Weight Loss Surgery in Kerala at VPS Lakeshore Hospital

Weight Loss Surgery in Kerala is performed regularly at VPS Lakeshore Hospital by team led by Dr. R. Padmakumar. Dr. Padmakumar is hailed as the leading Obesity / Bariatric Surgeon in India and UAE. He received Indywood Medical Excellence Award in 2018 for “Professional Excellence in Obesity and Diabetes Surgery“.

What is Bariatric Surgery?

Bariatric deals with Obesity. “Baro” is a Greek word which means heavy or large. Bariatric surgery is also referred to as “weight loss surgery” and is performed on people who suffer from obesity. It includes a variety of procedures, namely removing a portion of stomach (sleeve gastrectomy), removing the size of the stomach (gastric band), or re-routing the small intestine to a small stomach pouch (gastric bypass).

Bariatric Surgery (otherwise weight loss surgery) is proved effective and long term studies show that these procedures cause long term weight reduction, resolution of diabetes, improvement in cardiovascular risk factors and obstructive sleep apnea, etc.

When Weight Loss Surgery is indicated?

According to a medical guideline published by the American College of Physicians, Weight Loss Surgery or Bariatric surgery should be considered as an option for treatment in patients with BMI of 40 kg/m2 or above, who instituted and adequate exercise and diet regimen, but failed, and also in patients presenting with obesity-related comorbid conditions. Obesity-related comorbid conditions include diabetes mellitus, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), impaired glucose tolerance.

Obesity and overweight have in the last decade become a global problem and is a rising medical problem. Obesity raises concern because of its implications for the health. Obesity increases the risk of many diseases and health conditions. These include:

  • Type 2 diabetes (Diabetes Mellitus)
  • Coronary heart disease
  • Hypertension (High blood pressure)
  • Cancers (endometrial, breast, and colon)
  • Dyslipidemia (for example, high cholesterol)
  • Stroke
  • Liver and Gallbladder disease
  • Obstructive Sleep Apnea and respiratory problems
  • Osteoarthritis
  • Infertility
  • Asthma
  • Chronic Musculoskeletal Problem
  • Mental disorders

Obesity and Overweight definitely has detrimental health effects. People with BMI (Body Mass Index) exceeding the normal range has much greater risk of medical issues.

The first-line treatments of obesity and overweight include diet, excercise, behaviour therapy, and anti-obesity drugs. But for severe obesity this has limited success and success for long term is very poor. Weight loss surgery or bariatric surgery results in greater weight loss than these conventional treatments. Weight loss surgery can improve the quality of life and bring improvement in obesity related diseases (hypertension, diabetes mellitus, etc).

Different Weight Loss Surgeries and Procedures

Obesity and Infertility – Does obesity affect pregnancy?

Obesity and Infertility: Obesity is a life-long, progressive, life-threatening, genetically-related, multi-factorial disease of excess fat storage. BMI (Body Mass Index) = Weight in Kg / Height in M2. For Asian populations, classifications remain the same as the international classification, but public health action points for interventions are set at 23, 27.5, 32.5 and 37.517. Obesity has reached epidemic proportions in India in the 21st century, affecting 10% of the country’s population and another 12% being overweight. 1.5 million deaths are reported due to obesity in 2000 and 20 million deaths due to obesity in 2010.

What is Metabolic syndrome?

Metabolic Syndrome is a condition in which excess body fat is accumulated to such an extent that health may be negatively affected and the life span is shortened. It is a group of diseases where increased abdominal girth more than 90 cm in males and more than 80 cm in females generally associated with increased BMI, diabetes, dyslipidemia, hypertension, polycystic ovarian disease, sleep apnea and non-alcoholic steatohepatitis.

Obesity and Infertility:

How is Obesity related to Infertility? Obesity makes it difficult for women to get pregnant. If they get pregnant, then there is higher risk of losing it. Hormonal levels are also altered in obese women. Obesity related complications in pregnancy (BMI >35): Preeclampsia (5 times), stillbirths after 28 weeks gestation (3 times), early neonatal death (3.5 times), large-for-gestational-age infants (4 times), gestational diabetes (8 times). The infertility treatment including IVF also has lesser success in obese people.

