Sunday, 24 July 2011

Bariatric Surgery in Treating Obesity

Published in City Times

The bane of being weighty

Approximately 300,000 people die every year on account of obesity related health problems. Even being moderately excess weight, increases the risk of death, particularly among adults aged 30 to 64 years. Individuals who are obese with BMI greater than 30, have a 50% - 100% increased risk of premature death from all causes, compared to individuals with a healthy weight. In a nutshell, the risk of death rises with increasing weight, reveals Dr.Faruq Mohamed, Specialist General Surgeon, Welcare Hospital, Dubai.

Dr.Faruk further reveals that obesity has become a bigger problem in the Middle East than it was in the USA. As per recent statistics that have come out from the Global Obesity Task Force, Middle East and Africa have overtaken USA in the incidence of obesity, followed by European countries.

In terms of Body Mass Index (BMI) as a measure of obesity, individuals may be variously categorized as overweight, excessively so, obese and morbidly so as follows:
BMI (25 – 30) = overweight
BMI (30 – 40) = Obese
BMI (40 + ) = Morbidly Obese
BMI (50 + ) = Super Obese

Obesity and being overweight has disastrous impact on the heart and is associated with increased risk of diabetes, cancer, breathing problems, arthritis and reproductive complications.

According to Dr.Faruq, the incidence of heart disease including heart attack, congestive heart failure, sudden cardiac death, angina or chest pain and abnormal heart rhythm, is creased in persons who are overweight or obese with a BMI greater than 25. High blood pressure is twice as common in adults who are obese than in those who have a healthy weight. Further, obesity is associated with elevated blood fat or triglycerides and decreased HDL cholesterol or the “good” cholesterol.

Over 80% of people with diabetes are overweight or obese. Also, a weight gain of 11 to 18 pounds, increases a person’s risk of developing Type 2 diabetes to twice that of individuals who have not gained weight.

Dr.Faruk reveals that there is an increased risk of individuals falling prey to certain types of cancers, on account of being obese or overweight. These include endometrial cancer which is cancer of the uterus lining, colon, gall bladder, prostate, kidney and postmenopausal breast cancer. Further, women who gain more than 20 pounds from age 18 to midlife, double their risk of postmenopausal breast cancer, compared to women whose weight remains stable.

Sleep apnea which is disturbed breathing while sleeping, is implicated in obese persons and obesity is associated with a higher prevalence of asthma, says Dr.Faruk. For every 2 pound increase in weight, the risk of developing arthritis is increased by 9% - 13% and significant improvements in arthritic symptoms can be seen with weight loss.

Obesity during pregnancy is associated with increased risk of death in both the baby and the mother and increases the risk of maternal hypertension by ten times. In addition to many other complications, women who are obese during pregnancy, are more likely to have gestational diabetes and problems with labor and delivery, reveals Dr.Faruk. Additionally, infants born to women who are obese during pregnancy are more likely to be high birth weight and may therefore face a higher risk of Cesarean section delivery and low blood sugar which can be associated with brain damage and seizures. Besides this, obesity during pregnancy is also associated with an increased risk of birth defects in the baby, particularly neural tube defects like spina bifida. Obesity in premenopausal women is associated with irregular menstrual cycles and infertility.

Overweight and obesity are associated with increased risk of gall bladder disease, incontinence, increased surgical risk and depression. Obesity can affect the quality of an individual’s life by restricting mobility and decreased physical endurance as well as through social, academic and job discrimination.

Obesity can have inhibiting effects on children and adolescents, no less in social and other aspects as in their health. Children and adolescents who are overweight or obese have increased risk of developing hypertension, high cholesterol and heart diseases. Type 2 diabetes, previously considered an adult disease, has dramatically increased in them. Overweight adolescents have a 70% chance of become overweight or obese adults. This increases to 80% if one or both parents are overweight or obese. The most immediate consequence of overweight, as perceived by children themselves, is social discrimination, says Dr.Faruk.

Doubtlessly then, overweight and obesity have become global problems. Diet and exercise have been unable to do the trick in a number of instances, leading overweight individuals to Bariatric surgery, a last resort answer to the problem! This may be the only treatment choice for the highly or morbidly obese people.

In terms of management, it is different how the various categories are views. For individuals falling in the overweight category (BMI 25 – 30), they can bring down their weight substantially with diet, exercise and lifestyle and eating-behaviour modifications, emphasizes Dr.Faruk. The same method is however successful in 50% of people who are obese, falling in BMI between 30-35.

Obesity treatment in the form of bariatric surgery is indicated in all the other cases, says Dr.Faruk. However, there are a number of interventional methods patients can go in for, depending upon the severity of their obesity and other health factors. “For people with BMI between 30 -35, they actually are cases for intervention since 90% of these people, even though they manage to get into a decent range, in the long run, they fail to maintain the weight.”

