Dhaka, Bangladesh
Bariatric Surgery: Report of first two cases in Bangladesh

Bariatric Surgery: Report of first two cases in Bangladesh

Sayeed Ahmed Siddiky, Rafiques Salehin, ARM ShamsulAlam, Saima Siddiqua

Abstract Surgery is now considered to be the most effective treatment for reducing weight and 0maintaining weight loss in patients with clinically severe obesity. The use of bariatric surgery for treating severe obesity has increased dramatically over the past decade; about half of patients who undergo these procedures are women of reproductive age. Body mass index (BM!) is taken as a guide to measure obesity. Currently a patient with BMI 35 and above who fails to lose weight with adequate medical means is taken as an indication for bariatric surgery. But for those who have comorbidities like diabetes or sleep apnoea this surgery is indicated at BMI even lower than 35. Bariatric surgery has the potential of curing certain type 2 diabetes mellitus and hypertension as well as preventing comorbidities associated with very high BMI. In this paper we report the first two cases of bariatric surgery in Bangladesh. Introduction Obesity is defined as a body-mass index (EMI) (the weight in kilograms divided by the square of the height in meters) of30 or morel. The prevalence of obesity is rising to include more than 30% of the population. The majority of large and long-term epidemiologic studies have indicated that obesity is associated with increased mortality. The life expectancy of severely obese persons is reduced by an estimated 5 to 20 years5. Weight loss is known to be associated with improvement of intermediate risk factors for disease6, suggesting that weight loss would also reduce mortality. Surgery is now considered to be the most effective treatment for reducing weight and maintaining weight loss in patients with clinically severe obesity. Bariatric surgery is a superspeciality branch of surgery that deals with metabolic disorders and morbid obesity. These operations can be categorized into three types, restrictive, malabsorptive and combined8. Restrictive procedures include gastric banding and sleeve resection where the stomach volume is effectively reduced. In malabscrptive procedures a bypass is performed between stomach and jejunum; and in combined procedures stomach volume reduction is done along with gasrojejunostomy. In western countries bariatric surgery has now become very common, the reason being awareness of the dangers of obesity like diabetes mellitus, hypertension, coronary heart disease, hypercholesterolemia, various types of cancer, infertility, osteoarthritis, mental disorders, sleep apnea etc. It is alarming to note that even in Bangladesh the incidence of obesity is increasing. In this paper we report the first two cases of bariatric surgery in Bangladesh. Case Reports Case 1: A 48-year-old lady underwent abdominoplasty and sleeve resection of the stomach on 19th April 2008. Her initial pre-operative weight was 115 kg, which equates to a body mass index (BMI) of 46. Case 2: A 30-year-old lady doctor, with the initial pre-operative weight of 145 kg, hypertensive and BMI of 55, underwent abdominoplasty and sleeve resection of the stomach on 26th July 2008. Under general anaesthesia (GA), type IV abdominoplasty was done. Upper flap was raised to gain access to the abdominai cavity. Harmonic scalpel was used to divide greater omentum from the stomach. This division was made close to the greater curvature starting from 5 cm proximal to the pylorus and going up to the gastroesophageal junction. Extreme care was taken to avoid injury to the spleen, and 7.5 cm linear cutting stapler from Johnson & Johnson was used to remove two-third or 70% of the stomach. The first stapler was used in an oblique direction dividing the greater curvature 6 cm proximal to the pylorus; and the subsequent staplers fired vertically parallel to the lesser curvature and under guidance of a thick nasogastric tube. In this way stapling and division was continued up to the angle of His thus completely removing the greater portion of the stomach from the left side. The resulting tubular shaped stomach was then checked for staple line bleeding. Both the patients were evaluated by contrast X-rayon the 3rd post-operative day (POD) to check residual stomach size and leakage. After 3 months the first case had lost 25 kg. The abdominal girth reduced from 59 to 48 inches, i.e., reduced by II inches. The second case similarly lost 27 kg within the first two and half months. Her abdominal girth reduced by 10.5 inches. She had been cured of hypertension and no longer requires antihypertensive medications. Discussion Body mass index (BMI) is taken as a guide to measure obesity 1.10. Currently a patient with BMI 35 and above who fails to lose weight with adequate medical means is taken as an indication for bariatric surgery. But for those who have co-morbidities like diabetes or sleep apnoea this surgery is indicated at BMI even lower than 35. Bariatric surgery has the potential of curing certain type 2 diabetes mellitus II and hypertension as well as preventing co-morbidities associated with very high BMI. Post-operative follow-up is important to ensure strict adherence to nutritional advice. Patients are advised to take 5 small meals in a day and to avoid high calorie drinks. In gastric sleeve resection patients, vitamin BI2 injections are required to prevent post-operative megaloblastic anaemia 12. Possible complications after bariatric surgery include anaesthetic hazards, pulmonary embolism, injury to spleen and liver, staple line bleeding, leakage, wound infection and post-operative nutritional deficienciesl3-14. We have done both of our cases as open procedures; this is because they desired an abdominoplasty procedure at the same sitting. Conclusion With advancement in laparoscopic surgical techniques, it is easier to go for laparoscopic bariatric surgery first, and after the patient has lost weight plastic surgeons can carry out an abdominoplasty or a thigh-lift as per requirement. It is therefore important to build up teamwork with general surgeon, plastic surgeon, bariatric anaesthetist, nutritionist, endocrinologist and psychologist for safe and effective bariatric surgery in Bangladesh. Reprint from Bangladesh Journal of Medical Science (BJMS), Volume 15, number 01, March 2009, PP-71-73. As permitted by the author Dr. Sayeed Ahmed Siddiky.

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