Management of Obesity:

By lifestyle and medical methods weight loss is modest and rarely sustained. We had only few medicines to take care of Obesity. Leucine 2.25 gm with B6 30 mg per day increases fatty oxidation by 30 percent which may help to lose weight to some extent.

Obesity and Infertility – Treatment Options

Non-Surgical treatment: Intragastric Balloon (IGB):

Intragastric balloon for Weight Loss.

It is placing a deflated balloon in the stomach using endoscope and then filling it to decrease the amount of intragastric space. It can be left in the stomach for a maximum period of six months. It results in average weight loss of 10 to 15 kg. It may be used in patients with overweight who are not suitable for Metabolic Surgery

Surgical Treatment (Metabolic Surgery):

The term “bariatric” surgery is derived from the Greek word baros for weight; defines surgical procedures designed to produce substantial weight loss. Metabolic Surgery – Metabolic changes occurring cannot be explained completely by their effects on body weight alone; hence procedures which induce metabolic improvements come under the category of metabolic surgery.

Laparoscopic Sleeve Gastrectomy (more than 30 BMI patients) :

The portion of stomach which secretes Ghrelin and acid in excess is removed. This leads to reduction in food intake and also alteration in hormonal milieu which leads to usage of stored fat for caloric requirement. This has got very good results without significant nutritional deficiency and hence most preferred.

Modified Sleeve Gastrectomy with Ileal Interposition (BMI 25 – 30):

In this after a modified sleeve gastrectomy ileum is brought near the stomach by interposing proximally. The jejunum is connected after ileum. This ensures early entry of food to ileum but jejunum is not kept out of its route. There is significant increase in GLP1 hormone and resultant increase in timely secretion of insulin. There is no dumping or vitamin deficiency in contrast to bypass procedures.

Patients will be initially on liquid diet and later on changed to semi solids, gradually changed to solid diet in a month’s time. Patients will be on vitamins for a month or so, Pantoprazole for 2 months; Calcium will be optional. Biotin is advised if patient has significant hair loss. There is no need for long term vitamins.

RESULTS:

Around 85 to 90 % of diabetes patients treated by these surgeries get complete resolution of diabetes. Whereas, the rest of them get significant control of diabetes with reduced dose of medication. In addition to diabetic control the other benefits are loss of excess weight and control of triglyceride levels. Sleep apnea, arthritis, cardiac episodes, kidney disorders and cancers are also reduced significantly. Studies show that metabolic surgery is cost-effective and safe. IFSO Global Registry studied more than 1 lakh bariatric surgeries over 18 countries and has reported a mortality of 0.03%. SOS – Swedish Obese Subject Study (prospective matched cohort study with 15 years follow up) showed excellent results of metabolic syndrome resolution which is sustained even after many years.

When can pregnancy be planned?

Patients can conceive after 6 months of Bariatric Surgery. Generally, there is no need for any special nutrition or vitamin supplementation to these patients other than what is recommended for a pregnant lady routinely. Bariatric surgery might be effective in young infertile obese women who wish to become pregnant. Weight-Loss surgery resolves PCOS. Most of the improvement in PCOS symptoms occurred during the first 12 months after bariatric surgery.

Conclusion:

Metabolic surgery has emerged as the most preferred, highly effective, and safer means to achieve long term resolution of type 2 diabetes and excellent improvement in fertility status.

Weight Loss Treatment – Newer Modalities of Treatment for Obesity

Weight Loss Treatment : It will be a wish of everybody to have an attractive body figure. There was a time when majority were running around to find ways to increase body weight but today great majority are depending on various methods and advertisements modalities for reducing body weight. It is very happy to know that modern medicines has come up with good permanent techniques by which body weight as well as the abdominal fat can be reduced. These are surgical measures using laparoscope (Bariatric surgery) so that the patient is comfortable after safe procedure.

Body Mass Index (BMI) is an estimate in relation to the weight and height of a person; it is calculated as weight in kilogram divided by height 2 times (BMI =Weight in Kg/ height in M2). BMI of 20 to 25 is considered normal. 26 to 30 is over weight. Above 30 is obesity and above 37 will be considered as morbid obesity. If overweight is a predisposition for illness, obesity is a disease itself and needs treatment. Like in developed countries obesity is increasing in India also. On one side when nation is trying to reduce poverty related illnesses it is undesirable to see that people are getting illness due to over eating and resultant obesity related illness; and it is a thing to be strongly discouraged. It’s more problematic to have abdominal obesity like what we see in Kerala.

