About two-thirds of adults in the 21st century are overweight or obese due to modernization and rich available resources. Obesity and lack of physical activity have the second largest public health impact after smoking. Obesity is associated with an increased risk of cancer, multiple comorbid diseases, affects the quality of life, and reduces life expectancy by 5-20 years!!
What is Bariatric surgery?
Bariatric surgery involves the manipulation of the stomach or intestine or both to aid weight loss. It either limits the amount of food intake or reduces the ability to absorb nutrients or in some cases both. This type of surgery is usually performed when diet and exercise plans have failed and the person suffers from serious health conditions due to obesity. Bariatric surgery has major risks and side effects and the patient has to adopt permanent changes to his/her diet and also follow a restricted exercise regime in order to ensure the success of the surgery for a long time. Bariatric surgery may not be suitable for everyone and it is generally not recommended for cosmetic purposes.
BMI (Body Mass Index)
BMI is defined as weight in kg/height in meter square. It is an indicator of body fat
- The ideal BMI should be 18.5-24.9
- Underweight < 18.5
- Overweight 25-29.9
- Obese > 30
- Morbid obese > 40
Major comorbidities due to obesity
Endocrine
- Diabetes
Cardiovascular
- Hypertension
- Hyperlipidemia
- Hypertriglyceridemia
- Pulmonary hypertension
- Coronary and cerebral vascular disease
- Venous stasis
Gynecology
- Infertility
- Menstrual irregularity
- Polycystic ovarian syndrome
Orthopedics
- Arthralgia
- arthritis
- Low back pain
Gastrointestinal
- Cholelithiasis
- Gastroesophageal reflux disease
- Fatty liver disease
Cancer
- Breast
- Ovarian
- Endometrial
Psychological
- Obstructive Sleep apnea
- Depression
- Substance abuse
Others
- Fungal infections
Aim of bariatric surgery
- To reduce co-morbidities
- To improve quality of life
- To increase life expectancy
Indication for bariatric surgery
- BMI 40 or higher
- BMI > 35 with significant serious comorbidities (e.g. sleep apnea, type 2 DM, hypertension).
- All other options have failed to achieve or maintain clinically beneficial weight loss for at least 6 months.
Prerequisites of surgery
- No endocrine causes of obesity
- Intensive specialist managementÂ
- Fit for anesthesia
- Long term follow up
Ineligible patients/ contraindication for bariatric surgery
- History of substance abuse
- Untreated major psychiatric disorder
- Liver cirrhosis with portal hypertension
- Malignancy with poor survival prognosis
- Women who plan for pregnancy in the next 18 months
Types of bariatric surgery
Restrictive Surgery (restrict the amount of food ingested)
- Horizontal gastroplasty
- Vertical banded gastroplasty
- Adjustable gastric band
- Sleeve gastrectomy
- Intra-gastric balloon
- Advantages-
- Easy surgical procedure
- Less dietary deficiencies
- Less weight loss
- Disadvantages-
- More failure rate due to dilation
2. Malabsorptive surgery (limits digestion and absorption)
- Jejunoileal bypass
- Biliopancreatic diversion
- Biliopancreatic diversion with duodenal switch
- Advantages-
- Greater sustained weight loss
- Less dietary deficiencies
- Disadvantages-
- Increased risk of vitamin deficiencies and malnutrition
- Requires constant follow-up monitoring
- Intermittent diarrhea
3. Mixed procedures
- Sleeve gastrectomy with duodenal switch
- Implantable gastric stimulation
- Gastric bypass Roux-en-Y (most commonly performed by surgeons)
- Technically difficult surgery
- No protein-calorie malabsorption
- Little vitamins and minerals deficiencies
- Long term sustained weight loss
Complications of bariatric surgery
- Anastomotic Leak
- Slippage of banding
- Band intolerance
- stricture/ulcer formation
- Stoma obstruction
- Bleeding
- Bowel obstruction
- Wound Infection
- Incisional hernia
- Dehydration
- Vitamins and mineral deficiencies
- Malnutrition
- gallstones formation
- Conversion to open
- Pulmonary embolism
- Deep vein thrombosis
- Risk of dying as a result of serious complications
Health Side-effects after bariatric surgery
- Nausea
- Vomiting
- Bowel changes (diarrhea, constipation)
- Dumping syndrome
- Lactose intolerance
- Temporary hair loss
Diet modification after Bariatric Surgery
- No oral intake for the initial few days after surgery so that the gastrointestinal tract gets time to heal.
- Stage I (Liquid diet for first 2 weeks after surgery)Â
- Minimum 2 litres per day
- Non-carbonated
- Non-calorie
- Avoid caffeine-containing beverages
- Sip slowly
- No straw
Â
- Stage II (Pureed diet)
- Pureed food containing all essential requirements for the first month after surgery (eg. blended foods)
Â
- Stage III (Modified solid diet)
- Soft and easily chewable foods. Such as
- Soft boiled egg
- Ground meat
- Yogurt
- Soft and easily chewable foods. Such as
Â
- Stage IV (Solid foods)
- Usually introduced after 2 months of surgery
- Food should be broken into small pieces and chewed slowly to see the tolerance of the stomach and adapt gradually without causing any discomfort
Recovery time after surgery
- Recovery time is quick.
- The minimum hospital stay is for 2-3 days.
- Early mobilization after surgery is encouraged, that is walking after 4 hours and doing slow cardio after reaching home (walking, cycling, swimming, etc.)Â
- You can get back to your normal activities 4-6 weeks later but you will have to make long term lifestyle modifications.
Foods to be avoided after surgery
- Sugary and Highly Caffeinated Drinks
- Popcorn
- Tough meat
- Fried food
- Crunchy food
- Dried food
- Bread, Rice, and Pasta
- Alcohol
- Dry Foods
- Fibrous Fruits and Vegetables
- High-Fat Food
Lifestyle changes after surgery
- WalkingÂ
- Exercise daily
- Cycling
- SwimmingÂ
- Avoid sitting for a long time
- Avoid meal skipping
- Commit to a long time follow up
- Vitamins and mineral supplements (folate, B12, Calcium)
- Avoid tobacco for at least 1 year after surgery
Results after bariatric surgery
On average, you will use 5-7 pounds (2-3 kg) per week.
Some clinical studies show patients may lose up to 50-70% of their excess body weight within the first 6 months after surgery !!Â
But the expected result completely depends upon the person’s personal changes to their lifestyle.
Benefits after bariatric surgery
Bariatric surgery helps to eliminate serious health conditions associated with obesity, such as
- Diabetes
- Hypertension
- Sleep apnea
- High cholesterol level
- Gastroesophageal reflux disease
- Coronary and cerebral vascular disease
- Low back pain
- arthralgia/arthritis
Cost of bariatric surgery
- It is quite expensive
- The cost depends on various factors such as surgeon fees, anesthesia, hospital stay, follow-up, etc.
- In the UK it costs around £8,000 to £15,000 ($11000 to $20500)
- In Bangladesh 9-10 lakhs Taka ($10500 to $12000)
