Delhi, February'23rd, 2018: Morbid obesity is a serious health condition that results from change in lifestyle, unhealthy eating habits lack of physical exercise, medical conditions like hypothyroid and even certain genes are can be reason for obesity. It can interfere with basic physical functions such as breathing or walking. Those who are morbidly obese are at greater risk for illnesses including diabetes, high blood pressure, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, osteoarthritis, heart disease, and cancer.

India saw a more significant rise in obesity from its 19th position for both men and women in 1975 to rankings 5th and 3rd respectively in 2014, reflecting increasing obesity rates among women worldwide.India’s women are more likely to be obese than their male counterparts, there were 20 million obese women in India in 2014 compared with 9.8 million obese men.

While people in India have been trying touse different methods to get rid of their excess weight like exercise, yoga, dieting and so bariatric surgery is one such process.

What is Bariatric Surgery?
Bariatric Surgery is a variety of procedures performed on people suffering from obesity. Many a times physical exercise and dieting fails due to different medical or non-medical reasons. Sometimes patients weighs extremely high which makes it difficult to get into shape, Bariatric surgery is ideal solution for those people. Evidence suggests that bariatric surgery may lower the death rates for Patients with severe obesity.

The basic principle of bariatric surgery is to restrict food intake and decrease the absorption of food in the stomach and intestines. Bariatric surgery is designed to alter or interrupt this digestion process so that food is not broken down and absorbed in the usual way. A reduction in the amount of nutrients and calories absorbed enables patients to lose weight and decrease their risk for obesity-related health risks or disorders.

When does one need Bariatric surgery?
BMI which stands for ‘body mass index’ is a measure of height in relation to weight; it is used to define levels of obesity and help determine if the surgery is required. In case your BMI is 40 or higher, and you have a serious weight related problem or your BMI is 35 or more and at least one or more obesity related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders or even heart diseases, you may be a candidate of a bariatric surgery.



Types of Bariatric Surgery

- Gastric sleeve Resection
It was originally performed as a modification to other Bariatric Procedure. The weight loss procedure is very effective which removes approx50% portion of your stomach and reduces level of the hormone ghrelin. This hormone is responsible for hunger. The surgery permanently alters the size of your stomach by removing lower portion of the stomach.
Advantages:
• It does not require any on-going adjustments.
• It’s a purely restrictive procedure.
• Regular follow up is necessary to ensure weight loss is appropriate and intake is nutritionally adequate.
• It is the most physiological procedure with minimum nutritional deficiencies.

Disadvantages:
• Stomach may dilate and lead to weight regain after 2 years.

- Gastric bypass
A Gastric Bypass is an irreversible procedure which involves dividing the stomach into a smaller upper section, or ‘pouch’ and connecting the small intestine directly to that pouch. The result is that the ‘stomach volume’ is reduced, as is the length of effective small intestinal tract.

- Roux-en-y Bypass
In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The reminder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. This connected into the side of the Roux limb of the intestine, creating the "Y" shape that gives the technique its name

Advantages:
- It’s mainly restrictive with slight malabsorption.
- After a year, weight loss can average 77% of excess body weight.
- Upto 90 percent resolution in DM , HTN OSA at one year post surgery .

Disadvantages
- Poor absorption of iron and calcium can result in the lowering of total body iron.
- Chances of nutritional deficiency and marginal ulcers.

- Mini Gastric Bypass
It is quicker technically easier and risk mortality is very low about 0.5% according to most studies... The newly constructed stomach is smaller and tubular in shape. Between 2 to 7 feet of intestines are bypass. The surgeon will attach the remainder of the intestines to the new stomach.

Advantages:
• The surgery has most promising results around the globe in term of excess body weight loss and comorbidities resolution.
• People can eat all types of food, no mortality with the surgery and reversible operation
• Type -2 Diabetes, infertility, HTN; OSA resolution rates are higher as compare to Gastric sleeve Resection and Roux-en-y Bypass.
• Lower complication rates when compare to gastric sleeve and RYGB.
• It is a purely malabsorptive procedure.

Disadvantages:
• Risk of nutritional deficiency greaterthen RYGB.

How does bariatric surgery work?
Bariatric surgery work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiology changes in your body that change in your energy balance and fat metabolism. Weight loss is achieved by reducing the size of the stomach with a gastric band or through removal of a portion of the stomach or by re-routing the small intestine to a small stomach pouch.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less digestion and less digestion of food due to smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.

Advantages of Bariatric Surgery:-
- Produces significant long term Weight Loss, which is almost 60 to 80 percent excess weight loss.
- Restricts the amount of food that can be consumed.
- Produces favourable changes in gut hormones that reduces appetite and enhance satiety.
- Increases energy expenditure On top of decreasing medications and losing weight, bariatric surgery has other benefits as well.
- Bariatric surgery reduces cancer risk in morbidly obese patients
- Improved self-esteem and quality of life.
- Improvement in fertility and complications during pregnancy
- Longer span life.

Disadvantages:-
- Technically more complex operation than the AGB .Generally has a longer hospital stay than the ABG.
- Potentially may result in greater complication rates.
- Requires adherence to dietary recommendations, lifelong vitamin/mineral supplementation, and follow-up compliance.
- May lead to a long term vitamin/mineral deficiencies particularly deficits in vitamin B12, iron and calcium.

Bariatric surgery in India
There are many hospitals in India which are working their level best to provide necessary care and treatment to obese patients. These hospitals are performing all different types of weight loss surgeries including revision surgeries with success rates compared to International standards.

High volume centres have successfully provided better outcomes and improved quality of life for hundreds of obese patients with the help of committed consultants, allied specialists and dietician.

The additions of second generation single incision laparoscopy surgeries and robotic surgical operations are latest procedures for patients who have morbid obesity. `

Surgery for weight loss in India is substantially lower than in developed countries or available in only tertiary carehospitals. In spite of low cost, hospitals in India have a reputation for providing the best facilities and highly trained doctors to do it. Hospitals for weight loss surgery in India are also reputed to have the most modern operating theatres, ICU’s, equipment and infrastructure to deliver best care to their patients.

Here are some key factors one should consider while searching hospital for the surgery:
- All major equipment and facilities in all weight loss centres.
- A big line-up of experienced and skilled doctors.
- Highly qualifies paramedical staffs
- Easy accessibility due to strategic location.

Cost of Bariatric Surgeries
Bariatric Surgery sure is an expensive surgery. In India a bariatric surgery costs anywhere between Rs2.5 to Rs5lakh, and the equipment and technology alone costs around Rs1.75lakh. Surgeons with the Obesity and Metabolic Surgery Society of India (OMSSI) say they have written to the union government to ensure that bariatric surgery procedures are insured as they have been now established as metabolic surgeries rather than cosmetic ones.

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