Frequently Asked Questions

-related to OBESITY.

When to consider Surgery for Diabetes?

Good question! One is not asking all diabetics to be subjected to surgery. Instead, it is proposed as an option for some of them. And that too, for those who are eligible as is ascertained by some tests. Let us start by finding out who needs to look for options other than medicines and insulin for controlling blood sugar. Well, there may be different scenarios. First, a diabetic is well-controlled on medicines and lifestyle changes with no evidence of diabetic complications. Would this subject be a good candidate for surgery? An argument might be – why not? After all, surgery offers a permanent cure whereas medicines do not. And he or she might get worse with time and develop complications (kidney failure, high blood pressure, heart ailments, eye complications, infections, etc). Then what? Is it not a good idea to offer a surgical cure to all eligible? All true, but what if this patient was to have a complication from the surgery? What about the commitments required in terms of follow-up after surgery? If a person is doing well with medicines, is it not a good idea to leave him or her alone? Maybe. Sounds fair. Unless the patient is adequately informed and has decided for himself or herself to undergo surgery for long-lasting freedom of diabetes knowing fully well the risks and consequences of surgery. Well, the argument can continue. Let us examine other scenarios. A young person with lots of productive years left in life has diabetes uncontrolled on pills and insulin. Or, consider a diabetic who is rapidly developing complications. What about these people? If a cure is possible, is it not right to offer them a choice? Is it not fair to let them have the option of diabetes surgery? Let them decide if they are willing to take the small risk associated with surgery and the necessary follow-up. After all, a life free of medicines, insulin and complications is something every diabetic is looking for. There is a lot of evidence from scientific research in recent years that have demonstrated the benefits of bariatric surgery on diabetes. Way back in 1995, Pories et al1 shocked the world by reporting that bariatric surgery corrects diabetes within days after surgery much before significant weight loss has taken place. The claim challenged the established conventional belief that diabetes is a chronic non-remitting illness necessitating lifelong treatment with pills and insulin. Subsequent scientific research in this area established the role of the small intestine as an important cause of type 2 diabetes. It also demonstrated the role of realignment of intestinal flow done in bariatric surgery as the mechanism for the resolution of diabetes. A consensus summit in Rome in 2009 attended by the most respected bodies in the world has recommended strongly the use of bariatric surgery for diabetes under stipulated guidelines. In a huge meta-analysis comprising 135,246 patients by Henry Buchwald et al, 78.1% of diabetic patients showed complete resolution and 86.6% showed improvement2. There is an increasing burden of diabetes in the world today. India is unfortunately the place where this disease is going to strike maximally. We, as humans will be better prepared to combat this problem if we incorporate this effective solution as part of diabetes management. After all, surgery is now offering a cure for a disease, which was so long considered incurable. Pories WJ et al. Who would have thought it? An operation proves to be the most effective therapy for adults with onset diabetes mellitus. Annals of Surgery 1995; 222:3 Henry Buchwald et al. Bariatric Surgery: Systematic Review and Meta-analysis. JAMA 13 2004; 292(14): 1724-37.

Why not try diet and exercise?

Sure, be my guest! However, if you are very fat you would be wasting time and bandwidth. Why try to prove that falling from a plane without a parachute is not safe? It is already proven over and over again that, in severely obese individuals, bariatric surgery is the only scientifically proven way of losing real weight in the long term. All your gimmicks are short-term, not this! If you want to know why diet and exercise won’t work in the morbidly obese patient, you are not a complete idiot. Please search through this site and educate yourself. Enjoy!

How much does Bariatric surgery cost?

At Clinic Ramana, BMI conducts various weight loss procedures at very modest budgets. However, it is impossible to give you a number now. Do you need surgery? What procedure is the right one for you? How much of disposables, including staplers, are going to be needed? Would you like staple-line buttresses like Seamguard? Would you like to stay in the economy or a suite? Do you need ICU to stay? Will you have a complication? As you can see, there are too many variables. If you want to know, email me your details: I will give you a ballpark figure, if possible. Provided you are ready with all the details of your medical records.

What is weight loss surgery? is it liposuction?