Obesity: Reasons:

  • Hereditary factors
  • Food habits
  • Life style.

Though hereditary can be contributing factor for obesity, it is usually due to excessive food intake. Food rich in fat and low in fiber is the main culprit for obesity. Meat, sweats in excess quantity and repeated intake of food: causes obesity. Soft drinks, instead of ordinary water also contribute as they are energy sources, though people don’t consider it as food. One gm fat gives nine calories where as protein and carbohydrate gives four calories only. Sedentary life style with no exercise is another important factor which accelerates obesity.

Weight Loss Treatment – Why a necessity?

When weight increases, it directly affects heart and respiratory system. Heart when made to pump in greater force and to larger area will definitely weaken it. This will induce heart attack to a very early age. Cholesterol deposition causes reduction in lumen of blood vessels leading on to high BP (Hypertension). Chances of vascular events like heart attack and stroke are very very high due to blockage of vessels in these patients. Requirements for coronary angioplasty and cardiac bypass are 3-4 fold compared to persons of normal weight. Obesity also leads to sleep disorders and respiratory problems called as sleep apnoia. Excess fat causes damage of pancreas and induce insulin resistance. This in turn result in high blood sugar (diabetes mellitus). Increased weight damages joints and bones leading into early arthritis necessitating joint replacements. Women with increased body fat suffer from polycystic ovarian disease (PCOD). It is an important cause for infertility and is mostly reversible if persons loses excess weight. The loss of body image is a significant contributor for mental disease like depression. Morbidly obese people find it difficult to move around and use common facilities, commuting and seeing the response of the society at sight of the morbidly obsess person puts them down

Solutions:

Control of diet and increasing exercise are two things which an overweight person can do himself to counter the problems. There are drugs available in the market which may reduce the appetite. There are some drugs which can induce malabsorption of fat so that the calorific value of the diet is reduced. But these things can reduce weight to a minimum extent only. The permanent solution for obesity and related illness is surgery. Measures like reduction and size of stomach or diversion of food from the stomach to the distal part of the intestine have proved highly effective in causing dramatic reduction in fat and weight. As these procedures are done through laparoscopy, it is a thing which makes it comfortable, safe and simple for a patient.

Laparoscopy for Weight Loss Treament

Lapro means abdomen and scopy means to see. Surgeon makes one cm incision in the abdomen and puts a telescope which is connected to the monitor outside. Surgeons see the picture of the abdominal organ on the monitor and operate. Operating instruments are less than a pencil size which is introduced through 5 mm incision. In open operation a big wound is made for surgeon to visualize organs and for putting his hands for performing surgery. These big wounds were causing severe pain, increase risk of infections and chance for hernia due to poor healing. Keyhole surgery is very advantageous as no significant wound is made and hence patient will be going home very early and resume normal activities in few days time. As the images are magnified 20 times the precision of surgery is very much high. Even small blood vessels can be seen as big and equipments like harmonic scalpel seals these vessels perfectly so that the blood loss in significantly less. This avoids need for blood transfusion to tune 1 % of open surgeries and patient is saved of the associated illnesses like Hepatitis, AIDS, and Malaria. In obsess patients open surgery is extremely difficult opening these kind of patients will cause respiratory distress, blood clots in the vessels, slowing of the intestinal motility (Ileus). Laparoscopic surgery avoids such problems greatly and patients will be ambulant within few hours and there will not be a need for long term rest.

Weight Loss Treatment – 3 Types of Laparoscopic Procedures

  • Sleeve Gastrectomy
  • Banding
  • Gastric bypass

Sleeve Gastrectomy:

Using staplers a portion of stomach is removed and their by reduces the quantity of food patient take additionally. This reduces appetite, stimulating agents and acid secretions so that patient will be comfortable with small quantity of food. This is sure to bring down the weight of the patient drastically with desirable effects on con existing illness.

Banding:

In this an adjustable band is placed around the stomach so that stomach size at the area of food entry is reduced. Patient can adjust the size of stomach and quantity of food.

