As Dr Chalkoo explores the criteria for weight loss surgery eligibility, he sheds light on the global obesity pandemic and the imperative role of collaborative, specialised teams. The interview unfolds further to discuss the pioneering free weight loss surgery programme initiated by the J&K Govt at GMC Srinagar, emphasising the monumental impact on patients who would otherwise face exorbitant costs elsewhere.
Dr Chalkoo recounts the programme’s inception, detailing the challenges overcome and the subsequent success in conducting over 100 Bariatric surgeries. The interview touches upon the meticulous surgical procedures involved, showcasing the expertise required for these transformative operations. Dr Chalkoo elucidates on the considerations individuals should ponder before opting for weight loss surgery, stressing the importance of lifestyle changes and exhaustive medical evaluations. Here are the excerpts of the interview.
What criteria must individuals meet to qualify for weight loss surgery ?
Laparoscopic Bariatric surgery is a weight loss surgery and it is important to know about the effects of obesity on our health and general well being. It not only reduces the weight but corrects the comorbidities, associated with obesity. Obesity is a global pandemic and its resultant offshoot disorders are silent killers, like type 2 diabetes mellitus, hypertension, hypothyroidism, non alcoholic fatty liver disease and obstructive sleep apnea syndrome. The OSA is a lethal disorder and is associated with resistant hypertension, cardiac arrhythmias, myocardial ischemia, strokes, hyperuricemia, PCOD, migraine and hypnic headaches,sexual weakness including erectile dysfunction,intrauterine deaths and premature births,preclampsia and eclampsia, memory impairment, depression, fibromyalgia and chronic fatigue syndrome and many more. Unfortunately most of our patient community is not aware about this variant of OSA and its resultant deleterious effects on health. Bariatric surgery also corrects metabolic disorders that is why currently we call it Bariatric and metabolic surgery.
To justify a procedure of Bariatric surgery on legal and ethical grounds many guidelines were framed. We have American society for metabolic and bariatric surgery, European society for metabolic and bariatric surgery, the obesity and metabolic surgery society of India who have proposed there guidelines for Bariatric and metabolic surgery.
Broadly speaking BMI of 32kg/m2 is associated with comorbidities like type 2 diabetes mellitus, hypertension, hypothyroidism, OSA etc., not corrected by medical management and BMI of 35 kg/m2 without comorbidities. However Asian guidelines are proposing bariatric surgery even at 27kg/m2 BMI with comorbidities. Bariatric surgery is a collaborative team effort of multiple specialities like endocrinologists, intensivists, dieticians, anesthesiologist, critical care specialist, pulmonologist, sleep study specialist and psychiatrist. These patients are evaluated and assessed by a team of specialists and after the consensus is generated they are referred to a Bariatric surgeon for the needful. In the first go these patients are evaluated in the general OPD for there weight management. In this regard , we need to understand that a BMI of 18.9 -24.9 (BMI = Weight in kg / height in m2) is considered an ideal BMI with normal weight. If the BMI of a person falls below 18, we call it under nutrition and the person becomes prey to disorders like protein energy malnutrition, tuberculosis,viral and fungal disorders etc.
These patients who are in their normal BMI range are given advice of an everyday brisk walk of 30-45 mins to maintain their normal BMI. Patients with BMI of 24.9- 29.9 qualify for being overweight (over-nutrition) [ Malnutrition = overnutrition + undernutrition]. This is the first alarm for an individual to become alert about his weight. This group of patients are asked to visit a dietician. They are advised lifestyle modification, dietary advice and even in some groups the diet is changed from carb to keto diet. These patients are also advised to visit health clubs, gym centres and continue with recreational activities. The gym trainers change their body habits from apples to pears to carrots to normal. The idea of gym activities is to melt their body fat and grow their muscle mass. If the person, in the overweight range becomes concerned about his weight management most of these activities collectively revert back to normal BMI. If the BMI of the person ranges from 30 -35 kg /m2, he falls in class 1 obesity and its resultant medico surgical disorder, which are directly proportional to weight gain and class of obesity. Person with a BMI of 3540kg/m2 is class 2 obesity and BMI of 40 and above is in class 3 obesity. A person with a BMI over 50kg /m2 is called super obese. These super obese individuals lose the capacity to perform daily activities of life and become resistant to weight loss. They cannot socialise and become ridiculed by the public scorn. They lose confidence and get depressed and with that a new set of psychiatric disorders engulfs them. That is why it is important to mind their weight before it’s too late. Such super obese models have a high incidence of sudden death syndromes. They show a critical AHI index in their polysomnographic sleep studies due to their increased neck circumference.
