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Cutting Out Obesity

Weighing the benefits of bariatric surgery

iStock_000011861744_FullObesity has been a worldwide epidemic for the last few decades. This growing disease is now more prevalent among the young. Above a Body Mass Index (BMI) of 25 is the definition of being overweight. Further, a BMI of above 35 has been classified as being morbidly obese. In the smaller -built Asians, this has been redefined as 32.5.

There are many diseases associated with obesity. They include:

  • metabolic diseases such as diabetes mellitus, hypertension and hyperlipidemia (and all the complications associated with these diseases)
  • cancers such as breast cancer and colorectal cancer
  • chronic joint diseases such as chronic back pain
  • osteoarthritis of the spine, hips, knees and ankles
  • other illnesses such as skin infections, pancreatitis and much more

Those who are obese are also more likely to be depressed and have a shortened lifespan.

Oust Obesity – What are the options?

Diet and exercise are the mainstays of obesity management. However, the chance of weight loss of more than 10%, together with keeping that weight down over a sustained period of time, is less than 2% for the morbidly obese. All these statistics, coupled with the complications of obesity that are a huge financial burden to the family and the state, have stimulated the development of obesity management and surgery (bariatric surgery).

Surgeons or doctors in operating room of hospitalObesity surgery is currently the best method to reduce weight quickly and, more importantly, to sustain that weight loss. The procedures include:

  1. Laparoscopic Sleeve Gastrectomy (LSG)
  2. Laparoscopic Adjustable Gastric Banding (LAGB)
  3. Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)

These procedures are done laparoscopically (or keyhole surgery). There are many advantages of this technique, including less wound pain and complications, less lung complications, shorter hospital stay and faster recovery. The procedures have become very safe as compared to the surgeries done 40 years ago. The standardisation of surgical techniques used and the tremendous improvement in anaesthesia care has resulted in complications being minimised.

Laparoscopic Sleeve Gastrectomy

How it works: The stomach is stapled and divided vertically, close to the oesophagus almost to the area where the stomach ends at the duodenum. By doing this, about three-quarters or 75% of the stomach is removed. The remaining stomach is now in the shape of a long narrow tube resembling a shirt sleeve. The much smaller size of the stomach restricts the amount of food the stomach can hold at a time.

There is also a hormonal component. The fundus of the stomach is removed – this is an area where a hormone called ghrelin is produced. This hormone stimulates the sensation of hunger. By removing the source of its production, patients will not feel hungry anymore.

Results: The procedure is not reversible but over a period of many years, the stomach is known to slowly enlarge. The results of this procedure are very good. About 60% of excess weight will be lost over one to two years, and this can be maintained for at least five to ten years with close follow-up with the doctor. The follow-up and advice from the doctor is the most important factor for maintaining good weight loss over a longer period of time. Complications such as leak of the staple line or bleeding are very low.

Laparoscopic Adjustable Gastric Banding

How it works: This simply involves placing a band, with an inflatable balloon on the inside of it, around the upper portion of the stomach. The band will then restrict the amount of food you can eat. The balloon is connected via a tube to a port that is just below the skin on the abdominal wall. Water can be injected via this port to inflate the balloon on the band. This makes the opening through the band smaller and will further restrict the amount of food consumed.

The tightening of the band is progressively done over many months. On the other hand, water can also be removed if the restriction is too tight. Therefore, the procedure is considered adjustable and reversible. The band will remain in place for life.

Results: The band is easy to insert and the operative complications are very minimal. In fact, the long-term complications such as band erosions and stomach and oesophagus dilatation are a greater worry. Weight loss for the band is just as good as for the sleeve gastrectomy.

Laparoscopic Roux-en-Y Gastric Bypass

How it works: This is recommended for long-term weight loss and improvement of obesity-related medical problems such as diabetes, hypertension and high cholesterol.

A small pouch is first created at the upper part of the stomach. This allows the patient to eat a small amount. Then a part of the mid small intestine (jejunum) is divided and joined to this stomach pouch. This joint is deliberately made small to ensure that the passage of food is slow.

The other divided end of the jejunum is then joined to a part of the small intestine further down the path of the small intestine. This carries the digestive juices of the remaining part of the stomach, liver and pancreas. Thus, enzymes and food mix at a part of the small intestines further away from where this usually happens. The length of intestines left to absorb calories is shorter. This is the cause of malabsorption or decreased absorption of calories that results in weight loss.

Results: This procedure gives the best results in terms of weight loss over a long period of time. Diabetes improves immediately after the procedure even before weight loss. This is due to the hormonal changes that occur after the bypass. We perform this procedure for patients who have severe diabetes, hypertension and high cholesterol. Due to the slightly more complex nature of this surgery, there is a slightly higher rate of complications with regard to leaks and twisting of the bowel.

Intragastric Balloon

Some patients are below the BMI criteria for obesity surgery or are too ill to undergo surgery. They can be offered the Intragastric Balloon. It is inserted into the stomach via gastroscopy under sedation. The balloon insertion is safe with no scars on the abdominal wall. It will then be removed after six months and the projected weight loss is about 15% of the original weight. This is usually done in the day surgery setting and the patient can be home on the same day of the procedure.

There are many other procedures that have been described all over the world. Many of them do cause significant weight loss. The procedures described here are the ones that we do routinely and are the most common procedures done all over the world. They are safe and well researched and have proven long-term good results in terms of weight loss, improvement of obesity-related medical problems and procedural complications.

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Dr Ganesh Ramalingam is a Consultant General Surgeon, Gastrointestinal, Bariatric, Trauma, Endoscopic and Laparoscopic Surgery, at Mount Elizabeth Novena Hospital, Singapore.
Posted by ezyhealth on Mar 5 2015. Filed under Medical Express. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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