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Bariatric Surgery

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Laparoscopic Bariatric Surgery

Bariatric surgery is the only scientifically proven method for permanent and effective weight loss. Mechanism of weight loss after this is different from other methods. 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. Bariatric surgery is performed on stomach and small intestine. Excess fat is not removed in this method. 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. These are benefited from bariatric surgery. Bariatric surgery is very safe and effective tool for permanent weight loss.

ELIGIBILITY FOR BARIATRIC SURGERY

Obese individuals with BMI ≥ 30 kg/m2 with at least one medical co-morbid condition or BMI ≥ 35 kg/m2 even without co-morbid conditions are eligible for laparoscopic bariatric surgery. It is considered as a non primary alternative if the BMI is ≥ 27.5 kg/m2 but < 30 kg/m2. In western countries these cut off limits are 35 kg/m2 and 40 kg/m2 respectively. Higher BMI increases the incidence and severity of obesity associated medical problems. If these BMI categories are strictly applied to decide eligibility for bariatric surgery then many obese individuals will have no effective therapeutic options left. As bariatric surgery is very safe and effective, generally 30 kg/ m2 is taken as a cut off limit for bariatric surgery in India, regardless of associated medical problems.

Obese individuals should understand various surgical options, their mechanism of weight loss and the need for lifestyle modifications after surgery. They need to come for regular follow up at specified intervals. After diversion procedures, patients need to be on lifelong vitamin and mineral replacement.

TYPES OF LAPAROSCOPIC BARIATRIC SURGERIES

These are two main categories.

(1) Operations that restrict food intake

  • Laparoscopic adjustable gastric banding (LAGB)
  • Laparoscopic greater curve plication (GCP)

(2) Physiological operations that lower set point for fat storage

a) Laparoscopic sleeve gastrectomy (SG)

b) Diversion Procedures

  • Laparoscopic Sleeve Gastrectomy with Loop Duodenojejunal Bypass (SG – LDJB)
  • Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass (SG – DJB)
  • Laparoscopic Roux–en–y Gastric Bypass (Lap RYGB)
  • Laparoscopic Mini Gastric Bypass (Lap MGB)
  • Laparoscopic Bilio-Pancreatic Diversion with Duodenal Switch (Lap BPD-DS)
  • Laparoscopic Single Anastomosis Duodenoileal Bypass with Sleeve (Lap SADI S)
  • Laparoscopic Sleeve Gastrectomy with Duodenoileal Interposition (Lap SG-DII)
  • Laparoscopic Sleeve Gastrectomy with Jejunoileal Interposition (Lap SG-JII)

Presence of certain factors makes patients more or less suitable to one or other type of bariatric surgery. For example RYGB operation is not suitable for patients who need to take pain medications on regular basis. SG is preferred for patients at extremes of age, prior abdominal surgeries with extensive adhesions. Patients with large hiatal hernia or para-esophageal hernia, those who cannot come for regular follow up, who are super obese are not suitable for LAGB.

SLEEVE GASTRECTOMY & DIVERSION PROCEDURES RE-SET THE FAT SET POINT

Sleeve gastrectomy and diversion procedures like are physiological operations that alter several hormone levels in the body resulting in reduced fat set point. 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. Previously it was thought that the food restriction and mal-absorption are the main causes of weight loss. 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. Sleeve gastrectomy and diversion procedures are more effective than purely restrictive operations in inducing weight loss.

In purely restrictive operations like LAGB and greater curve 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. But these two operations won’t alter the fat set point. 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 less effective than those that reduce fat set point. Majority of the patients come for band removal or revision of greater curve plication.

COMPLICATIONS OF BARIATRIC SURGERIES

Bariatric surgeries are very safe when performed on suitable candidates after obtaining fitness. Complications are rare. 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.

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. If there is any suspicion, additional sutures are applied over the staple line. 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. In this way several complications are prevented.

RYGB has certain disadvantages – There is no valve mechanism to control stomach pouch emptying. This results in dumping of food into small bowel leading to fluctuation in blood glucose levels. As food doesn’t enter duodenum at all, there is risk of calcium, iron and magnesium deficiencies even if mineral supplements are given. As major portion of stomach is disconnected, it is not possible to find out any ulcer or cancer problems that develop in the stomach by means of endoscopy. All the problems associated with RYGB are avoided in SG – DJB. Calcium and iron deficiencies generally do not occur after SG – DJB, as first 4 cm of the duodenum is not bypassed.

In diversion procedures, there is risk of vitamin and mineral deficiencies, as food doesn’t enter proximal part of small bowel. So lifelong vitamin and mineral supplements are prescribed after diversion procedures.

ADVANTAGES OF LAPAROSCOPIC METHOD

Bariatric surgery is performed either by open method (cutting the tummy) or by laparoscopic method (putting small holes in the tummy). Compared to normal individuals, obese individuals are at high risk of developing postoperative lung collapse, lung infections, deep vein thrombosis (blood clots in legs), wound infections and incisional hernias. Compared to open surgery, these complications are significantly less after laparoscopic surgery. After laparoscopic bariatric surgery patient can walk on the same day, go home within 2 days and resume normal activities in 1 to 2 weeks. Cosmetically it is excellent as only small holes are created to perform surgery. Because of these uses, laparoscopic bariatric surgeries are popular.

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.

REVISIONAL BARIATRIC SURGERIES

Bariatric surgery is the only scientifically proven method for sustained long term weight loss. Any type of bariatric surgery is considered successful if that procedure can provide more than 50% excess weight loss in greater than 75% of patients for more than 5 years. It is possible that small percentage of patients regain weight after maintaining successful weight loss for few years. If gastric banding fails it is converted into either sleeve gastrectomy or gastric bypass by revisional surgery. If SG fails, either redo sleeve gastrectomy or conversion to SG – DJB or BPD – DS can be performed. If RYGB fails then it can be converted into LRYGB or BPD – DS. Nevertheless revisional surgery is technically challenging.

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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