Can you provide an overview of free weight loss surgery programme initiated by the J&K Govt at GMC Srinagar ?
You will be glad to know that we performed our maiden successful laparoscopic Bariatric surgery at GMC Srinagar on April 2018. Thanks to the team of surgeons and anaesthetists who made it possible with their sheer positive efforts.
The procedure of sleeve gastrectomy with cholecystectomy was performed on a female patient weighing 109 kgs, height of 5feet 3 inches with BMI of 42.56 with comorbidities of hypertension, hypothyroidism and sleep apnea; Opening the new vistas in this subject at our place. This high end surgery was an achievement for the department of surgery and anesthesia at GMC SRINAGAR ( GK ARCHIVES PUBLISHED 20TH APRIL 2018).
The gadgets required to perform this high end Bariatric surgery are costly and had to be procured from the open market by our patients. The cost of the procedure and the unawareness of this technique by the patients were the early hiccups in this venture. The department of surgery had the privilege to conduct many medical education programmes and updates patient and public. Subsequently, the department of surgery under the patronage of a worthy principal made these gadgets available for free distribution and application.
The institution is indebted to the government of J&K for this breakthrough initiative. Currently Bariatric and metabolic surgery is made totally free to the needy Patients at their doorstep,who otherwise had to leave the state and get the Bariatric surgery done at exorbitant cost in the country. This surgery mandates expert bariatric surgeons and competent and skilled intensivists, anesthesiologists and ICU specialists.
The institution is proud to have such experts available , who collectively perform such high end procedures in the surgical theatres. We have crossed more than 100 successful Bariatric surgeries at our institution with satisfactory response and results.We hope with continued patronage of our administration , the department will explore newer horizons in this subject and help the beneficiaries as well.
Could you elaborate on the surgical procedures involved in weight loss surgeries offered under this programme?
Bariatric surgery is a high end advanced laparoscopic procedure and needs highly skilled experts to perform these procedures. The Bariatric surgeon should be proficient in surgical stapling and intracorporeal suturing for which the learning curve is a long journey.
Currently, we have only a handful of Bariatric surgeons available with us who are imparting training to the young surgeons. There are many procedures in the menu of Bariatric surgery like laparoscopic sleeve gastrectomy, laparoscopic mini gastric bypass, laparoscopic Roux en y gastric bypass,laparoscopic proximal jejunal bypass and many others.
These procedures are actually performed on the stomach and the small intestine of the patient. They thematically work on restrictive absorption, malabsorption and combination of either, with the resultant aim to reduce the excessive weight of the patient and correction of comorbidities as well. There is enough evidence from the literature that these procedures are time tested ,safe without any deleterious effects on the individual.
The selection of the procedure is the choice of a Bariatric surgeon depending on the BMI of the patient, class of obesity and associated comorbidities. The procedure is performed through a few small buttonholes on the abdomen with almost no resultant scar. These procedures have a drastic effect on the weight loss and correction of comorbidities like diabetes mellitus, hypertension, hypothyroidism and sleep apnea syndrome.
This is really awesome for such patients , who otherwise have to stay on battery of drugs and on CPAP and BI- PAP’S life long. With the loss of excess weight, there body reshapes back , they gather back the confidence on them and start living life with optimism.
They start socializing and start building dreams for future. Every procedure has its own graph with regard to weight loss and correction of comorbidities in the post operative period. In some of these procedures one can loose as much as 30 to 40 kg of excess weight in a span of year, while in some other procedures one can lose to the tune of 100kgs over couple of years.
Are there any considerations that individuals should be aware of before opting for weight loss surgery?
Honestly speaking Bariatric or weight loss surgery is not the treatment of choice for such patients at the outset or in the first go. I must say, such obese patients , who even qualify for Bariatric surgery as per the guidelines should not take this option as their first choice.
They need to undergo lifestyle changes, dietary changes, joining the health clubs, gym centres and do rigorous exercises. Their comorbidities need to be medically handled by the respective specialist like endocrinologist, physicians, dieticians, pulmonologists, sleep study specialists and others. It is only when all this does not work, they should opt for Bariatric surgery.
