FAQs - Bariatrics

• If you are above 18 years & below 65 years of age.
• If you have BMI (Body Mass Index) 40 kgs./M2 or higher
• If you have BMI 35 kgs./M2 but associated with ailments ie. DM, Hyepertension,Heart Diseases,Arthritis etc.
• Your weight is more than 40 kgs. of ideal weight. You have been overweight for more than 5 years.
• Your serious attempts to lose weight have had only short-term success.
• You have failed to loose enough weight by dietary or weight-loss drug therapy for more than one year.
• You have understood the surgical procedure and are prepared to accept changes in your eating habits and lifestyle.
• You should not drink alcohol in excess
• You are willing to follow up with specialist who deal with such surgeries.

Bariatric surgery works by two principles
1. Restrictive mechanism &
2. Malabsorptive mechanism

• Gastric capacity for food is reduced
• Transit of solid food out of the pouch is slowed
• Satiety is achieved when pouch fills
• Hunger is delayed until pouch empties
• Less small bowel length for contact with succus entericus
• Less small bowel length to absorb food
• Bypass of pancreatic enzymes (some procedures)
• Reduced appetite (ileogastrostomy)
• Fat intake causes diarrhea

Restrictive

1. Lap. adjustable gastric banding (LAGB)
2. Lap. Gastric Sleeve Resection
3. Vertical Banded Gastroplasty

Malabsorptive

• Roux-en-Y gastric bypass (RGB)
• Biliopancreatic diversion with duodenal switch

Laparoscopic Adjustable gastric banding, is a form of restrictive weight loss surgery (bariatrics) designed for obesity patients with a (BMI) of 40 or greater - or 45 with those who have comorbidities that are known to improve with weight loss. The gastric band is an inflatable silicone prosthetic device which is placed around the top portion of the stomach via keyhole laparoscopic surgery

In gastric bypass operation the stomach is divided into a small upper pouch and a much larger, lower pouch. The small upper pouch is then joined to the small intestine..The small stomach pouch will feel full more quickly than when stomach was its original size, which reduces the amount of food taken and thus the calories consumed. Bypassing part of the intestine also results in fewer calories being absorbed. This leads to weight loss.

LGSR is a surgical weight-loss procedure in which the stomach is reduced to about 20-30% of its original size, by surgical removal of a large portion of the stomach along the major curve of stomach. The remaining stomach looks like a tube often called as stomach tube The procedure permanently reduces the s ize of the stomach. The patient feels full after a small intake of food.

Also very important is the fact that it preserves the pylorus, the valve that regulates emptying of the stomach. This acts as "natures band" and allows food to hold up in the stomach for a while, making the person feel full while the food trickles out. Coupled with the fact that there is no rearrangement of the bowel, it also means dumping and marginal ulcers are not a problem. The The normal satiety mechanism is preserved .

In this operation, also referred to as stomach stapling, divides the stomach into two parts - limiting space for food and forcing you to eat less. There is no bypass. Using a surgical stapler, the surgeon divides your stomach into upper and lower sections. The upper pouch is small and empties into the lower pouch - the rest of your stomach. Partly because it doesn't lead to adequate long-term weight loss, this weight-loss surgery has fallen out of favor.

In this procedure, the surgeon removes about 80 percent of the stomach. The valve that releases food to the small intestine is left along with a limited portion of the small intestine that normally connects to the stomach (duodenum). The surgery bypasses the majority of the intestine by connecting the end portion of the intestine to the duodenum near the stomach. This weight-loss surgery offers sustained weight loss, but it presents a greater risk of malnutrition and vitamin deficiencies and requires close monitoring. It's generally used for people who have a body mass index greater than 50.

This is not predictable; most of the patients will never loose so much to call them skinny ! But the majority can and do achieve a normal, healthy weight for their height and bone structure. Success after bariatric surgery is defined as losing 50 percentage of excess body weight. The weight loss differs with different procedures. Malabsorptive procedures it is more.

A	Gastric Band	Sleeve gastric resection	Gastric bypass
Complexity	Simple	Simple	Moderate
eversibility	Easy	Not reversible	Possible but difficult
Laparoscopy	Yes	Yes	Yes/open
Early Risk	Lower	Lower	Moderate
Hospital Stay	2 days	2-3 days	3-5 days
>Average Wt. Loss	50-70% of Excess weight	50-70% of Excess weight	80 -90% of Excess weight
Late risks	Band slippage/band erosion/band leakage/oesophageal dilatation	Strictures/ wt. gain	Ulcers, anemia, stricture, vitamin/ calcium / iron deficiencies, intestinal obstruction
Risk of Malnutriton	low	Low	high

After understanding all the aspects of the operations one can choose what is suitable to individual needs. The LAGB requires significant post-operative manipulation, has a re-operative rate that is high, but is the simplest procedure to perform.The LGSR is again simple with low risk but high chances of weight regain but have the option to get converted to gastric bypass or duodenal switch.The gastric bypass is the most studied of all the bariatric operations. It is generally a safe and effective operation. There is a higher early complication rate than the above two.

Any surgery has a degree of risk and should not be taken lightly. When you weigh the risks involved with surgery against the risks of the co-morbidities that accompany being over weight, the surgery is usually far less risky.

It can vary, hospital stay (excluding the day of surgery) can be 2-6 days depending on the. After leaving the hospital, you may be able to care for all your personal needs, but will need help with shopping, lifting and with transportation. Disease Improved Resolved Arthritis 47% 41% High cholesterol 33% 63% Heartburn 24% 72% Hypertension 18% 70% Sleep apnea 19% 74% Depression 47% 8% Urinary incontinence 39% 44% Asthma 69% 13% Diabetes 18% 82% Headaches 29% 57% Gout 14% 72%

Disease	Improved	Resolved
Arthritis	47%	41%
High cholesterol	33%	63%
Heartburn	24%	72%
Hypertension	18%	70%
Sleep apnea	19%	74%
Depression	47%	8%
Urinary incontinence	39%	44%
Asthma	69%	13%
Diabetes	18%	82%
Headaches	29%	57%
Gout	14%	72%

A person's quality of life is significantly improved after weight loss. Aside from the medical consequences of obesity, the social consequences ie.difficulty in sitting in seats which are smaller to the size,difficulties with simple acts such as tying shoes,and difficulties with basic personal hygiene improves dramatically. . Quality of life just three months after weight loss surgery returns to normal!

We take out patient's gallbladder only when at the time of surgery, the gallbladder contains stones since the risk of gallbladder removal is lower that the chance of developing significant symptoms from gallstones. For people who have gallstones and no symptoms, it has been shown that there is a one percent per year risk of developing problems related to the gallstones. After significant weight loss, patients who did not have pre-operative gallstones have a 30 percent chance of developing stones. If you take Actigall (bile salts) for six months, your risk for gallstones is only three percent.

It's possible you may not get enough vitamins from three small meals a day. You may be advised to take supplements.

Being physically active is important for maintaining the lost weight. Regular exercise is, of course, helpful in losing weight and improving your health. Becoming more active as the weight is lost will help you realize the benefits of a healthier weight and increase your long-term success. Look at increased activity as one of the rewards for being successful with weight control. Being able to walk upstairs without your knees and back hurting, and without getting severely short of breath, is a great thing to enjoy!

Many patients have become pregnant after bariatric surgical procedures.In fact, several studies have demonstrated that significant weight loss can improve fertility and one recent, excellent study from Australia showed that weight loss after the surgery improves fertility in morbidly obese women. There is also a syndrome called Polycystic Ovary Syndrome (PCOS), which can lead to infertility. This syndrome involves excessive hair growth and hormonal changes that generally resolve with dramatic weight loss after bariatric surgery. As far as getting enough appropriate nutrition to have a safe pregnancy, this has not been a demonstrated problem with either the LAGB,LGSR or the gastric bypass. However, you are recommended to consult with your bariatric program nutritionist to be safe if you do get pregnant.

The weight loss results in loosening the skin but it all depends upon the amount of weight lost, age of the patient and initial sagging of skin.If you skin becomes too loose then plastic surgery may be considered. As a rule, plastic surgery will not be considered for at least a year or two after the operation. Sometimes the skin will mold itself around the new body tissue.

• Eat three small meals a day.
• Not only is there an adjustment to make about the quantity but also quality of food you should eat. When you are able to eat solid foods again, eat food high in protein. Protein foods are very important for the healing of staple line of your pouch. Protein in the form of lean meats (chicken, turkey, fish) and other low-fat sources should be eaten first. These should comprise at least half the volume of the meal eaten. Foods should be cooked without fat and seasoned to taste. Avoid sauces, gravies, butter, margarine, mayonnaise and junk foods. Hair loss is one effect of not eating enough protein.
• You will also have to learn to eat slowly and chew your food thoroughly. Food not chewed properly will not pass through the narrow stoma and may cause vomiting.
• Stop eating as soon as you feel full. If you do not stop, you may have vomiting and it will put strain on the staple line.
• Do not eat sweets! This includes sweetened chewing gum, candy and regular sodas. Beware of hidden sweets (cereals with honey or sugar coatings).
• You may be unable to tolerate certain foods, especially those containing fat and sugar. A balanced diet of 1000 - 1200 calories a day is recommended.
• Drink 2 liters or more of water each day. Water must be consumed slowly, 1-2 mouthfuls at a time, due to the restrictive effect of the operation.
• Never drink water or any fluid with the meal. Drink fluids thirty minute to an hour after meals. Taking fluids before or at meal time may cause bloating, low food intake, vomiting, or dumping syndrome. It will also flush the food through the stoma and you will feel hungry again.
• Do not drink flavored beverages, even diet soda, between meals

No. Patients who follow the guidelines to eating after weight control surgery will become people who eat food for quality and flavor, not for volume. They enjoy food more after surgery than they did before surgery. They pay more attention to what they are eating, are often pickier eaters, and don't feel guilty about eating food.

You will find that even small amounts of alcohol will affect you quickly. Alcohol is high in calories and will significantly alter your calorie balance. It is suggested that you drink no alcohol for the first year. Thereafter, you may have a glass of wine or a small cocktail for social purpose not more than once a fortnight.

You should be able to take prescribed medication. You may need to use capsules or break big tablets in half or dissolve them in water so they do not get stuck in the stoma and make you sick. You should always ask the doctor who prescribes the drugs about this. You should avoid taking aspirin or other non-steroidal anti-inflammatory pain relievers. That's because they may irritate the stomach