Laparoscopic Gastric Bypass Surgery and Laparoscopic Gastric Banding ( lap band ) are increasingly getting popular in New Delhi, India amongst patients coming for Medical Tourism from USA, Europe, Australia etc. looking for a low cost option at International Standards.
CONTENTS OF THIS PAGE
Click here for free email advice
DEFINITIONS
AND RISK FACTORS
· With Minimal Access Surgery ( also known as Minimally Invasive Surgery or Laparoscopic Surgery ) reaching all parts of the body for various diseases, it was only a matter of time that this would be applied for the treatment of obesity in India as has been the case in the western countries.
· There are no incidence studies done in India looking for morbid obesity, though there are many reports that talk about the increasing menace of obesity and associated diseases. While a third of India’s population still falls below the poverty line, there has been a steady growth of the relatively affluent urban middle class, now estimated to number over 200 million. Those who have achieved affluence within a lifetime constitute a good proportion of this middle class. The Nutrition Foundation of India has just completed a study of the prevalence of obesity in urban New Delhi.
It would appear from the results of this study that nearly a third of the males and more than half of females belonging to what may be termed the ‘upper middle class’ in India are currently overweight using the WHO criteria of BMI>25, but the figure will be higher if the AIIMS recommendations for Indians is followed (see below). The prevalence of abdominal obesity in this group is even higher. Assuming that the ‘upper middle class’ in India number around 100 million (half the number of middle class), it may be computed that there are roughly 40 to 50 million overweight subjects belonging to the upper middle class in the country today. If present trends continue, the situation can get worse within a decade, and overweight could emerge as the single most important public health problem in adults. Overweight/obesity may not be considered as a specific disease but it is certainly the mother of important degenerative diseases in adult life.
Studies abroad tell us that nearly 97 million American adults are overweight; it is estimated that of these, 4 million are severely obese and 1.5 million are morbidly obese.
· More alarmingly, from 1960 to 1990, the incidence of obese American adults increased from 13% to 35%.
· Obese patients are at an increased risk of illness from coronary artery disease, hypertension, type II diabetes, respiratory insufficiency, venous stasis or thromboembolic disease, debilitating arthritis of weight-bearing joints, and depression, as well as uterine, ovarian, colon, breast, and prostate cancer.
· Body mass index (BMI) is used to define obesity. This is the figure obtained by dividing body weight by the square of height in meters. If your weight for instance is 80 kg and height is 5 feet 7 inches (1.70 m ), then your BMI would be 80/2.89 = 27.68 kg per m2
|
|
· People are classified as:
| WHO CRITERIA | RECOMMENDATION FOR INDIANS | |
| Normal | less than 25 kg per m2 | less than 23 |
| Overweight | more than 25 kg per m2 | more than 23 |
| Obese | more than 30 kg per m2 | more than 27.5 |
| Severe obesity | more than 35 kg per m2 | more than 32.5 |
| Morbid obesity | more than 40 kg per m2 | more than 37.5 |
∙ A waist-to-hip ratio of 1.0 or higher in men and 0.8 or higher in women defines upper body obesity and is an independent predictor of disease risk. This is also known as syndrome X and is a common problem seen in India.
∙ As BMI increases above 25 kg per m2, mean blood pressure and total blood cholesterol increase and mean high-density lipoprotein levels decrease.
∙ The most significant observation is that morbidly obese patients who are 20 to 40 years old may experience a 12-fold reduction in life expectancy compared with age-matched control subjects.
∙ Once classified, patients who are obese or severely obese are treated medically; bariatric surgery is reserved for patients who are morbidly obese or severely obese with concomitant obesity-related diseases.
∙ Hypertension is the most common comorbidity of obesity, which is corrected in up to 66% of patients who lose excess weight.
∙ The risk of coronary artery disease is also higher in the obese population.
∙ Venous stasis disease with significant chronic morbidity.
∙ These patients have an increased incidence of non-insulin-dependent diabetes mellitus.
∙ Adipose tissue acts as an endocrine organ; adipocytes secrete enzymes important in sex steroid and glucocoarticoid metabolism, resulting in excessive levels of androstenedione and estradiol. The hormones lead to feminization in men and masculinization, polycystic ovarian disease, amenorrhea, and infertility in women in women.
∙ The incidence of obstructive sleep apnea is 12 to 30-fold higher in the morbidly obese than in the general population.
