BARIATRIC SURGERY

     Bariatric surgery is scientifically proven, very safe method for long lasting and effective weight loss. Mechanism of weight loss after bariatric surgery is different from other methods. Sleeve gastrectomy and diversion procedures reset ‘fat set point’ to a lower level by altering several hormones and genes controlling ‘fat mass’.

     These are performed on stomach and intestine by laparoscopic method (by putting small holes on tummy). Bariatric and metabolic surgeries are essentially same. If the purpose of surgery is weight loss, then it is called bariatric surgery. If the purpose of surgery is remission from diabetes and other co-morbid medical conditions, it is called metabolic surgery.

      Majority of the obese individuals fail to lose 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 scientifically proven, very safe method for long lasting and effective weight loss. Mechanism of weight loss after bariatric surgery is different from other methods. Sleeve gastrectomy and diversion procedures reset ‘fat set point’ to a lower level by altering several hormones and genes controlling ‘fat mass’. 

These are performed on stomach and intestine by laparoscopic method (by putting small holes on tummy). Bariatric and metabolic surgeries are essentially same. If the purpose of surgery is weight loss, then it is called bariatric surgery.If the purpose of surgery is remission from diabetes and other co-morbid medical conditions, it is called metabolic surgery.

Majority of the obese individuals fail to lose 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.

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People think that weight loss after bariatric surgeries is mainly due to food restriction and malabsorption. But it is not true. Weight loss is mainly due to physiological and hormonal alterations after surgery. Role of food restriction and malabsorption is secondary. These surgeries alter several hormones and genes that control energy balance. These alterations reduce appetite, increase metabolism and heat production, reset ‘fat mass’ to a lower level leading to long lasting weight loss. These hormonal alterations include increased incretins (GLP 1, peptide YY), reduced anti-Incretins, and reduced ghrelin.

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Individuals meeting following criteria are eligible for bariatric surgery.

If you are an Indian/ Asian,

  • Your BMI is ≥ 32.5 kg/m2 and you have at least one medical co-morbid condition
  • Your BMI is ≥ 37.5 kg/m2 even if you don’t have any medical co-morbid conditions 
  • Your BMI is ≥ 27.5 kg/m2 but < 30 kg/m2, and  you failed to lose weight with lifestyle modifications.

If you are a foreign national,

  • Your BMI is ≥ 35 kg/m2 and you have at least one medical co-morbid condition
  • Your BMI is ≥ 40 kg/m2 even if you don’t have any medical co-morbid conditions 
  • Your BMI is ≥ 30 kg/m2 but < 35 kg/m2, and  you failed to lose weight with lifestyle modifications.

Higher BMI increases the risk of obesity related medical problems. If these BMI categories are strictly applied to decide eligibility for bariatric surgery, then many individuals will have no effective therapeutic options left for weight loss. 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.

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   Sleeve gastrectomy (SG), Roux-en-y gastric bypass (RYGB) and Mini gastric bypass – One anastomosis gastric bypass  (MGB – OAGB) are the most popular bariatric surgeries. But they have certain limitations. Bilio-pancreatic diversion with duodenal switch (BPD DS) is the most effective bariatric surgery since hormonal changes are very high, but malabsorption risk is also very high since most of the small intestine is bypassed. There are several modifications of BPD DS to reduce malabsorption without compromising on efficacy. These include ‘Single anastomosis duodenoileal bypass with sleeve (SADI S)’, ‘Sleeve gastrectomy with loop gastroileal bypass (SG LGIB)’, ‘Sleeve gastrectomy with duodeno-ileal interposition (SG DII)’, Sleeve gastrectomy with jejunoileal anastomosis (SG JIA)’ and ‘Sleeve gastrectomy with loop duodeno-jejunal bypass (SG LDJB)’. Adjustable gastric banding (LAGB), Greater curve plication (GCP) were once popular, but got out dated because of poor results.

KNOW MORE ABOUT DIFFERENT TYPES OF BARIATRIC SURGERIES –

SLEEVE GASTRECTOMY (SG)

SINGLE ANASTOMOSIS DUODENOILEAL BYPASS WITH SLEEVE (SADI S)

SLEEVE GASTRECTOMY WITH LOOP GASTROILEAL BYPASS (SG LGIB)

SLEEVE GASTRECTOMY WITH LOOP DUODENOJEJUNAL BYPASS (SG LDJB)

SLEEVE GASTRECTOMY WITH JEJUNOILEAL ANASTOMOSIS (SG JIA)

ROUX EN Y GASTRIC BYPASS (RYGB)

MINI GASTRIC BYPASS or ONE ANASTOMOSIS GASTRIC BYPASS (MGB – OAGB)

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH (BPD DS)

SLEEVE GASTRECTOMY WITH DUODENOJEJUNAL BYPASS (SG DJB)

SLEEVE GASTRECTOMY WITH DUODENOILEAL INTERPOSITION (SG DII)

