What is obesity?

Obesity is defined as an excess of body fat or adipose tissue in relation to lean body mass or excess weight of 20% greater than ideal body weight in men and 30% greater in women. Measuring the exact amount of a person’s body fat is not easy.

It develops when the number of calories taken in is greater than the number burnt up during daily activity. And it does not take many extra calories to put on weight.

Ten extra calories taken each day will lead, to a weight gain of one kilogram in a year’s time.

Obesity is commonly expressed as the Body Mass Index (BMI). This is measured by dividing the weight (kg) by the height² (m²) Body Mass Index

BMI = weight (kg) / height² (m²)

For example, if a person weighs 70kg and is 1.6m tall, his BMI is: 70/(1.6 x 1.6) = 27.34.

To calculate your BMI click here

The BMI scale is as follows:

• Normal – 18 to 25
• Overweight – 25 to 30
• Obese – more than 30
• Severe obesity – more than 35
• Morbid obesity – more than 40.

Obesity is commonly regarded as the inevitable consequences of our indulgence in food and lack of self-discipline. This conventional opinion is not accurate. The causes of obesity are multiple and complex and is not simply a result of overeating. Genetic as well as an environmental factors are the main causes of obesity. In the UK, obesity has reached an epidemic proportion and like any other disease, needs appropriate treatment. When obesity becomes severe, it is even called ‘morbid obesity’ (from the Latin, morbus meaning disease). It has serious implications on health, causing reduced life expectancy and a generally reduced quality of life due to a high risk of diseases such as diabetes, high blood pressure, cardiovascular disease, High blood lipids, arthritis, breathing problems & sleep apnoea, Gastro-oesophageal reflux, etc. There is even a greater link of cancers particularly prostate, breast , cervical and ovarian cancers.

Facts & Figures

• 1 in 5 of the adults in the UK are obese.
• Two thirds of all men and ½ of all women (this is more than half the adult population in the UK) are overweight or obese.
• Obesity is more common in the UK than in any other country in Europe.
• Every day, about 1000 Americans die of obesity related problems.
• Obese individuals have 50-100 times increased risk of death when compared to non-overweight individuals.
• Morbid obesity reduces life expectancy by an average 9 years and patients have only a 1 in 7 chance of a normal life span.
• Obesity in the UK has tripled since 1980. More alarming is that obesity in children has tripled in the UK since 1990. 16% of children between the ages of 6 and 15 are obese and this figure is increasing.

Long-term weight loss is usually not achieved by dietary measures alone, nor by behavioural therapy. Successive failure to lose weight causes enormous physiological as well as psychological problems and a surgical solution is therefore indicated. Eating less and exercising more seems to be the reasonable answer, but unfortunately this does not seem an effective way of maintaining weight control in the long term for many people. It is not uncommon for people to be able to loose significant amounts of weight whilst dieting only to find that they put it all back on again over the following months.The constant failure to control weight with diets, etc., can bring on clinical depression. Once morbid obesity has developed, only surgery can offer a long-lasting help.

Click here for Treatment of Obesity ‘Overview’

LAPAROSCOPIC GASTRIC BAND

Adjustable Gastric Banding System is designed to induce weight loss in obese patients by inducing early feeling of satiety and decreasing food intake, hence limiting food consumption.
The laparoscopic band (Gastric restrictive surgery) has evolved over the past decade as the treatment of choice for morbid obesity.

The LAP-BAND®

There are a number of bands available. The placement of the band is performed Laproscopically using keyhole surgery. The main difference between the adjustable gastric banding and other operations is that the gastric band can be adjusted to the patient’s needs and well being.

The Laparoscopic placement of this band combines the advantage of a non-invasive gastroplasty with the advantages of keyhole surgery. The band divides the stomach into a small proximal pouch and a large distal pouch. The inner surface of the band is inflatable and connected by tube to an access port, which is fixed to the abdominal wall. This should allow for an easy post-operative adjustment. The small proximal pouch acts as the new stomach and a feeling of satiety is reached after ingestion of only a small amount of food (15ml). It is important to point out that the stomach is not divided and the anatomy is not greatly altered after surgery. At any time, you can revert back to the normal anatomy by removing the band.