Er, no. Actually, liposuction is sucking out fat through some cuts made in the belly, butt, thigh or other body part. Usually, 5 to 6 liters of fat are removed. This is purely a cosmetic procedure, and is unsuitable for the severely obese individual. Bariatric surgery (aka weight loss surgery) is different. We don’t suck out fat, nor do we chop off large chunks of fat. We alter the size and shape of the stomach in some way, and help create weight loss that is substantial and sustained. This means this is what you want!

What exactly is done in this Bediatric surgery?

Um, it is BARiatric surgery, not BEDiatric. You do need to be in bed, but that’s for one day. Before I was a bariatric surgeon, I was a stand-up comedian in a BAR, but they fired me. I make BED jokes. Bariatric surgery is the name given to a group of surgeries to affect permanent weight loss in severely obese people. The highlights of the surgeries are: It is a laparoscopic approach. The size and/or stomach are altered in some way. Also, the digestive tract may be altered in some cases. Minimal hospital stay. Rather painless. Stitch-less. Almost bloodless. Causes permanent weight loss. Relieves and even cures several obesity-related conditions like diabetes, high blood pressure, sleep apnea, etc. Is a major undertaking in a patient’s life. This is not your slimming centre approach!

Can I eat normally/everything after this surgery and still lose weight?

If you want to eat as you have always done, this would be the wrong approach. You can’t hope to have a 3000-calorie meal and lose fat at the same time. Well, sometimes you can (we don’t have any posts on the duodenal switch yet), but let us keep things simple here. You need to be committed to your weight loss goals, not your eating-more-food goals. If this fundamental shift in mindset is not there in you, you need to refocus. You could come to meet us at Clinic Ramana, and we can take this forward. That said, there are procedures, like gastric bypass, where you can eat only a limited amount of food (kid portions). In operations like sleeve gastrectomy, the volume of the stomach is more, and your portion sizes can be higher.

What will happen to the skin folds that will hang after i lose weight?

If you lose a lot of weight, like a hundred kilos, for example, obviously your skin folds are going to hang loose. In some time, usually a year, there is some adjustment of the slack, and the sag is not noticeable in those who have less weight to lose (to begin with). In extreme cases, the redundant skin needs to be trimmed out. Not a big deal, actually, but a small price to pay for a life-altering surgery!

Where can we see the before-after pictures of your patients?

You can’t. Not because our patients haven’t had a fat loss (we would be out of work if it were so), but because we don’t use our patients’ pictures to attract others. Patient confidentiality, heard of it? We believe in it. Your weight loss story is private unless you want to share it with others. If you are interested in finding out how life is for people who have undergone weight loss surgery, please be in touch with us (see our Contact Us page for details) and we will help you get in touch with many of our patients. That said, some of our patients, like this one, have posted their pictures. See if you can have a look.

Is there a cure of diabetes if i am not obese?

We don’t know yet. There is no standard recommendation for non-obese diabetics. So, if your BMI is, say, 27 and you want surgery, we would need to refuse standard metabolic surgery procedures. However, there are a couple of experimental procedures like Ileal Interposition and Duodeno-jejunal bypass that are being done in a couple of centres in India. We do not yet have long-term data. There is an argument that the sleeve gastrectomy done in all the cases of ileal interposition would account for the favourable metabolic outcomes thereafter. Proponents, however, claim that SGIT has inherent and powerful metabolic benefits. Does the procedure have long-term side effects or even long-term benefits? We simply don’t have the data yet.

Can you cure type i diabetes?

No. Most Type I diabetics will have to rely on insulin. They are not candidates for surgery. However, there are a few papers that have shown benefits. That said, this is not standard treatment. We are also not talking about islet cell transplants for the reason that for most people they are not relevant.

How do you prevent fatal clots in the lungs?

Blood can clot in the leg veins in the obese and those undergoing prolonged lying down, as in many post-surgical states. The clot can then migrate to the right side of the heart and into the pulmonary arterial system, where it gets trapped. This blocks the outflow of blood from the right side of the heart and can cause sudden and fatal cardiac arrest. Therefore, it seems logical to say that deep vein thrombosis (DVT) and pulmonary embolism (PE) are better prevented than managed. The three ways we prevent DVT are: Give low-molecular heparin that keeps the blood thin and prevents it from clotting. Use Sequential Compression Devices that pump the veins in the calf to keep blood from stagnating in the veins. Mobilize the patient from the day of surgery. This last is crucial, especially in the patient who is unable to move easily on account of joint or spine problems or even excessive weight.