SLEEVE GASTRECTOMY WITH JEJUNOILEAL INTERPOSITION (SG JII)

SLEEVE GASTRECTOMY WITH TRANSIT BIPARTITION (SG TB)

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING (LAGB)

BANDED SLEEVE GASTRECTOMY (BSG)

BANDED ROUX EN Y GASTRIC BYPASS (BRYGB)

GREATER CURVE PLICATION (GCP)

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Bariatric surgeries are very safe and highly effective if they are performed on right candidate by qualified surgeons. Major complications like bleeding, leak, blood clots in legs are very rare (< 1%). Hair loss and skin loosening can occur because of weight loss but these are temporary. Once weight is stabilized all the lost hair will come back and skin gets tightened in majority of individuals. Medications are needed to prevent formation of stones in gall bladder during weight loss. Vitamin and mineral supplements are necessary after surgery to prevent deficiencies.

Individuals eligible for metabolic and bariatric surgeries are fully evaluated by a dedicated team comprising of expert metabolic & bariatric surgeon, dietician, endocrinologist, physician, cardiologist, pulmonologist, sleep apnea specialist, psychiatrist and psychologist. This is to perform surgery at maximum safety and minimize risks near to zero. Patients are counseled well about various surgeries, pre & post operative requirements. Operation suites for these surgeries are designed at international standards, equipped with high end technology including full HD laparoscopic systems, advanced vessel sealing devices to perform complex bariatric and metabolic surgeries. Advanced surgical ICU facilities and 24 hr intensive care specialists coverage ensures maximum safety.

Dr. Amar performed ‘Sleeve gastrectomy’ surgery on his father Dr. V. Brahma Reddy in Jan 2014. He lost 34 kg and leading a diabetes free life. Dr. Amar also performed ‘Sleeve gastrectomy with duodenoileal interposition’ surgery on his brother-in-law Mr. Srinivasa Reddy in Mar 2013 for uncontrolled diabetes. He lost 23 kg and his sugars are under control even without medications. He also performed ‘Sleeve gastrectomy with loop gastroileal bypass’ surgery on his mother-in-law Mrs. Vijaya Lakshmi in Aug 2016 for obesity and diabetes. She lost 31 kg and leading healthy active life without diabetes.

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Intra gastric balloon (IGB), endoscopic sleeve gastroplasty (ESG) are less effective compared to bariatric surgeries for weight loss because these endoscopic procedures act mainly be food restriction. Hormonal changes after these endoscopic procedures are negligible. Chances of weight regain are very high once balloon is removed or stomach expands after ESG. They have a role in well motivated individuals with mild obesity.

KNOW MORE ABOUT ENDOSCOPIC METHODS FOR WEIGHT LOSS

INTRA GASTRIC BALLOON (IGB)

ENDOSCOPIC SLEEVE GASTROPLASTY (ESG)

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Sleeve gastrectomy (SG) and gastric bypass (RYGB, MGB – OAGB) are most commonly performed obesity surgeries worldwide. In most individuals, weight loss is long lasting after SG, RYGB and MGB – OAGB surgeries. But some individuals regain lost weight, even after properly performed surgery. This is due to hormonal adaptation or not sticking to lifestyle modifications.

These need revision surgery in the form of adding ‘ileal diversion’. This is necessary to restore significant hormonal changes needed to induce weight loss again. Examples include ‘duodenal switch’ (DS), ’single anastomosis duodenoileal bypass’ (SADI) and ‘loop gastroileal bypass (LGIB)’. Individuals with inadequate weight loss after first surgery, also benefit with revision surgery.

Mr. Srinadh used to weigh 147 kg. He underwent sleeve gastrectomy elsewhere in 2009. He lost 25 kg. But regained even more weight and reached 164 kg. In Mar 2016, Dr. Amar performed revision bariatric surgery, laparoscopic single anastomosis duodenoileal Bypass (SADI) on him. He is now 76 kg. He is happy, healthy and fit.

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SINGLE ANASTOMOSIS DUODENOILEAL BYPASS WITH SLEEVE (SADI S)

SLEEVE GASTRECTOMY WITH LOOP GASTROILEAL BYPASS (SG LGIB)

BILIOPANCREATIC DIVERSION WITH DUODENAL SWITCH (BPD DS)

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Bariatric/ metabolic surgeries can be performed safely even in unmarried females and married females planning for pregnancy in future. These surgeries improve fertility. Only precaution needs to be taken is pregnancy should not be planned in first 18 months after surgery. Obesity leads to infertility. Bariatric surgery improves fertility.

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Bariatric and metabolic surgeries are done in individuals between 18 and 65 years age. Surgeries can be considered in those below 18 years, if all other methods failed to induce weight loss. Surgeries can also be considered in selected individuals above 65 years, if their general condition allow them to undergo surgery.

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