Medical Procedure in Obesity Control

Clinically severe obesity is considered a chronic disease that is difficult to treat through diet and exercise alone. The condition is a major health problem not only in the West, but also in countries which are becoming more affluent. It is typically defined as a body mass index (BMI) of 40 or more. For Asians, it is a BMI of 32 to 36.9 for people with problems such as diabetes and high blood pressure; and a BMI of more than 37 for others. About 1.15 billion people are either overweight or obese. In the United States, more than 12 million people suffer from severe obesity. From this condition stem other medical, psychological, social and economic problems including job loss and higher insurance fees. According to medical literature, people suffering from severe obesity find it impossible to achieve long-term weight loss with just dietary or behavioral modifications alone. There is 100 per cent failure rate and this series of failures, known as the Yo-yo Syndrome, puts further stress on these already high-risk patients. Surgery is recommended for these patients.
GASTRIC BYPASS SURGERY a procedure was adapted 50 years ago from surgery performed on patients with stomach cancer. It makes the stomach smaller and allows food to bypass part of the small intestine so one feels full more quickly than when the stomach was its original size and so, eats less. As calorie intake drops, one loses, weight. The most common operation is a Roux-en-Y gastric bypass where a small pouch at the top of the stomach is created by using surgical staples or a plastic band. The smaller stomach is connected directly to the middle portion of the small intestine, bypassing the rest of the stomach and the upper portion of the small intestine. Risks include infection in the incision, a leak from the stomach into the abdominal cavity or where the intestine is connected, and a blood clot in the lung. The stomach size is reduced as much as between 80 and 90 per cent, and the length of the intestines is also shortened so a leak is likely to result if the surgery is not carried out properly. After a Roux-en-Y gastric bypass, an iron and vitamin B12 deficiency occurs more than 30 per cent of the time; about half of those with an iron deficiency develop anemia; and the connection between the stomach and the intestines narrows 5 to 15 per cent of the time, leading to nausea and vomiting after eating.
VERTICAL BANDED GASTROPLASTY OR STOMACH STAPLING
The procedure is formed by making a small pouch at the top of the stomach with a capacity of one ounce (28g). The outflow from the pouch into the rest of the stomach is reinforced with a band to prevent stretching. This technique works by limiting the amount of food that can be consumed. It produces the least amount of weight loss, about 40 to 60 per cent of excess body weight. One advantage of the procedure is it is completely reversible. The stapling can be removed if necessary without affecting the body in any way, for instance, in cases where the stomach stretches by continuous eating or when the staples break. It also causes no nutritional deficiencies. The disadvantage is the patient must stick to his diet and is bound to vomit if he eats too fast and does not properly chew his food.
INTRAGASTRICBALLOON SYSTEM
A silicon balloon is orally inserted into the stomach with the help of an endoscope while the patient is heavily sedated — to create a “full” sensation. The balloon is filled up with blue saline water from 450ml to 600 ml through its tube, then the tube is removed. Should the balloon burst for any reason, the patient would know because the blue dye is passed out in the urine. The patient would then need to have the balloon removed. The balloon can be inserted for up to six months as stomach acids will weaken the silicon material. It is a quick procedure, but patients are kept for observation in hospital for a day or two because they might have trouble adjusting to the balloon in the stomach. The weight loss averages about 15kg in six months. Side effects include cramps, nausea and vomiting, especially in the first week. Reflux could happen and it is dealt with the use of acid suppression tablets.
LAPAROSCOPIC GASTRICBANDING OR LAP-BAND
The Lap-Band procedure was introduced to the medical community during the Third Scientific Congress for University Surgeons of Asia, held at the National University Hospital in August 1998. Dr Ravintharan, who has performed some 80 such operations, said more than 300 Lap-Band procedures have been performed in Singapore to date, with the youngest patient being 17 years old. An adjustable silicon gastric band is introduced through 1cm incisions in the abdomen and then wrapped around the upper part of the stomach to create a small pouch. It restricts the size of the stomach, thus the volume of the food intake, and helps patients feel satisfied on smaller meals as the small pouch is rapidly filled up. The pouch also empties slowly through the constriction so the patient does not get hungry fast. The operation is performed under general anesthesia and takes between 30 minutes and an hour. The patient is required to stay in the ward for a night. Once implanted, the band can be tightened or loosened, via a port implanted under the patient’s skin. This is done under local anesthesia. Dr Ravintharan said the band could be tightened every two to three months if the patient so chooses, until the desired healthy weight is reached and this method can reduce the patients’ excess weight by half. Advantages include no cutting of the stomach; pouch and stomach size can be adjusted to the patient’s needs with no operation; laparoscopic removal is possible and the procedure is fully reversible. However, as Lap-Band is a major operation, the downside includes risks of anesthesia and operative complications, such as deep vein thrombosis, bleeding from the perforation of the stomach, and infection at the band or port site. Such major complications are however, uncommon, and the chances of the patient dying as a result of the operation are 1 in 1,000, according to medical literature. Most patients stay in hospital for three days and return to work in two weeks.