Obesity is a major health problem approaching an epidemic proportions. An NIH consensus conference on the surgical treatment of obesity recommended consideration of surgery in patients with a BMI of greater than 40 kg/m2 without medical complications or a BMI of greater than 35 kg/m2 if severe co morbidity were present. Obesity accelerates the progression of coronary arteriosclerosis in young men (age range 15 to 34 yr). Obesity increases the risk of developing:
Type 2 diabetes,
Coronary artery disease,
Endometrial, breast, Prostate, and colon Cancers.
Severe obesity is a chronic condition that is difficult to treat through diet and exercise alone. Gastrointestinal surgery for obesity, also called Bariatric surgery, is an option for persons who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems.
Bariatric is derived from the Greek term bars, meaning weight. Bariatric surgery creates an anatomic barrier preventing over-consumption and accumulation of excess calories either by restricting the gastric reservoir or by inducing malabsorption. Bariatric surgery alters the digestive process and is classified into two categories:
Nearly all morbidly obese patients with satisfactory postoperative weight loss, experience substantial improvement in the quality of their lives. At present, Roux en Y Gastric Bypass (RYGB) may be the only Bariatric operation that has produced durable long-term weight loss at an acceptable level of risk.
Body mass index (BMI) above 40
Significant obesity comorbidity (e.g., hypertension, diabetes, sleep apnea, pickwickian syndrome, incapacitating osteoarthritis)
Obesity-related physical problems that interfere with employment, walking, or family function may be a candidate.
Procedure of Bariatric Surgery:
Promote weight loss by closing off parts of the stomach to make it smaller, thus restricting the amount of food the stomach can hold. Restrictive procedures do not interfere with the normal digestive process.
As a result of this surgery, most persons lose the ability to eat large amounts of food at one time. After an operation, the person usually can eat only ¾ to 1 cup of food without discomfort or nausea. Also, food has to be well chewed.
Restrictive operations for obesity include the following:
Adjustable gastric banding
Vertical banded gastroplasty
Both the methods are used to create a small stomach pouch.
2. Malabsorptive Procedure
The most common gastrointestinal surgeries for weight loss, combine stomach restriction with a partial bypass of the small intestine. A direct connection from the stomach to the lower segment of the small intestine is created, bypassing portions of the digestive tract that absorb calories and nutrients.
Biliopancreatic diversion (BPD):
In this more complicated malabsorptive operation, portions of the stomach are removed. The small pouch that remains is connected directly to the final segment of the small intestine, completely bypassing the duodenum and the jejunum. Although this procedure successfully promotes weight loss, it is used less frequently than other types of surgery because of the high risk for nutritional deficiencies. A variation of BPD includes a “duodenal switch,” which leaves a larger portion of the stomach intact, including the pyloric valve that regulates the release of stomach contents into the small intestine. It also keeps a small part of the duodenum in the digestive pathway.
Roux-en-Y gastric bypass
Roux-en-Y gastric bypass (RGB) is an accepted operation for the control of body weight in morbidly obese patients. This operation is the most common and successful malabsorptive surgery. First, a small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum, and the first portion of the jejunum. This bypass reduces the amount of calories and nutrients the body absorbs
Operative Consideration :
Severely obese patients tolerate general anesthesia remarkably well. However, Endotracheal intubation may be difficult.
Patients may require admission to the intensive care unit postoperatively.
Patients with sleep apnea, congestive heart failure, and severe asthmatic bronchitis should spend one or two nights in the intensive care unit for close monitoring of their cardiopulmonary status
Complications from bariatric surgery:
The risk of formation of gallstones.
Dumping Syndrome, (stomach contents move too rapidly through the small intestine includes nausea, weakness, sweating, faintness, and sometimes diarrhea after eating)
Constipation / Diarrhea
Vitamin B12 Deficiency
Anemia (due to reduced absorption of Iron in the stomach)
Metabolic bone disease (due to less calcium absorption in the small intestine)
Incisional Hernia / Abdominal Hernia
Bleeding (including splenic injury)
Gastrointestinal leaks(inadvertent injury to the GI tract)
Wearing away of the band and breakdown of the staple line.
In very less cases post operative infection or death from complications may occur.
Early technical complications and inadequate weight loss, well-known sequelae of this procedure, necessitated reoperation . The incidence of major postoperative complications following revisional bariatric procedures is substantially higher compared to primary operations.
Patients who have gastric bypass occasionally require revision, either for inadequate weight loss or for complications. The incidence of major postoperative complications following revision Bariatric procedures is substantially higher compared to primary operations. Early morbidity rates range from 15% to 50%. The mortality rate reported after revision operations ranges as high as 10%, undoing any Bariatric operation without conversion to another weight-reduction procedure is invariably associated with the patient’s promptly regaining the lost weight.
Indications for reoperation includes
Dilated gastrojejunal anastomosis
Inadequate weight loss without demonstrable enlargement of the anastomosis
Staple line breakdown
Enlarged proximal gastric pouch .
Reoperation consisted of :
Completely redoing the initial RGB
Redoing the anastomosis alone
Staple line revision
Intraoperative dilatation of the anastomosis
Intractable marginal ulcer
Major postoperative complications are:
RGB revision for early technical failure
Inadequate weight loss is associated with a high incidence of major complications
subsequently, negligible weight loss.
Intractable marginal ulcer.
Severe metabolic complications
Therefore repair of RGB for technical failure or complications is not recommended.
Gastric bypass patients with anatomically intact operations and unsatisfactory weight loss have probably “outeaten” the operation.Gastric bypass patients with unsatisfactory weight loss are best converted to a more malabsorptive modification of Roux-en-Y gastric bypass, or in some cases biliopancreatic diversion. Unfortunately, some patients who are converted to a malabsorptive procedure suffer severe metabolic complications.
The more extensive the bypass, the greater the risk for complications and nutritional deficiencies. Persons with extensive bypasses of the normal digestive process require close monitoring and life-long use of special foods, supplements, and medications
Why to undergo gastric bypass surgery in India
Revision Gastric bypass surgery in India has seen a phenomenal growth during recent past. Most patients from countries like USA and UK travel to India for treatment.
Few main reasons:
India offers wide range of cheapest pricing options of treatment.
While planning a treatment in India, one does not require waiting in patient queues or registering for a waiting list.
Moreover the doctors and the medical facilities in India are comparable to the best in the world.
Another main reason for choosing India for revision gastric bypass surgery is comfort of communication; one does not face a problem as most people speak English.
Above all, India always offers a good holiday, which can help in fast health recovery. Another important reason why more and more people from overseas are considering India for health treatments is the advancement and the medical and technical superiority of the medical fraternity in India. Hence India is the most ideal destination for Medical tourism.