Think Slimmer, Think Bariatric

Bariatric surgery is a beacon of hope for morbidly obese patients. But will it rake in the moolah for the Indian healthcare industry, asks Nayantara Som

Two years ago, 36-year-old Nirav Rijhwani, a hotelier from Ulhasnagar, Mumbai suffered from morbid obesity. Despite refraining from overeating, he weighed 140 kgs. To add to his woes, he had high blood pressure. Out of sheer desperation, he underwent cosmetic surgeries like liposuction and myriad forms of dieting and exercise. He did lose 20 kgs, but with the passage of time he gained weight again and came back to square one. "My distress ended only when I underwent a gastric bypass surgery. Two years later, I now weigh 91 kgs- a drop of 49 kgs. There are no restrictions in my life. My blood pressure is normal. I can now indulge in any kind of food," beams Rijhwani. He now gets a feeling of satiety and satisfaction even after having two chappatis. Rijhwani is not alone.

Anil Sharma (name changed), another hotelier from the city, weighed 143 kgs. Like Rijhwani, he tried dieting and was even under medication for one year. Hope came in the form of the gastric banding surgery, two months ago. "Now, I have lost eight kgs- a feat which I could not have achieved from one year of severe dieting and exercise. With my hectic schedule, I can now work for 15-16 hours with vigour and stamina without experiencing any form of fatigue," he says.

"Bariatric surgery is the best solution as it is not an ongoing lifelong treatment" - Dr Ramen Goel Bariatric Surgeon Bombay Hospital

All this is courtesy the emerging techniques in bariatric surgery. Anil and Nirav are not the only people to experience the trauma of morbid obesity and reap the benefits of bariatric surgery. Morbid obesity has become a menace for millions of overweight people across the world. India alone accounts for 25 million people suffering from obesity with five million suffering from morbid obesity. It brings along with it a host of other diseases like diabetes, hypertension, cardio-vascular problems, gallbladder disease, menstrual irregularities, arthritis-joint pains, psycho-social problems and gastrointestinal disorders. These health effects can be disabling and demoralising for the patient, leading to further psychological problems. "Bariatric surgery is the best solution for the simple reason that unlike conventional methods like dieting, it is not an ongoing lifelong treatment and at the same time there is a significant loss in excessive weight with a simultaneous cure for a number of chronic diseases," points out Dr Ramen Goel, Consultant Laparoscopy and Bariatric Surgeon, Bombay Hospital and Medical Research Centre.

An obese patient from California operated by Dr Shrihari Dhorepatil

In the past five years, the number of people, both men and women, undergoing bariatric surgery in India is phenomenal. According to Dr Shrihari Dhorepatil, Consultant Bariatric Surgeon, Jehangir Apollo Hospital, Pune, who conducted the first bariatric surgery in the country, "When I started this surgery in 1998, people would snigger because they assumed that obesity did not exist in India. They were unaware that treatment like bariatric surgery existed at all. But gradually with globalisation, surgeons and the common people realised that obesity is a major issue in India. After five years of performing bariatric surgical procedures, obese patients and other surgeons have started taking interest and are convinced about this surgery."

This surgery is gradually picking up in metropolitan cities because unlike rural or small towns, the percentage of obese people in the metros is comparatively higher. Dr Dhorepatil who is also the Honorary President of the Obesity Surgery Society of India, adds, "Back in 1998, I knew there was a lot of scope to this surgery. International doctors came to India because they knew India has a lot of potential. Gradually over the years bariatric surgery started picking up in the country."

Gone are the days when people would reluctantly force themselves into severe dieting and exercising and after resisting all temptations would manage to lose a meagre 8-10 kgs. "Bariatric surgery helps you eat the cake as well as have it. You get to lose all the extra fat in a jiffy and at the same time lead a normal and healthy life, otherwise not possible for these morbidly obese patients," adds Dr Dhorepatil, who also operates in PD Hinduja National Hospital, Mumbai

The Hot Seats

Cities like Mumbai, Delhi and Chennai have become the hot seats for bariatric surgery. It is not just for Indian patients that this emerging surgery has become the latest obsession; people from all over the world flock to India, which is gradually becoming the Mecca for healthcare.

Bariatric experts get their patients from foreign countries. This in turn is good income not only for the Indian healthcare industry, but also for other industries directly or indirectly involved in the expansion of the medical tourism industry in the country. Surgeons like Dr P Chowbey, Chairman, Department of Minimal Access Surgery, Sri Gangaram Hospital, Delhi proudly point out that in a year he gets at least 100 cases which is quite an achievement considering that five years ago, bariatric surgery was unknown in the country. Dr Muffazal Lakdawala, Bariatric Surgeon, Dr LH Hiranandani Hospital, says, "After cardiac surgery, it is here to create waves in the country."

