Blog

Last year two boys Ramesh and Piyush (names changed) aged 19 and 22 attended our obesity clinic in Belle Vue. They were severely obese with body weights of 135 and 130 kgs respectively. They had been trying to lose weight in vain for the last few years. They had heard and read about bariatric surgery through some friends and the Internet. As predictable, they had various physical and psychological disadvantages compared to their friends. Their parents were totally against the idea of their son to undergo surgery for weight loss and they believed (unscientifically of course) that diet, activity and drugs could help them.  They were scared of the complications, which we explained were remote but possible. Ramesh managed to convince his parents and underwent surgery last year. Piyush’s parents did not agree for the process. Today, Ramesh is 80 kgs with a lot of self confidence and friends. He takes part in all our support meetings and helps others in making decision for surgery. Piyush continues to make efforts to reduce weight. He did lose about 10 kgs once but regained some part of it. His parents do not wish to take the risk of surgery.

I did not share this story with the readers to prove that those who do not opt for surgery are wrong. Instead, this article is written for the purpose of dispelling myths and unscientific fears amongst patients who are severely obese and are unwilling to undertake bariatric surgery (surgery for severe obesity). This is also for the guardians of the patients who have not allowed the patient to undergo surgery.

Let me first make it very clear. Agreeing for surgery is totally a personal opinion and no surgeon should persuade, leave aside force for surgery beyond a certain point. And this is because no surgeon can claim to produce 100 %results and promise 0% complications. Hence all surgeries (and bariatric surgery is no exception) should be taken seriously and should be a personal choice.

However the issue of decision-makingshould be based on the risk- benefit ratio and not on the basis of their fears, counseling and their expectations. This means if the benefits from a particular solution outweigh the risks involved, it can be taken. So let us see how much is the risk after the bariatric surgery. The incidence of serious problems like leakage and infection is less than 1 %.  Most subjects are ready to exchange their poor lifestyle (like eating sweets and drinking colas) for a good weight loss. Now, let us look at the benefits. Weight loss after bariatric surgery is significant and permanent. There is dramatic improvement in how one enjoys life. Not to mention that diseases like diabetes, high blood pressure, snoring, heart diseases, heartburns, joint pains, infertility, etc either improve or disappear altogether. Also to be considered is the risk involved in staying obese. The chance of early death in a severely obese is significant. Talking more about daily problems, many of these subjects have diseases mentioned above. Not only that, an obese individual has a poor quality of life. Just to state an example, many of them are unable to perform a normal sexual act as a direct result of fat in their genital area.

Having this knowledge is important in decision-making. If an obese subject can accept the way he or she is and does not want to take that small risk of surgery, they do not need to undergo surgery. However, if someone does not want to continue leading life the way they do and are willing to accept the small risk of surgery, they can definitely consider bariatric surgery and benefit from the advantages it provides.

YouTube video on Bariatric/Obesity Surgery.

Colorectal surgery (surgery of food pipes) is done for various diseases such as cancers, inflammatory bowel disease, diverticulitis and rectal prolapse. The good news is that unlike in the past all these surgeries can now be done by laparoscopy.  This translates into less pain, less scar, more comfort and decreased hospital stay. There is now enough evidence to demonstrate that colon and rectal cancers can also be treated effectively and more comfortably  with laparoscopy.  Gone are the days when a long wound was required to do these surgeries.

Anal surgery has also undergone a sea of change. Conventional Surgery for piles and fistula used to be a painful affair requiring wound dressings in the postoperative period for days and sometimes weeks. This translated into prolonged hospital stay, delayed return to work and normal life. This made the patients search for alternative less painful options. More often than not they would land up with quacks who offered them magic pills, local creams, “innovative anal interventions” and many other unscientific  treatments.

Modern technology has now made it possible to perform these surgeries through painless and wound free methods. Nowadays, one can do stapler procedure for piles whereby the procedure is done at the rectal level, which leaves no wound at the anal level and consequently no pain, and need for dressings. A blessing indeed to thousands of patients, who suffer with the disease quietly without treatment because of their fear.

Similarly, anal fistulas can now be treated with two novel techniques- endoscopic method (known as VAAFT) and the plug technique.

In the VAAFT technique, the fistula tract is treated from inside by a very fine bore endoscope and the opening at the anus is closed with staples.

In the plug technique the tract is blocked with an artificial material shaped like the tract.

In both these techniques the fistula is healed without any pain or wound. There is also no risk of damage to the anal sphincter (muscle responsible to hold stool) since the procedure is performed from inside the tract. Moreover it is an outpatient procedure and does not result in any disruption in work or normal life.

These revolution in colorectal and anal surgery is indeed a source of some cheer for patients suffering with piles, fistula and cancers of colon and rectum. At least they can now get away with much less pain and wound.

Watch full Video on YouTube on Anal Surgery.

Why do gallstones form?

