What is Bariatric Surgery?
The surgery done to help you in losing weight is called Bariatric Surgery. It works in one or both of the following two ways. The first method restricts the amount of food you can eat by reducing hunger and by causing fullness after a small meal. This is called Restrictive Surgery. It does so by reducing the capacity of your stomach (the organ where food is stored for digestion to begin). The second method causes the food to bypass the area where it is to be digested and absorbed. Hence, the food will only be partially digested, and only some part of it will be absorbed. This is called Malabsorptive Surgery.
Both of these mechanisms lead to a decreased availability of calories to the body leading to consumption of stored fat. This leads to gradual, sustained weight loss. After the target weight is reached, the weight stabilises as a result of a balance between the body's requirement and calories consumed.
What types of surgery are available?
There are a number of surgeries available for weight loss. Some of them are purely Restrictive and some are combined Restrictive and Malabsorptive. The various types of surgeries are
1. Lap Band
2. Lap Sleeve Gastrectomy
3. Lap Gastric Bypass
4. Lap Biliopancreatic diversion (BPD-DS)
These are well established and accepted methods of Bariatric Surgery the world over.
There are many newer methods being developed and studied. Some of them have shown promising results but their long-term risks and benefits are yet to be determined. Some of them are
1. Intragastric Balloon
2. Mini Gastric bypass
3. Endoscopic sleeve
4. Gastric Plication
These procedures are not yet accepted as standard treatment for obesity.
Types of Bariatric Surgery
- Lap Band
In this procedure an adjustable silicon "band" is place around the beginning of the stomach so as to create a small pouch (typically 30-50 ml) hence providing an early feeling of fullness. It is gradually released into the rest of the intestine. This is a purely restrictive procedure. It provides moderate amount of weight loss (50% of excess weight loss) and is reversible. The band needs to be adjusted in the initial days after surgery. Some people will begin to regain some of the lost weight after a few years. The advantage is that it can be reversed by removing the band by another surgery.
- Lap Sleeve Gastrectomy
Also called stomach stapling, this operation involves removal of a large portion of the stomach. The remaining stomach forms a narrow tube of 100-150 ml. This leads to a marked reduction in hunger and fullness after a small meal. It has been shown to provide good weight loss (60% or more of excess body weight) with minimal side-effects. It also causes remarkable improvement in many obesity related diseases like diabetes, high BP, respiratory problems etc. Vitamin and mineral supplements may be required after the operation depending upon your condition and lab results.
- Lap Gastric Bypass
Also called Lap Roux-en-Y Gastric Bypass, it is the "Gold Standard" and has withstood the test of time. In this procedure a small (30-ml) pouch of the stomach is created and joined to the intestine, bypassing a variable length of the intestine. Thus it restricts the capacity of the stomach AND bypasses the digestive tract. This procedure results in good weight loss (60% - 70% of excess body weight) but is associated with more nutritional problems. Hence a close follow-up with your doctor is required and you may be required to take vitamin and mineral supplements for a long period of time.
- Lap BPD-DS
This procedure is called Bilio-pancreatic diversion with duodenal switch. It provides the maximum weight lossbut is associated with the highest number of problems after the operation, many of them being nutritional. Supplements are required life-long and close follow-up is essential. It is also a difficult procedure to perform. Hence it is reserved for extremely obese individuals. It may sometimes be performed in two stages to reduce the risk.
- Lap Mini Gastric Bypass
This procedure is a variation of the standard gastric bypass. It is easier to perform and has been shown to give good weight loss. However its long-term effects and problems have not yet been ascertained. Therefore, this procedure does not form a part of the standard Bariatric Surgery procedures.
Also called Intragastric Balloon Placement, in this procedure a silicone balloon is placed inside the stomach and filled with 1-1.5 litres of saline water resulting in reduction of hunger and early feeling of fullness. The balloon can be left inside for one year after which it is either removed or a new one is placed. This is not a permanent solution as removal of the balloon usually results in the appetite coming back to normal. As a result weight is also gained again. It is usually used in individuals who have a prohibitively high risk for surgery. Once some weight is lost and the patient becomes fit for surgery, a definitive procedure is performed.
- Other Experimental Procedures
Many innovations are going on in this field the world over. Many newer technologies and techniques are being tested. Until the results are validated by long-term studies these procedures cannot be recommended routinely.
What other options are available?
- Medication - There are some medications which are available to help lose weight but most of them are associated with significant side-effects, some of which may be troublesome.
- Herbal Products - There are a lot of herbal products also available, but it is difficult to determine their efficacy and safety.
- Weight Loss Surgery (Bariatric Surgery)- Surgery is an important method to help you lose weight, especially in people who are extremely obese (BMI more than 35, 33 in Asian populations). The surgery is not plastic surgery (which is used to remove fat from various parts of the body in order to give shape to the body), but it changes the way you feel hunger and the way you eat. It will cause you to lose weight gradually over a period of time (typically one and a half to two years) and will allow you to lose more weight than any other method (typically 60-70% of your excess weight). It is also currently the only way to lose large amount of weight and to keep it off. The weight loss you get with surgery is durable weight loss.
Who can get the surgery done?
Any adult who is morbidly Obese (BMI more than 38 or BMI more than 33 with associated problems due to obesity) is a candidate for surgery provided the risk of surgery is not too high. Surgery is recommended with caution to children below 18 years and people above 65 years of age, but can be done if the benefits outweigh the risks.
What are the other benefits apart from weight loss?
Apart from weight loss and increase in general fitness, many diseases which are linked to obesity are remarkably improved Bariatric Surgery. Diabetes is improved in a large proportion of individuals and medicines can be stopped in two-thirds. It may come back after many years but the requirement for medicines is reduced. BP is easier to control and medicines may be stopped. Breathing problems like OSA are resolved. Osteoarthritis of knees is improved considerably. Knee replacement surgery can be delayed by losing weight and the results of knee replacement are better if it is done after losing weight. Other problems like Stress Urinary Incontinence, Fatty Liver and high cholesterol are also remarkably improved. Life expectancy is also improved.
How much weight loss can I expect after surgery?
Right after surgery there will be no weight loss as no fat is removed during the surgery. Rather there will be a gradual and sustained weight loss starting with the first month and lasting for up to two years until your weight stabilises. You can expect to lose more than 60-70% of your excess weight depending upon the type of surgery performed.
Risks of bariatric surgery
- Excess bleeding during the operation.
- Infection during and after operation.
- Unacceptable reaction due to administration of anesthesia.
- Blood clot formation due to patient body conditions.
- Possibilities of lung and breathing problems.
- Possibilities of leaks in the gastrointestinal track.
- Death (though rare).
There are also other potential problems that you may have to deal with. They are :
- Bowel obstruction over a period of time.
- Dumping syndrome resulting in diarrhea and vomiting.
- Gallstones, hernia, low blood sugar, malnutrition, perforation of stomach and ulcers.
Benefits of bariatric surgery
- You will get relief from reflux disease.
- There will be improvements to heart related diseases.
- You will be able to control blood pressure.
- Sleep related disorder will be under control.
- You will less likely contract type 2 diabetes.
- Possibilities of stroke will be reduced.
Bariatric surgery is a major procedure that will leave the patient in hospital for a long time, but the cost of bariatric surgery in India is comparatively lower than in advanced countries. Before you decide on the cost of bariatric surgery in India, consider the benefits of getting it done in India after all the attendant expenses is taken into account.