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The prevalence of obesity has reached pandemic proportions in 21st century. According to 2007 NFHS, 12.1 % of the Indian males and 16% of the Indian females are either overweight or obese. The problem is compounded by the propensity of obesity to increase the risk of developing other diseases like Diabetes Mellitus(DM), Hypertension(HTN), Hyperlipidemia, Obstructive Sleep Apnoea(OSA), Stroke, and Non Alcoholic Fatty Liver Disease(NAFLD).

 

Lifestyle modifications with diet, exercise, and behavioural modifications still remain the mainstay for treatment of obesity and related comorbidities. However, for the severely obese, the chances of sustained weight loss with diet and exercise alone are less than 3%. 

 

Metabolic surgery, also known as bariatric surgery has emerged in the past seven decades to treat severe obesity and related disorders. The principle of bariatric surgery is either restricting food intake by reducing the stomach capacity or inducing malabsorption by bypassing segments of intestine. Most of the currently done surgeries employ both of these principles to induce weight loss. 



Procedure Schematic Diagram Description Outcome
Laparoscopic Adjustable Gastric Band (LAGB) Inflatable band is placed around the upper part of stomach to create a small proximal pouch. The band is connected to a port implanted in the abdominal wall through a tube which can be used to instill or aspirate saline to adjust the size of the proximal pouch.
  • Percent excess weight loss(%EWL) at 12 months is about 50%.
  • Recent long term data with mean follow up of 14 years reported need for revisional surgery in 53% of patients either due to insufficient weight loss or band related complications.
Laparoscopic Sleeve Gastrectomy (LSG) Popularized initially as first stage procedure for two stage operations in super obese, it has quickly developed as a stand alone procedure. The procedure involves a longitudinal resection of stomach over a bougie with staplers to create a lesser curvature based pouch of about 150 mL.
  • %EWL at 1, 2, 3, 4, and 5 years are 62.4%, 64.7%, 64%, 57.3%, and 60% respectively. 
  • Although not a malabsorptive procedure, positive impact on sugar control has been seen owing metabolic benefits of weight loss.

Procedure

Schematic Diagram

Description

Outcome

Laparoscopic Roux en Y Gastric Bypass (LRYGB)

Introduced in mid 1960s, this is  the best studied procedure in the field of bariatric surgery.

Technique involves creation of a small proximal pouch totally separated from remaining stomach and anastomosed to the Roux limb of jejunum. BPD limb is attached to the alimentary limb bypassing 150-200 cm of small bowel. The length of BPD limb from Ligament of Treitz is 20-50 cm and length of Roux limb is 75-150 cm depending on BMI.

  • % EWL at the end of 2 years is 60-70%.
  • 90% resolution in GERD and venous stasis ulcers.
  • 80% experience resolution of DM in 5 years.
  • 70% experience resolution of hyperlipidemia.
  • 50-65% resolution of HTN. 

Laparoscopic Mini Gastric Bypass (LMGB)/ Single Anastomosis Gastric Bypass (SAGB) 

First described by Robert Rutledge in 2001, this surgery has quickly gained popularity throughout the world.

Stomach is divided at junction of body and antrum to create longest possible gastric pouch. A lesser curvature based tube of stomach is constructed over a bougie using staplers. A jejunal loop 150-200 cm distal to the Ligament of Treitz is brought antecolic and anastomosed to the stomach tube. 

  • % EWL at 12, 18-24, & 60 months are 76%, 74.6%, & 71%.
  • Impact on resolution of comorbidities is comparable to LRYGB. 
  • Advantages include shorter operative time, lower complication rate, better weight loss and shorter operative time.

2013 European Congress at Liverpool and American Society for Metabolic and Bariatric Surgery (ASMBS) have proposed the following indications for bariatric surgery in 2013. 

  1. People with BMI 40 Kg/sq metres or more with or without co-existing medical problems and for whom bariatric surgery would not be associated with excessive risk. 
  2. People with BMI 35 Kg/sq metres or more with comorbidities in whom surgically induced weight loss is expected to improve the disorders such as DM, HTN, OSA, Hyperlipidemia, Obesity Hypoventilation Syndrome, Pickwickian Syndrome, NAFLD, GERD etc.
  3. People with BMI 30 – 34 Kg/sq meters with diabetes or metabolic syndrome may also be offered a bariatric procedure with limited evidence of long term benefit.

 

Classification

Principal cut-off point (Kg/sq meters)

Cut-off points for Indian/Asian population (Kg/sq meters)

Normal range

18.5-24.9

18.5-22.9

23-24.9

Pre obese

25.0-29.9

25.0-27.4

27.5-29.9

Obese class I

30.0-34.9

30.0-32.4

32.5-34.9

Obese class II

35.0-39.9

35.0-37.4

37.5-39.9

Obese class III

>/= 40

>/= 40

*For Asian population, classification remains the same but public health action points are set at 23.0, 27.5, 32.5, & 37.5 Kg/sq meters.

It is well known by now that achieving a significant weight loss and sustaining it with diet and exercise is increasing difficult with increasing BMI. For BMI>40, the chances of sustained weight loss with diet and exercise alone are less than 3%. 

 

Obesity comes with associated group of comorbidities like diabetes, hypertension, arthritis, high cholesterol, and sleep apnea. All of these diseases significantly impact the Quality of Life and reduce the lifespan.

 

Bariatric surgery, by decreasing the weight and improving the metabolic status, significantly decreases mortality and improves quality of life. More than 70% patients experience a total resolution of diabetes, Hypertension and sleep apnea. 



Like all other gastrointestinal surgeries, bariatric procedures are complicated by leaks, bleeding, anastomotic strictures, and marginal ulcers. Internal hernia can be seen after LRYGB.  Nutritional deficiencies are an issue after bariatric surgery and require sincere supplementation and monitoring.

The patient has to undergo evaluation and counselling by a  multidisciplinary team comprising of a bariatric surgeon, anaesthetist, nutritionist, psychiatrist, and primary care nurse at a specialized bariatric centre before surgery. More than 90% people experience very significant improvement in Quality of life and resolution of their comorbidities. Long-term regular follow up is required to sustain the benefits of the procedure.  With the appropriately selected procedure, compliance to lifestyle modifications, and regular follow up following advantages are seen. 

 

  1. Reduction in excess weight, leading to improved and active social and sexual life.
  2. Complete or partial resolution of Diabetes.
  3. Complete or partial resolution of Hypertension.
  4. Resolution of Sleep Apnea Syndrome.
  5. Decreased risk of acute coronary event.
  6. Improvement in sexual and reproductive life.
  1. National Family Health Survey, 2005-06. Mumbai: International Institute for Population Sciences. 2007
  2. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, Schoelles K (2004). “Bariatric surgery: a systematic review and meta-analysis”. JAMA. 292 (14): 1724–37
  3. Garg H, Aggarwal S. Bariatric surgery:current concepts in Roshan Lall Gupta’s Recent Advances in Surgery 14. 
  4. WHO expert consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004; 157-63
  5. The Surgical Management of Obesity Philip R. Schauer and Bruce Schirmer. Schwartz’s Textbook of Surgery. 10th Ed.