BARIATRIC SURGERY:COSMESIS OR THERAPY

Few surgical procedures have caught public imagination and expectations the way, weight loss intervention has done during the recent past. This is compounded by the fact that relevant procedures are now available through minimal access surgical approach offering a quick recovery and return to routine life. Moreover surgeons look upon these bariatric surgeries as a new and challenging modality that they are keen to add to their repertoire offering better reputation and financial incentives in addition to established benefits to their patients. The concept was infact introduced  in  the  early  1950's  with  intestinal  bypass  acting through  inducingmalabsorption. However it was not until 1965 that DrEdward E. Mason and Dr. Chikashi Ito at theUniversity of Iowadevelopedthe  original  gastric  bypasswhich  has  since  shown  more  promise  with  fewer complications and it is by virtue of this that the former has come to be known as the 'father of obesity surgery'.The boom in different procedures to be adopted has however led to a number of queries not only in the minds of those seeking intervention but the ones offering benefits related to ideal body weight and redressal of co-morbidities, that is the doctors as well.  Technical debates are raging  and recommendations  changing  as  the  concept  continueto  gain  acceptability  and momentum.  Contrary  to  the  general  perception  that  these  procedures  are  meant  primarily  for cosmetic reasons, the actual benefits are now believed to be health related. Studies have shown that bariatric surgery contributes to diabetic control, psychological benefits,reduced risk of cardiac events and reduction in mortality of 23% from 40%1. A lot of research has been afoot for more than half  a  century  looking  into  possible  surgical  cures  for  metabolic  diseases  such  as  high  lipid  , cholesterol and blood sugar. In 1995 Dr Walter Pories et al published a paper2concluding that gastric  bypass  is  an  established  and  effective  therapy  for  morbid  obesity  and  its  associated morbidities, producing a  durable and complete control of diabetes mellitus.In 2007, encouraged by the significant  impact of bariatric procedures on actual cure of metabolic upsets as described, the American Society for Bariatric Surgery (ASBS) which was established in 1983 changed its name  to the American Society for Metabolic and Bariatric Surgery (ASMBS).Given the recent public interest in the visible benefits of weight loss surgery and much wider availability  of  doctors  and  centres  offering  various  procedures  it  is  essential  to  have  some consensus on standardization of indications for the said intervention.  The American College of Physicians recommend that those with a BMI of at least 40 Kg/m2 who have failed an adequate exercise  and  diet  programme  and  with  co  morbidities  such  as  hypertension,  impaired glucose tolerance , diabetes mellitus , hyperlipidemia and obstructive sleep apnoea should be offered the procedure after consultation with the prime surgeon3. The American Society for Metabolic and Bariatric Surgery (ASBMS) in its recent guidelines however has suggested a BMI of 30 Kg/m2with co morbidities as an indication for bariatric surgical intervention. Procedures recommended for affecting weight loss  act  by way of altering the anatomy of gastrointestinal tract (stomach and digestive system) and inducing physiologic changes in the body that affects energy balance and fat metabolism. Theycan be classified broadly into three types4;Predominantly malabsorptive :These procedures are mainly reliant on creating a physiological upset of normal absorptive mechanisms.  They  include  biliopancreatic  bypass,  jejunoileal  bypass  and  endoluminalsleeve. None of these are however in vogue given the metabolic and nutritional upset they create.Predominantly restrictive :Procedures such as adjustable gastric banding, vertical banded gastroplasty , intragastric balloon, gastric plication and sleeve gastrectomy result in a limited gastric volume thereby producing  early  satiety  and  reduced  oral  intake  .  Moreover  since  the  continuity  of  the alimentary canal is not disturbed metabolic complications are not much of an issue5.Mixed:Gastric  bypass,  sleeve  gastrectomy  with  duodenal  switch  and  implantable  gastric stimulation are procedures that apply both techniques simultaneously.Bariatric Surgery is usually supported by a dietary plan in the immediate post operative period, consisting of a clear liquiddiet, followed by a blended or pureed sugar free diet for at least two weeks. The restrictive element of these procedures limitsthe capacity of the stomach inducing nausea and vomiting in case of excessive intake. Vitamin and mineral supplements are needed to compensate  for  decreased  absorption  of  these  essential  items.  High  protein  diets  are  usually recommended in light of the decreased consumption of food. The actual success of weight loss surgery depends on factors other than surgery alone such as longterm nutrition and dietary habits, exercise and life style changes. Although there are demonstrable health benefits linked to bariatric interventions, the patient seems more concerned with the visible degree of weight loss. A meta-analysis6from University of California Los Angeles looked at weight loss as a result of different procedures at thirty-six months and concluded that Biliopancreatic diversion offered maximum benefit at 117 pounds followed by Roux en Y gastric bypass and then vertical banded gastroplasty. Studies7 have also shown that bariatric surgery improved diabetic status in more than 85% of the affected and afforded remission in 78%.One of the key questionsrelated to bariatric surgery is the amount of risk associated with this intervention. Complications related to the procedure as reported from time to time include gastric dumping syndrome, anastomotic leaks, incisional hernias, infections, pneumonia, osteopnia, secondary hyperparathyroidism,rhabdomyolysis,  gallstones  and  hyperoxaluria.  Studies  have shown a mortality of less than 0.3% in individual undergoing surgery and a lower risk of death in the later group as compared to those plagued by obesity and its co-morbidities who do not have the procedure.Taking  all  the  facts  into  consideration  bariatric  surgery  certainly  promises  to  attract headlines with introduction of modified interventional procedures from time to time as research into the best possible modality with maximum benefits and least risk continues. Patient variation and surgeon's expertise has its bearing on the ultimate choice in this respect as improvement in health, longevity and quality of life tops the list of core determinants acting as a guiding principle in making the ultimate decision regarding the interventionindicated.