∙ Cancer mortality rates are increased in the morbidly obese compared with the general population.
∙ Mortality rates for obese women are increased for endometrial, gallbladder, uterine, cervix, ovarian, and breast cancers.
∙ Mortality rates for obese men are increased for colorectal and prostate cancers.
∙ Nonsurgical treatments include caloric restriction, exercise, behaviour modification, and drug therapy.
∙ The long-term results of caloric restriction programs have been poor.
∙ Exercise programs without some type of caloric restriction are generally ineffective beyond the loss of 6 to 10 pounds.
∙ Long-term success with behaviour modification programs is also lacking.
∙ Pharmacologic programs are popular, but they are equally ineffective as a treatment for morbid obesity; they use appetite-suppressing medications that act by increasing the central nervous system concentration of serotonin, a mood-elevating neurotransmitter believed to be involved in eating disorders.
∙ Amphetamines and newer potentially addictive sympathomimetic medications are also used without significant long-term success.
∙ Other medications are available that reduce the absorption of fat through the inhibition of lipase.
CURRENT SURGICAL THERAPIES FOR MORBID OBESITY
1. Restrictive ( surgical reduction of the stomach size to reduce amount of food intake)
Vertical Banded Gastroplasty -- NOT DONE COMMONLY
Laparoscopic Gastric Bypass --
Laparoscopic Adjustable Gastric Banding -- POPULAR PROCEDURE
Laparoscopic Sleeve Resection -- GAINING POPULARITYSPECIALLY IN INDIA
2. Malbsorptive ( surgical re-routing of the consumed food leading to reduced absorption )
Jejunoileal Bypass -- NOT DONE ANYMORE
Biliopancreatic Bypass --
3. Combined restrictive and malabsorbtive ( size reduction with bypass )
Laparoscopic Gastric Bypass with long limb of intestine -- POPULAR PROCEDURE
Duodenal Switch --
4. Other Procedures
Gastric Pacemakers -- UNDER EVALUATION
Gastric Balloon -- TEMPORARY MEASURE
∙ Patient with a BMI the exceeds 35 to 40 kg per m2 and obesity-related comorbidities are potential candidates for surgical treatment of morbid obesity.
∙ Surgery should be offered only to patients who are well informed and motivated and who are acceptable surgical risks; the patients should be evaluated preoperatively by a multidisciplinary team of nutritionists, nurse clinicians, internists, psychologists or psychiatrists, and surgeons.
∙ Patients should be screened for common obesity-related conditions; tests to be considered include chest radiography, electrocardigraphy, cardiac stress testing, echocardiography, arterial blood gas and pulmonary function testing, polysomnography, lower extremity Doppler ultrasound, and glucose tolerance testing.
∙ The most commonly performed restrictive procedure is vertical-banded gastoplasty, and the most commonly performed malbsorptive procedure is Roux-en-Y gastric bypass.
The stomach size is reduced by applying staplers across it and thereby reducing the amount of food a person can eat at a given time.
·
Gastric Banding is the most popular restrictive procedure currently.
A band is
placed
around the upper most part of the stomach. This band divides the stomach
into two portions, one small and one larger portion. Because food is
regulated, most patients feel full faster. Food digestion occurs through the
normal digestive process. Other advantage is that it is EXTERNALLY
adjustable ( the band can be tightened or loosened to regulate the amount of
food passing ). RISKS:
Gastric perforation or tearing in the
stomach wall may require additional operation, access port leakage or
twisting may require additional operation, may not provide the necessary
feeling of satisfaction that one has had enough to eat, nausea and vomiting,
outlet obstruction, pouch dilatation, band migration/ slippage.
· The vertical-banded
gastroplsty is associated with a relatively low complication rate
but is only moderately effective for significant weight loss hence has lost
popularity.
Prospective randomized studies that compared vertical-banded
gastroplasty with gastric bypass demonstrated
significantly less weight loss for patients undergoing vertical-banded
gastroplasty.
· Gastric
bypass ( short limb ) is more effective in “sweets eaters” than vertical-banded
gastroplasty because dumping symptoms curtail the
high dietary intake of sweets. If the intestinal joint is made lower down,
this procedure becomes a combined restrictive + malabsorbtive procedure (
see below ).
·
The Gastric Sleeve Resection
removes a great part of the stomach and leads to 'considerable'
loss of
weight. This is useful in those with a
BMI between 35 and 40. Also, this
procedure is being done in BMI over 60 to downgrade the obesity to a more
manageable level of about 50, after which a gastric bypass / duodenal switch
can be done.
