimination. This leads to social isolation.

  • Infertility : Obesity wreaks havoc with male and female hormones, disrupting normal cycles and function, and leading to inability, or difficulty to conceive, or even a miscarriage. The commonest associated condition is PCOD (Polycystic Ovarian Disease)

  • Urinary stress incontinence : Increased intraabdominal pressure stresses the muscles of the pelvic floor compounding the effects of childbirth, which can lead to improper function of the bladder. This results in leakage of urine when coughing, sneezing or laughing or inability to hold the urine until the patient can reach a toilet.

  • Menstrual irregularities : Morbidly obese individuals often experience menstrual disruptions, such as heavy frequent, irregular or absent periods and increased pain during the cycle.

  • Blood Clots : Obesity can lead to faulty valves in the veins that promotes sluggish flow in vessels causing a clot in the lower limbs. The most feared problem is when one of these clots breaks away and floats into the lungs. This is called a Pulmonary Embolus and can be a fatal complication

  • Cancer: Some types of cancers are more common in the obese; e.g. ovarian, endometrial and breast in females, gallbladder and prostates in males to name a few.

  • Hypoventilation of Obesity - The increased weight of the chest wall dramatically affects the efficiency of breathing thus decreasing the amount of oxygen available to the body.

Almost all the above mentioned Co morbidities are potentially reversed by Bariatric surgery

What is the role of non-surgical treatment of Morbidly Obese?

Non-Surgical Treatment includes Drugs, Low calorie Diets and Exercise programs. Drugs (Sibutramine,Orlistat) do not have long term significant weight loss, need to be taken for long time and may have significant side effects. Drug effects are temporary as weight is regained on stopping the drug. Low calorie diets and exercise programs again have temporary effects.

Surgical Treatment is the only proven approach to the treatment of Morbid Obesity adjuvant to lifestyle modifications.

When do we consider surgery?

Patients considered for weight loss surgery must be at least 100 pounds overweight and have a BMI of at least 37 or a BMI of 33 with associated comorbidities such as hypertension, diabetes, or sleep apnea etc. Weight loss surgery is definitely not for those who want a quick fix or who simply don't want to diet. So a history of documented dietery weightloss attempts is asked to identify patients with lifelong commitment to follow-up care and extensive dietary, exercise and medical guidance.

Surgical

We recommend considering surgical weight loss options for these patients. In fact, the risk of death from not having surgery is greater than the risks of surgery ( see Obesity related conditions)

Types of Bariatric Surgery

  • Restrictive procedures make the stomach smaller to limit the amount of food intake giving early satiety and fullness

  • Restrictive and Malabsorptive techniques reduce the amount of food intake and also limit the length of intestine that comes in contact with food so that the body absorbs fewer calories

Gastric Sleeve--Sleeve Gastrectomy--Vertical Sleeve Gastrectomy(VSG)--Vertical Gastroplasty—

Greater Curvature Gastrectomy--Gastric Reduction:

  • The Vertical sleeve gastrectomy (VSG) generates weight loss solely through gastric restriction (reduced stomach volume).

  • In VSG approximately 2/3 of the stomach is stapled off along its greater curvature, leaving behind 1/3rd stomach along lesser curvature, which is roughly the size and shape of a Banana or Sleeve.

  • This operation does not involve any “rerouting” or reconnecting of the intestines. Hence it is technically a simpler operation than the gastric bypass.

  • Food absorption is normal, with no malabsorption.

  • It is known to reduce hunger because Ghrelin (hunger stimulating hormone) producing part of stomach is removed.

  • Provides satiety with small amount of food and unlike gastric band & gastric bypass, patients feels full with liquids as well.

Gastric Banding

The Adjustable Gastric Band is a hollow band made of sylastic which is placed around the upper third portion of your stomach to create a small stomach pouch that initially holds 2 ounces of food, and eventually holds up to 4 to 6 ounces. Creating this restricted stomach space in the upper portion ofthe stomach causes a longer lasting feeling of fullness because the nerves that signal the brain when you're full are located in the upper area of the stomach. The band further works by slowly allowing the food you eat to be released into the lower portion of the stomach for digestion. Patients are allowed to return home the same day or sometimes require to stay overnight with release from the hospital about 24 hours post surgery. This can be done in the outpatient department during followup visits.

Adjustment:

Immediately after surgery the band is empty. About six weeks after surgery, or whenever a plateau in weight loss is reached, the surgeon may add a small amount of saline in the band. While the band can hold about 4 to 5 cc's of saline, only small amounts of saline are added each time.

This can be done in the outpatient department during follow up visits.

Advantages of gastric band:

  • It can be adjusted to increase or decrease restriction.

  • Surgery can be reversed.

  • Digestion and absorption is normal.

Gastric bypass operations

Gastric bypass procedures are combination operations. That is, they combine both restrictive and malabsorptive techniques:

  • Create a small stomach pouch to restrict the amount of food you can eat.

  • Construct a bypass of the duodenum and other parts of the small intestine to cause malabsorption.

Gastric Bypass (Roux-en- Y gastric bypass )

Roux-en- Y Gastric Bypass (RGB). This is the most common bariatric procedure. First, small stomach pouch is created with staples. This restricts food intake. Then a Y shaped section of the small intestine is attached to the pouch to allow food to bypass the first and second segments of the small intestine.Thereby changing various hormones secreted by this part.

Thus it helps to cure Type 2 Diabets. This reduces your body's ability to absorb nutrients and calories.

Duodenal Switch(BPD - DS)

(Duodenal Switch, Biliopancreatic Division (BPD). BPD procedure 3/4 of stomach is removed which restricts food intake and reduces acid output. The small intestine is divided and attached to the stomach pouch so that the food you eat moves through the intestine with little absorbtion. In duodenal switch stomach is sleeved retaining the natural stomach outlet. the majority of the small intestine is bypassed so very little food is absorbed.This is generally performed in super obese patient.

Role of Liposuction

Liposuction / lipoplasty / suction lipectomy - is commonly mistaken as an anti-obesity procedure.

It is best for removal of abnormal fat deposits in non-surgical candidates for cosmetic body contouring. So the best candidates are normal weight people with firm, elastic skin who have pockets of excess fat in certain areas that do not respond to traditional wt-loss methods.

It is not recommended as a treatment of morbid obesity. It can be an adjunct to surgical procedures after adequate wt-loss has been achieved to remove certian resistant areas of fat deposits.


 
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