OBESITY – LAP SLEEVE GASTRECTOMY & BENEFITS
Obesity is abnormal accumulation of body fat, usually 20% or more over an individual’s ideal body weight. It is defined as Body Mass Index (BMI) equal or more than 30. BMI is calculated as the ratio of body weight in kg to square of height in meters. There are other ways of measuring obesity like fat thickness, waist circumference.
The incidence of obesity is increasing day to day. “In every region of the world, obesity doubled between 1980 and 2008,” As per WHO’s The World health statistics 2012 report, Today one in six adults that is, half a billion people (12% of the world’s population) are considered obese.” Though India is a developing country with malnourishment, now a days India is gaining weight. Obesity has reached epidemic proportions in India in the 21st century, with morbid obesity affecting 5% of the country’s population. It is more prevalent in urban population & females.
Studies show that in India, nearly 15 to 20% of children are overweight and 30% are in the risk of falling in this category. It is these statistics that ring major alarm bells. In India, many studies have shown that the prevalence of overweight among adolescents varies between 10% and 30%. Another important concern is that as high as 60 to 70% may continue to be overweight or obese in adulthood.
Causes of obesity:
- Hormonal disturbances
- Diet habits: Excess eating of high calorie food, Irregular eating habits
- Life style: sedentary habits
Effects of obesity & relation with Diabetes:
Obesity has its deleterious effects on all systems such as Respiratory disease, Stroke, Cardiovascular problems, Gall stone disease, Gout, Osteoarthritis, Hormonal abnormalities, Diabetes & Cancer. Diabetes and obesity are mutually related. India is diabetes capital of the world. 40.9 million people are diabetic in India, this is expected to rise to 69.9 million by 2025.
Glucose maintenance in the body is a complex process. Whenever food enters the system glucose needs to be absorbed into cells by insulin. Secretion of insulin is helped by incretins which are the substances produced by hind gut that stimulate the Beta cells to produce insulin. Secretion of insulin inhibited by anti incretins secreted by fore gut. Poor sugar control is the major contribute for the development of Diabetes which is due to excessive calorie intake, poor secretion of insulin, insulin resistance. All these are strongly associated with obesity.
- Metabolic syndrome
- Type II Diabetes
- Obstructive sleep apnea
- Venous & Lymphatic stasis
- Chronic respiratory hypoventilation
- Hypertrophic cardiomyopathy
Complications of Obesity:
- Psychological –
- Eating disorders
- Poor self esteem
- Social isolation & stigmatism
- Greater the BMI – Early the premature death
- Increased incidence of co-morbidities & cancers
Management of Obesity:
Obesity management is a multidisciplinary approach with several modalities like conservative, medical, non surgical, minimally invasive & major surgical approaches.
Conservative approach is the base line primary modality achieved through changing dietary habits, life style. This will certainly help in early phases of obesity but requires a lot of dedication, commitment.
Medical management mainly targets on inducing early satiety.
Non surgical methods are Gastric balloon which will be placed endoscopically. It is useful when BMI is 25-30.
Surgical approach is well known as Bariatric or Weight reduction surgery. Most people are not successful losing weight with diets. As someone becomes overweight, the risk of developing other serious diseases dramatically increases. Surgery has proven to be the most effective method to treat severe obesity. Surgery is of choice when both conservative & medical management fails.
LAPAROSCOPIC SLEEVE GASTRECTOMY:
In Indian scenario with difficult long term follow up, regular additional nutrition, mineral, vitamin supplementation, Laparoscopic Sleeve Gastrectomy is effective weight reduction surgery for obese. There won’t be any major anatomical, functional alteration of digestive tract & with almost nil post operative morbidity & mortality. Studies also suggested that weight reduction following sleeve gastrectomy is as equal as of with gastric bypass.
-Under General anesthesia, patient will be positioned in low lithotomy or over bean bag for easy position mobilization and accessibility.
-Pneumo peritoneum is created with Hasson’s or visi port technique
-Abdomen visualized & access operability.
-On regular basis we preferred to use Nathenson’s self retaining liver retractor & 3 working ports
-Short gastric vessels are ligated along the greater curvature of stomach till fundus of stomach
-Stomach mobilized above till OG junction
-Using 32 / 34 French bougie as guide, vertical sleeve gastrectomy done with Ultra GI Endo stappplers.
-75% of the stomach was removed (Restrictive bariatric)
-Hemostasis achieved & abdomen closed in layers after taking specimen out through umbilical port.
Sleeve gastrectomy is a restrictive procedure. It greatly reduces the size of the stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass the intestines. After this surgery, patients feel full after eating very small amounts of food. Sleeve gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, the procedure reduces the amount of the “hunger hormone,” ghrelin, produced by the stomach. The duration of this effect is not clear yet, but most patients have significantly decreased hunger after the operation.
Postoperatively patients monitored as like any other laparoscopic surgery. 2nd post operative day contrast scan can be performed to see any contrast leak followed by patients will be started liquid diet as tolerated and can be discharged on the same day. Further follow up will be after a week and diet will be gradually increased from clear liquid to full liquids and to soft diet as tolerated under guidance of experienced dietician.
-No major morbidity & almost nil mortality
-Very short hospital stay, early return to activity
-Restrictive bariatric surgery with effective weight loss by limiting intake & decreasing hunger
-No functional, major anatomical disturbance
-It does not involve any digestive anastomosis, no mesenteric defects are created eliminating the risk of internal hernia
– It is not associated with Dumping syndrome, the risk of peptic ulcer is low and the absorption of nutrients, vitamins, minerals and drugs is not altered
At APOLLO, we perform Laparoscopic sleeve gastrectomy as a multidisciplinary team with well trained and qualified laparoscopic and bariatric surgeons, high end anaesthesiologists, well trained ot staff including nurses and technicians and good quality equipment, ICU set up as back up if necessary, dieticians, psychologists and behavioural therapists and fitness experts on a regular basis and achieving effective & satisfactory results. Our patients usually discharge on 2nd post operative day with liquid diet. And patients are back to work in less than a week. We have seen effective weight loss of around 60% percentile in 6 months without major nutritional disturbances. However, bariatric surgery is not a resort in cases of childhood obesity because the child needs to attain his full growth potential until the age of 18 and so as to not interfere with normal growth physiology
- How long does the surgery take?
A gastric sleeve surgery takes anywhere between 1.5 to 3 hours.
- How long will I have to stay in the hospital?
- When can I go back to work?
One should be able to work and resume all normal activities in 2 weeks, and full recovery can be expected in 30 days.
- How much of my stomach will be removed?
- How much and how fast a weight loss can I expect?
Maximum weight loss is seen in the first 10 months and one can expect to lose
upto 21% weight by the third year.
- Advantages of gastric sleeve over gastric banding
Gastric sleeve requires no readjustments and therefore no reoperations. Also, the fullness produced is more satisfying than the feeling of obstruction caused by banding.
- Advantages over gastric bypass surgery:
A gastric sleeve does not involve any rerouting and is hence faster, easier and safer. Also, there are no vitamin and mineral deficiencies.
Dr.Rajnesh C. Reddy
Surgical Gastroenterologist,Laparoscopic surgeon Senior Consultant
Apollo Health City