The
stomach is joined to the intestine at a point further down to cause
malabsorbtion of the consumed food. Jejunoileal
bypass (left picture) and bilio-pancreatic bypass (right picture) had serious nutritional complications and
are not done commonly.
· These operations often result in a high degree of patient satisfaction because patients are able to eat larger meals than with a purely restrictive or standard gastric bypass. procedure. These procedures can produce the greatest excess weight loss because they provide the highest levels of malabsorption.
· RISKS : For all malabsorption procedures there is a period of intestinal adaptation when bowel movements can be very liquid and frequent. This condition may lessen over time, but may be a permanent lifelong occurrence. Abdominal bloating and malodorous stool or gas are common. Lifelong monitoring for protein malnutrition, anemia and bone disease is recommended. Nutritional deficiencies of iron, vitamin B12, folate, calcium, and the fat soluble vitamins A, D, and E can occur. Lifelong vitamin supplementing is required. It has been generally observed that if eating and vitamin supplement instructions are not rigorously followed, at least 25% of patients will develop problems that require treatment. Changes to the intestinal structure can result in the increased risk of gallstone formation and the need for removal of the gallbladder and re-routing of bile, pancreatic and other digestive juices beyond the stomach can cause intestinal irritation and ulcers. Revision of the gastric bypass is required in 2% to 15% of cases as a result of staple line dehiscence, marginal ulcer, outlet stenosis, or inadequate weight loss.
COMBINED RESTRICTIVE AND MALABSORBTIVE
In recent years, better clinical understanding of procedures combining
restrictive and malabsorptive approaches has increased the choices of
effective weight loss surgery for thousands of patients. By adding
malabsorption, food is delayed in mixing with bile and pancreatic juices
that aid in the absorption of nutrients. The result is an early sense of
fullness, combined with a sense of satisfaction that reduces the desire to
eat. According to the American Society
for Bariatric Surgery and the
National Institutes of Health, Roux-en-Y gastric bypass is the most
frequently performed weight loss surgery in the United States. In this
procedure, stapling creates a small (15 to 20cc) stomach pouch. The
remainder of the stomach is not removed, but is completely stapled shut and
divided from the stomach pouch. The outlet from this newly formed pouch
empties directly into the lower portion of the jejunum, thus bypassing
calorie absorption. This is done by dividing the small intestine just beyond
the duodenum for the purpose of bringing it up and constructing a connection
with the newly formed stomach pouch. The other end is connected into the
side of the Roux limb of the intestine creating the "Y" shape that gives the
technique its name. The length of either segment of the intestine can be
increased to produce lower or higher levels of malabsorption.
The Mini-Gastric Bypass, which uses the loop reconstruction, has been suggested as an alternative to the Roux en-Y procedure, due to the simplicity of its construction, which reduced the challenge of laparascopic surgery. It is claimed that construction of a long tubular gastric pouch reduces the risk of inflammatory complications, and renders it as safe as the RNY technique. Many bariatric surgeons shun the procedure, and most would assert that it remains unproven and investigational in nature at this time. Those doing the procedure claim to have many satisfied patients.
The other procedure in
this group is of Duodenal switch.
With this procedure, the surgeon
removes approximately 60 percent of the stomach so that it takes the shape
of a tube. The small intestine is then divided much further downstream than
with gastric bypass so that more intestine is bypassed and two intestinal
pathways are created: one for food, and one for the digestive juices, both
of which meet to form a common channel. Duodenal switch preserves the
pylorus and the outlet muscle that controls emptying of the stomach. It also
offers the ability to eat near normal portion sizes and produces reliable
weight loss. Since this operation induces a state of decreased absorption,
patients typically experience more bowel movements and need to be monitored
for vitamin, mineral, and protein levels.
· Patients who require revisionary surgery after a jejunoileal bypass, a vertical-banded gastroplasty, a gastric bypass, or a biliopancreatic bypass can be categorized into two groups.
Those with insufficient weight loss
Those with metabolic or surgical complications
· The major complication that requires revision after a primary gastric bypass is a marginal ulcer.
· Insufficient weight loss is the most common indication to revise a vertical-banded gastroplasty or a gastric bypass; inadequate weight loss is usually due to a staple line dehiscence or an outlet dilation.
