Obesity is an abnormal accumulation of body fat in proportion to body size. Body mass index (BMI) is calculated by dividing the body weight (in kilograms) by height (in metres) squared. Generally BMI does correlate with percentage of body fat, but this relationship is independently influenced by sex, age, & race. Asian populations, however, are known to be at increased risk for diabetes & hypertension at lower BMI ranges than non-Asian groups. You are at increased risk for coronary artery disease, diabetes, and hypertension if you (man) have a waist circumference greater than 40 inches (102 cm) or if your (woman) circumference exceeds 35 inches (88 cm). Thus, an overweight person with abnormal fat pattern may be at high risk for these diseases even if that person is not obese by BMI criteria. ^TOP^
BMI = Weight in Kg/ Height in m²
Underweight:<18 Healthy Weight:18 -25 Overweight: 25 -30
Obese: >30 Morbidly Obese: >40 Super Obese: >50
The initial evaluation of overweight and obese patients begins with the exclusion of secondary causes of weight gain and the identification of comorbid disorders such as hypertension, diabetes, heart disease, respiratory problems and sleep apnoea. Once screening is completed, the approach to the treatment of overweight and obesity is similar to that of other chronic diseases: begin with lifestyle improvements including dieting & exercise and then consider medical and surgical options. ^TOP^
Being overweight is associated with a variety of medical conditions including high blood pressure, cardiovascular disease, diabetes, high blood cholesterol and other lipids, an increased risk of developing certain cancers, sleep apnoea, gastro-oesophageal reflux and arthritis etc.
Shorter Life Expectancy. Compared to people of normal weight, obese people have a 40% increased risk of dying prematurely by 7-10 years.
Obese people have more risk for:
– Metabolic Syndrome, Insulin Resistance
– Diabetes (type 2)
– Joint problems ( arthritis)
– High blood pressure
– Heart disease – heart attacks MI and strokes
– Pulmonary Hypertension, right ventricular failure, oedema of legs
– Liver problems – Fatty infiltration, NASH, Cirrhosis
– Certain types of cancer (breast, oesophagus, uterine, colon) – more predisposed to
– Digestive disorders (e.g., gastroesophageal reflux disease, or GORD/ heartburn)
– Breathing difficulties (e.g., obstructive sleep apnoea OSA, asthma)
– Problems with fertility and pregnancy PCOS
– Psychological problems such as depression
– Urinary Incontinence
Risks to psychological and social well-being
– Negative self-image
– Social isolation
Day-to-day living difficult
– Normal tasks become harder when you are obese, as movement is more difficult. Even walking becomes a major task and you can become bed-bound
– You tend to tire more quickly and you find yourself short of breath
– Public transport seats, telephone booths, and cars may be too small for you
– You may find it difficult to maintain personal hygiene
You have to first meet the following criteria (in accordance with NICE guidelines) to be suitable for weight reduction surgery and then you have to balance the benefits with risks of surgery.
1. A BMI greater than 40 or a BMI greater than 35 with associated co-morbidities such as diabetes, sleep apnoea, high blood pressure etc.
2. Age greater than 18.
3. To have adequately tried all appropriate and available nonsurgical measures of weight reduction such as dieting or drug therapy and have failed to maintain weight loss before considering surgery.
4. Should be fit for an operation.
5. Must understand the need for long-term follow up.
6. Do not have any serious psychological problems or alcohol abuse.
A balloon is inserted into the stomach via an endoscope and inflated to ½ – 1 litre of fluid. This gives the feeling of fullness and helps to reduce the intake of food. For a week after the procedure one can be very sick and therefore may have to be hospitalised during that period and given fluids by the vein. You may lose some weight but this is a temporary measure lasting for about 6 months. ^TOP^
Gastric banding involves placing a band around the upper stomach; this band has a balloon inside leading to a narrow tube connected to a reservoir placed under the skin. The operation is performed laparoscopically (keyhole surgery) and takes only about 40 minutes. You will be allowed home at between 12 and 72 hours after surgery. You start with fluids on the same day which is continued for another 4 weeks. You then start on soft diet and then gradually build up to solid food over the next couple of weeks. About 6 weeks after the procedure, the balloon in the band is inflated using a special needle placed through the skin into the reservoir. This will tighten the band. The amount of fluid in the balloon will need to be adjusted over subsequent weeks to produce the required weight loss. ^TOP^
The operation is performed laparoscopically and takes approximately 30 minutes. Sleeve Gastrectomy involves removing 2/3 to 4/5 of stomach vertically preserving the continuity of stomach. The weight loss following SG depends on the type of SG performed: 1. If it is done as a single stage procedure as in lower BMI obese patients, then you lose about 60% – 80% of your excess weight. 2. If it is done as a first stage of Duodenal Switch DS, then you lose about 30-50% of your excess weight and you have to have the second stage DS once your weight stabilises over 1 ½ years, otherwise you put on weight. Fluid is started on the first postoperative day and built up to full diet by six to eight weeks. ^TOP^
The operation is performed laparoscopically and takes approximately 1 ½ hours. It is similar to Sleeve Gastrectomy in its effect without resecting any stomach. The stomach is plicated on the greater curvature of the stomach by 2 rows of non-absorbable sutures. By plication the luminal volume in the stomach will be reduced by 70%. This reduced space causes fullness with even small amounts of food. This, unlike SG is potentially reversible though sometimes with difficulty. Though weight loss may be about 60% over a couple of years, weight regain can occur in 40% of patients. There is also a failure rate (not even achieving 30% excess weight loss) of 6-20%. ^TOP^
The operation is performed laparoscopically and takes approximately 1 hours. The upper part of the stomach is divided and joined onto the small bowel so that the main reservoir of the stomach and some part of small bowel are bypassed. The hospital stay is 3 to 5 days. Fluid is started on the first postoperative day and built up to full diet by six weeks. ^TOP^
What is mini Gastric Bypass MGB or Omega Loop Gastric Bypass?
