Now, everyone knows that bariatric surgery is a serious undertaking for the patient with its potential for complications (about which much has been written by us in this website). Everyone also knows that liposuction is a simple way of removing body fat without any complications. Some plastic surgeons or slimming centers may encourage this line of thinking by being effusively positive and optimistic about the benefits of the procedure.
The ethical and responsible plastic surgeons (and we know several) clearly know the place of liposuction in the management of the obese patient.
They explain the potential complications of liposuction as including infection, embolism and skin complications. They reserve it largely for spot reduction, a cosmetic indication, avoiding the obese patient who needs more than spot reduction of a few pounds of fat.
Additionally, I have always suspected that post-liposuction, the patient (whose lifestyle usually goes unchecked) puts on more fat that accumulates in other body parts, leading to an unsightly obesity. Today, my suspicion stands vindicated.
As the New York Times reports:

…fat came back after it was suctioned out. It took a year, but it all returned. But it did not reappear in the women’s thighs. Instead, Dr. Eckel said, “it was redistributed upstairs,” mostly in the upper abdomen, but also around the shoulders and triceps of the arms.

However, the human mind likes gratification, even if it lasts all of one year (heck, even one minute of a sweet treat is irresistible), and so the study shows that the women still were happy with the results of the liposuction, in spite of more belly fat than before. Irony.

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Before we proceed, do you know what is a lap gastric bypass all about?

An important factor to be considered by every patient/doctor involved in a gastric bypass is how the stoma for the pouch would be created, as it is one of the known factors leading to weight regain.

The stoma is the opening we create between the gastric micro-pouch and the upper small bowel (jejunum). Too big a stoma will lead to food exiting the pouch quicker and resultant weight regain. Too small a stoma would lead to obstructive symptoms and misery.

So what is the ideal stoma size: 12 mm, 14 mm, 18 mm, or 25 mm? And how would we create this stoma? Does the stoma size stay that way all life at the same size?

Easy, tiger, easy. One thing at a time!

Ideal stoma size:
Different people seem to be using different sizes. A popular way of creating the stoma is with the EEA circular stapler and the OrVil device. The stoma created is either 21mm or 25mm in size.
The stoma is a little big but it is known to contract in size later. The risk of stenosis being highest in the circular stapler group, it is perhaps better to keep stoma size around this level. A smaller stoma may stenose and cause obstructive symptoms. The incidence of stenosis is less than 3 percent.

The hand-sutured technique (my personal favorite) is known to stenose the least in the long term. Here the stoma size is 12 mm/36 Fr. In case you are wondering how we can measure in millimeters in lap surgery, we pass a 36 Fr gastric tube through the mouth into the pouch. The anastomosis between the pouch and the jejunum is fashioned over this tube.
A stoma can be created with the Linear Stapler. This leaves the anterior (front) walls open, and need hand-suturing to complete the process. The stoma also tends to be excessively wide, in my experience. Therefore, at BMI, we don’t favor this method, preferring the hand-sewn and EEA techniques instead.
So the keen patient here would be wondering, “Which is better or best?”
Like most things in life, it depends. Each method of stoma creation has its pros and cons.
The EEA circular stapled method is quick and mechanised, so suturing is not a major issue. The stoma is reliably and safely created, with minimal leak rates. However, it is expensive, needs the surgeon to be familiar with the device, and has the highest stenosis rates. On top of that, technical disasters are not unknown (study in colorectal context).

The hand-sewn method (best demonstrated by Kelvin Higa) is also safe, reliable and avoids mechanical stapler failures and disasters. It needs the highest level of skills in the surgeon, and is more time consuming in most hands. Experts, however, can complete this quickly.

The Linear Stapler method is easy for most surgeons, but has very little to recommend it.

One final issue with the stoma: do we need stoma to be buttressed, or glued? It may by nice to do and for us to see in the operating room, but it probably does not reduce leak rates significantly. In the high-risk patient we may choose to use it. Some studies do report significant benefits in reduction of bleeding, leaks and stenoses.

The bottomline is to ask your surgeon how he would create the stoma, and what he prefers. Then make up your mind to go for it. You have more to gain by that decision: that one thing that will transform your life.

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]]> http://www.bmi-india.com/gastric-bypass-choosing-the-stoma/feed/ 0 http://www.bmi-india.com/is-diabetes-curable-by-surgery/ http://www.bmi-india.com/is-diabetes-curable-by-surgery/#comments Sun, 06 Feb 2011 10:11:13 +0000 ramana http://www.bmi-india.com/?p=542 Note: This article discusses only Type II Diabetes Mellitus

It has always been a given for generations that ‘once a diabetic, always a diabetic’. Absolutely like the truism for high blood pressure, asthma and hypothyroidism. You know that if you are unlucky enough to get these labels stuck on you, you are going to take pills or injections all your life and suffer the disease as it progresses into making each organ weaker than ever before. No more.