Gallstones are so common in West Bengal that we can safely presume that everybody knows at least one patient who has it. It is very difficult to say what causes it and why it is so common here. A few scientific guesses are – higher body fat, infection in bile ducts, poor movements in bile ducts, etc.

Why is it so common in West Bengal?

As to why it is commoner in our region there are no proven answers. Genetics, diet, environmental influences have been implicated. Since there is paucity of data as to what causes gallstones, there is very little we can do to prevent its formation.

What are the symptoms of gallstone disease?

Once formed gallstones may or may not cause symptoms. It may produce mild symptoms like pain and indigestion or it may cause severe diseases such as jaundice, infection, pancreatitis, etc.

What is the treatment of Gallstone Disease?

All  gallstones need not be treated especially if the patients are elderly and asymptomatic.

Those who do require treatment, it is important for them to bear in mind that medicines never work practically. Hence requiring surgery. Unfortunately, many patients would like to believe that pills can provide magical cure and consume these for weeks and months before surrendering for surgery. Obviously, the delayed treatment may result in poorer outcome.

How is laparoscopic surgery for gallbladder stone done?

Laparoscopic surgery implies performance of surgical procedures with the assistance of a video camera and several slender instruments. During the surgical procedure, small incisions of 5 to 6 mm are made and plastic/ metal tubes called ports are placed through these incisions. The camera and the instruments are then introduced through the ports that allow access to the inside of the patient. The camera transmits an image of the organs inside the abdomen onto a television monitor. The video camera becomes a surgeon’s eyes in laparoscopic surgery. Through these ports, instruments are introduced and utilized to free the gallbladder from the bile duct and the liver. Once totally free it is delivered out of a 1 cm port. To facilitate its delivery through the small incision, the gallbladder is sucked and stones extracted to make it collapsed.

What is the advantage of Laparoscopic Surgery?

The fear of the knife is a universal phenomenon. Nobody wants to undergo surgery because of the fear of pain, prolonged hospital stay, delayed return to work and complications. With the advent of laparoscopy these problems have been largely solved.

Laparoscopic surgery is almost painless. The hospital stay is usually for 1 to 2 days. Most can join work in 5 to 7 days. Most good centers will have a complication rate of less than 1 %.

There are so many centers for laparoscopic surgery. Where should I get it done?

Do some research before handing your precious body to surgery. Most people are unaware of the factors they need to consider. Lets face it. Many amongst us want to get it done at the most affording price possible. The net result is we go health shopping with only budget in mind. Do we do the same when we buy clothes, food or homes for ourselves? True, that money is an important consideration. But so is safety and comfort.

So, how should we choose?

First, look for a center or surgeon with high volume of laparoscopic surgery. This will ensure a low complication rate.  Experience counts, you know. Although this is nowadays a safe surgery, complications like bile duct injury may have disastrous lifelong consequences.

Second, do some research on the outcome of patients from these centers. Did they have wound infections? A very rare complication after laparoscopic surgery, but may spell hell for the unfortunate few. The worst part is, it is because of poor cleaning technique of laparoscopic instruments employed in some centers, something that may be beyond control of the surgeon. And it takes weeks to months to heal. Ask somebody who has had it.

To summarise, if you do need laparoscopic removal of gall bladder, choose not only on the basis of the cost or proximity of a center to your home, but choose on the basis of safety and comfort also. It will not necessarily come at a higher cost. But you need to know where to look. After all, your body is precious. Hand it over to somebody who thinks so too.

Can I get laparoscopic surgery with fewer holes?

Yes. The technology is now available. For the select few, who are very conscious of marks on their beautiful belly, one can opt for a single hole surgery, too. Of course, this will cost a bomb.

Watch the video on Gallbladder Surgery on YouTube.

Obesity has become the most important epidemic of our times. It is responsible for many diseases such as diabetes, hypertension, heart disease, snoring, arthritis, hernias, infertility, etc. Thus it is not only a cosmetic problem. Obese people try many methods to lose weight not only to look better but to be healthier.

Although dieting and physical training remains the most important way to lose weight, it is not always easy or successful especially if someone is severely obese. This would mean in simple language that women above 90 and men above 100 kgs are less likely to lose significant weight in long term based on diet-activity program. Many do resort to plenty of unscientific practices and gimmicks to lose weight but they lose their time and money only instead. The readers are advised to check for any scientific basis before adopting any method for weight loss.

Bariatric surgery comes as a boon to all the patients who are unable to lose weight. There are many reasons why it has become so popular ( In fact it has overtaken laparoscopic removal of gallbladder as the commonest laparoscopic procedure in the West):

1. It is a laparoscopic surgery (keyhole surgery in the abdomen), hence there is minimal pain, no scars and patient can be discharged 24 hours after the surgery.
2. The weight loss is significant and lasting. For example, Shruti , 28 yr old(name changed) who weighed 110 kgs a year back is now 70 kgs, a year later from surgery. Obviously she looks prettier.
3. There is resolution of diseases associated with obesity such as diabetes, hypertension, arthritis, snoring, etc. There is improvement in the confidence level, sex life and quality of life. Obese diabetics benefit tremendously from the procedure.
4. The risk of complications is very low.

