Morbid adiposity

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 reports.

More 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 activity.

Obesity surgery

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 conditions.
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 Jejuno-lleal Bypass.

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 weight-loss.

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 gastric banding.

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 morbid obesity.

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 complication rate.
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/
Visit: http://lap-band-surgery.org/
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