Dr.Amitabh Goel

Bariatric Surgery

Defination:

Bariatrics: The field of medicine that offers treatment for the person who is overweight with a comprehensive program including diet and nutrition, exercise, behavior modification, lifestyle changes and, when indicated, the prescription of appetite suppressants and other appropriate medications. Bariatrics also includes research into overweight, its causes, prevention, and treatment.

The word bariatrics was derived in the 20th century from the Greek baros (weight) + -iatrics (medical treatment). Other words derived from the same Greek root include barium and barometer.

Patients with morbid obesity are assessed by a multidisciplinary team representing the fields of nutrition, psychiatry, medicine and surgery, and perform a thorough physical examination and investigations.

Bariatrics is the field of medicine that specializes in treating obesity. Bariatric surgery is the term for operations to help promote weight loss. Bariatric surgical procedures are only considered for people with severe obesity and not for individuals with a mild weight problem and who are overweight.

There are many detrimental health effects of obesity with an increased risk of developing heart disease, diabetes, gall bladder disease, asthma, obstructive sleep apnoea, chronic musculoskeletal problems, polycystic ovary syndrome, impaired fertility, psychosocial problem as well as some forms of cancer.

Diagnosis

Although not a direct measure of body fat, the Body Mass Index is widely adopted and promoted as a marker for excess body weight.[9] However, it is not flawless: a very muscular person may be assessed as obese, and an elderly person with low body weight but high body fat (this can happen due to low muscle mass and bone density) may be assessed as healthy. Other markers for the evaluation of obesity include waist circumference (associated with central obesity), and a patient's risk factors for diseases and conditions associated with obesity.[10] Besides these indirect methods, body fat can also be measured directly.

Obesity prevention

Obesity can be prevented in many ways and the best time to start prevention is from a young age, you can help your children to stay away from fatty foods and unhealthy lives even if it is too late for you. If you prevent obesity you are also preventing medical conditions such as chronic diseases like diabetes, high cholesterol, high blood pressure, heart disease, arthritis and cancers. Preventing obesity is one of the main things that we need to focus on with obesity being the world biggest health epidemic at the moment and on the rise. Many people are loosing out on exercise and children are suffering the most.

Obesity can be prevented by consuming a varied diet and getting plenty of exercise. Low carbohydrate diet programmes also doesn't give off the desired effect as they focus mainly on high protein substitutes; the body uses up stored energy and muscle instead of the carbohydrates it needs, leaving you tired and dull. The correct protein supplement can give you the edge required to reach your fat loss or muscle building goals faster. Be sure to choose a protein supplement that is designed with the results you want in mind.

Taking the stairs instead of the lift and walking to the shop instead of taking the car, will help you get the exercise that you need to burn your fat.

Weight Loss Programs

Dietary Counseling

Dietitians and nutritionists can advise patients as to what foods they should be eating to help ensure they are receiving enough vitamins and minerals. It is also important for a meal program to be formulated that satisfies the patient's caloric requirements to maintain good health while continuing to promote weight loss [16] . The diet cannot be so restrictive that the patient cannot maintain their efforts for the long term. Regular adjustment of diet plans to meet the changing needs of the patient is a key component [17].

Exercise

Exercise is important to any weight-loss program. Ramping up the patient's metabolism, burning calories, and improving the overall health of the body are all achievable through exercise [18] . Patients meet with Fitness Trainers and Exercise Physiologists who design custom programs to encourage safe exercise for each patient. As the patient progresses in physical capability these programs continue to be modified to promote maximum effectiveness without endangering the patient. Vigorous exercise is essential in helping an individual reduce the size of fat cells and to retain lean muscle mass.

Psychological Approaches

Investigating and addressing a patient's psychological state is a key component [19] . If there are psychological issues that are coming into play regarding the patient's health, they must be taken into consideration when customizing a weight loss plan for them. A positive attitude and mental focus are seen as essential to successfully achieving one's weight loss goals. Mental issues that lead a patient to engage in emotional eating or other negative behavior must be addressed. Eating behaviorists and health coaches will work with patients to help give them the tools they need to navigate this process. Occasionally, a more in depth psychological intervention is necessary. In these cases, the patient may require the help of a psychologist or psychiatrist (with the possibility of prescription drug therapy for treating mental health issues which may affect the patient's ability to adhere to the program.) [20] . Mental health is treated with equal important to physical health and they both play a role in a medical weight loss program.