Riya, a plump 50-year-old diabetic who was taking insulin injections for many years, was fed up of her lifestyle and the fact that she was developing complications of diabetes and high blood pressure. Being highly educated, she searched the Internet for newer options. Every website she visited mentioned high cure rates after gastric bypass surgery. She came to us at Belle Vue Clinic, where we did the same surgery on her (keyhole method). Riya’s blood sugar, always in the high 300s, normalized immediately after her surgery. Discharged after a couple of days, she joined back her school in a week, no longer worried about her blood sugar. Her colleagues are now asking her about her secret – how did her weight and blood sugar get under control so quickly?

In 1994, an American doctor called Walter Pories published a scientific paper provocatively titled, “Who would have thought it? An operation is the cure for Type II Diabetes Mellitus!” This paper showed the astonishing results that an operation called gastric bypass led to patients getting cured of diabetes in nearly 90 percent of cases. Blood sugar levels stay normal even several years after the operation.

Since then, this kind of operation, called ‘Metabolic Surgery’ or ‘Bariatric Surgery’ has become a standard across the globe.

What is done in the gastric Bypass?

We staple the stomach to form a very small pouch. When swallowed food comes from the food-pipe   into this pouch, it meets a dead end. So we need to create a way for the food to go down. To do this, we take the small intestine up and create a channel between it and the stomach pouch. So, now the food goes into the small gut, bypassing most of the stomach and upper small bowel.

How Does This Work?

This works by reducing the stomach’s capacity to take in food, leading to satiety upon consuming a small portion of around an ounce of fluid. There is reduced spike in blood glucose after food (less volume + less absorption= low nutrient absorption).

The net effect of this operation is that undigested food reaches the small bowel, leading to the release of some hormones called incretins. These incretins (a group of around 200 chemicals) act to bring down the blood sugar levels and also halt the deterioration of pancreatic hormonal function that is the hallmark of Type II Diabetes Mellitus.

It is now clear that the alarming rise in cases of diabetes is linked to the widespread obesity in towns and cities. Indeed, 80 percent of new diabetics are fat to varying degrees. So far, doctors have been advising diabetics to lose weight by diet control and exercise, and to take medicines for diabetes. To a large extent, this is a hit-and-miss method of treatment, as there is no sure and predictable response in patients, largely because everyone differs in how strictly they follow their dietary discipline. Most people cheat on their diet, don’t exercise beyond the irregular morning walks and keep getting new complications of diabetes every year.

Most of these patients who undergo the gastric bypass procedure are also very obese. Says Dr. Arindam Ghosh, a bariatric surgeon based in Ludhiana’s Apollo Hospital, “Many of my diabetic patients are obese Punjabis weighing up to 200 kgs. Some of them live in the US and Canada, where the obesity levels are far greater than in India.”

Even though increasing numbers of our patients are searching the Internet daily for information, awareness levels are still abysmal. Patients think surgery involves physical removal of fat from their body. The younger generation is taking the lead. Yogesh Sharma, a 19 year old student who weighed 168 kgs, came to me for surgery to reduce his weight and cure his diabetes after convincing his parents that his decision was the correct one. To their credit, the Sharmas saw merit in the scientific approach. Most people are, however, very scared of the very word ‘surgery’ and would rather see their lives slowly but surely getting spoiled by disease.

Many people like Ruchita Doshi, a 57-year-old lady who has undergone spine surgery, regret their decision, “I wish I had undergone bariatric surgery before. My obesity led to arthritis and spine disease for which I needed to spend rupees three lakhs on treatment. Now they say I cannot be operated as I am undergoing dialysis because of diabetic nephropathy (end stage kidney disease).” Ruchita shares the opinion of many doctors that surgery for diabetes cure would have offset the costs of the complications of the primary disease. What are you doing about your obesity and diabetes?

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]]> http://www.bmi-india.com/is-diabetes-curable-by-surgery/feed/ 4 http://www.bmi-india.com/alcohol-causes-obesity-%e2%80%93-lets-analyse/ http://www.bmi-india.com/alcohol-causes-obesity-%e2%80%93-lets-analyse/#comments Wed, 03 Nov 2010 16:16:26 +0000 sarfaraz http://www.bmi-india.com/?p=504 Alcohol has been in the center of research in the past few decades for a lot of reasons. While nobody with a sane  mind questions the vices of smoking, sensible drinkers have hotly contested the alcohol debate.
We know that alcohol is very high in calories, and it also can affect the way the body metabolizes energy. The body reacts by storing it as fat rather than using it as fuel 1. However, the relationship of alcohol and obesity is far more complex than perceived earlier.
It is no longer assumed that alcohol consumed in moderate quantities and evenly spaced out can cause obesity. On the contrary, researchers believe that it may have beneficial effects on health as far as obesity is concerned 2.
This is what Dr R A Breslow, Ph D had to say after conducting a national survey in USA, “In our study, men and women who drank the smallest quantity of alcohol – one drink per drinking day – with the greatest frequency – three to seven days per week – had the lowest BMI’s while those who infrequently consumed the greatest quantity had the highest BMIs”. 3
So, more than one drink a day, and certainly binge drinking, is likely to increase your weight, while lesser amounts evenly spread won’t.
What however can determine and confound the effects of alcohol consumption on weight gain is the environment in which one is drinking. Eating high calorie snacks, little activity and smoking often go together with a drinking session, which compounds the problem as each on their own have been linked to weight increase.
A paper by  Arif et al from Texas, USA published in 2005 shed some more light on the alcohol debate. It stressed that the beneficial effect of drinking disappears beyond consuming two drinks a day and may actually result in weight gain with heavy drinking 4.
Hence the bottom line about the effects of alcohol on obesity may be summed up as follows. On the basis of recent research data available we may safely conclude that alcohol in moderate consumption may be safe (lets not rush to call it healthy and advocate it as a routine measure to prevent obesity) whereas consumption in large quantities and especially when associated with high calorie snacks may be highly detrimental.

1. Zurlo F, Lillioja S, Esposito-Del Puente A, Nyomba BL, Raz I, Saad MF, Swinburn BA, Knowler WC, Bogardus C, Ravussin E. Low ratio of fat to carbohydrate oxidation as predictor of weight gain: study of 24-h RQ. Am J Physiol. 1990; 259:E650–657.
2. Jequier E. Alcohol intake and body weight: a paradox. Am J Clin Nutr. 1999;69:173–174.
3. Breslow RA, Smothers BA. Drinking patterns and body mass index in never smokers: National Health Interview Survey, 1997–2001. Am J Epidemiol. 2005;161:368–376.
4. Ahmed A Arif and James E Rohrer. Patterns of alcohol drinking and its association with obesity: data from the third national health and nutrition examination survey, 1988–1994. BMC Public Health. 2005; 5: 126.

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]]> http://www.bmi-india.com/alcohol-causes-obesity-%e2%80%93-lets-analyse/feed/ 5 http://www.bmi-india.com/the-obesity-pill-a-myth/ http://www.bmi-india.com/the-obesity-pill-a-myth/#comments Wed, 27 Oct 2010 13:59:41 +0000 ramana http://www.bmi-india.com/?p=489 I, like many others, have long believed that science will, one day, announce the discovery of a pill that will end obesity. One pill, and pow! no more cravings, and fat will melt off your muscles like wax from a lit candle.



(pic: bmj.com)

Many companies have clearly shared that fantasy or vision. Billions of dollars are at stake to be the one to discover the ultimate pill. The Ultimate Pill™ will have the following characteristics:

1. Help burn fat

2. Allow you to eat normally without putting on fat

3. Have no side effects

4. Be cheap and easily available

5. Reverse obesity-related changes (this is perhaps taking things too far)

Obviously, we are nearly talking science fiction here.

The various drugs that have been used in the past are now mere footnotes in the history of obesity medicine. Heard of fenfluramine? A few years back, rimonabant was said to be the wonder drug, working through some mysterious cannabinoid receptors in the brain (how exotic it sounds!). That fell through, because people were getting depressed enough to commit suicide.

Sibutramine and Orlistat have been heavily prescribed by physicians around the world to effect weight loss short of bariatric surgery. Sibutramine causes appetite suppression, while orlistat affects fat absorption and allows unhealthy eating without the fear of weight gain. So they said.

We have said it before that orlistat can cause liver problems, and is a candidate for withdrawal. Now the world is told that sibutramine has been withdrawn in the US, Canada and Europe because of heart attacks (the SCOUT study).

The BMJ says:

The therapeutic cupboard containing antiobesity drugs has never been well stocked. The European Medicines Agency (EMA) recently decided that sibutramine must follow the example of rimonabant, withdrawn last year because of safety concerns. This leaves just one drug—orlistat—to face the rising tide of obesity across the continent. The demise of sibutramine carries both irony and wider messages for the management of obesity.