The lap band is what you do? i had a friend do it, and she had a lot of problems with it, finally ending with another surgery. it scares me!

Lap Band is only one type of bariatric surgery. We do not prefer it, because: It is purely restrictive in nature. Requires a very motivated patient who would stick to a diet. Up to a third of patients end up with another surgery to remove it because of complications. There are better options Weight loss is the least among the various weight loss procedures, though the short-term results are excellent. 6. Patients can cheat the surgery by drinking liquid calories.

Why are you recommending the gastric bypass for me?

Gastric Bypass is a well-tested and proven procedure. It has superb results in terms of weight loss and remission of diabetes, hypertension, sleep apnea, lipid disorders, etc. In addition, it is an anti-reflux procedure par excellence. After the bypass, your eating habits will be corrected favourably when you realise that you can’t tolerate refined sugars and sodas.

Can diabetes be considered a surgically curable disease? how?

Yes, Type II Diabetes Mellitus can be considered a surgically curable disease. 80% of diabetics are obese, and bariatric surgery gives persistently normal blood glucose levels in 75-100% of patients. The reason why operations like the gastric bypass or sleeve gastrectomy are so successful is not only that weight loss improves blood glucose levels, but increases insulin sensitivity. Additionally, incretins are secreted from the gut, leading to more insulin secretion, and preventing further death of the insulin-secreting cells of the pancreas (“apoptosis of the beta cells” in tech-speak). In obese patients, diabetes cure (or control) is well-known. However, even in the non-obese, metabolic surgery may be feasible. Ileal Interposition is a new procedure spearheaded by Aureo De Paula, a Brazilian surgeon. In this procedure, a long segment of the ileum (distal small bowel) is placed in between the upper small bowel (jejunum), leading to incretin release and diabetes control. This form of metabolic surgery is promising and initial results are excellent. However, as this is still an unestablished procedure, we need to be wary of drawing wide-based conclusions from it. It is best to consider it as a promising procedure that may stand the test of time, but we need to treat it as a last resort to stubborn diabetes in the non-obese. When the diabetes is progressing despite medical treatment, it may be appropriate to try metabolic surgery as a last resort.

The gastric plication is cheap. can i go for it?

The Plication is a very safe and economical procedure, but we don’t recommend it as a first choice, because it is still new and long-term results are not available. Initial reports are encouraging, but that is all we can say. Now, if you need bariatric surgery and cannot afford the standard procedures like the bypass or the sleeve, then this may be considered a cost-effective procedure that is better than not doing bariatric surgery.

Is bariatric surgery permanent, or is it reversible? that way i don’t need to eat small all my life!

There are procedures that are reversible: the Lap Band is the most popular, while the Gastric Plication is a new-kid-on-the-reversible block. However, it is important to understand one’s priorities. Is it a priority for you to eat more? Then you are likely to be unhappy with anything other than eating more food. In the process, you will become obese and sick, and depressed, and the last time I checked, depressed people aren’t happy. If you make weight loss and health your priority, then you would not think of reversing your bariatric procedure. You would look at the operation not as a temporary fix, but as a permanent way to stay leaner, healthier and be able to eat smaller portions without feeling out of control.

What is my post-operative recovery going to be like?

Normally, you would be in the hospital for 48 to 72 hours after surgery. We will get you out of bed as early as the same evening of surgery, and send you home on a liquid diet and minimal medicines. We usually do not prescribe antibiotics. A liquid diet is continued for 2 to 3 weeks. Don’t worry about this, as you will feel no hunger, and we would often need to encourage or prod you to drink more! You can be moving around at home once you get back (pain not being a factor in almost all cases), and join work after around ten days. You are allowed to bathe using soap and water all over from Day One. There are no stitches, so that is an added bonus!

Is Bariatric surgery safe? can i die from it?

Yes, bariatric surgery is very safe, as multiple studies and our own experiences have shown. There is a small chance of peri-operative death, around 0.4%. This is almost the same as the mortality rate after other accepted-as-safe procedures like an appendectomy.

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