Behaviorist Therapy

Patients need to learn a new set of behaviors to encourage healthier choices in their daily routine [21]. Everything from lifestyle changes to the way a patient performs seemingly basic activities such as grocery shopping, cooking, and food planning are key to the long term success of the medical weight loss program. These sustainable and rewarding new behaviors lead to a healthier body and better quality of life.

Anti-Obesity Drugs

If diet and exercise are ineffective alone, anti-obesity drugs are a choice for some patients.[22] Prescription weight loss drugs are recommended only for short-term use, and thus are of limited usefulness for extremely obese patients, who may need to reduce weight over months or years.

Dietary management

Healthy Tips for Weight Loss
Start your day right
Do not skip breakfast. Skipping breakfast can leave you hungry, tired and looking for less healthy foods later in the day.
Begin your day with a healthy high fiber, low fat breakfast consisting of dalia, muesli, oats, whole wheat bread, sprouts etc.
Eat your breakfast like a king, your lunch like a prince and dinner like a pauper.

If you want to lose weight, starving yourself does not help - you need to eat well. When your body doesn't receive the required nutrients, your metabolism slows down. Metabolism is the rate at which you burn calories while resting. If you don't eat enough, fewer calories will be burnt and there will be less fat loss.

Adopt 5-6 small and frequent meal patterns throughout the day.

Eat three meals a day and two mini meals daily. Have 4-5 portions of fruit daily. Eat five portions of vegetables a day (one portion is one ladle/serving spoon). This will help not only in healthy weight loss but also take care of indigestion and hyperacidity which happens when a meal is skipped or is overdone.

Home - cooked food

Carry home-cooked food for lunch to avoid unnecessary snacking on junk and fried foods. Use cooking methods that retain nutrients as well as are good for weight reduction. E.g. baking, grilling, stir-frying, and steaming.

Eat slowly, chew your food well

It takes 20 minutes before your stomach sends a clear message to your brain that you are full. If you take the time to chew your food well, you will end up eating less.

Eat healthy at binge time

A lot of unhealthy snacking happens after lunch, irrespective of the amount taken during lunch, because it eases out the day's bulk stress and pressure. Avoid snacking on namkeens, bhujias, fried items like samosas, chips etc. Healthy snacking needs to be maintained.

Exercise regularly

Even though regularly scheduled aerobic exercise is best for weight loss, any extra movement helps burn calories. Look for ways to walk and move around a few minutes more each day. Taking the stairs more often and parking farther away from your destination are simple ways to burn more calories.

Obesity Work-up and Diagnostics

Safe weight loss through surgery requires a strong commitment from the patient and the team of medical experts providing care. Education, one-on-one counselling, complete medical exams and testing, and continued support are top priorities, so our patients understand the requirements, responsibilities and benefits of undergoing bariatric surgery.

Our care begins months before surgery, which is scheduled to prepare patients and guide them through dramatic changes in their overall health. This care continues through the months and years following surgery to keep patients on course. Additionally, our program has been carefully designed and configured to provide the highest level of comfort and compliance.

Laboratory Studies

Complete blood count (CBC)
AA and HIV
Renal Profile
Thyroid function tests
Lipid profile
Coagulation tests
Serum iron and total iron binding capacity (TIBC)
Vitamin B-12, folic acid
Blood typing
Urinalysis
Serum cortisol (if needed e.g. in patients of Cushings)

Diagnostic Procedures

Ultrasonography Whole Abdomen
Electrocardiogram (ECG)
Chest radiography
Upper GI Endoscopy
PFT
2-D Colour Doppler
Sleep Apnea Test(Optional)
CT Scan (Optional)
Peripheral Doppler (Optional)
Stress Echo and Stress Test (TMT) (Optional)

Surgical Management of Obesity

The Bariatric Surgery Programme running by Dr. Amitabh Goel and his team at prestigious hospitals in Indore has helped obese patients lose weight through either laparoscopic gastric banding or sleeve gastrectomy or gastric bypass surgery. Our team of experts including dedicated surgeons, physicians, endocrinologist, nurses, dieticians, physiotherapist and psychologists - are ready and willing to meet with patients one-on-one to share knowledge and expertise, and ensure their full recovery. Our holistic, multidisciplinary approach addresses all aspects of health - including psychological and medically related conditions - before, during and after surgery.

In fact, we provide patients life-long, post-surgery support to be absolutely certain that they achieve and maintain lifestyle changes and their goals.

Bariatric surgery options

After a rigorous review that examined safety, surgical outcomes, quality of care and overall performance, the Bariatric Surgeon Dr. Amitabh Goel offers eligible patients three bariatric surgery options:

Laparoscopic adjustable gastric band

Laparoscopic sleeve gastrectomy

Laparoscopic gastric bypass surgery

We believe that these procedures provide the best surgical options for weight control in the obese patient. These procedures have been shown to offer the best combination of weight loss with fewer nutritional risks.

Additionally, we maintain an extensive database of our patient records to stay in touch and continue to provide support.

Weight loss operations fall into three categories:

Restrictive procedures, which make the stomach smaller to limit the amount of food intake.

Malabsorptive techniques, which reduce the amount of intestine that comes in contact with food so the body absorbs fewer calories.

Combination operations, which employ both restriction and malabsorption.

Bariatric Procedures

Obesity is a complex, clinical disorder with many contributing causes and factors. The condition is often associated with a wide range of medical problems, including high blood pressure, heart problems, diabetes, sleep apnoea, depression, and arthritis. For many patients who are severely overweight, surgical treatment is the only proven method that will help them achieve the long-term weight control required to improve their overall health and enable them to perform normal activities.

Restriction Operations

These procedures are least commonly performed. They encourage weight loss in two ways:

Reduce the amount of food you can eat. We shrink your stomach by creating a small pouch at the top of the stomach where food enters from the oesophagus. This makes it impossible for you to eat much. At first, the pouch only holds about one ounce of food. It expands to hold 2-3 ounces over time.

Slow the speed of how the food empties from your stomach. The lower outlet of the pouch is only about 1/4 inch in diameter. Because it's so small, food empties slowly and you feel full longer.

There are two types of laparoscopic restrictive operations:

Gastric banding: A band of special material (Siliastic band) is placed around the upper end of the stomach. This creates a small pouch and narrow passage into the rest of the stomach.

Sleeve gastrectomy: In this surgery approximately 80 percent of the stomach is removed laparoscopically with the help of staplers so that the stomach takes the shape of a tube or "sleeve".

The Day of Surgery

On average, surgery for obesity takes about two hours and is performed under general anesthesia. When possible, most bariatric surgeons use laparoscopy, a procedure in which a tiny video camera is inserted inside the patient's abdomen. Through the laparoscope, the surgeon can view the procedure on a separate video monitor. The camera allows doctors to perform minimally invasive bariatric surgery that uses only a small abdominal incision. Compared to more invasive techniques, laparoscopy has fewer complications, and patients can return to work and other activities more quickly. There is also a lower risk of infection, and some recent studies have shown that patients experience less pain after laparoscopic bariatric surgery.

Laparoscopic Adjustable Gastric Bypass

In this procedure, a silicon band lined with an inflatable balloon is placed laparoscopically around the stomach near its upper end creating a small pouch (15 to 30 cc vol.) and a narrow passage into the larger remainder of the stomach.

When you eat, satiety or fullness of stomach comes early and thus you would start eating less, which in turn leads to significant weight loss.

This balloon is connected to a small reservoir that is placed under the skin of the abdomen through which the diameter of the band can be adjusted by injecting fluid into it as an outpatient procedure.

Highlights

Performed laparoscopically with 5 small incisions (most less than 5 mm and one 15 mm)
Adjustable silastic gastric band used
Operative time approximately one hour
Short hospital stay, 1 to 2 days
Oral intake of liquids on first post operative day
Quick recovery, one week to work
Resume strenuous activity in 2 weeks

Advantages of LAGB

Eliminates feeling of being hungry
Food is absorbed normally
No vitamin and protein deficiency
No cutting or stapling of the stomach
Adjustable without additional surgery
Fully reversible: Stomach returns to normal if the band is removed

Disadvantages of LAGB

Band complication: Leak, infection, slippage and migration
Office adjustments

Lap. Sleeve gastrectomy

Sleeve gastrectomy is a technique that offers the same results as the gastric bypass but with less risk.

The Gastric Sleeve is a new procedure that induces weight loss by restricting food intake (a restrictive procedure); the patient is going to eat a smaller amount of food.

With this procedure, the surgeon removes approximately 80 percent of the stomach laparoscopically with the help of staplers so that the stomach takes the shape of a tube or "sleeve". In addition of being restrictive, this procedure has seen that the hormone that regulates the appetite, the ghrelina, diminishes, causing the patient to avoid excess desire to eat.