Gastric Balloon would be the ideal solution for the obese with BMI 30-35. “This is a non-surgical procedure, effective in bringing about a change in the lifestyle and eating behaviour of the patients. These people would manage to lose about 20 – 25 kg of weight in about six months. Following this weight reduction, the individuals can maintain their weight by right thinking, eating, etc.”

The Gastric Balloon, made from silicone, is filled with saline and put into the stomach, through the mouth, endoscopically. The balloon is left to float in the stomach, giving a sense of fullness thus making the person eat less. By limiting the intake of foot, the balloon helps weight reduction. 15 – 35% of people can actually lose 20 – 25 kgs weight and maintain themselves at the reduced weight with changed lifestyle patterns.

In the first week following the procedure, patients experience some side effects including nausea and feeling itchy inside the stomach. But once they get over the first week, things settle down with no problem. The silicone by itself does not create any cause for concern.

While the balloon can continue to remain in the stomach for long, manufacturing companies do not guarantee efficacy of the balloon beyond six months, reveals Dr.Faruk. “After six months, we expect that the patients will have changed their ways to an extent that, even after removing the balloon after six months, they will manage to maintain their weight, consistently. Having said that, if someone wishes to have the balloon for longer periods of time, this can be done by changing the balloons every six months. This is done easily as an outpatient procedure which takes about an hour and is done under sedation.”

Gastric Balloon is contra indicated in individuals who have peptic ulcer or any disease of the stomach and who have undergone any gastric surgery.

Treatment with Gastric Balloon cannot be used in patients who are excessively obese, and in children below the age of 18 years. The procedure is not done on patients who are on certain medication for other problems since it can cause bleeding or ulceration.

Currently the most popular technique is the Adjustable Gastric Banding (AGB) which involves making twin partition of the stomach. The band is position at the top part of the stomach to create a pouch that will hold 32 – 40 ml of food. This pouch allows only a small amount of food to be taken at a time such that the person feels full after eating this little quantity. Food that enters the small pouch will slowly pass down to the rest of the stomach to be digested.

This is a relatively non-invasive procedure, which yet again restricts the amount of food intake. The Gastric band, made of silicone is laparoscopically inserted in the stomach and it involves no cutting or stapling. Hence complications from this controllable, adjustable and reversible technique, is minimal. Also, the band can be left in the stomach forever without causing any problem to the patient. However, the procedure is not without its downside. Since the band sits on top of the stomach, it can induce vomited in the patient. Further, big chunky food can get stuck. Also, over a period of time, the silicone can erode into the stomach, though this is an extremely rare possibility, reveals Dr.Faruk.

AGB is best suited to individuals with BMI between 35 – 45 in whom the success rate is 40% - 60% weight reduction in 70% of individuals in about two years. The weight loss normally takes place between 18 – 24 months. With the pouch in place, patients will have to eat only certain types of food and avoid others; hence in individuals who cannot comply with these restrictions, the method is a failure.

Gastric Bypass is a treatment option reserved for patients with BMI of over 50 or for those with BMI below 45 who have been assessed as non compliant. “We expect much better weight loss with Gastric Bypass, 70% - 80% success, because we don’t need all that degree of co-operation from the patients. With the bypass patients can eat whatever they want because there is reduced absorption of food, resulting in weight loss.

The procedure involves bypassing most of the stomach. A small upper pouch is connected to the distal part of the small intestine whereby the food eaten will bypass most of the stomach and small intestine and will not be absorbed. The downside of the treatment involves higher surgical risk, increased incidence of long term side effects including risk of a leak from where the stomach is attached to the intestine and nutritional deficiencies and diarrhoea.

Biliopancreatic Diversion or Bypass is yet another surgical technique done in individuals with BMI of over 50. The procedure is less food restrictive than the other procedures but it too has a significant malabsorptive component which acts to maintain long term weight loss. As in the gastric bypass, here also, the patient must be monitored closely for nutritional deficiencies. The complications of the procedure involve malabsorption of certain nutrients and there’s a fair incidence of gall stone formation because there is less absorption of the bile salts, reveals Dr.Faruk.

Dr.Faruk emphasizes that there is risk with any surgery and that they degree of complications increase from the Balloon procedure to the Biliopancreatic Bypass. 10 – 20% of patients who have undergone surgery for weight loss may require follow up surgeries to rectify complications like abdominal hernias.

The major emphasis should be in the prevention of obesity rather than in the treatment of the problem, more so because it is assuming alarming proportions in young children and teenagers, emphasizes Dr.Faruk. “The real emphasis should be on educating people on healthy eating habits and having regular exercise and bringing about legislation to control the availability of energy rich food which is currently available very freely.”


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