Patients who undergo this procedure must be very careful about chewing their food very slowly and thoroughly. After 5 years most patients can maintain 50% of targeted excess weight loss. However, like any other surgical procedure, the key to success is patient compliance with the dietary advice.

ADVANTAGES

• • Short Hospital stay and early return to normal activity. Most people can return to work within couple of weeks and they can resume strenuous exercise within 6 weeks.
  • Surgery can be reversed
  • Food consumed passes through the digestive tract in the usual order allowing it to be fully absorbed into the body
  • Band can be adjusted to increase or decrease restriction

RISKS

• • Band slippage/migration
  • Pouch dilatation
  • Gastric perforation or tearing in the stomach wall may require additional operation
  • Reservoir leakage or twisting may require additional operation
  • May not provide the necessary feeling of satisfaction that one has had enough to eat.

The operation

The operation to insert the gastric band can usually be completed Laparoscopically. 4 to 5 small cuts in the abdominal wall are formed, the largest of which is about 4cm in diameter for the port which is used to inflate and deflate the band. The port is usually felt under the skin after the operation. Initially the balloon within the band is left completely deflated at the end of the operation.

Whilst the operation is not completely painless there is less pain following a laparoscopic procedure than one involving a large cut in the abdomen. Most patients are able to go home within 48 hours.

Click on the image below for a step by step Lap Band procedure video.

What would you expect after the procedure?
It is important to realize that the operation is the first step in a major life adjustment and not a quick fix. Motivation is the Key to Success

During the convalescence period, the small wounds will heal and you will have to adjust to a new eating behaviour as discussed with your surgeon and dietician prior to the operation.
The dietician will advise you on the diet after you surgery. For the first two weeks you will only be allowed liquid food. Then for the following two weeks you will have sloppy and mashed food. This is very important to allow proper settlement of the band in its position around the stomach without any displacement or slippage of the band down the stomach. During the healing process, tissue adhesions develop and help fix the band in the right place. Patients who eat solid food too soon after the operation stand a higher risk of displacing the band causing a stretch and enlargement of the new upper gastric pouch. This will lead to poor weight loss and, in some cases, the need to re-operate. (See Laparoscopic Gastric Banding – post-operative advice).

Band Adjustment

At 6-8 weeks after the surgery, the band may be tightened to increase the feeling of satiety. By then band will have settled and the swelling around the stomach has resolved.. Some weight loss will have occurred during the first few weeks. The adjustment is usually performed in the clinic and only occasionally under X-ray control. Occasionally, if the band is too tight {patients complain of having difficulty swallowing solid food} it will be necessary to remove some fluid. There is no need for sedation or anaesthesia during band adjustment; the only discomfort experienced being the passage of a fine needle through the skin into the reservoir. Thereafter, you will gradually be able to introduce normal food into your diet. Still you might find some difficulty with certain foods such as fresh white bread, red meat and vegetables that contain a lot of fibre which will need to be carefully chewed.

Complications of the gastric band

Like any operation, insertion of the gastric band does have risks associated with it, although every care is taken to reduce these to a minimum. Most problems are cause by pre-existing diseases such as heart disease or high blood pressure although wound and chest infections, clots in the legs and lungs, as well as other complications, can occur.

Complication specifically related to the gastric band also occur. These include slippage of the band, migration into the stomach, increase in the size of the stomach and gullet, rupture of the balloon and misplacement or infection of the port. These may lead to the need for the band or port to be removed, repositioned or replaced. One in 10 patients will need further surgery for these or other complications

Click here for Non-surgical treatment of Obesity

Click here for Surgical Treatment of Obesity

There are a number of means of treating obesity. These include dieting, exercise, behavioural therapy, medical therapy and surgery.

