Bariatrics

People tend to gain weight when their calorie intake is far more than the calories spent. The food that we eat is the source of calories. The calories are spent or utilized to perform activities. The calories not spent, converts into fats and is stored in body areas such as thighs, chest, hips etc. There are two ways of losing weight- the first is to decrease the amount of calorie intake, and the second is to increase the number of calories spent. Restricting the food intake can help limit the number of calories. Exercising helps burn calories.

Food eaten moves from the mouth to the stomach, where it is broken down and partially mixed with gastric juices. This food then passes on to the intestine where most of the absorption takes place. The amount of food that can be eaten is decreased if the size of the stomach is reduced by a surgical intervention. The number of calories absorbed in the body can be decreased if the portion of the small intestine from where most of the absorption takes place, is bypassed.

Bariatric surgery is considered a treatment option in the following cases if the patient has been unable to achieve a healthy body weight over a long period of time, even under medical supervision:

• Patients between the ages of 18-65 years
• If the patient has a body mass index (BMI) of over 37.5 kg.m2
• If the patient has a BMI of more than 32.5 kg/m2 who have associated serious weight-related problems such as diabetes, high blood pressure, arthritis or heart disease

Bariatric Surgery will not be done if the following exists:

• Absence of a period of identifiable medical management.
• Patient who is unable to participate in prolonged medical follow-up.
• Non-stabilized psychotic disorders, severe depression, personality and eating disorders, unless specifically advised by a psychiatrist experienced in obesity.
• Alcohol abuse and/or drug dependencies.
• Diseases threatening life in the short term.
• Patients who are unable to care for themselves and have no long-term family or social support that will warrant such care.

Restrictive weight loss surgery is of two types- Adjustable Gastric banding and Vertical Sleeve Gastrectomy. Both operations make less room in the stomach for food.

It is a completely reversible procedure performed laparoscopically. A silicone band is wrapped around the upper part of the stomach to create a small stomach. Small quantities of food can fill up the small stomach providing satiety. The narrow outlet of this small stomach delays progression of food into the intestine and the person feels full for longer periods.

This removes a part of the stomach, making the stomach smaller. This results in a stomach, which is roughly the size and shape of a banana or sleeve. Since this operation does not involve any “rerouting” or reconnecting of the intestines, it is a simpler operation than the gastric bypass or the duodenal switch.

There are several types of gastric bypass procedures, but they all involve bypassing part of the small intestine to varying degrees. For this reason, procedures of this type are referred to as malabsorptive procedures, because they involve bypassing a portion of the small intestine that absorbs nutrients.

Although a gastric bypass procedure is malabsorptive, it can also be restrictive because it reduces the size of the stomach so that the amount of food you can eat is restricted due to the smaller stomach.
A small pouch on the top of the stomach is created by using a special surgical stapler and the pouch is connected directly to a part of the small intestine. After this surgery, when you eat, food bypasses most of your stomach and the first part of your small intestines. That makes this surgery both restrictive and malabsorptive.

Bilopancreatric Diversion with Duodenal Switch surgery is very similar to gastric bypass. It involves two components. A small pouch is created by removing a portion of the stomach and later a portion of the small intestine is bypassed.

While malabsorptive procedures are more effective in contributing to weight loss than those that are solely restrictive, they also carry a greater risk of developing nutritional deficiencies.

Roux-en-Y gastric bypass, the most commonly performed bariatric procedure, is both malabsorptive and restrictive. The procedure involves stapling the stomach to create a small pouch that holds less food, and then shaping a portion of the small intestine into a “Y.” The “Y” portion of intestine is then connected to the stomach pouch so that when food is being digested it travels directly into the lower part of the small intestine, bypassing the first part of the small intestine (called the duodenum) and the first part of the second section of the small intestine (called the jejunum). Bypassing these sections of the intestine restricts the amount of calories and nutrients that are absorbed into the body.

• You must have a dietician evaluation.
• You must have a psychological evaluation.
• In addition to a complete medical history, your physician and anaesthetist will perform a complete physical examination to ensure you’re in good health before undergoing the procedure. You will undergo blood tests or other diagnostic tests.
• You may be asked to begin exercising and alter your diet several weeks before surgery.
• If you’re a woman of child-bearing age, you may receive birth control counselling so that you do not become pregnant in your first year after surgery due to the risk to the foetus from rapid weight loss.

Your surgeon will explain the procedure and give you specific information regarding preparing for surgery. You will be advised to:

• Quit smoking and discontinue the use of all tobacco and nicotine products as it may lead to delayed wound healing after the surgery.
• Drink more water and limit other beverages.
• Stay mentally and physically fit by focusing on your health.
• Not to eat or drink anything for 10-12 hours before surgery and have a light dinner because the stomach must be empty before anaesthesia
• Ask a friend or family members to be at the hospital during the surgery for support.

Weight loss surgery is major abdominal surgery with significant risks. However, experience counts and our Consultants have an extremely low complication rate. The following potential complications include, but are not limited to:

• risk from general anesthesia
• bleeding
• infection
• pneumonia
• blood clot in the legs or lungs
• hernias (internally or externally)
• blockage or obstruction
• injury to liver and/or spleen
• pulmonary and/or cardiac and/or renal failure

There’s a risk of needing another operation or conversion to an open operation with a bigger incision. One of the most serious complications of gastric bypass is a stomach leak that can cause peritonitis to develop. Peritonitis is an inflammation of the peritoneum, the smooth membrane that lines the cavity of the abdomen.
There may be other risks depending upon your specific medical condition.

With the gastric band, there’s a risk that the band can either slip or erode.
There’s a risk that you will not lose weight if you don’t follow the diet and exercise program.

With the gastric bypass procedure, malabsorptive symptoms may be more serious, with an increased risk of anaemia. Your body may not absorb adequate amounts of iron, calcium and vitamin B12, leading to the risk of metabolic bone disease and osteoporosis.
Stomal stenosis occurs when there is a stricture (tightening) of the opening between the stomach and intestine after a Roux-en-Y procedure. When this occurs, vomiting after eating and sometimes after drinking may occur. Stomal stenosis can be treated easily but should be treated immediately.
“Dumping syndrome” is likely to occur with these procedures because the food in the stomach moves to the intestines quickly. Symptoms include nausea, sweating, fainting, weakness and diarrhoea.
Be sure to discuss any concerns with your physician prior to the procedure.

You will be encouraged to move around as much as you can while you are in bed, and then to get out of bed and walk around as your strength improves. This is your best defence against blood clots.
At first you’ll receive fluids through an Intravenous infusion. After a day or two you’ll be given liquids, such as broth or clear juice, to drink.
Your physician will instruct you about how long to eat pureed foods after surgery. By one month after your procedure, you may be eating solid foods. You’ll meet with the dietician before going home and while you’re here, you’ll have a clear liquid diet that will be limited to a medicine cup every 15 minutes.
A nutritionist will instruct you about taking nutritional supplements to replace the nutrients lost due to the reconstruction of the digestive tract.
You will be discharged from the hospital after two to five days based on the type of surgery. Before you’re discharged from the hospital, we’ll schedule an appointment for a follow-up visit with your physician.

Visit your surgeon as scheduled as it is very important to keep him informed about the progress.

You should call your doctor immediately, in case of:

• fever of 100⁰F or above
• redness, swelling or increased pain or drainage from the wound
• chest pain or shortness of breath
• nausea or vomiting that may last for more than 12 hours
• pain or swelling in the legs

Continue the breathing exercises you began in the hospital, and gradually increase your physical activity as tolerated. It may take several weeks to return to your previous levels of stamina. You may be instructed to avoid lifting heavy items for several months in order to prevent strain on your abdominal muscles and the surgical incision.
Weight loss surgery can be emotionally difficult because you’ll be adjusting to new dietary habits and a body in the process of change. You may feel especially tired during the first month following surgery. But once your body adjusts, you’ll start to feel better. Exercise and attending a support group can be helpful at this time.

You need to take complete rest for one or two weeks before performing daily activities like exercising and jogging.
You may return to normal activities within a week after laparoscopic adjustable gastric banding and two to three weeks after laparoscopic gastric bypass surgery. The surgeon may allow activities like walking and changing position in bed on the very first day after the surgery. Doing these activities promotes circulation, speeds up the recovery and minimizes complications.

The gastric bypass operation allows you to lose up to 80% of your excess body weight. It is almost 100% effective in reversing obesity related co-morbidities including sleep apnea, hypertension and diabetes.
The adjustable gastric banding operation allows you to lose 50% of your excess body weight at two years. It’s also effective in reversing obesity related co-morbidities.
The sleeve gastrectomy is between the gastric bypass and gastric banding in terms of weight loss with 60% excess weight loss at 1 year.

It’s very important that you understand this surgery won’t remove your sense of hunger. It won’t cause you to lose your desire to eat and it won’t remove any of the psychological cravings that you may have for food. If you eat when you’re stressed, you’ll still feel like eating when you’re stressed. Therefore, it’ll be very important that you understand the stresses that make you feel like eating and identify other ways of resolving these issues. Part of your Bariatric Surgery team will include a psychologist to help you understand your eating triggers and how to cope with them.

Daily intake of protein with a multivitamin & mineral intake will prevent any possible nutritional deficiency. Iron & calcium supplements are required as well. Special dietary advice is provided to post-op patients & regular follow up is essential.

Patients are strongly advised to resume physical activity after surgery to ensure that body metabolism is maintained at high levels. All recommendations are in relation to time after surgery.
Long walks: 10 days later
Aerobic activities like swimming: 20 days later
Weight training etc.: 30 days later
Abdominal exercises: 3 months later
Do not lift heavy objects during the first six weeks after the surgery.