Factors To Be Considered Before Undertaking Surgery

Experts in the field are of the unanimous opinion that bariatric surgery is not suitable for all morbid obese patients. There are certain factors to be considered by both the doctor and the patient, such as the medical history of the patient, the BMI (Body Mass Index), and the psychiatric history of the patient. These factors are a pre-requisite and if neglected can have dangerous consequences. Dr Goel recalls, "I once had a patient who wanted to undergo the surgery. However her BMI was below 35 kg per m2. So it was not possible for me to go ahead. Later however I found out that she was schizophrenic. I realised that more than bariatric treatment she needed to undergo psychiatric treatment." Dr Om Tantia, Bariatric Surgeon, ILS Multispeciality Clinic, Kolkata opines, "I always suggest intensive psychiatric counselling for the patient before the surgery. Sometimes it may so happen that a patient is not motivated to undergo a surgery. The motivation factor is very important. It is through this analysis that we can predict the success of surgery." Usually a patient with a BMI of less than 35 kg per m² is not operated on.

Dr Tantia adds, "A patient might have a hormonal or a metabolic problem, we then ensure that we treat this problem first and then go in for surgery." The other factors include age, sex of the patient, expectation of weight loss by the patient and the diet of the patient. The patient's sex is taken into consideration primarily because unlike a male patient, women go through three phases where there is increase in body weight- puberty, pregnancy and menopause. These cannot be ignored, as the surgeon will then decide the course of the treatment and surgery. After a thorough study and research on these factors, the bariatric surgeon, a team comprising of a dietician, an obesity physician, an endocrinologist, a psychologist and a host of other specialists in consultation with the patient finalise the exact surgery to be undertaken.

Kinds Of Surgeries Conducted

Restrictive Surgeries: The stomach size is reduced so the individual does not feel hungry due to decrease in food intake. There are three procedures in this category namely the Gastric Banding surgery, sleeve gastrectomy and the Gastric Stapling surgery.

Gastric Stapling: In the gastric stapling surgery, staples are placed in the lesser curves of the stomach to create a tube and subsequently a smaller stomach. It is the same procedure as the gastric banding surgery except that this surgery has become obsolete. It is an open surgery and has inherent problems. Moreover, bariatric surgery can now be conducted by minimally invasive surgeries. Hence gastric stapling is no longer practised by surgeons.

Gastric Banding: This is the most common form of bariatric surgery undertaken in India. This involves creating a small pouch in the upper part of the stomach by means of a band inserted through a laparoscopic surgery. Earlier the band was inserted through an open surgery. "Patients usually opt for laparoscopic surgery because it is less painful, cosmetically better and there are fewer chances of infection," says Dr Goel, who had also conducted the first gastric banding surgery in India in 2001 at Inlaks Hospital, Mumbai.

The band is applied around the stomach around 20 mm below the gastro-oesophageal junction to create a small pouch or an artificial stomach. The Swedish Adjustable Band is most commonly used. With the creation of this artificial stomach, the ghrelin hormone, which is a hunger hormone, is reduced drastically. The patient gets a feeling of fullness and satiety even after consuming a small amount of food.

Normally, it takes two hours for the stomach (which has a capacity of 1-1.5 litres) to completely digest the food. As a result, there is a tendency for a person to indulge in many in-between meals thereby increasing the calorie content of his body. The gastric banding surgery ensures that digestion takes place in 4-5 hours. The food taken trickles down from the pouch at a very slow pace to the major portion of the stomach. Dr Shashank Shah, Director, Department of Laparoscopic and Obesity Centre, Ruby Medical Hall, Pune explains, "The pouch which is created empties like an hour glass, thus delaying digestion and there is a longer period of satiety."

Such surgery ensures 50 per cent to 70 per cent loss of excess weight within 12-18 months. There is a chance of a 10 per cent weight recurrence but experts dismiss it as rare. The cost for such surgery varies between Rs 80,000 and Rs 1 lakh with the band itself costing between Rs 80,000 and Rs 1.15 lakh depending on the type of band used. The cost of hospitalisation plus the band is between Rs 1.6 lakh and Rs 2 lakh. This is the most common surgery conducted in India. Dr Chowbey points out, "In gastric banding surgery, the band is easily adjustable and it is completely reversible. This surgery is really picking up in India."