What are the Goals and aim of weight management?

Obesity is a chronic condition and its management should be lifelong.Any weight loss should be encouraged and for some, weight maintenance, rather than weight gain, may be a realistic goal.

Is there a medical treatment for obesity?

Yes, In the UK there are two drugs licensed to help in weight reduction.

1. Orlistat (which stops fat taken in the diet being absorbed). Orlistat is not absorbed from the gut, and is therefore free from systemic side-effects; however patients eating inappropriate high amounts of dietary fat may experience oily bowel motions, flatulence or leakage.
2. Sibutramine (which works as an appetite suppressant). It inhibits reuptake of serotonin and noradrenaline, which control food intake. It has been shown to be an effective aid to weight reduction and maintenance. It is contraindicated in patients with high or poorly controlled blood pressure (>145/90 mmHg) or significant cardiovascular disease. Blood pressure must be checked at 2-weekly intervals for 3 months. Patients must show 2 kg loss at 4 weeks and 5% at 3 months in order to continue treatment.

Both produce modest weight loss but are currently only licensed for up to 2 years use. Like any other medications, they have side effects and patients tend to regain their former weight when they stop taking the medications.

What is the aim of Surgery?

The aim of surgery is to prevent the development of diseases associated with obesity, and to help alleviate them if they are already present. It is not cosmetic surgery, but the treatment of a disease, and the objective is to restore health and quality of life.

Who is suitable for obesity surgery ?

Obesity Surgery, also known as Bariatric Surgery
is generally indicated in individuals who have a BMI of 40 or 35 with obesity related diseases (comorbidities such as diabetes, arthritis, high blood pressure, etc.), who are motivated to lose weight and had previous meaningful attempts at weight reduction using diet or medications. They should understand the role of surgery and accepts the risks involved and have a low operative & Anaesthetic risks. They should understand the need for follow up. Surgery is recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m² in whom surgical intervention is considered appropriate.The aim of surgery is to lose 5-10% of original weight, by focusing on long-term lifestyle changes rather than a short-term, quick-fix approach, addressing both diet and activity, and using a balanced, healthy-eating approach. It is also important to set realistic targets for outcomes other than weight loss, such as increased physical activity, healthy eating.

Click here for Surgical Treatment of Obesity

Various Surgical procedures have been devised to reduce weight.
They are categorised as such:
Restrictive operations:
In which the size of the stomach is restricted so that people feel full after only a small amount of food. This can be achieved by placing a band around the upper stomach or by stapling or dividing the stomach.

Malabsorptive operations:

In which part of the bowel is bypassed leading to a reduction in the amount of food absorbed.

The intra-gastric balloon is a plastic balloon placed in the stomach. This will induce a sensation of fullness and will help the patient to eat less. There will be a modest Weight loss, because the balloon must be removed after 6 months. The balloon is used as a short term rather than permanent solution to weight problems. Its complications include nausea & vomiting, Balloon rupture and intestinal obstruction.
Click here for Surgical Treatment of Obesity

Adjustable Gastric Banding System is designed to induce weight loss in obese patients by inducing early feeling of satiety and decreasing food intake, hence limiting food consumption.

The gastric band is placed around the upper part of stomach. It is connected by a small tube to a reservoir placed over the abdominal muscles under the skin. The placement of the band is performed Laparoscopically using (keyhole surgery). The main difference between the adjustable gastric banding and other operations is that the gastric band can be adjusted to the patient’s needs and well-being. The band divides the stomach into a small proximal pouch and a large distal pouch. The small proximal pouch acts as the new stomach and a feeling of satiety is reached after ingestion of only a small amount of food (15ml). It is important to point out that the stomach is not divided and the anatomy is not greatly altered after surgery. At any time, you can revert back to the normal anatomy by removing the band.You will be allowed home after 24-48hrs and you will be visited by your doctor after the procedure and before your discharge. The post operative diet and further instructions will be given to you then.
There are a number of bands available such as the LAP-BAND® Patients who undergo this procedure must be very careful about chewing their food very slowly and thoroughly. After 5 years most patients can maintain 50% of targeted excess weight loss. However, like any other surgical procedure, the key to success is patient compliance with the dietary advice.