· The cause of weight loss failure after vertical-banded gastroplasty is a change in dietary habits toward high-calorie liquids and sweets and, after gastric bypass, an enlarged gastric pouch (increased capacity).
· Unique complications that require revision unrelated to inadequate weight loss are acid reflux after vertical-banded gastroplasty and marginal (stomal) ulceration after gastric bypass.
· Most patients with stomal ulcers respond to medical therapy; however, if the stomal ulcer persists or recurs, truncal vagotomy, reduction of the gastric pouch to less than 50 ml, and revision of the gastroenterostomy should be performed.
· Laparoscopic vertical-banded gastroplasty and various gastric bypass surgeries are technically challenging operations.
· Laparoscopic adjustable gastric banding and sleeve resection are less technically demanding procedures.
· Laparoscopic bariatric surgery is an evolving field; a select number of laparoscopic surgeons have attained comparable results to equivalent open bariatric procedures.
· Long-term follow-up is required for this minimally invasive surgery, however the reports so far are quite encouraging as the patient does not need a major cut and the surgery is done through 5 or 6 keyhole sized cuts.
OTHER PROCEDURES ( new !! long term results awaited )
Intragastric
Balloon is a
soft, silicone balloon that is inserted into th stomach and filled with
sterile saline. with the balloon you will have a feeling of satiety, or lack
of hunger. The balloon will be removed after six months.
The Gastric Stimulation System is designed to provide electrical stimulation to the stomach for the treatment of obesity. The system is comprised of an implantable pulse generator, an external programmer, and a gastric stimulation lead. The implanted pulse generator delivers electrical pulses to the stimulation lead. The lead conducts the pulses to the smooth muscle of the stomach. The external programmer can noninvasively communicate with the implanted pulse generator and allows the electrical parameters to be adjusted. The lead is implanted in a laparoscopic procedure with 2 - 4 trocars used during the implantation: one for the camera, two for operating ports and one (optional) for liver retraction. It is placed in a subcutaneous pocket in the abdomen. The regular surgery time is less than one hour. Gastric stimulation is designed to help patients lose weight in combination with standard behavior and dietary modifications. It is normally indicated for patients with a body mass index (BMI) of greater than 40 or 35-40 with one of more comorbidities. The programmer consists of a computer connected to a small programming wand. It is used to check and, if necessary, change electrical values of the IGS before and after implantation. Communication is accomplished noninvasively via radio frequency signals.
Table below should give an idea of costing by the hospitals. The charges vary depending on the size of the hospital and the city they are located.
| No. | HEADING | LAP BAND | LAP BYPASS |
| 1 | Operation charges ( surgery and anesthesia ) | 900 | 1200 |
| 2 | Operation room charges ( OR, Consumables, Medicines ) | 1000 | 1200 |
| 3 | Staplers / Lap Band (Expensive imported from Europe / USA) | 3500 | 4500 |
| 4 | Room charges @ | 175/day | 175/day |
| 5 | Doctors visits | 500 | 500 |
| 6 | Investigations | 400 | 400 |
| TOTAL ( APPX ) | 7000 | 9000 |
TOTAL COST SHOULD BE AROUND $9000 IN MOST CASES OF GASTRIC BYPASS AND AROUND $7000 FOR GASTRIC BANDING
Hospitals may be offering the treatment for lesser cost by squeezing the expenses, but it should be kept in mind that cost squeezing at times binds the hands of the treating doctors and may not be always in the best interest of the patient. Doctors usually would like to have the liberty of keeping the patient in the ICU for a day, extra day stay in the hospital, extra tests or medicines to be on the safer side etc.
Click here for free email advice
The author Dr Arun Prasad MS, FRCS is a senior laparoscopic surgeon at Apollo Hospital, New Delhi.
Also a teacher in Laparoscopic Surgery at Ethicon Institute of Surgical Education, Mumbai and tutor for Surgical Skills Course for the Royal College of Surgeons, Edinburgh.
He was a surgeon at Charing Cross Hospital and Medical School, London and a teacher in Laparoscopic Surgery at The Royal College of Surgeons, London.
He belongs to the world's first generation of Laparoscopic Surgeons and is a pioneer in this field.
GO TO SURGERY TIMES ( HISTORY OF SURGERY AND CURRENT STATUS)
RELATED TOPIC : MEDICAL TOURISM
GO TO MAIN INDEX PAGE BY CLICKING HERE
