In November last year, Zoya Khan underwent bariatric surgery at Mumbai's Breach Candy hospital. With such procedures not uncommon across the city any more, it would have been an unremarkable event were it not for the fact that Zoya was just 11 months old then. According to her doctor, Dr Sanjay Borude, the procedure relieved the 19-kilo Zoya of respiratory problems, and avoided her from suffering the same fate as her older brother, who had died due to a similar genetic disorder.
Ever since then, the medical fraternity has been hotly debating whether or not Zoya was too young to have gone under the knife. But their discomfort surrounding this form of weight-loss surgery stems not just from one case. Numbers from 2011 indicate that there has been alarming rise in bariatric procedures across the country. The fear, experts say, is that a high-risk operation, meant only to save lives, may be fast becoming a fad, the new lyposuction as it were, with the patients not always aware of the problems it could lead to.
In the past year, there was a 127 per cent rise in bariatric procedures in India, of which Mumbai accounted for nearly one-third. In terms of aggregate, data with The Obesity Surgery Society of India (OSSI) showed that the number of procedures had gone from 2,200 in 2010 to over 5,000 in 2011. It was an unprecedented rise, much sharper than the increase in other surgeries such as heart by-pass, or knee, hip and joint replacement. And given that India does not have a full-fledged registry for obesity-related operations, this official count is just the tip of the iceberg.
Pune-based Dr Shrihari Dhorepatil, the first surgeon to conduct an open bariatric surgery in India in 1997, stresses that this procedure is "not an alternative method" for someone who is too bored to exercise or diet for a long time. "It's a life-saving procedure and people need to understand that. There cannot be a scenario that every second person who wants to be slim opts for a bariatric surgery," he said, adding that patients who opted for bariatric surgery in Western countries were put on a exercise and a diet regimen for up to three years to see if there was any other way out. "Here, these is no such control."
Though widespread obesity been dogging the West for several years, it is a fairly new problem in India. According to official figures, obesity now affects 55 million Indians (approximately 0.5 per cent of the total population), of which 8-10 percent are morbidly obese. In contrast, the obesity figures in the United States are close to the 30 per cent mark.
With bad sleeping and eating habits, and the increased levels of stress, those in the obesity bracket have an 80 per cent higher chance of suffering from type II diabetes and cardiac problems. But the new solution, bariatric surgery, comes with its own set of problems.
Dhorepatil says it had taken him six months to convince his first patient, a 27-year-old woman, to go under the knife. "She was the mother of two children and extremely apprehensive," Dhorepatil, who trained in Australia and founded the OSSI, said. Now, he conducts about 90 such operations in a year. "Initially there were only a handful trained doctors and the surgeries could be monitored. These days, every second surgeon is performing it," said Dhorepatil, expressing fears that "bad surgeons" may soon start "running amok".
Doctors such as Dhorepatil fear that as the field is becoming glamourous because of greater clientele, "anyone and everyone" has started performing weight-loss surgeries, and that the motivation of hospitals is slowly changing from necessity to easy money. A bariatric surgery costs anything in the range of Rs 2 and Rs 5 lakh, depending on the hospital and the kind of surgery it is (see box).
Thirty-year-old Amit Patel, a businessman from Ahmedabad, for example, weighed 155 kilos and approached a surgeon in Anand in August, 2010. The doctor suggested a sleeve gastrectomy that stapled his stomach to restrict his food intake. "A week after the surgery, I continued to feel uncomfortable. An endoscopy revealed a leakage through which food particles and air bubbles were seeping out. The doctor, however, made it look like a routine side effect and put me on a feeding tube for more than a month," Patel said.
Two months later, the doctor advised him to use a stent to stop the leakage. "There were times when I thought I had ruined life by undergoing this surgery. I thought everyone who had warned me against it was right. We finally figured he could not do it right. We decided to consult another doctor," said Patel.
He consulted Dr Muffazal Lakdawala, who suggested a revision surgery for the leakage of more than two inches. Patel now weighs about 72 kilos. Bariatric surgeon Lakdawala, who consults with Saifee Hospital, who also operated upon BJP leader Nitin Gadkari, says surgeons often fail to choose the right procedure. "There are many who cannot perform the gastric bypass (bypassing the initial segment of the small intestine so food directly enters the middle section) and end up opting for the easier sleeve gastrectomy," said Lakdawala, who does about 300 procedures in a year, many of them revisions of a previous surgery gone wrong.