Gastric bypass:

In this the stomach is connected to a distal part of the intestine so that the absorption is reduced and thus causes weight reduction.

Many studies have shown that surgery as a weight loss treatment in addition to causing dramatic weight loss improves or resolves the conditions associated with obesity. The requirement for insulin is reduced to 90% and hypertension medication can be discontinued by almost 80% of persons. The joint problems, sleep apnea improve and quality of life will be very good.

Patient may require procedures like liposuction, lipectomy or abdominoplasty for cosmetic purpose. So it is advisable for everyone who has obesity to resort to the above mentioned procedure. So that they will be back to normal life with good quality.

Intragastric Balloon or Gastric Balloon Placement for Weight Loss

Intragastric Balloon Placement is placing a deflated balloon in the stomach using endoscopy and then filling it to decrease the amount of intragastric space. It can be left in the stomach for a period of 6 months and results in average weight loss of 10-15 kg in half a year. It may be used in patients who are overweight and not coming to the category of sleeve gastrectomy.

If you suffer from Metabolic Syndrome and have tried various treatments without results, metabolic surgery may be indicated. At present, surgery combined with behavioral changes is the only documented method for achieving long lasting weight loss for patients with morbid obesity.

Intragastric Balloon Placement

A silicon balloon is placed in the stomach, under endoscopic guidance. A gastric balloon aims to reduce feeling of hunger and helps to feel fullness of stomach. The intragastric balloon device is not considered a permanent weight loss procedure. There are different types and sizes of balloons in the market. All balloons are temporary and need to be removed after a period of time (6-12 months).

Indications for Intragastric Balloon Placement or IGB

  • More than 30 BMI – obesity class I (BMI 27.5 – 32)
  • Class II obesity (BMI 32-37) in whom surgery is not possible due to medical conditions or patient’s dislike for surgery.
  • In Morbidly obese (BMI > 37) as a procedure before bariatric surgery to reduce surgical morbidity.
  • Any patient with an excess weight of 10 -20 kg (BMI 23-27.4), with failed dietary measures especially in cases with PCOD (Polycystic Ovarian Disease) and infertility.

Multidiscipilnary Approach – Bariatric Team for Intragastric Balloon Placement for Weight Loss

The insertion of balloon does not require surgery. You will be supported by a multidisciplinary team that includes a bariatric surgeon, a gastroenterologist, a dietician and an anaesthesiologist.

Doctor consultation helps in

  1. Assessment
  2. Guidance
  3. Discussion about various procedures. You may ask any questions that you feel are necessary.
  4. The team confirms that intragastric balloon is a good option for you.

After this you may be advised investigations and consultations that are felt necessary for the assessment of your health condition.

Intragastric Balloon Placement – Preprocedural Evaluation

  • Hemogram, RBS, HbA1C
  • Liver function test, Lipid Profile, Thyroid function test, Renal function test
  • S. Calcium, S. Magnesium
  • S. Cortisol, Blood Group
  • Hbs Ag, HIV I & II, Anti HCV, VDRL , Urine RE
  • C peptide fasting, C peptide 1 hr pp, Insulin fasting
  • GAD Antibodies , IA2 Antibodies (in diabetic patients)
  • ECG, X-Ray Chest PA, USG abdomen, Dexa Scan.

Consultations:- Anesthesia, Cardiology, Counseling, Diabetology, Dietician

The Placement of Intragastric Balloon

Your doctor does an endoscopy under mild anesthesia with a flexible tube equipped with a camera to see the inside of the stomach. If there is no local disease during endoscopy he sets up the intragastric balloon in the stomach. The gastric balloon consists of a silicon elastomer based material, which is soft and pliable. The balloon is inserted uninflated through the mouth and taken down the esophagus. It is coated with a local anesthetic to facilitate the passage.

