Sunday, 24 July 2011

Gastric Banding in the Treatment of Obesity

Published in Panorama

Surgery to treat obesity

Millions of people world over are attempting to reduce and control their weight, with varying degrees of success. Despite the growing awareness of the health hazards associated with weight gain and obesity in particular, the number of people plagued by the problem is increasing. Generally speaking, people who have a Body Mass Index (BMI) higher than 30, face the risk of developing health problems associated with excess weight. (BMI = weight in kilogram/height in square metres). An ideal BMI would vary between 20-25. BMI between 25-30 is considered overweight, over 30 is obese and BMI over 35 indicates severe or morbid obesity requiring surgical intervention, according to Drs. Hamed Abuthina, Consultant and Laparoscopic Surgeon, International Specialist Medical Centre, Dubai and Catherine Bergeret Galley, Specialist Plastic and Anesthetic Surgeon, Belhoul International Hospital Centre, Dubai.

While liposuction is not the solution to obesity, it may improve the contours of the body in people who have specific areas of localized fat deposits and who have tried in vain to lose weight by dieting and exercise, says Dr. Catherine. Liposuction surgery involves the removal of fat cells from the body and works best on people who enjoy a good physical condition otherwise and whose skin has good elasticity. “We do a thorough assessment of the patients to determine whether they are suitable candidates for the procedure, regardless of age,” assures Dr.Catherine.

The procedure which may be done under local or general anesthesia involves firstly marking the area and then making a small incision in the skin. A tube or cannula attached to a high pressure vacuum suction or to a syringe system is inserted through this incision. The tube is maneuvered to loosen the fat from surrounding tissues which is then suctioned out. Depending on the area from which the fat is removed and the amount of it that is removed, the process may last from half an hour to a few hours.

Pain is minimal under liposuction since it does not involve large incisions. Antibiotics and analgesics may be given to prevent infection and control whatever little pain may be caused, according to the doctor. Complications from liposuction, bleeding, infection, skin discoloration and uneven skin surface are very rare and correct themselves in time.

When all other therapies to lose weight fail, surgery may be the only way out, explains Dr.Abuthina. “The aim of surgery is to reduce food intake and decrease intestinal absorption of the patient. These procedures include the Roux-en-Y Gastric Bypass, Vertical Banded Gastroplasty (VBG), Silicone Ring Gastroplasty (SRG) and Gastric Banding.”

“In the Roux-en-Y Gastric Bypass”, explains Dr.Abuthina, “we use staples to construct a proximal gastric pouch with an outlet that is a limb of the small bowel, thus bypassing most of the stomach and some of the small intestine.” The idea is to restrict food intake by making the stomach smaller and removing some segments of the intestine so that smaller amounts of food are absorbed.

Complications associated with gastric bypass arise due to cutting and suturing of the gasatrointestinal tract, according to the doctors. “This procedure may also lead to long term micronutrient deficiencies, particularly of vitamin B 12, folate and iron,” warns Dr.Abuthina. “In addition to vitamin deficiencies, gastric bypass patients commonly react to the ingestion of substances with a high sugar content with gastrointestinal distress, called ‘Dumping Syndrome.’ These patients tend to absorb sugar very fast and end up with profuse sweating, diarrhoea and vomiting.”

In addition, a major drawback of gastric bypass relates to its efficacy. Dr.Abuthina explains, “In 25% of cases, this surgery is not successful because individuals tend to regain weight and become obese again after a period of 8-9 years. Of course this is chiefly because these patients do not adhere to a strict diet pattern which we advocate for them. If they continue to be chocoholics and eat plenty of sweets, this procedure is not going to help!”

VBG and SRG reduce stomach size by using rows of staples to create a small stomach pouch along the lesser curvature of the stomach. These procedures suffer from the complication of stapling. Also, metabolic deficiencies could arise from these procedures, says Dr.Abuthina.

The most popular surgical method to reduce morbid obesity appears to be the Gastric Banding technique. This minimally invasive surgery involves creating a small gastric pouch to limit the amount of food that the stomach will hold at any time.

How is the procedure undertaken? According to the doctors, an adjustable Silicon gastric band, 12mm wide is placed around the stomach by means of Laparoscopic surgery. The band is equipped with an elastic balloon that can be inflated to the desired volume by means of injection. It is placed around the upper part of the stomach and causes the stomach to be divided into two sections. The smaller part, above the band becomes a pouch with capacity of 15-20ml. The diameter of this constriction called stoma can be altered according to individual needs. Since the capacity of the stomach is thus reduced, it can hold less food. When less food is consumed, the body will draw on its own fat reserves to obtain the necessary energy, thus resulting in weight reduction.

Since the inflatable ring controls the flow of food to the rest of the digestive tract, this will make the patient feel full after eating a small quantity of food and keep him feeling full for considerably long periods of time, thereby reducing the urge to keep eating between meals, adds Dr.Catherine.

Dr.Abuthina further clarifies, “Patients coming in for this treatment are first required to go on a strict liquid diet for at least 4-6 weeks after surgery. If they don’t adhere to this, the entire surgical process would be a failure. We need the proximal pouch to gain rigidity and establish well. If the patients eat solids or too much, the pouch may expand, creating more space, thereby defeating the purpose of the procedure. Once the pouch gains the required rigidity in about 6 weeks, intake of solid food may resume. So to ensure candidate suitability for the procedure, we test them prior to surgery. We keep them on a completely liquid diet for 3 weeks prior to surgery. If during this period the individuals show signs of flouting the prescribed liquid diet, we may not perform the surgery on them.”

“The high point of this procedure,” explains Dr. Abuthina, “is that it is reversible and avoids the complications associated with staple line leakage and disruption. The band can be removed if the patient does not want it for whatever reason. Also, you will not run into problems of deficiency of nutrients because even if only small quantities of food are taken, they are well absorbed and assimilated.”

And of the currently available minimally invasive surgical techniques to treat morbid obesity, gastric banding is very effective. It not only leads to satisfactory weight reduction but it is also associated with a low rate of complications. Slipping of the band, infection and vomiting may occur, which are all treatable. It helps the patient to achieve a reasonable long term quality of life within a relatively short period. Dr.Abuthina adds, “In fact, diabetics and hypertension patients may be cured indirectly of their problem due to this surgery since a lot of their problem is because of being overweight. Similarly, joint strains due to over-weight may be cured.”

Are there other precautions taken prior to proceeding with gastric banding? Patients are assessed for physical, psychological and medical fitness. If they are hypertension patients or diabetics, the pressure and blood sugar levels are stabilized.

Is there a minimum and maximum age for the procedure to be performed? “The patient should be at least 20 years old. Because we do not want to interfere with the natural and normal growth of the individual during the adolescent years unless the person’s weight is extremely out of control. The maximum age is 55 years since anyway by this time, these people would have become heir to diseases brought on by obesity and over weight.

Does the presence of the band hinder normal activity in these patients? None at all, assures Dr.Abuthina. “Of course in the initial few weeks, the patients need to be cautious while exercising or participating in sporting activities. Once these weeks are seen through, they may continue with normal activities they have been doing.”

Both doctors, however, caution, that these surgical methods in themselves cannot guarantee success unless patients adhere to diet control and abstain from binging on weight inducing foods.


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