This means that in this class of obese people, if we operate on a thousand, two will die. If you take these same thousand people and just let them carry on the same way (with medical treatment, etc.) HALF of them would be dead in 20 years! In fact, the five year mortality of these patients is high enough to justify bariatric surgery.

Even though this is pretty impressive stuff to demonstrate how life-saving and life-altering bariatric surgery can be, what happens to an individual case where the patient dies? For that family, the mortality rate is 100%! Can things be any worse for them? No.

Therefore, if we could try and reduce the mortality of surgery even further, why would we not do it?

If we could weed out the highest risk cases, it would be half the battle won. We could then simply try not to operate on this high-risk class of patients, UNLESS there is a clear and explicit understanding and acceptance that they have a significant chance of dying within a month of surgery.

So the highest risk is seen in these groups:

1. Elderly
2. Males
3. High BMI
4. Smokers, alcoholics
5. History of pulmonary embolism/DVT
6. Re-do bariatric surgery

• Causes of 30-day bariatric surgery mortality: with emphasis on bypass obstruction– Mason EE, Renquist KE, Huang YH, Jamal M, Samuel I.
• The SOS Study: Sjöström
• The Pennsylvania bariatric mortality study
• Long-Term Mortality after Gastric Bypass Surgery: Ted D. Adams, et al.
• Medicolegal analysis of 100 malpractice claims against bariatric surgeons: Cottam D, Lord J, Dallal RM, Wolfe B, Higa K, McCauley K, Schauer P.

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This is an oversimplification, IMO.

I have mentioned before that the sleeve, in spite of being an easier and faster procedure, may be more problematic in terms of leak alone. The leak rate of the sleeve is around 2-3 percent, while that of the bypass is around the same, but the leaks behave differently.

The sleeve leak (as discussed in details before) is a high pressure leak, occurring usually at the angle of His, and tends to persist unless stented.

The bypass leak occurs at multiple possible sites, half in the gastrojejunostomy, but being a low pressure leak, tends to dry out on its own once the surgical re-exploration is done and issues sorted out.

(pic from referenced article)

Leaks after a bypass are usually detected on Day 3, give or take some. The detection may be because of routine dye study, but usually the patient already has a high pulse rate, fever, abdominal pain, dirty drain output, etc. It is important to remember that around a third of patients may have no clear evidence of a leak in spite of CT scan or dye test or both. In fact, in an older study, only a pulse rate over 120 and a rapid breathing rate were consistent in patients with leaks, and only 2 out of 9 leaks showed up on the dye study.  This means that a laparoscopic re-exploration is the most reliable of investigations for a leak!

Upon detection of a leak after the bypass, the patients is usually re-explored laparoscopically. The procedure may include any or all of the following:

1. Re-suture of leak with omental graft
2. Re-do the full anastomosis
3. Partial remnant gastrectomy (in case of remnant staple line leak)
4. Drainage
5. Gastrostomy

While around 2 percent of bypasses may leak, when they do occur, they inflict considerable collateral damage: gastrogastric fistula, wound complications, lung problems, DVT/PE, etc.

It is also important to remember that a downstream problem like an obstruction of the jejunum may cause leaks from the staple line above.

Are there groups which have a predictably higher leak rate?

Yes, it may be said that the leak risks are higher in:

1. Revisional bariatric surgeries (around 13-14%)
2. Males.
3. Higher BMI.
4. Multiple co-morbidities.
5. Patients with previous abdominal operations.
6. Circular stapled anastomoses (hand-sewn method has the lowest leak rate of 0.4%): controversial!
7. Inexperienced surgical hands.
8. Those who have had an intraoperative mishap (colon/splenic injury, for example).
9. One leak may predispose to another.
10. Buttressed staple lines may have an advantage in leak rates.

The mortality of jejuno-jejunal leaks is close to 40-50 percent, while a GJ leak has a 10% mortality.

What happens once a leak is detected and the patient re-explored? Initial days may be stormy or tense, spent in the ITU with ventilatory support given to some patients (remember, many of these patients are already sick with other co-morbidities), and then the sepsis gets controlled and the nutrition support started (through the gastrostomy tube or through a central vein in the neck, etc.). The patient recovers slowly and the leak heals with time. In the rare case, if a leak persists beyond a month, a stent may be required.

With this post, our continuing exploration of the Achilles heel of all bariatric operations has been, you will admit, rather thorough. If this and the other articles frighten you, then be assured that this was and is not the goal of my writing. We at BMI believe that an informed patient is the best one, and we owe it to you to even out the information asymmetry in this highly technical branch of medical care. All surgeries have side effects, but they occur in a small minority of patients. In the given case, each complication hits hard, and a prepared patient handles it better. As bariatric surgeons, we need to brief you adequately as to the possible downsides of what is otherwise a transformational event in life.

