A smaller stomach

After the surgery, patients don't feel hungry for weeks often, the inability to "eat as much you crave" leads to depression - people eat more than advised and end up vomiting

Two years ago, Rajeev Kumar had to think twice before getting up from his chair or even climbing a flight of stairs. The action would leave him breathless and cause intense pain in his joints. At 41, he weighed 162 kilos, his waist size was over 52 inches; his Body Mass Index (BMI), well over 40, indicated that he was ‘morbidly obese’, a health condition that can further lead to diabetes, high blood pressure, sleep apnea, gastroesophageal reflux disease (GERD), gallstones, osteoarthritis, and even heart disease. But for Kumar, more than the repercussions of his weight on his health, it was the acute depression that worried him. Unable to lead “a normal social life like others”, he took a life-altering decision.

 

In 2011, Kumar underwent a Laparascopic Sleeve Gastrectomy (LSG), an irreversible procedure that curtails the size of the stomach by surgically removing two-thirds of the left side of the stomach — this means reducing its capacity from 150 cc to around 60 cc. This results in a new stomach which is roughly the size and shape of a banana and looks like a sleeve or a tube. Among bariatric procedures, sleeve gastrectomy is the most commonly performed, costing between Rs 3.5 lakh and Rs 4 lakh.

Naturally, now with a smaller stomach, the individual begins to consume less food, shedding weight with alarming speed. The science behind it is simple — the procedure eliminates the hunger inducing hormone called ‘Ghrelin’, hence patients feel full after consuming small amounts of food.

LAPAROSCOPIC SLEEVE GASTRECTOMY

• Procedure takes 45 minutes -an hour
   
• Cost : Rs 3.5 lakh-Rs 4 lakh
   
• A diet of only fluids for 15 days following surgery followed by semi-solids in coming months
   
• Post-surgery, doctors advise not to smoke. Alcohol can be consumed in small quantities

Fifteen months since the operation, Kumar has lost almost half of his body weight — he now weighs 94 kilos. His waist size, he beams, is a comfortable 40 inches. His lifestyle too has changed drastically. “I run for around 8 kms everyday!” He has thrown aside his blood pressure medication, his snoring habits have ceased, his joint pains resolved and his breathlessness cured, he claims. He now plans to travel to Leh by road.

Nehali Motha, 25, suffered a ligament tear two years ago and was bed-ridden for a year due to surgical complications. Unable to perform basic activities like bathing or dressing herself, she grew frustrated and gained weight, reaching an alarming 127 kilos. When conventional methods like naturopathy, aerobics and various diets failed to produce lasting results, she too, underwent a single-incision laparoscopic sleeve gastrectomy in 2010. Since then, she has lost 51 kilos. Last year, she got married.

While these stories present a rosy picture, leading one to believe that bariatric surgery is a “miracle fix”, for one with weight issues, such is not the case, insists Fortis group of hospitals Director & Chief (Bariatric, Advanced Minimal Access and Metabolic Surgery) Muffazal Lakdawala, who performed the surgery on both Kumar and Motha. Lakdawala, who is also the first Asian surgeon to perform the scar-less Sleeve Gastrectomy, cautions, “This surgery is recommended only to those who are morbidly obese and have no other option. For those who undergo it, it is often the only life-saving option.” He wishes the surgery wouldn’t be treated as such a “taboo”.

Lakdawala who jokes that he has “cut open half the builders in Mumbai” for the same reason, has also performed bariatric surgeries on BJP President Nitin Gadkari, NCP’s Nawab Malik, State Cabinet Minister Nitin Raut and BJP’s Vinod Tawde. He has also operated on the heaviest man in Asia who weighed 285 kilos (627 pounds) in Tianjin, China.

Though the kilos continue to drop, life after the surgery isn’t easy. The toughest challenge is the patient’s new diet — the changes made to your gastrointestinal tract will require permanent changes in your lifestyle, explains Lakdawala. While the new diet varies from patient to patient, few guidelines must be followed diligently. For 15 days following the surgery, patients are put on a diet of fluids only. But for someone attuned to fatty foods and compulsive eating, isn’t a liquid diet a grave challenge? “No,” says Lakdawala, “In fact, for a few weeks after the surgery, we have to force patients to eat. They don’t feel hungry at all.” And so they’re started on a smaller diet of fluids followed by semi-solids. It is only within six months after the surgery that the patient begins to resume a “normal” diet of eggs and toast for breakfast, around two rotis in his meals, along with fruits.