If the procedure is not performed properly, patients may develop infection, deep vein thrombosis, abscess, vomiting and pneumonia and the complications may even prove fatal. "It is a high-risk operation and the chances of complications are as high as in the case of a brain surgery or a complex cardiac procedure," said Dhorepatil. According to data compiled in the West, the death rate in the field is a notable 0.5 per cent. "It's not for somebody who doesn't need it as a live-saving measure."
According to the Asia-Pacific Guidelines, a person who is disease free with a Body Mass Index (BMI) of 37.5 (25-30 kilos overweight) is a legitimate candidate. Any person who suffers from obesity related diseases like diabetes, PCOD, sleep apnea and has a BMI of 32.5 (17-20 kilos overweight) can undergo bariatric surgery as well. BMI can be calculated by dividing your weight (in kilograms) by the square of your height (in metres). The Asia-Pacific guidelines have set the age range of those who can undergo the procedure to between 18 and 65 years.
But the onus of thorough homework, says Lakdawala, falls on the patients. "It is critical to choose a surgeon with experience and training. He/she should be able to provide examples of other patients he has successfully operated upon," he says.
He points to several patients who swear by it. One of them, 31-year-old Malad resident Jatin Mishra describes the surgery performed on him as "life-changing". He weighed 152 kilos, was severely diabetic and had also undergone an angioplasty to open up his 50 percent blocked artery. "I used to overeat. I tried running and going to the gym. But nothing worked," he says. The restaurateur underwent a sleeve gastrectomy at the Saifee hospital. He now weighs 83 kilos.
"I don't suffer from health issues any more. I eat everything within limits," said Mishra, who is getting married in February. Sheetal Tata, 36, weighed 104 kilos and suffered from diabetes and Polycystic Ovarian Syndrome (PCOS), which prevented her from getting pregnant. After the surgery, she lost 32 kilos, conceived naturally and delivered a healthy baby in December last year.
Despite the high costs and growing popularity, the insurance sector is also still to warm up to bariatric surgeries. Some surgeons point out that cynics believe obesity is a self-inflicted problem. But others beg to differ. "It is paradoxical that the insurance companies pay up when an obese person develops a heart attack and has to undergo a surgery. Why not pay for a preventive procedure?" said Dr Ramen Goel, bariatric surgeon attached to Bombay Hospital. "A few patients who go to the consumer court and prove that the surgery was carried out for medical reasons have managed to get money from insurance companies. But the rest have to pay from their pockets," said Goel.
Most medical claims are rejected on the grounds that weight loss surgeries are not considered life-saving. "The procedures are still at an experimental level and it is difficult to investigate if they were performed for cosmetic or medical reasons. Until the time there is more clarity and rules, it will be looked at with suspicion in every insurance office," said Dr Nayan Shah of Paramount TPA.
The authorities in India do not seem to be stirred by the clamour for guidelines in the field. Dr VM Katoch, head of the country's premier research body Indian Council of Medical Research's (ICMR), thinks obesity is more a problem for the "elite" and not a priority. "It is an exotic disease," he said. "Given our limited resources, we are trying to focus on diseases that affect the masses," he said. At least for now, patients opt for the surgery at their own risk, many of them not even aware of what the risks are.
The types
Gastric Banding
Gastric banding is a reversible procedure which involves placement of a silicone band around the upper part of the stomach thus resulting in a stomach shaped like an hour glass. This procedure is recommended mostly for younger patients.
Sleeve Gastrectomy
This is the surgical removal of two thirds of the left side of the stomach. The open edges are attached by surgical staples to form a sleeve or a tube with a banana shape.
Gastric Bypass
This involves the creation of a small stomach pouch with the help of staples and further bypassing the initial segment of the small intestine. As a result, the food directly enters the jejunum (middle section of the small intestine) thus restricting the amount of food consumed and malabsobrtion due to bypassing the intestines. This procedure is known to cure Type II diabetes.
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