Studies show that morbidly obese people find it
virtually impossible to lose weight in the long term through
diet and exercise. This life-threatening predicament can
only be successfully treated with surgery. Callan Emery
than half of the population in the Gulf region are
considered overweight and in the United States obesity is
now considered one of the leading causes of preventable
death. Experts in the region like Dr Abdul Rahman Al
Musaijer, Di-rector of the Research Programme on Environment
in Bahrain, and Dr Khaled Al Jabri, Endocrinologist at the
Al Jazeira Hospital, say the statistics are alarming.
They have reported that in the UAE alone about 50 per cent
of males and 60 per cent of females are overweight or obese.
Often referred to as the “new world syndrome” obesity is now
considered one of the leading causes of Type II diabetes and
heart disease, both potentially fatal diseases.
In ancient times, obesity was regarded as a sign of
fertility and wealth. And even though Hippocrates (460-377
BC) noted the fact that excess weight was caused by
nutrition and a lack of physical activity, and was also a
cause of heightened mortality, this view was ignored until
the modern era.
Until quite recently adiposity was thought of as a glandular
disease. Even today many people have the perception that
obesity is caused by self-inflicted over eating and a
weakness of mind. However, scientific research shows a
growing consensus that obesity is multifaceted and strongly
influenced by genetic disposition.
There are a variety of treatment regimes available for
people who are overweight - Body Mass Index (BMI) 25-29.9 -
or obese (BMI 30-39.9), such as reduced calorie intake,
behavioural therapy, drug therapy and increased physical
However, scientific studies have shown that such therapies
are ineffective in the long term for people suffering from
morbid obesity (BMI 40+). In such cases surgery is the
option most often recommended by physicians.
Morbid obesity is chronic and lifelong. It is an extreme
health hazard with medical, psychological, social, physical
and economic comorbidities. There is increased risk of
developing high blood pressure, Type II diabetes, heart
disease, stroke, gallstone disease and cancer of breast,
prostate and colon. There are in fact 30 medical conditions
which are directly related to obesity.
Morbidly obese people are victims of prejudice and public
ridicule due to their size which often results in
psychological illness such as depression. Discrimination at
work and employment also often result in poor socioeconomic
Morbid obesity is now recognised as a significant cause of
preventable early death.
There are various surgical procedures available to morbidly
obese patients. These are generally classified in two
categories: Gastric Bypass and Gastric Restriction.
The gastric bypass operations include Roux-en-Y, where a
small pouch is created along the uppermost portion of the
stomach, and the small bowel is attached to the pouch. This
surgery can be done either in an open surgery (RNY) or
laparoscopic surgery (Lap RUNY). Bypass operations also
include other procedures that are rarely used today such as
Extensive Gastric Bypass: (biliopancreatic diversion) and
Restriction operations for obesity include Gastric Banding
and Vertical Banded Gastroplasty (VBG). These types of
procedures serve only to restrict food intake by separating
the top portion of the stomach, where food enters from the
esophagus, from the bottom portion, where the food mixes
with digestive juice.
Restriction operations are simpler, with less risk and
long-term side effects in comparison to Gastric Bypass
operations. However, according to the Hampton’s Center for
Bariatric Surgery, Southhampton, USA, only half of patients
lose 50 per cent of their excess weight and 20 per cent do
not lose any weight with the gastric banding procedure as
opposed to 70 per cent to 80 per cent with the more risky
Gastric Bypass operations.
The Adjustable Gastric Band
Nonetheless, there are many advantages to gastric banding,
particularly since the development of a relatively new
device known as the Laparoscopic Adjustable Gastric Band (LAGB).
Unlike obesity surgery that involves cutting, stapling or
stomach rerouting, the laparoscopic implantation of the
increasingly popular LAGB is reversible and, as its name
implies, the band is adjustable.
The LAGB is made of a silicon elastomer, a material known
for its good tissue compatibility. It measures 13 mm in
width, and the inner diameter of a closed band is 9.75 cm or
10 cm in a slightly larger version. The band is implanted by
minimally invasive laparoscopic surgery and fitted around
the upper part of the stomach, dividing it into two
sections, the smaller ‘pouch’ above the band has a capacity
of approximately 15-20 mm (pouch); the larger remaining part
is below the band. The constriction creates an artificial
stoma restricting the amount of food that passes from the
‘pouch’ to the stomach.
Depending on the patient’s needs, after the device is
implanted the narrowed opening between the pouch and the
lower part of the stomach can be adjusted in size by
inflating or deflating the hollow band. Inflating the band
makes the opening smaller, causing food to pass more slowly.
Deflating the band makes it wider, causes food to pass more
quickly. This adjustment is made by adding or removing fluid
inside the hollow band via an injection port which is
connected to the band via a 50cm-long catheter. The
injection port is placed under the skin in a muscle in the
chest wall. It uses a high-pressure plastic-septum, which
can be punctured with a specially designed needle up to a
thousand times without becoming damaged.
The laparoscopic implantation of the band is not simple. Dr
Karl Miller, Associate Professor of Surgery, Head of the
Surgical Department, Krankenhaus, Hallein, Austria, warns in
a paper, Review: Laparoscopic Bariatric Surgery, published
by the International Fede-ration for the Surgery of Obesity,
that “as with all laparoscopic procedures, there is a
learning curve for banding that can vary quite
substantially. Trouble-free banding requires experience and
practice. In one study two surgeons report a re-operation
rate of 30 per cent in the first 50 patients and a
significant reduction of 13 per cent for the next 47.
Another study reported that the largest number of
complications occurred in the first 25 patients.”
Once the gastric band is implanted only small meals can be
tolerated and this requires considerable nutritional
discipline on the part of the patient. Generally this
results in a reduction of caloric intake to a point below
the body’s daily requirement, which in turn causes
According to US studies, quoted by the Food and Drug
Administration (FDA), which approved the device in 2001,
“the average weight loss was 36 per cent of a patient’s
excess weight three years after the device was implanted.
More than half of the patients lost at least 25 per cent of
their excess weight; some patients lost over 75 per cent,
but some lost no weight”.
Further, Miller says, studies have produced evidence of a
significant reduction in blood sugar and cholesterol levels
and blood pressure even with a modest weight loss of only 10
per cent after surgical treatment. The improvement in
comorbidity is in direct proportion to weight loss after
Although a relatively new procedure, LAGB operations are
being carried out in the Middle East on patients who qualify
for the procedure. Emirates Hospital in Dubai, UAE, for
example, says it does several LAGB operations every month
and that is becoming an increasingly popular way of treating
The gastric pacemaker
Initial results from a multi-centre survey of the new
Transcend Implantable Gastric Stimulator (IGS), also known
as the gastric pacemaker, show that it offers a promising
new therapy for the treatment of obesity with a low
The Transcend Implantable Gastric Stimulator, developed by
Transneuronix, is a battery operated system that is
implanted by laparoscopic surgery under the skin of the
abdomen. Via two leads it delivers mild electrical signals
to the stomach wall. The electrical stimulation slows the
absorption of food leading to the person feeling full for
longer and thus eating less.
The system is currently one of the least invasive surgical
techniques to treat morbid obesity, although the costs of
this intervention are considerably higher than the AGB.
l For more information visit the International Federation of
Obesity Surgery: http://www.obesity-online.com/ifso/