Narayana Health Care

Over 50 million people have been diagnosed with diabetes in India. It is not an overstatement to call India the diabetic capital of the world. It is estimated that the diabetic population will increase to 87 million by 2030 an increase of around 58%. WHO estimates that 3.8 million deaths are due to high blood sugar levels. Thus, there is an urgent need to address this issue which has turned into an epidemic.

Type 2 Diabetes is a situation where the pancreas produces enough insulin but the body is unable to use it. Diabetes is a syndrome leading to several other diseases like blindness, heart, and blood vessel disease, strokes, kidney failure, nerve damage, and in severe cases amputations. Bariatric (Obesity) surgery may play a crucial role in obese patients when contemporary therapies are not sufficient alone.

What is Weight Loss Surgery?

Bariatric or weight loss surgery includes a variety of procedures performed laparoscopically on patients who have obesity and associated problems. By this surgery, weight loss is mostly achieved by restricting the absorption area and altering gut hormone levels that are responsible for hunger and satiety, leading to a new hormonal weight set point. There are a variety of procedures described which include gastric bypass, sleeve gastrectomy, and other weight-loss surgeries.

When are Weight Loss surgeries recommended?

Such surgeries are recommended in cases when obesity threats general health that weight reduction becomes essential and crucial for overall well-being. General indicators along with obesity indicating the adoption of these kinds of surgeries might include:

• Heart diseases
• High blood pressure
• Non-Alcoholic Fatty Liver Disease (NAFLD) or Non-Alcoholic Steato-Hepatitis (NASH)
• Sleep Apnea
• Type 2 Diabetes

Of course, contemporary approaches should always be resorted to in the first instance. However, where the contemporary therapies do not work coupled with ineffective weight loss attempts by exercising and dieting, the surgery will prove immensely beneficial in controlling the otherwise uncontrolled diabetes.

Who performs Weight Loss Surgery?

A Bariatric surgeon is the one who performs the procedure. The team typically includes a bariatric surgeon, an endocrinologist, a pulmonologist, a cardiologist, a trained nutritionist, a psychologist, and a physician.

Preparing for the Procedure:

It is important to note that the bariatric surgeries should not be resorted to without properly assessing the patients. The selection of patients is typically based on the following parameters:

• Body Mass Index (BMI) more than 35 Kg/m²
• One or more of the above-mentioned problems
• BMI>40 Kg/m² when it is called morbid obesity
• Failure of contemporary methods for weight loss

Of course, the final call needs to be taken by your team of doctors.

How is the Bariatric surgery performed?

Bariatric procedures can be divided into two types namely: Restrictive procedure and Malabsorptive procedure. Restrictive procedures are devised to reduce the size of the reservoir (stomach) and Malabsorptive procedures reduce the absorptive area.

1. Gastric Bypass – Here a small stomach pouch is made by dividing the stomach. The food when eaten gets into the small pouch bypasses the other half of the separated stomach along the top portion of the small intestine. This leads to more and early satiety and absorption of fewer calories.
2. Gastric sleeve (also called sleeve gastrectomy) – Here a large part of your stomach is removed. It leads to a reduction in the size of the stomach, reducing a hormone named ghrelin, making you feel early satiated and less hungry.
3. Adjustable gastric band – As the name suggests, an adjustable band is tied around the top portion of the stomach. The benefits are obvious in terms of no cutting or removing organs to limit the chances of post-surgery complications. As side effects, the band may slip or may experience wear later. In such a scenario, the patient may need surgery to fix it.
4. Mini Gastric Bypass – This is an emerging technique and being performed more frequently. It reduces the absorption as well as the size of the stomach.
5. Gastric balloon – An inflated balloon is placed in your stomach via mouth for up to 5-6 months. Balloon reduces the space in the stomach and you can’t eat much and hence will lose weight.

The bariatric surgery team will help you decide which surgery is best indicated, after evaluating you thoroughly. The evaluation for surgery is done by various members of the team starting from surgeon to nutritionist to any other doctor as per the disease profile of the patient. Once the surgery is performed, you will not be allowed to eat for 2 days giving your stomach time to heal. Oral liquids are allowed from day 1 or 2 of the surgery. The diet is slowly graduated from liquid to solid in the subsequent days.

What precautions do I need to take post-surgery?

• Strict exercise regimen

• Mandatory Diet Plan

1. Eat smaller frequent meals
2. Add more vegetable and protein to your plate

• Switch to low fat and calorie options

The risks are equivalent to any other Laparoscopic surgery. Few risks are being enumerated:

• Bleeding
• Infection
• Adverse reactions to anesthesia
• Breathing problems
• Leaks at the operated area
• Death (rare)

Longer-Term Risks and Complications:

• Malnutrition including vitamin deficiencies
• Bowel obstruction
• Dumping syndrome, which leads to diarrhea, flushing, light-headedness, nausea or vomiting
• Gallstones
• Hernias
• Low blood sugar (hypoglycemia)
• Ulcers
• Vomiting
• Acid reflux
• The need for a second, or revision, surgery or procedure
• Death (rare)

Reports from various centers across the country revealed that up to 80% of patients operated upon have not shown any sign of diabetes post-surgery. Additionally, patients typically lose 60% to 80% of their extra weight. It is also observed that the procedure leads to better blood pressure, cholesterol, and triglyceride levels. Last but not the lease, the procedures did improve the quality of life many folds.

The risk of death from complications of diabetes is more than the risks of bariatric surgery. The earlier the surgery is performed, the better are the results.

However, a word of caution while opting for Bariatric surgery. As of now for Type 2 Diabetes, bariatric surgery should be reserved only for obese uncontrolled diabetic patients and not for every diabetic patient. It is now being recommended for overweight and normal-weight uncontrolled diabetic also, but strong evidence is still pending. Accordingly, the role of evaluating the team becomes more crucial in terms of appropriate selection and hence mandates the properly trained Bariatric surgery team.

Dr. Neeraj Goel, Senior Consultant – Gastrointestinal Oncology, Liver Transplant & HPB Surgery,  Dharamshila Narayana Superspeciality Hospital, Delhi