However, the surgery has a couple of disadvantages. There are chances of the band being eroded in the stomach; the band might even migrate from the upper stomach and slip down. But such instances are very rare since surgeons take many precautions before inserting the band inside the stomach. Moreover, the food follows the normal passage and mixes up with all digestive juices. Hence, there is no restriction on the calorie absorption capacity. Such surgery is not applicable for patients who consume many sweets and patients who are in the habit of snacking where the fat content is absorbed completely. A gastric bypass is usually suggested.

Sleeve Gastrectomy:This surgery is a recent procedure where a portion of the stomach is sliced off in order to reduce its size. This is a recent technique and unlike gastric banding and gastric bypass, this has not really picked up in India. The surgery costs around Rs 2 lakh. It does produce the same benefits like reduction of food intake and calorie absorption and a complete cure to diseases like diabetes. Being a recent development, experts like Dr Goel are apprehensive that with the passage of time the stomach might dilate and come back to its original size making no difference to body weight. Only time will reveal the beneficial aspects of this surgery.

Malabsorptive procedures Biliopancreatic Diversion

Combined procedures Gastric Bypass Roex-en-Y

Restrictive procedures Laparoscopic Adjustable Gastric Banding

Three popular surgeries in India

Malabsorptive & Restrictive Surgery

Besides reducing the stomach size, a part of the small intestine is bypassed to reduce fat absorption. The two procedures in this category are the gastric bypass surgery and the bilio-pancreatic diversion.

Gastric Bypass: After gastric banding, gastric bypass is another surgery picking up in India. In this procedure, a part of the stomach is bypassed. Bypassing the stomach makes the stomach smaller and makes the food bypass part of the intestine. A person feels full and satiated more quickly than he would feel when his stomach was of the original size. The most common form is the Roex-en-Y gastric bypass. It is usually conducted on people who have a BMI of more than 40 kgs per m² and who are obese for at least five years. People who are alcoholic or psychiatrically ill are advised not to undergo the surgery.

In the Roex-en-Y bypass, the stomach is made smaller by creating a smaller pouch using staples or plastic bands. A small portion of the stomach is connected to the middle portion of the small intestine thereby bypassing a large portion of the stomach and the upper part of the small intestine. The surgery usually involves a 4-6 day stay at the hospital. Most people return to their normal routine within 3-5 weeks of surgery. The surgery guarantees a 70-80 per cent loss of excess weight. The cost varies between Rs 2.5 lakh and Rs 4 lakh. Surgeons advise patients to take, on a regular basis, supplements of vitamins and calcium to make up for the loss of nutrients from the body.

Apart from a drastic reduction in the body weight, this surgery is a cure for a number of diseases like diabetes, hypertension and high triglycerides. Dr Shah elaborates, "Ninety per cent of the patients suffering from such diseases are cured even before they start losing weight. For the remaining 10 per cent it is well controlled."

There is one major side effect to gastric bypass surgery. Dr Chowbey explains, "Most of the patients experience a dumping syndrome. This happens when the food moves quickly through the stomach and the small intestine. It causes nausea, fainting, sweating and sometimes even diarrhoea. This is made worse by intake of high calorie food." If supplements to the nutrients are missed then the patient will get vitamin/protein/mineral deficiencies. Dr Chowbey adds, "Another complication from the surgical point of view is that there might be a leak in the joints/anastomosis sites where the two parts of intestine are joined. But this happens in one or two per cent of cases."

Biliopancreatic Diversion: A biliopancreatic diversion is usually conducted on superobese persons. The BMI should not be less than 60 kgs 50 kgs/ per m². The stomach is made much smaller and the food is allowed to pass directly to the middle part of the smaller intestine so that fewer calories are absorbed. It is a combination of the gastric bypass surgery (because the stomach is connected to the small intestine) and the sleeve gastrectomy (because a part of the stomach is sliced to reduce its size).

There are two types of biliopancreatic diversion surgeries: a biliopancreatic diversion surgery and the biliopancreatic surgery with a duodenal switch. Cost for such surgery varies between Rs 1.5 lakh and Rs 3 lakh.

Other Surgeries

Intra Gastric Balloon Method: In this surgery, a silicon balloon with a 600 ml capacity and filled with a saline dye, is inserted into the stomach through a laparoscopic method. The patient will feel an irritation for 3-4 days but that is negligible. The cost of this surgery is between Rs 1 lakh and Rs 2 lakh with the silicon balloon itself costing between Rs 80,000 and Rs 85,000. The balloon will have to be taken out within 8 months of surgery. Surgeons usually perform this operation on super obese patients to reduce their weight and then undertake gastric bypass and gastric banding surgery.