Ref:

Diagnosis and Contemporary Management of Anastomotic Leaks after Gastric Bypass for Obesity

J Am Coll Surg

Rodrigo Gonzalez, MD, Michael G Sarr, MD, FACS, C Daniel Smith, MD, FACS, Mercedeh Baghai, MD, Michael Kendrick, MD, Samuel Szomstein, MD, FACS, Raul Rosenthal, MD, FACS, Michel M Murr, MD, FACS

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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/the-lap-gastric-bypass-what-is-it/ http://www.bmi-india.com/the-lap-gastric-bypass-what-is-it/#comments Wed, 20 Apr 2011 23:30:54 +0000 ramana http://www.bmi-india.com/?p=568 Lap Gastric Bypass Animation


The bypass (as it is called in short) is an operation that is used for severe obesity and related diseases like Type II Diabetes Mellitus. It has excellent results in the short as well as the long term. It consists of the following steps:
1. Laparoscopic (keyhole) access into the abdominal cavity.
2. Stapling the stomach to create a micro-pouch (20-30 ml capacity) the is connected to the food passage (esophagus). The rest of the stomach remains in situ but is disconnected fully from the pouch.
3. The food that comes into this micro-stomach or pouch needs an exit to travel further down and get digested. So, we have to hook up the upper part of the small gut (jejunum) to it. This is done in a way known as Roux-en-Y, a standard method that prevents bile from refluxing into the esophagus and causing nasty symptoms. The channel connecting the jejunum and the pouch is created by using a stapler, or hand-sutured.
4. The spaces between the small bowel and the large bowel, as well as the holes in the mesentery (the fat anchoring the bowel) are stitched up to prevent the later development of internal hernias.
5. The port sites are closed internally.
6. End of procedure.

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]]> http://www.bmi-india.com/the-lap-gastric-bypass-what-is-it/feed/ 1 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/hair-loss-after-gastric-bypass-surgery/ http://www.bmi-india.com/hair-loss-after-gastric-bypass-surgery/#comments Tue, 29 Jun 2010 04:38:14 +0000 ramana http://www.bmi-india.com/?p=406 Hair loss is one of the commonest laments in female patients after gastric bypass surgery (whether for weight loss or surgical cure of Type II Diabetes Mellitus), and is at once one of the least heralded topics in the subject. This is but natural: after all, surgeons are more bothered by complications that are life-threatening and serious.



(even men go crazy over hair loss!) Pic credit: here.

But who is man enough to tell a lady that her hair loss is not serious?

Though it is not possible to discuss the physiology of hair loss in any kind of detail in this platform, we should have a working knowledge of how and why this happens.

Hair follicles are the living part of hair, the latter being keratin strands without inherent blood and nerve supply. When hair follicles get less nutrition or blood supply, the hair falls off. The important things to understand here are that:

1. The hair follicle itself is capable of recovering fully and regenerating hairs, and

2. The hair loss that the patient notices is a reflection of the insult suffered by the hair follicle several weeks beforehand.

So, in practice, what happens is that a patient notices clumps of hair coming off in the bathroom or during sleep, three or more months after the gastric bypass. A panic appointment is made, and we take time to assuage the panic. Usually, women being women (please forgive the unintended sexism), the reassurance wears thin, as the hair loss continues. In the meantime, the visible scalp areas elicit comments in the patient’s family and circle (“OMG! What is wrong with you? My aunt had something like this, and they later said it was cancer!!” is one of the comments you may hear), and the panic washes up once too often (“But, doctor, you never told me about this!”).

True, as surgeons, while we dwell at length about leaks, thromboembolism, weight loss plateaus and other such major issues, we may not harp much on the hair loss thing. One of the reasons is that this is a reversible phenomenon. Once the weight loss is achieved and the patient’s nutritional intake comes to near normal, the hair loss stops and the regrowth is established.

Anecdotal reports of benefits exist for various supplements, including biotin, primrose oil and flaxseed oil and horsetail extract, among others. It is all up to you to experiment and find out which one would work magically for you!

One thing we do strongly advise is not to go for hair transplants and other major interventions like this. After all, there is such a thing called common sense: why over-think something that is self-correcting?

For a nice overview of nutritional and metabolic complications after bariatric surgery, read this article in Diabetes Care.

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]]> http://www.bmi-india.com/hair-loss-after-gastric-bypass-surgery/feed/ 2 http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-three/ http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-three/#comments Fri, 14 May 2010 14:11:57 +0000 ramana http://www.bmi-india.com/?p=359 In Part One, we outlined the nature of the beast. In Part Two, we dealt with ways of cooking it. Now, in this part, we will clean up the remains. Sorry to our Gujju (and other vegan) friends for this analogy!

