Obesity Management in Obesity Surgery

Obesity has been recognised as a worldwide epidemic for the last few decades. A Body Mass Index (BMI) of 25 has been pegged as the landmark, above which is the definition of being overweight. A BMI of above 35 has been classified as being morbidly obese. The obesity societies of Asia has redefined the BMI criteria for Asians as 32.5. 

There are many diseases associated with obesity. The long list includes metabolic diseases like Diabetes Mellitus, Hypertension and Hyperlipidemia (and all the complications associated with these diseases), cancers like breast cancer and colorectal cancer, chronic joint diseases like chronic back pain, osteoarthritis of the spine, hips, knees and ankles and other illnesses like skin infections, pancreatitis and much more. There is evidence that those with morbid obesity are more likely to be depressed and have a shortened life-span.

Diet and exercise have been the mainstay of obesity management. However, the chance of weight loss of more than 10% together with keeping that weight down over a sustained period of time, is less than 2% for the morbidly obese. All these statistics, coupled with the complications of obesity that is a huge financial burden to the family and the state, has stimulated the development of obesity management and surgery (Bariatric surgery).

Over the last 40 years, obesity surgery is proven to be the best method to reduce the weight of morbidly obese patients quickly and, more importantly, to sustain that weight loss. In general, there are two main categories of obesity surgery. The restrictive surgeries like the Laparoscopic Adjustable Gastric Band (LAGB) and the Laparoscopic Sleeve Gastrectomy (LSG) have about 80% success in helping the patient lose about 60% of their excess weight within a year or two and this has been shown to be maintained and improved upon for at least 5 to 10 years. The second category is the malabsorptive group of surgeries which is typified by the Laparoscopic Roux en Y Gastric Bypass (LRYGB). This procedure has been shown to not only have a better weight loss profile, but it maintains the weight loss a longer time. With these procedures there is also a reduction or resolution of the complications of obesity by at least 80%.

These procedures, as the name suggests, are done laparoscopically (or keyhole surgery) and there are many advantages of this technique which would include less wound pain and complications, lesser respiratory complications, lesser hospital stay and faster recovery and time to work. The procedures have become very safe as compared to the surgeries done 40 years ago and the current perioperative complications are minimal due to the fact that the surgical techniques used are standard and the anaesthesia care has improved by leaps and bounds.

There will be a group of patients who are below the BMI criteria for Obesity surgery or are too ill to undergo surgery. These patients can be offered the Intragastric Balloon that is inserted into the stomach via gastroscopy under sedation. The balloon insertion is safe and there will be no scars on the abdominal wall. It will then be removed after 6 months and the projected weight loss is about 10%.

This article was contributed to Tab A Doctor by,
Dr Ganesh Ramalingam, Consultant General Surgeon, Panasia Surgery

Breathing Better

“Respiratory illnesses account for more than 50 per cent of clinic consultations and about 35 per cent of hospital admissions. It is also one of the leading causes of death in children under the age of 5 years in Malaysia, along with infectious diseases, injuries, congenital disorders and neurological problems,” says Dr Salehuddin Samsudin, Consultant Paediatrician and Neonatologist at the Sime Darby Medical Centre ParkCity. 

The most vulnerable are children less than 6 months old, premature infants and the immune compromised. According to Dr Salehuddin, asthma and upper and lower respiratory tract infections are the main respiratory diseases that are seen in paediatrics. Asthma affects about 10 to 15 per cent of children and is the commonest chronic respiratory illness in childhood. Although asthma may present at a very early age, it is very difficult to make an accurate diagnosis in children under the age of 5 years. This is because there are many other respiratory illnesses that can mimic asthma in this age group such as bronchiolitis, viral pneumonia or mycoplasma pneumonia. A strong family history of allergies, eczema and asthma makes the diagnosis more likely. Children with asthma have recurrent reversible narrowing of their lower airways. They usually have sudden breathlessness, coughing or wheeze, which is often worse at night or with exercise.

Dr Salehuddin says that asthma is often treated with bronchodilators (medications that relax the bronchial muscles) in the more severe episodes but in many recurrent cases a good preventive strategy is to use inhaled steroids. “Compliance with treatment and regular contact with your paediatrician is important to ensure the symptoms remain under control. It is also essential to avoid any known triggers such as house dust mites, pollen and cigarette smoke.”

The most important intervention is for the parent to stop smoking. He adds that even if parents smoke outside the house, there will be enough smoke particles on them and their clothing to trigger an attack in susceptible children. “Upper respiratory tract infections such as middle ear infection, tonsillitis and pharyngitis (throat infections) are mostly caused by viral infections.

However, there are bacterial organisms such as streptococcus that normally live in one’s nose and throat, which could also invade and cause ear and throat infections. Other more virulent organisms can also be passed on from one person to another via direct contact or droplets,” explains Dr Salehuddin.

Lower respiratory (usually below the trachea) or chest infections on the other hand, can be severe but are less common than upper respiratory tract infections. The same organisms that cause upper respiratory tract infections can also cause lower respiratory tract infections. Pneumonia, bronchiolitis and whooping cough are sometimes preventable by taking the necessary vaccinations.

“Parents should look out for symptoms of high fever, productive or wet cough with fast and increased work of breathing which usually accompanies chest infections,” advises Dr Salehuddin.

A careful clinical examination will usually show that the child has rapid breathing with increased respiratory effort, a crackling noise when listened with a stethoscope or reduced air entry, which could be a sign of fluid collection or a collapsed lung. A chest X-ray would be able to confirm the diagnosis safely even in very small babies. 

“Treatment is usually with oral or intravenous antibiotics and oxygen or respiratory support in more severe cases. There is no evidence that cough medications can alter the natural progression of the disease although it is often used to improve the coughing symptoms,” he says.

Although respiratory illnesses in children can get severe at times, identifying signs and symptoms early on and seeking immediate treatment will help keep the illnesses at bay.

This article was contributed to Tab A Doctor by,
Dr Salehuddin Samsudin, Consultant Paediatrician and Neonatologist, Ramsay Sime Darby Health Care, ParkCity Medical Centre