ADVANTAGES

• Short Hospital stay and early return to normal activity. Most people can return to work within couple of weeks and they can resume strenuous exercise within 6 weeks.
• Surgery can be reversed
• Food consumed passes through the digestive tract in the usual order allowing it to be fully absorbed into the body.
• Band can be adjusted to increase or decrease restriction

The operation:

The operation to insert the gastric band can usually be completed laparoscopically. 4 to 5 small cuts in the abdominal wall are formed, the largest of which is about 4cm in diameter for the port which is used to inflate and deflate the band. The port is usually felt under the skin after the operation. Initially the balloon within the band is left completely deflated at the end of the operation.

What would you expect after the procedure?

It is important to realize that the operation is the first step in a major life adjustment and not a quick fix. Motivation is the Key to Success. During the convalescence period, the small wounds will heal and you will have to adjust to a new eating behaviour as discussed with your surgeon and dietician prior to the operation. The dietician will advise you on the diet after you surgery. For the first two weeks you will only be allowed liquid food. Then for the following two weeks you will have sloppy and mashed food. This is very important to allow proper settlement of the band in its position around the stomach without any displacement or slippage of the band down the stomach. During the healing process, tissue adhesions develop and help fix the band in the right place. Patients who eat solid food too soon after the operation stand a higher risk of displacing the band causing a stretch and enlargement of the new upper gastric pouch. This will lead to poor weight loss and, in some cases, the need to re-operate.

Band Adjustment

At 6-8 weeks after the surgery, the band may be tightened to increase the feeling of satiety. By then band will have settled and the swelling around the stomach has resolved. Some weight loss will have occurred during the first few weeks. The adjustment is usually performed in the clinic and only occasionally under X-ray control. The balloon in the band will be inflated using a special needle placed through the skin into the reservoir. The amount of fluid in the balloon will be adjusted over subsequent weeks to produce the required weight loss.
Occasionally, if the band is too tight (patients complain of having difficulty swallowing solid food) it will be necessary to remove some fluid. There is no need for sedation or anaesthesia during band adjustment; the only discomfort experienced being the passage of a fine needle through the skin into the reservoir. Thereafter, you will gradually be able to introduce normal food into your diet. Still you might find some difficulty with certain foods such as (fresh white bread, red meat and vegetables that contain a lot of fibre which will need to be carefully chewed).

What are the golden rules of achieving and maintaining weight loss after surgery?

• Eat only three small meals per day.
• Eat slowly.
• Chew your food thoroughly. ü Avoid drinking while eating
• Stop eating as soon as you feel full.
• Avoid snacking
• Avoid sweets and ice-cream which are high in calories and tend to go down easily.
• Drink only low calorie drinks, or better still NO calorie drinks.
• Exercise regularly.

What are the Complications of gastric band operation?

Like any operation, there are risks associated with gastric band albeit minimum compared to other Bariatric procedures. Although every care is taken to reduce these to a minimum, most of these complications are caused by pre-existing diseases such as heart disease or high blood pressure etc. Wound and chest infections, clots in the legs and lungs, in addition to other complications, can occur. There are also specific Complications related to the gastric band, these include:

• Slippage of the band
• Migration into the stomach
• Pouch dilatation (increase in the size of the stomach and gullet)
• Reservoir leakage or twisting (this may require additional operation).
• Gastric perforation or tearing in the stomach wall.
• Rupture of the balloon and misplacement or
• Infection of the port. These may lead to the need for the band or port to be removed, repositioned or replaced.
• It may not provide the necessary feeling of satisfaction that one has had enough to eat.

