Sometimes, weight regulation is beyond willpower; people rely on bariatric surgery. While it is a safe medical procedure, awareness about how it works and what the benefits are, along with the associated precautions, could help people make informed decisions. THIP Media, in conversation with Dr Dhananjay Pandey, explores the various aspects of Bariatric surgery.
Dr. Dhananjay Pandey, MS, FNB (Minimal Access Surgery), is a Senior Consultant at the Institute of Minimal Access, Bariatric, and Robotic Surgery, Max Super Speciality Hospital, Vaishali, Delhi NCR. With a Fellowship in Bariatric and Robotic Surgery and an Equivalency Certificate in Robotic Surgery, he brings state-of-the-art expertise to help patients live better lives.
Q: What bariatric surgery is and how it works?
Dr Dhananjay Pandey: Bariatric or metabolic surgery is a type of surgical procedure in which the anatomy of the digestive tract (stomach and small intestines) is altered such that it induces substantial weight loss and improves or resolves obesity-related metabolic conditions, such as type 2 diabetes, hypertension, and dyslipidaemia. It works by-
- Restricting the amount of food that can be consumed at a time, thereby making one feel full after eating only a small amount.
- These procedures, particularly gastric bypass, work mainly by triggering major hormonal shifts, ultimately inducing similar weight‐loss effects but with greater improvements in metabolic disorders.
Q: Who is considered an ideal candidate for bariatric surgery?
Dr Dhananjay Pandey: We need to understand BMI (Body Mass Index) in order to define the ideal candidate for metabolic procedures. BMI is defined as the weight in kilograms divided by the square of the height in metres (kg/m²).
The World Health Organisation has defined criteria for bariatric surgery based on BMI. If the BMI of a person is:
- More than 35 kg/m² with associated comorbidities like poorly controlled type 2 diabetes, hypertension, or sleep apnoea, or if the BMI is
- Greater than 40 kg/m², even in the absence of any metabolic diseases, then bariatric surgery needs to be considered.
In the Asian population, the threshold for bariatric surgery is usually low. Candidates become eligible for bariatric surgery if the BMI is more than 32.5 kg/m² with associated comorbidities or the BMI is more than 37.5 kg/m² even in the absence of any metabolic diseases.
Q: What are the main types of bariatric surgery, and how do they differ?
Dr Dhananjay Pandey: Broadly speaking, there are two types of metabolic procedures. Restrictive and Malabsorptive.
Restrictive
It is a procedure wherein the size of the stomach is reduced to the tune of 60-80%, ultimately leading to limited food intake. An example of a restrictive procedure is sleeve gastrectomy. As there is a reduction in the size of the stomach, even small amounts of food produce a sense of fullness, thereby limiting calorie intake. Also, during this procedure, the gastric fundus, the part of the stomach that produces ghrelin, an appetite stimulant, is removed. As a result, ghrelin levels fall, which dampens hunger.
Malabsorptive
It works by rerouting part of the small intestine so that food bypasses the proximal segments where most nutrient absorption occurs. During this procedure, a few metres of small bowel are bypassed, and the stomach is attached further down the intestine. As the food doesn’t pass through the initial parts of the small intestine (duodenum and part of jejunum), fewer nutrients are absorbed, which contributes to weight loss. The strength of a malabsorptive procedure depends on how much of the small intestine is bypassed. Stronger procedures are being reserved for severe metabolic syndrome. Commonly performed malabsorptive procedures are Roux-en-Y gastric bypass and one anastomosis gastric bypass.
Q: A lot of individuals consider it a “shortcut” to losing weight. How accurate is that?
Dr Dhananjay Pandey: Let us understand this very clearly: metabolic surgery should not be misunderstood to be solely a weight loss procedure. Severe obesity is a chronic disease and is invariably associated with metabolic syndrome. Although bariatric surgery induces a loss of 60-80% of excess weight over a period of 6 months to 1 year, the major benefit associated with it is the resolution or improvement of comorbidities. Therefore, it should not be considered as a one-stop solution for weight loss.
Q: What are the most common myths or misconceptions about bariatric surgery you come across?
Dr Dhananjay Pandey: Common myths and misconceptions:
- Bariatric surgery is a quick fix for weight loss: It is a cosmetic surgery. It is neither a cosmetic procedure nor a quick fix. It requires a lot of motivation and willingness in order to undergo this surgery. Also, the results are not immediate. It is not a cosmetic procedure. It is a surgical procedure of the gastrointestinal tract that is performed to ensure the resolution or improvement of metabolic disorders.
- It is a very risky procedure: The risk profile for this surgery is similar to any other gastrointestinal procedure, like cholecystectomy or hernia repair, from a surgical perspective, provided it is performed by a trained bariatric surgeon at a centre where bariatric surgery is performed on a regular basis.
- It requires prolonged hospitalisation and bed rest: This surgery requires hospitalisation, usually for a couple of days. Patients are back to their routine activities after a couple of days and can even resume travelling to the office in a week.
- One cannot eat well after this surgery: The diet is modified for a couple of weeks after surgery. Patients can resume their regular diets by the end of the first month.
Q: What can patients expect in the first few months after surgery in terms of results and challenges?
Dr. Dhananjay Pandey: Following surgery, patients can anticipate the following outcomes:
Expectation in terms of results: Weight loss is rapid during the initial couple of months after surgery. So is the resolution of metabolic diseases. Type 2 diabetes, obstructive sleep apnoea, and hypertension are some of the common conditions that completely resolve in the majority, even before significant weight loss has occurred. This gives a lot of satisfaction to the patients.
Expectation in terms of challenges: Nausea or vomiting is a common complaint typically seen with restrictive procedures. Tips to avoid it are chewing food well, eating slowly, and avoiding the consumption of liquids with meals, especially in the early days after surgery. In the initial couple of months after surgery, the patient might complain of fatigue or weakness and sometimes constipation, which is due to decreased oral intake of fluid and fibre. It can be easily tackled by ensuring adequate fluid intake and protein and multivitamin supplementation as prescribed.
Q: How important is follow-up care after bariatric surgery?
Dr Dhananjay Pandey: Surgery is only the first step towards achieving the goal of weight loss and resolution of associated metabolic disorders. Diet and lifestyle modification, including regular exercise, are of paramount importance. Follow-up becomes the key to success.
Follow-up is usually at an interval of 3-6 months during the initial couple of years after surgery. Later on, it can be once a year. And if someone asks about the duration of follow-up, it should ideally be lifelong.
It is this periodic examination that ensures nutritional wellness of the patient, along with sustained weight loss as well as comorbidity resolution in the long run.
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