Once the balloon is in the stomach, it is filled with a sterile saline solution colored in blue (BIB system) or air (Heliosphere system), through a catheter attached to the balloon. When a balloon is filled, the doctor gently pulls on the inner end of the catheter to remove it. The balloon has a self-sealing valve that prevents the leakage of liquid or air. The balloon floats freely in the stomach. The procedure time is about 20 minutes. You will be monitored in the hospital for a few hours before returning home (Generally overnight)

Medications

During the initial days of the insertion of the balloon, nausea, vomiting, abdominal pain, acid reflux are common. Your doctor would prescribe medications to minimize gastritis. Medicines for nutritional supplementation/ multi-vitamins may not be generally needed. You can contact the doctor during the following days. You have to have food as prescribed by the dietician. It is important to drink more water to avoid dehydration. Some patients take a light meal. A radiograph of abdomen or abdominal ultrasound is rarely indicated for persistent abdominal pain. Nutritional assessment is done after one month and three months. A consultation (in person or by phone) every month will be scheduled. The consultations help to assess the progress of weight loss.

Dietary Counseling

The first consultation is scheduled a week later. Nutritional and behavioral modification is the key to loose weight and keep it off after removal of the balloon. Your physical activity is evaluated and diet is adjusted to your body needs and profession. A psychological treatment may be necessary in case of eating disorders.

Gastric Balloon Withdrawal

Intragastric balloon is removed when:

  • Weight loss is adequate.
  • 6-8 months time
  • Spontaneous rupture
  • Patient not tolerating

Removing the balloon is carried out after 6 months. The balloon is no longer effective because the stomach has adapted to it. The gastric secretions make it porous and then it can deflate. The gastric balloon is removed the same way it has been introduced – through the esophagus and mouth – without surgery. The removal is performed under mild general anesthesia under endoscopic control. The removal lasts around 15 minutes. The balloon is punctured and the fluid or air is removed and then the empty balloon is brought outside.

Complications:

No major complication. Nausea and vomiting during the first week in 7.4 % which settles itself

Frequently Asked Questions

How much weight can I loose with gastric balloon?

The balloon is an effective aid for losing weight in combination with diet and eating behavior modification program. Dietary counseling is done monthly and sometimes more frequently if needed. The weight you lose will depend on your motivation and the quality of diet. The balloon is not an appetite suppressant. This an effective aid for the modification of habits and eating behavior. The weight loss is between 10 and 20 kg for 6 months when the balloon is in place. After its removal the weight maintenance and prevention of weight regain will depend on how you adapt long-term lifestyle changes in eating and exercise. It is therefore important to continue the diet plan after removal of balloon.

Our Result

Average weight loss:- 15 to 20 kg

  1. Diabetes, Hypertension, Dyslipidemia
    • Complete resolution: – 50%
    • Reduction of medicines: – 50%
  2. Rate of PCOD resolution with positive pregnancy is excellent
  3. Sleep apnea (Snoring) very good control

Laparoscopic Sleeve Gastrectomy for Weight Loss ( > 30 BMI Patients)

Laparoscopic Sleeve Gastrectomy is a surgical procedure for weight loss. In this procedure, the stomach is reduced to about 15% of the original size of the stomach by removing a large portion of the stomach along the greater curvature. The portions of stomach which secretes Ghrelin (hormone which increase appetite and cholesterol) and acid (which digests food) in excess is removed.

Ghrelin or the “hunger hormone” is also called lenomorelin. Ghrelin is secreted when the stomach is empty and when the stomach is stretched the secretion of Ghrelin stops. Ghrelin acts on hypothalamic brain cells to increase hunger and to increase the secretion of gastric acid and motility of gastrointestinal tract to prepare the body for intake of fodd.

Sleeve Gastrectomy leads to reduction in food intake and also alteration in hormonal milieu which leads to usage of stored fat for caloric requirement. Thus, by natural way, weight gets reduced and in few months’ time major portion of excess weight is lost. There is no need for taking medicines continuously and the weight loss will be sustained. Studies show this as the best method.

Laparoscopic Sleeve Gastrectomy (more than 30 BMI patients): Laparoscopic Sleeve Gastrectomy (LSG) is a well established bariatric procedure of treatment for people who are obese and having type 2 diabetes, not achieving desirable control with medical and dietary therapies, especially when there are other major comorbidities.

