Bariatric and Metabolic surgery in india
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 the 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.
Non-surgical treatment of morbid obesity
Nonsurgical treatments include caloric restriction, exercise, behavior modification and drug therapy. 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. However, 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 anaerobic exercises to ensure fat loss without loss of muscle mass. Long-term success with behavior 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. 10% weight loss is seen but is regained once the medicine is stopped. Xenical and Reductil are the most popular drugs prescribed.
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.
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. An 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 due to removal of Ghrelin producing fundus and incretin effect on metabolism. This is useful in those with a BMI between 35 and 45.
Risks: The pouch may stretch and long term results of weight loss are awaited.
Combined Restrictive and Malabsorbtive is a procedure where 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.
The 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.
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.
Which is the Best Laparoscopic bariatric surgery (Minimal Access / Robotic surgery for Obesity) ??
Procedure is tailored to patients based on the following:
- 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
Current surgical therapies for morbid obesity
Surgical approach can be by 3 methods
- Open surgery (not done any more)
- Laparoscopic Surgery (most centres)
- Robotic Surgery (selected centres)
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.
Dr. Arun Prasad
MBBS, MS, FRCSEd, FRCS
Senior Consultant Surgeon - Minimal Access Surgery
Gastro intestinal, Robotic, Bariatric & Thoracoscopy
Apollo Hospital, New Delhi, India