That is why such patients come to us as referrals from these experts as and when they feel they are fit candidates for Bariatric surgery. Before putting the patient for Bariatric surgery , counselling is done with the patient and his attendant about the procedure , it’s effects and aftermath.
These patients are put on a Bariatric diet ( Pre sleeve diet ) for a period of 2 to 3 weeks to get a few kilos off and shrink their liver. This is also the period when they undergo preanaesthetic checkup by the Bariatric anaesthelogists who at times advice them to be put on CPAP /BPAP to improve their oxygenation for a period of 2 to 3 weeks. They are assessed and taken for Bariatric surgery.
How will the medical team at GMC Srinagar ensure the safety and success of these procedures?
Yes. It takes time to optimise these patients as they are not only obese but have comorbidities which makes them risky for surgery. It is mandatory for the medical surgical team to make the surgery almost risk free, that is why they visit different experts to label them as the safe indications for the Bariatric surgery.
This majorly rests on anaesthesiologists and critical care specialists who finally stamp them as fit for surgery after respective assessments by the different experts in there pre anaesthetic evaluation and checkup.
These patients invariably need an ICU setting in their post operative management which is taken care of by the ICU specialists. If the procedure is performed by a team of skilled Bariatric surgeon and anesthesiologist, these patients invariably are off the bed in the Ist post operative day.
What kind of post surgery support and follow up care will be provided to patients who undergo weight loss surgery under this programme?
The success of Bariatric surgery does not lie only on the pre operative optimisation of these patients, but also on the Postoperative care, management and follow up. Fortunately, these patients get out of the bed on the 1st post operative day only and start ambulation.
Most of them are off the artificial supports of life like oxygenation, CPAP, BI PAP and ICU care. Within a few days only their comorbidities start reverting back to normalcy like diabetes, hypertension, OSA and others. Some of them even lose 4 to 5 kgs even in the 1st post operative period only.
This imbibes confidence and hope in them. Most of them stay for 1 to 3 days in hospital and are discharged safely back home with the advice of diet schedule and post operative follow up schedule. They are advised to have first follow up at the end of week to 10 days for general assessment and also asked to follow up to respective specialist for the assessment of their comorbidities.
They are advised to have a strict follow up for the first 3 months after surgery, then, they visit 6 monthly with the idea to receive advise about their diet, exercise and biochemical assessment of their comorbidities. In some of the procedures , these patients have to receive nutritional supplements and vitamins at 3 to 6 monthly intervals.
They are asked to purchase the weight machine and to do their self weight assessment at their home. Almost all these patients lose their weight and get their comorbidities corrected. Most of them stop their anti diabetic ,anti hypertensive ,anti thyroid drugs or lessen the dosage for them.
They are also advised to maintain their weight loss and avoid the regain of weight , which is a concern in some of these procedures. They are advised to follow a strict diet regime, avoid alcoholism, binge eating,grazing and stay back on track with dietary ,behavioral and exercise interventions.
MA: What do you think about future insight of bariatric surgery as a Bariatric surgeon?
Dr: That is an interesting question and this is my personal perception about this subject as regards to its future insight . I have a strong intuition about the future perspective of this subject. I feel the way the research in this subject is going on at global level, the future will come up with a good news for these metabolic syndromic patients. There is a lot of research going on small gut as the target organ for most of these metabolic disorders .
They have assessed differences from small gut which contribute to different comorbidities and surgical manipulation of small gut would be an answer for most of them. The time may come up with surgical endocrinologists ( not endocrine surgeons) who will correct most of the medical metabolic disorders. This will happen for the total good of the patients. Let’s wait and watch.
MA: In what ways do you foresee this initiative positively impacting the lives of patients and the community in large?
Dr : I strongly feel this is high time we need to have structured Bariatric units especially in our tertiary care hospitals . Wherein all this is available under one roof with interpersonal collaboration and coordination for better management of this melody for better patient care.
I am afraid to tell you that obesity and its associated disorders are going to be the major killers of humanity in our part of the globe too .We are different wrapped up by this monster;probably another few decades will see worse time , if we don’t prepare for it now. In this regard it is mandatory for us to create the gadgetary skilled personnel and definite infrastructure to combat this rapidly arriving killer monster. Let’s hope with our constant effort , hardwork and future insights, we can combat this ordeal.
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