Feasibility

Bariatric surgery is restricted to a few centres in India. Most centres are concentrated in western India, with a centre each in Delhi and Chennai. It is yet to develop in eastern India. Even after India becoming a hub for bariatric surgery, the fact is that there are a total of only eight-ten surgeons in the entire country, with six surgeons in the west and one each in Delhi and Chennai and a few other cities. Dr Dhorepatil opines, "Bariatric centres and surgeons are concentrated only in the metropolitan cities because obesity is a problem which is restricted to the big cities especially among the rich class of people."

Is this an indication that bariatric surgery is controlled by a few major hospitals in India? Is money the main hindrance to set up such centres? The answer is both yes and no.

Money can be a constraining factor at times. Bariatric surgery is extremely specialised surgery. Depending on their monetary stability, hospitals have to invest from a few lakh to crores of rupees to set up a centre for bariatric surgery. Special equipment is required for the purpose.

A sturdy operating table, weighing up to 300 kgs to bear the obese patient is needed. Also required are special bariatric tables, special stretchers to carry the patient to the operating theatre, and special anaesthesia to be given to the patient. In India, this is not pragmatic for small hospitals.

"I suggest that bariatric surgeries be done in selected places" - Dr P Chowbey Chairman, Department of Minimal Access Surgery Sri Gangaram Hospital Delhi

Most experts in the fraternity opine that money is not the only factor. Being extremely specialised surgery, it needs the expertise of not just the surgeon performing the surgery but of a team of other specialists. Dr Tantia mentions, "Bariatric surgery is all about a good team. The surgeon's work constitutes only 30- 40 per cent of the work. The remaining part rests with the other experts in the team." Experts feel that for now it is better if such surgeries are handled by a few concentrated centres. "I suggest that such surgeries be done in selected places like heart surgeries 25 years ago. It can be dangerous if handled by an amateur. It is analogous to a good fighter pilot needed for a good aircraft," Dr Chowbey opines.

A few surgeons are going abroad for training. According to Dr KP Balsara, Consultant in Laparoscopic and Gastrointestinal Surgery, Jaslok Hospital and Research Centre, Mumbai, one of the surgeons who went abroad for training, "I went to Switzerland for around 10 days where there was special training for obesity surgeries." To which Dr Chetan Shah, GI/Laparoscopic surgeon, Jaslok Hospital and Research Centre adds, "Surgeons need to go abroad as these are technically advanced surgeries which have to be learnt from experts."

Medical Tourism

From being a healthseeker, India has now become the hub for world class treatment. Initially it was orthopaedic treatment and heart surgeries which dominated the scenario. Now, there is another member in the club-bariatric surgery. Apart from NRIs, patients come from as far as West Africa, the Middle East, Europe, USA, Canada, and South East Asian countries (mainly Thailand and Malaysia).

"In the US bariatric surgery will cost around USD 38,000. Over here the cost is only around USD 8,000" - Dr Muffazal Lakdawala Bariatric Surgeon Dr LH Hiranandani Hospital

The wide gulf between the cost charged in India and offshore is perhaps one of the main reasons for scores of people flocking to the country like never before. Dr Chowbey explains, "Bariatric surgery abroad would cost Rs 30 lakh. In India we charge one-tenth of the cost." The cost factor coupled with the world class treatment are the main reasons for India gradually becoming the epicentre for medical tourism. Dr Lakdawala indicates, "Apart from US nationals, I even get patients from Dubai. They see that it is a wiser option to get operated here. In the US bariatric surgery will cost around USD 38,000. Over here the cost is only around USD 8,000."

In addition to this Dr Goel adds, "I think the comfort zone is better here. Patients mainly the NRIs feel more at home while having the surgery in India than abroad and at the same time they get to save a lot of money."

On the macro level, will it be a boost to the economy? Almost all experts lean to the affirmative. Dr Goel feels "Revenue is not for the hospitals alone. The hotel industry, the travel agents organising pick-ups for the patients, all benefit in the long run. Wockhardt for instance organises the hotels, the airport pick up and drop for the patients. It is all a chain reaction." Dr Dhorepatil objects, "The economy of the country covers a wide spectrum of subjects. Bariatric surgery will definitely bring a boost to the hospitals in the country but as far as the economy of the country is concerned, it is like a drop in the ocean."

Only time can tell us whether bariatric treatment is the next big thing. The trend is definitely positive as Dr Lakdawala puts it, "People now know the competence and expertise of Indian surgeons. And hospitals here are well equipped with international standards. Now there is no looking back for us." One should keep in mind that surgery is not the only solution to the menace of obesity. It is not an end in itself but a means to an end. However, it is here to bring a three dimensional change in the face of the Indian medical industry.

nayantara@expresshealthcaremgmt.com