In a nutshell, the reason for the growing popularity of bariatric surgery is because as an investment in health, it offers high return.

Watch Surgery for Obesity and Diabetes video on YouTube.

There are many reasons of having jaundice. On many occasions, jaundice is due to medical diseases like hepatitis requiring medicines only.  Sometimes however, stones, strictures (narrowing of bile duct) or tumors, blocking the channels carrying bile, can cause them.

Many bile duct stones can be removed by Endoscopy without the need for any hospital stay or surgery. However, some patients will need surgery- conventional or Laparoscopic.  The latter method obviously is more comfortable for the patients.

Tumors in the Gall Bladder, Bile duct, Pancreas and Liver can cause jaundice. Normally, people would be unhappy to hear that they have jaundice due to tumor in their abdomen. But one should appreciate that jaundice could be an early warning signal that can be helpful in diagnosing a tumor early. Then it would be beneficial if the patient reported to the Gastrosurgeon early since this could mean a possible cure for the patient.

Sadly, many patients do not pay attention to this symptom and waste their time with inadequate investigations and unscientific treatment. When they ultimately land up with the surgeon, the tumor is too advanced for treatment. It is important that patients detect and report their jaundiceearly so that these tumors can be picked up in the initial stage for treatment. Cure of these tumors are possible only if detected early.

Another important thing to remember is that endoscopy can also relieve jaundice due to tumors by the use of a stent.  But it is wise to remember that it is only a temporary method to relieve jaundice and surgery is the only definitive treatment.

There has been a lot of progress in the treatment of these tumors. Surgery for  the tumors in the pancreas by a procedure called Whipples operation- earlier thought to be a formidable operation-  has become increasingly safer due to improved technique and technology. Liver tumors can now be removed safely with the improved understanding of liver anatomy and availability of better tools to cut liver. Even blood requirement has become rare for these procedures. However, these surgeries should be conducted in centers performing these surgeries routinely for better outcome.

To conclude, patients should be aware that jaundiceneeds to be evaluated early to identify which are amenable to medicines and which will be best served by endoscopy or surgery.  It is especially important to pick up jaundice caused by tumors because their early surgery is the only way to cure them.

The Occam’s Razor suggests that entities should not be multiplied endlessly. Although it is true in many situations, in some fields where evolution and progress is ongoing, this is not true. One such field is in Bariatric surgery where yet another procedure is making great promise. It goes by the name of Mini Gastric Bypass (MGB).

Dr R Rutledge, an American surgeon devised the procedure in 1997 and the author had the honour and privilege to learn the procedure directly from him.

Literature suggests that when compared to the other bariatric procedures, MGB is a simpler, shorter and a very effective technique in weight loss surgery. In fact it takes less than an hour to do this surgery. Most patients are home the next day.

The other significant short-term advantage is the time to get back to a solid diet after surgery. In other bariatric procedures, it is common for the patients to get back to solid food after a period of 3 to 6 weeks. However a patient after MGB can get back to a solid diet as early as 2 days! No more listening to the patients post surgery “Doctor, when can I eat? I am tired of drinking”.

The MGB works differently from other procedures in the sense that it causes more malabsorption than standard procedures like sleeve gastrectomy and conventional gastric bypass. So a patient who eats more will still lose weight or maintain the weight loss achieved even years after bariatric surgery- a phenomenon not seen consistently in other procedures. This has been documented in some studies where MGB was found to be more effective in sustained weight loss even at long term where the durability of other procedures have been questioned.

There is one more novel advantage of MGB. In all the bariatric procedures thus far, the surgery would be the same irrespective of the weight loss and metabolic effect desired. In MGB, however the procedure can be tailored to produce a measured response. In this manner, the surgery can work as a pill with the dosage in our control. Practically this is achieved by altering the length of the bowel bypassed in MGB. Shorter bypass achieves a lesser weight loss and metabolic control. The longer bypass obviously achieves more.

The other great thing about MGB (it doesn’t seem to end!) is that it is both easily reversible and revisable. Let me explain. If for some reason (and that would have to be something great, considering the benefits) a patient wanted to undo the procedure, it would take less than an hour in the operation theater to do so.  Lets take another situation. If after some time after bariatric surgery, the patient does not have the desired result of weight loss- it may have been too much or too less of weight loss- then the surgery can be revised by performing another simple procedure.

Though there is a lot of evidence in the benefits of bariatric surgery on obese diabetics, there is actually little data and good evidence on the benefits of bariatric surgery on non-obese diabetics. Some studies are showing promising results of MGB even in non-obese diabetics.

With excellent long-term weight loss and these wonderful benefits, it is not surprising to know why this surgery is fast becoming more popular with the obese and diabetic patients.

You can see how we do the procedure at the YouTube