If you have had bariatric surgery and are now having reflux, what now?



(Are you worried about your reflux? Pic source: here)

We need to see what procedure you had. If you had a Band, tough luck! Because, as we mentioned before, the Band does cause reflux and also esophageal dilatation. Now, many surgeons will quickly accuse me of bias here. To which I plead guilty. I have always maintained that the Band is not exactly my favorite operation. While I maintain that it causes reflux in a lot of patients, there are conflicting reports worldwide.

For example, in Dixon’s study, they have found fantastic results after the Lap Band in terms of reflux symptoms and otherwise, too. Ten years later, the Australians reported excellent results in this paper.



(your favorite antacid may help. Pic: here)

After sleeve gastrectomy, reflux is temporary but may be distressing. If you have this problem, here is a list of what to do:

* Chew your food slowly or drink your liquids slowly.

*Avoid processed carbs

*Stay away from coffee, alcohol and tea

*Stop smoking, really stop it, will you?!

* Walk around after dinner

* Take an hour or two (or more) to sleep after dinner

* Keep the head end of the bed elevated

* Take PPIs as prescribed. PPIs are drugs that banish acid secretion.

* For short term burning sensation, drink  little cold water and have some preparation like Mucaine gel or Xylocaine viscous (local anesthetic).

* Contact the bariatric team for further advice.

After sleeve, reflux may be distressing and persistent in a small subset of patients. As this recent paper says, there may be an association between a wider proximal stomach tube and a narrower distal tube. This means that the upper part of the stomach tube is wider than the lower part. However, this is not related to the size of the bougie (the rod like thingie that is used as a sizer for the tube prior to stapling). Whether 3 cm or 6 cm of the lower part of the stomach (the antrum) is left behind has no relationship to the severity of reflux. Most of these patients also respond well to medical treatment.

Well, that should wrap up the subject pretty much for you! Please get in touch with us if you need more information.

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]]> http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-three/feed/ 1 http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-two/ http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-two/#comments Fri, 14 May 2010 12:23:56 +0000 ramana http://www.bmi-india.com/?p=355 In Part One, we outlined the nature of gastroesophageal reflux and how it occurs, as well as how we detect it clinically.

So let us now assume that you are awaiting bariatric surgery and have reflux symptoms. So how does your reflux have an implication on your surgery? Will bariatric surgery (after all, we are operating on the stomach) make your reflux worse or better?

Let us take this procedure by procedure:

The Band: The band produces a mechanical obstruction right below the junction of the food pipe and the stomach. While this produces a barrier for the downward descent of food and accounts for the restriction in food intake after its placement, it does just the reverse for acid reflux. In other words, it tends to make reflux symptoms worse. Not to waste too many words on this, the Band is out if you have reflux.

The Gastric Bypass: This is the ultimate anti-reflux operation. It has a nearly 100 percent success in banishing reflux. After all, the pouch is separated from the stomach, where most of the acid is produced. What more, the small gut (jejunum) that is connected to the pouch acts to drain the acid away from the food pipe downwards. The special “Roux-en-Y” way in which we attach the jejunum to the pouch is the key to banishing reflux disease.

Sleeve Gastrectomy: Sleeve gastrectomy converts the stomach into a straight tube. In addition, it removes the part of the stomach from where muscle fibers go as a sling to loop around the LES (Lower Esophageal Sphincter). So it is possible that this operation weakens the sphincter and enhances reflux. In fact, clinically, most patients tend to have some degree of reflux after the sleeve, but this is self-limited and resolves soon. Once weight loss is begins, reflux also tends to reduce and go away.

In patients with a lax esophageal hiatus (the gap in the diaphragm through which the food pipe enters the abdomen) or with hiatus hernia, the sleeve can be done along with a repair of the hiatus (a procedure known as cruroplasty). This is also an accepted modality of treating reflux in the bariatric patient.

So the sleeve is a good bariatric procedure with a fairly good tolerance for the patient with some degree of pre-existing reflux symptoms.

The Duodenal Switch: This operation does not do much more than the sleeve for reflux. Indeed, the sleeve gastrectomy is the first part of the DS operation.

To sum up, if you are looking at bariatric surgery and you have symptoms and evidence of reflux esophagitis, then you should NOT consider the Band. If reflux is making your life miserable, then a bypass will be the best operation for you. If you don’t want the bypass for any reason, by all means consider the sleeve procedure.

In Part Three, we will examine the rest of the reflux story.