Laparoscopic Sleeve Gastrectomy
Stomach Removed through Laparoscopic Sleeve Gastrectomy Procedure

Indications for Laparoscopic Sleeve Gastrectomy

  • Obese class II and obese class III patients
  • Obese class I patients with obesity related comorbidities that could not be controlled with medicines.
  • Patients who failed to lose weight with conservative modalities

Contraindications for Laparoscopic Sleeve Gastrectomy

  • Patients with age group <15 and >65 years
  • Chronic liver diseases
  • Major cardiovascular diseases that cause a high risk for anesthesia
  • Drug or alcohol abuse currently
  • Uncontrolled psychiatric illness and lack of comprehension of the risks-benefits

The portion of stomach which secretes Ghrelin and acid in excess is removed. This leads to reduction in food intake and also alteration in hormonal milieu which leads to usage of stored fat for caloric requirement. Thus, by natural way, weight gets reduced and in few months time major portion of excess weight is lost. There is no need for taking medicines continuously and the weight loss will be sustained. This has got very good results without significant nutritional deficiency and hence most preferred.

It is safe and effective in weight reduction as well as resolution of associated comorbidities especially diabetes mellitus in obese class II and obese class III categories. LSG is generally recommended in patients with BMI>35 kg/m2. The study conducted by Dr. R. Padmakumar et al. shows that laparoscopic sleeve gastrectomy is effective in obese class I group as well (resolution of diabetes is 86.6% in patients with obese class I) and the resolution of type 2 diabetes achieved is sustained.

Bariatric Surgery for Obesity and Obesity-Related Conditions

Obesity is a disease.

Bariatric Surgery or Bariatrics is the branch of medicine dealing with the study of obesity, the causes, prevention and treatment of obesity. The Greek word Baro means heavy or large. Diet, exercise, anti-obesity drugs, behavioural therapy are first line treatments of obesity, but success is limited in people with severe obesity. Bariatric Surgery or Weight Loss Surgery is considered in people struggling with severe obesity.

Obesity is a medical condition. Obesity occurs due to excess body fat accumulated in the body and is considered a serious medical condition due to the adverse health effect obesity has on the body. Obesity has many detrimental health effects on the body. Medical issues include cardiovascular dieseases, diabetes mellitus, OSA or obstructive sleep apnea, asthma, etc..

Diet and excercise, behaviour therapy, and anti-obesity drugs are the first-line treatments for obesity and overweight. But for severe obesity this has limited success and long term success is very poor. Weight loss surgery or bariatric surgery results in greater weight loss than these conventional treatments. Weight loss surgery aids in improving the quality of life and brings improvement in obesity related diseases such as diabetes mellitus, hypertension, etc.

Bariatric Surgery – Different Types

  •  Laparoscopic Sleeve Gastrectomy (LSG)
  •  Roux-en-Y Gastric Bypass
  •  Mini Gastric Bypass (MGB)

Non-Surgical Weight Loss Procedure:

 Intragastric Balloon Placement (IGB)

Related Links

Laparoscopic Sleeve Gastrectomy

Bariatric Surgery Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy is a surgical procedure for weight loss. Sleeve gastrectomy is also known as a vertical sleeve gastrectomy or gastric sleeve procedure. In this procedure, the outer margin of the stomach is removed to restrict the amount of intake of food leaving the size of the stomach to about 15% of the original size of the stomach.

Gastric Bypass – Roux-en-Y

Bariatric Surgery - Bypass Procedure for Weight Loss

Gastric Bypass is a surgical weight loss procedure for treatment of morbid obesity. In this procedure the stomach is divided into a small upper pouch and a large lower pouch. The small intestine is then reattached to the pouch that creates a bypass for food, which results in absorption of less calories and nutrients.

Intragastric Balloon Non-surgical Procedure for Weight Loss.

Intragastric Balloon for Weight Loss

This procedure involves using an endoscope to place a deflated balloon in the stomach. The balloon is then inflated to decrease the amount of intragastric space. The balloon is then left in the stomach for a period upto 6 months. Due to the restricted amount of food intake there is an average weight loss of 10-15 kg. This is highly effective in overweight people not classified as obese.

Bariatric Surgery may help in lowering the risk of Stroke and Heart attack

Bariatric Surgery helps in lowering the risk of stroke and mycardial infarction (heart attack) in patients suffering with type 2 diabetes and severe obesity according to a study published in the Journal of the American Medical Association (JAMA).

The study was conducted to investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. This observational study concluded that patients with type 2 diabetes and severe obesity who underwent bariatric surgery, compared to those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes.