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Laparoscopic Bariatric (Obesity) Surgery

Ramen Goel
 

Bariatric surgery is the only available definitive treatment modality to achieve significant and sustained weight loss in obese. At present the surgery is performed in patients with BMI > 35 kgs/sq m. National Institute of Health, USA has recommended that " …in morbidly obese individuals, where conservative measures have failed, bariatric surgery is the only available treatment modality to achieve sustained weight loss and reduce obesity related morbidity….”1

Historically, bariatric surgery started in early 50s with the Jejuno-ileal bypass (JIB) producing dramatic weight loss results. Most of JIB patients subsequently developed serious mal-absorptive complications with resultant abandonment of the procedure. Subsequent procedures like Gastroplasty (Mason and Printen, 1971),2 Gastric Bypass (Mason, 1967),3 Bilio-Pancreatic Diversion (Scopinaro), Gastric Band (Kuzmak, 1983)4 were performed as open surgical procedures. In 1993, Belachev and colleagues began performing Laparoscopic Gastric Banding,5 Wittgrove and Clarke performed lap gastric bypass in 1994,6 which changed the outcome of the surgery completely. This led to significant reduction in peri-operative morbidity and mortality. Now, majority of bariatric surgeries are performed through minimally invasive route with higher patient acceptance.

Types of Bariatric Surgeries
A – Restrictive —Reduction in stomach capacity results in satiety with small meals. This leads to reduced calorie intake and consequent weight loss. The different kinds of restrictive procedures include

  • Intra-gastric Balloon (BIB)
  • Gastric stapling / Vertical Banded Gastroplasty (VBG)
  • Gastric banding (LAGB)
  • Sleeve Gastrectomy
B - Mal-absorptive – Reduced stomach capacity with small bowel bypass results in reduced calorie intake along with reduced calorie absorption. The different kinds of mal-absorptive procedures include
  • Gastric bypass (RyGBP)
  • Biliopancreatic diversion (BPD)
  • Duodenal Switch (DS)

    Indications for Bariatric Surgery1
  • Patients with Body Mass Index > 40 kg/sq m
  • BMI > 35 kg/sq m with co-morbidities.
  • Age – 18 to 65 years.
  • Minimum 5 years obesity.
  • Failed conservative treatment.
  • No alcoholism or psychosis.
  • Agrees to long follow – up.

Fig. 1 : Vertical banded gastroplasty.

Fig. 2 : Gastric band surgery.
   

Fig. 3 : Gastric bypass surgery.


Fig. 4 : Effects of VBG, Obesity Surgery, 2002; 12 : 319-323.
   


Fig. 5 : Effects of VBG, Obesity Surgery, 2002; 12 : 319-323.


Fig. 6 : Effects of VBG, Obesity Surgery, 2002; 12 : 319-323.

 

In USA, 60% population is overweight and 8-10 million people are morbidly obese and may require surgery over a period of time. In India, the incidence of overweight in different studies vary from 40%-76% and thus the problem is no less serious.

Post – Op Course
The post operative recovery varies with the type of surgical procedure. However, like any other laparoscopic surgery, all patients are mobilized in the evening and orally allowed within 24 hours of the surgery. Gastric band patients are sent home next day after surgery while patients of RyGBP or BPD usually stay in hospital for 4-6 days. The post-op complications may include infection, pulmonary atelectasis, DVT, pulmonary embolism, anastomotic leak, incisional hernia etc. The peri-operative mortality in most of series is < 0.3%.

Post gastric band surgery patients need gastric band adjustment (tightening), usually 2-3 times in the first year. This is an OPD procedure and done under local anaesthesia.

The weight loss after surgery is usually 50-90% of excess weight, depending on the type of procedure, patient’s adherence to post-op instructions etc. Most of the patients are able to maintain 50-65% excess weight loss even 5 years after surgery.

Open Vs Laparoscopy
The laparoscopy has completely altered the results of bariatric surgery for following reasons –
-Smaller incisions results in less pain and better post-op respiratory effort in obese, whose pulmonary functions are already compromised.
-Early mobilization reduces risk of pulmonary embolism in patients with diminished vascular return and difficulty in walking
-Reduced possibility of wound dehiscence results in reduced hospital stay and significant reduction in incisional hernia incidence (cf 30% in open surgery)
-Higher acceptance of surgical option for weight loss

Surgery vs. Non Surgical Weight Loss Options
Non surgical treatment of morbid obesity (diet+exercise+behavioural therapy+medicines) may result in weight loss but recidivism rate is > 90%. In contrast, post-surgically > 50% patients are able to maintain > 50% weight loss even after 5 years.

The associated co-morbidities worsen with each failed attempt to maintain the lost weight. However, post mal-absorptive procedure, > 65% type II diabetic patients are cured of their illness, 25% do not require anymore medication and 10% are controlled diabetic with reduced medication.

Similarly, in patients with high triglyceride levels, a precipitous drop is noticed after bariatric surgery (BPD)

Current Status
In USA, over 150,000 bariatric surgeries were performed in 2004 and the numbers are expected to increase further. Bariatric surgery is gradually gaining acceptance in Indian society. At present, 8-10 surgeons are performing this surgery in India.

References

  1. Grundy SM. Gastrointestinal surgery for severe obesity: NIH Consensus Development Conference Panel. Ann Intern Med 1991; 115 :956-61.
  2. Mason EE. Vertical banded gastroplasty for morbid obesity. Arch Surg 1982; 9117:701-7.
  3. Mason EE, Ito CC. Gastric bypass in obesity. Surg Clin North Am1967; 47 : 1345-54.
  4. Kuzmak LI. A review of seven years’ experience with silicone gastric banding. Obes Surg 1:403-408, World J Surg 1998; 22 : 955-63.
  5. Belachev M, et al. Laparoscopic adjustable gastric banding. World J Surg 1998; 22 : 955-63.
  6. Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y technique and results in 75 patients with 3-30 months follow up. Obes Surg 1998; 6 : 500-4.

 

STATINS IN TYPE 2 DIABETES AND HAEMODIALYSIS

Statins reduce cardiovascular events in persons with type 2 diabetes mellitus. This study randomly assigned patients with type 2 diabetes receiving haemodialysis to receive 20 mg of atorvastatin per day or matching placebo. Atorvastatin reduced all cardiac events combined but not all cerebrovascular events combined or total mortality.

N Engl J Med 2005; 353 : 238.

Consultant Laparoscopy and Bariatric Surgeon, Bombay Hospital, New Marine Lines, Mumbai 400 020.
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