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]]> http://www.bmi-india.com/acid-reflux-and-bariatric-surgery-part-two/feed/ 1 http://www.bmi-india.com/handling-social-commitments-after-bariatric-surgery/ http://www.bmi-india.com/handling-social-commitments-after-bariatric-surgery/#comments Sun, 14 Feb 2010 04:36:47 +0000 ramana http://www.bmi-india.com/?p=329 So you have had a gastric bypass and are now on the way to normal life. You have a party you need to go to. Fine. Till you realise that you can’t eat most things there, and people are staring at you — someone who is saying ‘No’ to every dish being offered. It’s not that you are being picky. It’s just that you are not feeling like it (some foods turn you off) or you know some foods will make you sick. Like gulab jamuns and sodas.

At work, your colleagues are eating samosas and cutlets along with sweet tea or coffee from the vending machine. You politely say, “No” to all these, because you know these are not good for you, and you don’t want to eat this junk, anyways. “What’s wrong with you?” your colleagues ask. You mumble about being on a special diet. But this situation is going to come up every now and then. Life will keep throwing up newer situations every day to challenge your status quo, your resolve and your health. Temptations are everywhere. How should you,  the patient, handle this?

Here are some suggstions:

1. Do not be shy of admitting or revealing to people that you have undergone a gastric bypass (or any bariatric procedure). You don’t need to advertise the fact, but do tell those people with whom you are regularly interacting and breaking bread. The truth shall set you free!

2. Once people realise you cannot eat like they do, they will not impose their foods on you. This will make social life far easier and healthier.

3. Avoid people or situations that are not compatible with your freedom of choice. This does not mean I want you to be a social recluse. I am merely asking that you avoid those people who do not have the sense not to force their food choices on the unwilling or unable.

4. Carry a couple of ‘lifesavers‘ — foods that you could just pop out of your bag and eat when you don’t find anything you can eat. Realise that society is still far away from being responsible and user friendly to special populations. Yes, with a small stomach and many medical problems, you are part of a special population.

5. Prepare for a party. This means calling up the host in advance, and specifying your needs (for example, you could ask for a small portion of a salad, a tomato/chicken soup, a small serving of a kebab or grill (paneer/fish/meat). If you cannot ask the host, tell your family member or person accompanying you to find your kind of foods for you, even talking to the host if needed.

6. If all the above are not working, don’t eat anything. This kind of sucks, but not as much as getting sick after eating junk.

Note that the above is more valid for the bypass patient, but also very relevant to the patient of the lap band, and less so for the patient of the sleeve gastrectomy.

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]]> http://www.bmi-india.com/handling-social-commitments-after-bariatric-surgery/feed/ 2 http://www.bmi-india.com/how-much-weight-can-i-lose-doc/ http://www.bmi-india.com/how-much-weight-can-i-lose-doc/#comments Tue, 01 Sep 2009 12:43:16 +0000 ramana http://www.bmi-india.com/?p=202
This is one of the commonest questions we face as providers of obesity care. The question may be posed by a matronly lady in her fifties, an out-of-shape PYT, or by a morbidly obese patient looking at bariatric surgery.



(pic source: here.)

The answer to that question, therefore, has to be contextual. In the more common non-surgical weight loss candidate, the question is not easily answered. How much of weight someone could lose is dependent on so many variables that it is foolhardy and unwise to venture a straight answer. This is in direct contrast to the typical slimming center approach of treating the entire complex subject of weight loss as a potatoes-by- the-kilo thing. You want to lose ten kilos? No problems, pay x amount.

The answer I give in the above context is, “How much do you want to lose, and what are you willing to do for that?” The focus, therefore, comes squarely back to the patient. It is not I who will melt your fat. It is you who will do so. I will merely set you on the right path for it. You would need to walk the path. If you are looking for a painless option, find yourself a slimming center, have a nice day!

The bottom-line being that in fat loss, you have to work hard– there is no escaping that. You will have to find a way to avoid the cravings. You will have to get up from bed for your workout. You will have to take your fish oil capsules. You will have to push yourself for that last rep when your body is screaming for you to rest at the end of your workout. I can only help you if you stand up to be counted.

If you have the requisite motivation, as I say in this article, we will surely guide you to success. But you can take all the credit for that. We only facilitate weight loss, demystify it, and bring a scientific perspective to it.

When a bariatric candidate asks, “How much fat can I lose?”, the answer is, “It depends“. Again, a contextual answer. In procedures like the gastric bypass, around 70-75% of excess body weight loss is typical. After this, the results depend on how well the patient controls his lifestyle. In the lap band procedure, weight loss is around 50%, much less. But then the mortality risks of this procedure are also less. On the other hand, more complex procedures like the duodenal switch have a greater (85%) weight loss, but also a higher risk of mortality.

In perspective, the more successful procedures (in terms of fat loss) come with a higher risk, and the lowest risk procedures give you the lowest fat loss rates.

Nature demands that we get something only if we take risks!

If you are the guy or girl intent on losing around 10 to 20 kgs of fat, the answer to your quest is that of course you can be successful but are you willing to be successful? Do you have what it takes to work your way to success?


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