Highlights

Performed laparoscopically with 5 small incisions (most less than 5 mm to 12 mm )
Endostapler used to divide stomach
Takes about 1 to 2 hours to complete
Stay in hospital for 2-3 days
Begin drinking on the second day
Liquid diet for 2 weeks after the operation
Return to work in 1 to 2 weeks
Resume strenuous activity in one month

Advantages

It is performed laparoscopically
It does not require disconnecting or reconnecting the intestines, as in bypass
No implant and adjustment required as in band surgery
Food is absorbed normally
No vitamin and protein deficiency
It is a technically simpler operation than the gastric bypass
Weight loss surgery for high risk patients, specially anaemia, severe asthma, for patients on steroids, inflammatory bowel disease

Disadvantages

Remaining stomach may stretch out
May require follow -up weight loss surgery for super-obese
Not reversible

Gastric Bypass Operation

Gastric bypass procedures are combination operations i.e. they combine both restrictive and malabsorptive techniques.

This is the most common bariatric procedure. First, we create a small stomach pouch with staples or a vertical band. This restricts food intake. Then, we attach a Y-shaped section of the small intestine to the pouch to allow food to bypass the first and second segments of the small intestine. This reduces your body's ability to absorb nutrients and calories.

Comparing the Procedures

Patients generally have more success with gastric bypass operations than restrictive procedures.

Risks are similar for both restrictive and gastric bypass procedures. The risk of nutritional deficiencies for iron, calcium, and Vitamin B12 are higher in patients who undergo gastric bypass operations. Also, there is risk of intestinal leaking.

Gastric bypass operations also may cause "dumping syndrome". This is when food moves too fast through the small intestine. It causes nausea, weakness, sweating, faintness, and sometimes diarrhoea.

In sleeve gastrectomy there is no intestinal bypass malabsorption i.e. vitamin and protein deficiency is minimal.

No intestinal obstruction with sleeve and band as no bypass of intestine done.

Open vs. Laparoscopic Surgery

Open and laparoscopic refer to how the abdominal cavity is entered and not the type of surgery being performed. So each type of weight loss surgery may be performed as either an open or a laparoscopic procedure.

When performing open surgery, surgeons create a single incision to open the abdomen for the operation. Typically, for women it is 4 1/2 to 6 inches, and for men, it is 5 1/2 to 7 inches.

With laparoscopic surgery, multiple, small incisions are made in the abdominal wall to accommodate a small video camera and surgical instruments. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them a better view and access to key structures.

Recent studies show patients, who have had laparoscopic weight loss surgery experience,

less pain after surgery

easier breathing and lung function

fewer wound complications such as infection or hernia

quicker return to pre-surgical levels of activity

We offer the less invasive laparoscopic procedure whenever possible. Speak with your surgeon to find out if you are a good candidate for laparoscopic surgery. Laparoscopic surgery uses all the same techniques as open surgery and has similar results in terms of excess weight loss.

Life after Bariatric Surgery

Healing time and long-term success after bariatric surgery depend largely on your diet and exercise habits. After bariatric surgery, following your surgeon's fitness and nutrition guidelines will decrease the risk of complications and increase the chance that you will be satisfied with the outcome. Physicians recommend that you also join a weight loss surgery support group to connect with peers who have undergone a bariatric procedure.

Diet after Bariatric Surgery

You should expect to make drastic changes to your diet after undergoing bariatric surgery. The stomach will be reduced to a much smaller size and, as a result, the amount of food you can eat is very limited. In order to ensure good nutrition and health, you must also pay very close attention to the types of food you eat. Foods that were well tolerated prior to surgery for obesity may cause discomfort afterwards. Discussing your diet with a nutritionist both before and after bariatric surgery can prepare you to make educated and healthy food choices.

Exercise after Bariatric Surgery

Exercise plays a crucial role after bariatric surgery. Patients take in far fewer calories directly following surgery, sometimes causing the body to react as if it were starving. In its search for more energy, the body can begin to burn muscle instead of fat. To prevent this, it is imperative to begin exercising regularly as soon as possible. This alters the metabolism so that the body begins to burn fat instead of muscle. Exercising also helps patients lose weight more rapidly.

Post Bariatric Plastic Surgery

After bariatric patients lose significant amounts of weight, they often have an excess of loose skin on the arms, thighs, buttocks, and midsection. Post bariatric plastic surgery is designed to tighten areas of loose skin so you feel more confident about your appearance.

Ongoing Support

Joining a support group is one of the best things a patient can do after bariatric surgery. Bariatric surgery requires many lifestyle and behavioral changes, and patients usually need the support of family, friends, and healthcare professionals to help get through any rough spots.