Omega Gastric bypass is basically half the gastric bypass in that there is no Roux-en-Y formation of the gastric bypass. A loop of small bowel is joined to a long gastric pouch much further than in the gastric bypass and no further attempt is made to diver the bile and pancreatic juices away from the gastric pouch. It is more malabsorptive procedure than gastric bypass and the weight loss could be about 60-70% excess weight similar to gastric bypass. ^TOP^
This operation acts in a similar way to the gastric band but produces a restriction that is fixed and cannot be adjusted in the same way as the gastric band. It has the same complications of bypass surgery without the benefit of MalabsorptionGastric banding is performed instead of gastroplasty by most surgeons. ^TOP^
This is purely Malabsorption operation without the restrictive component. This operation is similar to the gastric bypass but involves bypassing a much greater part of the small bowel and removing distal stomach leading to a significant degree of malabsorbtion. Whilst it can be a very effective way of loosing weight it is also associated with a number of potentially serious complications. It is usually reserved for the super – super obese. ^TOP^
Like BPD, this is also generally used in Super Super Obese persons (Mega or Tera obese) or in people with severe metabolic problems. DS is basically a modified BPD and includes 2 parts – Restrictive and Malabsorption. 1st part is Sleeve Gastrectomy taking out ¾ of stomach and the 2nd part is the duodenal switch i.e. the distal bypass. These 2 parts can be staggered so that one can have Sleeve Gastrectomy first and then duodenal switch 6 – 18 months later, reducing the risks operation considerably. With SG (1st stage) the loss of weight is about 30-50% of their excess weight and with DS (2nd stage), the loss of weight will be further 30% making a total of about 75-80% excess weight. ^TOP^
For people with a BMI less than 40 – 45 Sleeve Gastrectomy and to an extent Gastric banding is the treatment of choice. For those with a BMI greater than 40 – 45, diabetes or sleep apnoea, gastric bypass surgery or Sleeve Gastrectomy is the treatment of choice. If there is severe Gastro-oesphageal reflux then gastric bypass is the only answer. For those with BMI of more than 65, Duodenal switch with sleeve gastrectomy may be the right one: Performing Sleeve Gastrectomy first is less risky and make them fit for the next stage of the operation a few months later in these high risk patients. However, these guidelines are not fixed and selection of the type of surgery should be made after discussion with your surgeon. ^TOP^
It depends upon the type of operation you had and how compliant one is with the diet and exercises. Studies suggest that you will loose between 30 and 74 percent of your excess weight, the most rapid period of weight loss being in the first 18 to 24 months following surgery. There is a tendency to regain weight over time and so it is important to develop and maintain good eating habits. However, studies have demonstrated that patients undergoing gastric bypass maintain a weight loss of 50 to 70% of excess weight at between 5 and 6 yrs and one study demonstrated a maintained loss of 50% at 14 yrs. Studies suggest that gastric bypass surgery and BPD/Duodenal Switch are the most effective surgical treatment in maintaining long term weight loss. With gastric banding one may lose about 50% of excess weight over 3 – 5 years. ^TOP^
All surgical procedures are associated with some risk. In deciding whether to undergo weight reduction surgery it is necessary to balance the risks of the procedure against the risks of obesity. Complications that can occur following surgery include wound and chest infections, bleeding, injuries to the stomach and bowel and leaks from join in the bowel. It has generally been supposed that surgery on overweight patients is associated with increased risk of complications. Death though rare is a complication one should not ignore. Laparoscopic banding is associated with least peri-operative complications but associated with increasing complications over a few years. Gallstones can occur either before or after surgery or become symptomatic after surgery as one loses a lot of weight.