Post-surgery, close attention to how one eats — otherwise a fuss-free task — is necessary. The patient must chew the food thoroughly and eat very slowly. Digesting steaks or other chunks of meat might be difficult if they aren’t ground or chewed thoroughly. Lakdawala also advises to avoid drinking fluids while eating as they will “make you feel full before you have eaten enough food”. Often, fluids consumed with meals can lead to vomiting, which in turn leads to hunger sooner after a meal.

Desserts and other items with sugar are discouraged, if they have more than 3 to 5 grams per serving size. Carbonated drinks, high-calorie nutritional supplements, milk shakes, fatty foods, are a big no-no. Eating between meals, or “snacking”, is no more a possibility.

Moreover, while weight loss might be guaranteed by the surgery, its maintenance is not. “One must monitor the liquid calorie intake as consumption of frequent amounts of liquids could lead to increased caloric intake,” says Lakdawala. He advises patients against smoking after the surgery, as it leads to acidity; alcohol, he says, is allowed in small quantities. Kumar, who used to drink around three alcoholic drinks at social gatherings earlier, now opts for a single glass of wine. He avoids beer.

Take note: for women who want to get pregnant, it is strongly advised to conceive a year and a half after the surgery. “The period of weight loss is not good for the baby’s nutritional status,” says Lakdawala.

“Eating in moderation is not a choice, but the only option [after the surgery],” explains Ishi Khosla, a clinical nutritionist. While the patient can eat everything — rotis, vegetables and desserts — it is the quantity that is reduced drastically, she adds. Often, the inability to eat “as much as you crave” leads to acute depression, as a result of which, people eat more than advised and vomit, adds Khosla. While she would recommend such a surgery to those who are morbidly obese, she points out : “It is a last resort for most. When regular exercise regimes and diets fail, then this surgery becomes the only option.”

While demand for such surgeries has spiralled in the last few years with around 3,000 of them being performed in a year — Lakdawala himself performs around 50 in a month —, the surgery is known to have some disastrous consequences. In 2006, television anchor Oprah Winfrey and a panel of experts, in an episode called “Suddenly Skinny”, declared that as many as 30 per cent of patients who undergo the surgery will struggle with new addictions like alcoholism, gambling, compulsive shopping and sex addiction.

But these cases are more relevant to the US where obesity is more widespread, insists Lakdawala, who also set up the Centre for Obesity and Diabetes Surgery in Mumbai. At the CODS clinic, Lakdawala is often regaled with pleas and requests from girls between 20 to 25 years of age, who weigh around 100 kilos, and still want the surgery. While he advises against it in such cases, at times, he has no choice. “Some of them are suicidal or depressed. They are under familial pressure to get married. Their mothers encourage them to go under the knife,” he laments. But Lakdawala’s team ensures that the patients are briefed by counsellors and psychiatrists about the challenges of life after surgery.

Although the short-term effects of weight loss surgery are understood, not much is known about the long-term effects on nutrition and body systems. The patients have to go for quarterly check-ups and take life-long vitamin supplements. They may also need periodic checks for anaemia (low red blood cell count) and Vitamin B12, folate and iron levels.

Gadkari, who underwent the surgery last year, has now lost 23 kilos. A few days ago, an ecstatic Gadkari visited Lakdawala after returning from a vacation. “He told me his family was very happy because he could walk for over three kms without feeling faint or breathless!” Sapna Kinger, 39, who went under the scalpel in 2010, too, has lost around 40 kilos since the surgery. Formerly a victim of acute depression owing to her weight issues, she refused to get out of bed or step out of the house. Today, she works in the corporate sector. She adds after a thoughtful pause, “While life may be difficult after the surgery, it can’t be as hard as it was before the surgery...”