One in 10 patients will need further surgery for these or other complications.

Click here for Gastric Bypass Procedure

The gastric bypass operation is a combination of a restrictive and malabsorptive procedure. It is a complex procedure requiring formation of a small gastric pouch using stapling devices to divide the upper stomach and produce a 20cc pouch. The upper part of the stomach is divided and joined onto the small bowel so that the main reservoir of the stomach is bypassed.A small amount of small bowel is also bypassed. The hospital stay is 3 to 5 days. Fluid is started on the first postoperative day and built up to full diet by six weeks. Compared to the gastric band, there are serious albeit uncommon complications associated with this procedure. There is also a nutritional requirement of vitamins, Iron and calcium.
The malabsorption is not as severe as with Biliopancreatic Diversion but can help maintain weight loss.
The duodenum and upper small bowel is bypassed. This can produce nutrient malabsorption and deficiency. Iron and calcium deficiencies are common and protein deficiency can occur. Supplements must be taken to prevent the metabolic effects.

What are the Complications of the gastric bypass operation?
All surgical procedures are associated with some risk. In deciding whether to undergo weight reduction surgery it is necessary to balance the risks of the procedure against the risks of obesity. The risks associated with gastric bypass are those caused by pre-existing diseases such as heart disease or high blood pressure although wound and chest infections, clots in the legs and lungs, as well as other complications, can occur. Specific complications include:

• Vomiting, reflux, diarrhoea and metabolic effects.
• Anastomotic leak from the joins in the bowel leading to peritonitis.
• Narrowing of one of the joins.
• Ulceration of the gastric pouch.
• Conversion to an open procedure, in 5% of cases.
• Small bowel obstruction can occur in the immediate post-operative period or later due to adhesions. This is one of the main causes of re-operation. The incidence of re-operation is 5%.
• Long-term metabolic side effects such as calcium deficiency with bone softening.
• Anaemia and hypo-proteinaemia
• ‘Dumping’ (an unpleasant condition with feelings of sweating, anxiety, fast pulse and nausea).
• Death in 1% of cases.

Click here for Adjustable Gastric band

This involves converting the stomach into a long thin tube by stapling it along its length and removing the excess stomach. There is no gastric pouch like ‘Gastric bypass operation’; here the food passes straight into the small bowel, similar to the route it took prior to the surgery. However, the stomach is smaller in size and will hold less, hence the feeling of fullness & satiety. The procedure can be the first phase of a two stage operation which can either be a pancreatico-biliary diversion or a Roux-en-Y gastric bypass few months later. Patients who have a sleeve gastrectomy lose a considerable amount of weight and they may not need to undergo further surgery. Patients can loose up to 70% of their excess weight with a sleeve gastrectomy alone. The general complications of a sleeve gastrectomy are the same as the other weight reduction operations.

The commonest specific complication is leakage from the staple line.

Click here for Pancreaticobiliary bypass

This operation involves a sleeve gastrectomy and bypass of most of the small bowel. Whilst the sleeve gastrectomy acts to restrict the amount of food eaten, much of the effect of this procedure comes from malabsorption produced by bypassing most of the small bowel. Unlike the gastric bypass operation where the small bowel is divided 80 cm from its upper end the small bowel is divided 300 cm from where it joins the large bowel (close to its far end). Once divided the far piece of small bowel is called the intestinal limb and the near end of the small bowel the pancreatico-biliary limb. The bowel is divided again at the point where the stomach becomes the duodenum (the duodenum is the very first part of the small bowel). The far end of the small bowel (intestinal limb) is then brought up and joined to the duodenum. Food will now pass through the refashioned stomach and straight into the very last part of the small bowel. It is then necessary to join the near end of the small bowel (pancreaticobiliary limb) to the intestinal limb 100cm from the point where it joins the large bowel. This ensures that all the digestive juices that come from the gallbladder, pancreas and small bowel are mixed in with the food and digest it.

Click here for Sleeve Gastrectomy