Gastric band results in band erosion or slippage of band; these two are serious complications that can occur in 10% people and the band has to be removed. Similarly Gastro oesophageal reflux / heartburn becomes a major problem in 10 % patients where the band has to be completely emptied or band removed; it can result in recurrent chest infections (aspiration pneumonia). Port or tubing problems can occur in 15% patients and require small surgeries. And of course there is 10-15% failure rate. Conversion of band to other weight loss surgeries takes a long time and also is attendant with complications.
Gastric bypass can develop leaks at the joins and can have serious sepsis. If severe pain occurs within a day after the operation it is most likely from leak and has to be operated urgently to rectify the leak. Internal Hernias can occur in about 1-3% and therefore one has to seek medical help urgently and it has to be corrected by surgery (laparoscopic or open) otherwise they can end up having dead bowel and therefore risk of death. So follow up is crucial in the first 2-5 years after surgery. Peptic ulcers at the join can occur in about 3% people therefore have to take PPIs – acid tablets for a couple of years or longer if they are on pain killers like Ibuprofen/volterol. They can develop Dumping syndrome, a group of unpleasant symptoms – lightheadedness/fainting, shaking, sweating, tummy pain (colic) and/or diarrhoea can occur if they take wrong foods (high calorie or fatty) or eat and drink at the same time. Occasionally hypoglycaemia (low blood glucose level) can be very difficult to cope but in majority of the people change of their food habit will solve the problem.
MGB or Omega Loop gastric Bypass is supposed to have less complications than RNY gastric bypass but the bile refluc into stomach and oesophagus can be difficult to cope with and then it may have to be converted to Roux-en-Y Gastric bypass to divert the bile and pancreatic juices away from the stomach and so the oesophagus. We do not know the long term effect of this bile reflux into stomach and oesophagus.
Gastric Sleeve/ Sleeve Gastrectomy SG can also develop leak from the long staple line of the stomach and the risk is higher than with the gastric bypass. It can be difficult to deal or prolonged if the problem is not picked up in the first few days. They may require multiple surgeries to correct the problem or may even has to have their Sleeve converted to gastric bypass though extremely rarely. GORD/ heartburn can be a problem in a minority of patients. That’s why Hiatus Hernia, if present, is repaired at the time of SG
Gastric Plication can cause intense nausea in the first 1-2 weeks and may have to be put on Intravenous drip for a couple of weeks even. By Laparoscopy, a couple of stitches may have to be removed to open up the stomach a bit if the vomiting persist. The stitches can cut through the stomach and can also cause leak from the stomach. There is also danger of gangrene of part of stomach and herniation of stomach through the stitches though rare.
Duodenal switch DS can develop leaks at the joins as in gastric bypass and these have to be rectified urgently. DS can result in serious nutritional deficiencies if they are not careful with the diet. If they take wrong foods like fatty foods, they can get diarrhoea (loose stools) up to 20 times. They can develop protein deficiency and deficiency of fat soluble vitamins Vitamin A, D, K & E. So they have to be careful with the diet. That’s why these people require close monitoring for deficiencies. They can also develop internal hernias though rarely. ^TOP^
Weight reduction surgery has been reported to improve several comorbid conditions including diabetes mellitus, sleep apnoea and obesity associated hypoventilation (resulting in hypoxia resulting in sleepiness during the day time even), high blood pressure and serum lipid abnormalities (high cholesterol and triglycerides). ^TOP^
You will need to eat a normal balanced diet after surgery. The operation will help in weight reduction but it is important to develop healthy eating habits and eating small portions. Sweets, ice cream and sugar rich drinks must be avoided since they contain a large number of calories, which will cause weight gain. Patients undergoing bypass surgery will need to take vitamins, iron and calcium supplements lifelong and increase the protein intake.
You should not become pregnant during the period of rapid weight reduction but there is no reason not to after your weight loss has stabilized which is usually about 18 – 24 months after the operation. ^TOP^
Weight reduction surgery is a partnership between patient, the patient’s family, surgeon, dietician and other healthcare individuals. In order to loose weight and keep it off it is necessary not just to have the operation but also to eat a balanced diet and to exercise regularly. Many overweight patients find exercising difficult, either because they are embarrassed to go out, or because have arthritic joints or they find their ability to exercise is simply limited by their size. Even so exercise is an important part of losing weight & keeping it off. ^TOP^
You may or may not. The skin is elastic and tries to mould to your body contour. Sometimes the excess skin may have to be removed – tummy tuck, thigh tuck etc. ^TOP^
It all depends upon the type of work you undertake. You can go back to work usually by 10-14 days. Some can go back to work within a week and some after 3 weeks. ^TOP^
You have to wait for 18 to 24 months i.e. until your weight has been stable for at least 6 months and you are eating well. Otherwise the food is not sufficient for you and the baby before that time and there is serious risk of spontaneous abortion of the baby or bay developing congenital abnormalities. ^TOP^