Sibutramine fell at the crucial hurdle of cardiovascular risk. Arterial disease—which leads ultimately to myocardial ischaemia, heart failure, and stroke—affects most obese people to some degree and is their major cause of death. Much evidence suggests that weight loss decreases morbidity and mortality associated with cardiovascular disease,3 and this is an important justification for all antiobesity measures, including drugs. Unfortunately for sibutramine, an interim analysis of the SCOUT (Sibutramine Cardiovascular Outcome Trial) study found that the drug increased morbidity from cardiovascular disease. The odds were always stacked against sibutramine, because cardiovascular risk is embedded in its mechanism of action. Sibutramine acts centrally to reduce food intake; it inhibits the presynaptic reuptake and degradation of serotonin and noradrenaline, thus enhancing the appetite suppressing actions of both neurotransmitters.

Why drugs have not yet worked for weight loss in obese patients may be due to the fact that obesity is a heterogeneous disease with multiple factors, whereas the drug tends to be focal in its mechanism of action.

So, sadly, another drug has failed. The role of bariatric surgery is as crucial as ever. It is now the only scientifically proven method of weight loss. What is more, it is safe and effective. As study after study keeps showing us. But will the naysayers hear the truth?

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]]> http://www.bmi-india.com/the-obesity-pill-a-myth/feed/ 0 http://www.bmi-india.com/gastric-plication-a-new-wls-procedure/ http://www.bmi-india.com/gastric-plication-a-new-wls-procedure/#comments Sun, 18 Jul 2010 04:22:12 +0000 ramana http://www.bmi-india.com/?p=456 Many bariatric surgeons are excited about the procedure Gastric Plication (LGP) as a bariatric procedure. It promises to be a simple method (remember, “Less Is More!”) that gives weight loss results as good as sleeve gastrectomy without even the risks of that procedure (staple line leaks (read part one and part two here) or bleeding).

What is done is that the greater curvature of the stomach is freed from the tissues attached to it (known as the gastrocolic omentum) using a vessel sealing device like the Harmonic Scalpel or the Ligasure. This is the first step of the sleeve gastrectomy procedure, as well.

However, unlike the sleeve, here we do not use the stapler to remove 80% of the stomach. We merely imbricate/plicate the stomach using running stitches from above downwards, layer by layer, till most of the stomach is pushed inwards, creating a narrowing of the passage, and a tunnel along the lesser curvature, just like the sleeve.


Lap Gastric Plication

In the same vein, if someone wants to reverse the procedure, the stitches may be removed by laparoscopy (making this a potentially reversible procedure like the Lap Band), though this would neither be a good thing nor a great experience!

Some patients have significant reflux symptoms after LGP, as after the sleeve, as we have discussed before.

It is possible that the stitches may give way later and hamper the weight loss, but preliminary results, as presented in the recent International Conference of Obesity in Stockholm, show good results akin to the sleeve.

More info later!

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]]> http://www.bmi-india.com/gastric-plication-a-new-wls-procedure/feed/ 45 http://www.bmi-india.com/weight-loss-surgery-for-dummies/ http://www.bmi-india.com/weight-loss-surgery-for-dummies/#comments Wed, 07 Jul 2010 10:23:53 +0000 ramana http://www.bmi-india.com/?p=425

(pic source: here)

I am  excited (only in a manner of speaking) to announce to you a NEW series of articles for the layman who has just heard of bariatric surgery. This will be part of a new page. You will find, over the next several weeks, more and more articles that don’t deal with each issue in the kind of depth that you find in my regular articles, but function rather like a ‘Weight Loss Surgery For Dummies’. In fact, this is what I think I will call this series. Maybe this could be a book in the future and my retirement plan!

Oh, wait, this book has already been written!



So, a new series called ‘The Complete Idiot’s Guide To Weight Loss Surgery” is going to start. The reason for this is that a lot of viewers/readers of this site, as well as BMI patients, are happy merely with a ‘Do This, Not That’ kind of approach, and don’t much care for the heavy science in the regular articles.

That said, in my opinion, the ‘heavy’ articles are the meat-and-potatoes of this site, and I hope this will become like a Wiki for obesity surgery. This site is meant to be a highly referenced source of reliable evidence-based and practical information regarding obesity and weight loss surgery in the internet, without the overt commercialisation, mis-representation and selling in many sites.

Stay tuned for more good stuff, and keep visiting.

If you like this blog, please do consider subscribing to our RSS feed. It is easy, and at the lower right side of the front page!

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