The skinny on weight loss surgery

Weight loss surgery very much on menu for those who can’t seem to lose extra pounds through diet and exercise.

A number of white sheets cover the woman on the bed, leaving only the vast expanse of her doughy tummy exposed. Her legs splay out beyond the bed, propped up on stools, allowing Dr Mumtaz Maher absolute access to her abdomen.

The lights are dim, the curtains are drawn, Jagjeet Singh’s dulcet notes fill the room.

I am standing inside an operation theatre at Karachi’s luxurious South City Hospital. Above the smooth white dome of the woman’s tummy — bloated partly from obesity, partly from the carbon dioxide pumped inside her — hangs a high definition monitor showing her viscera in intimate detail. The stomach wrapped protectively in layers of yellow fat, the liver resting chummily on top of the stomach, the spleen down below, a discoloured purple — all throbbing rhythmically.

Machines beep and buzz and hum. The anaesthesia unit exhales periodically. A wide screen TV mounted on the wall behind the doctor displays the woman’s vitals in reassuring detail. There are nearly half a dozen doctors in the room.

Then, the cutting starts.

Through one-inch incisions in the woman’s tummy, long, rigid laparoscopic instruments with fine, specialised heads are introduced in the abdomen. One of these, a Harmonic Scalpel, shaped like a pair of pliers, firmly grips the jelly-like fat adhering to the stomach and clips it off. With each clip, the fat falls away and a hiss of vapour rises from the scalpel. Soon the greater curvature of the tummy is free of fat and the rosy pink organ comes in full view. Then a laparoscopic stapling instrument loaded with a stapling cartridge is introduced in the body cavity. I watch in fascination as the instrument starts scissoring through the stomach, cutting off most of it so that only a thin strip — or ‘sleeve’ — remains. As it cleaves, it also seals, leaving behind three rows of staples on both edges so that the stomach remains closed at all times. Cut off from its blood supply, the bisected portion of the tummy starts turning a sickly purple. The surgeon pushes it to one side and starts suturing the layer of fat removed earlier on the now much smaller tummy that remains. Finally, the bisected portion of the tummy is teased out of the body through an incision in the abdomen and then the incisions themselves are stitched up.

The woman on the operating table does not have cancer, nor does she suffer from peptic ulcers. What has prompted her to get most of her stomach removed is, in fact, nothing more than obesity. Piling on weight after her pregnancy, the 40-year-old is now morbidly obese. And when I say morbid, it is not an expression of my distaste for fat people, but a medical term based on a coldly objective, scientific benchmark, the Body Mass Index, a number obtained by dividing the weight in kilograms of a person by the square of his height in metres.

When I had gone to see Dr Maher earlier, the first thing he did was take my BMI. A BMI of 25-30 indicates that the person is overweight, over 30, one is obese and a BMI greater than 35 means that the person is morbidly obese. My BMI is 20. Clearly, I am no candidate for a sleeve gastrectomy, the weight loss surgery that South City Hospital enthusiastically promulgates, a banner at the entrance advertising this sure-shot way to banish those extra pounds.

In the urban centres of Pakistan, surgical weight loss has experienced a surge in popularity. Dr Maher, whose clients include celebrities who shall remain unnamed, has done 200 gastric sleeve surgeries over a period of three years. A team of bariatric surgeons at the National Medical Centre (NMC) offer a more extensive menu: gastric bypass, banding and even the insertion of a gastric balloon (See Box: Weighing In). Doctors estimate that 20 bariatric surgeries taking place every month in Karachi alone.

Still, I ask myself, does being overweight really justify the drastic decision of getting one’s stomach cut out, or alternatively, one’s bowels rearranged? To listen to some bariatric surgeons, you would think that obesity is the biggest blight yet to scourge mankind.

“What is wrong with being fat?” asks Dr Maher but as soon as I open my mouth to respond, I realise that this is merely a rhetorical question. “In childhood you cannot compete in games, and are made fun of at school. Then in your teens, you have psychological and social problems. Girls are unable to get married because they’re fat. After getting married, you cannot conceive because of polycystic ovaries. Employment becomes an issue. One girl wanted to be part of hotel management but was refused training because she was considered too obese to be attending to clients.”

I look up from my furious scribbling to check if Dr Maher is entirely serious, but there isn’t a trace of irony in his tone. And he isn’t finished yet: being fat gets worse.

“Then there are medical reasons. The skeleton is built for a certain weight, if you add 40 kg more, the joints have to take a lot of pressure, the heart has to work harder, the fat causes hardening of the arteries, deposition of cholesterol, and insulin resistance. And then diseases get established: arthritis, heart failure. Fat, from childhood to middle age and old age, is a problem.”

Most of the people who opt for surgical weight loss claim that they were galvanised by existing or potential health issues. Among the list of ailments that weight loss surgery corrects are diabetes, hypertension, arthritis, and sleep apnea.

“We make it very clear that we’re not here to create Marilyn Monroes. We’re here to make sure that their medical problems get sorted out,” says Dr Amir Khan, who visits from the UK every few months to perform gastric bypass surgery at the NMC.

But what is also clear is that self esteem and body image issues play a big role.

At a BMI of 47, Aisha*, opted for a gastric bypass surgery because she had constant back pain, but the 44-year-old says that being thinner and looking younger was part of the lure. “Obviously, that makes a difference,” she says, rolling her eyes. “How you look is important and being fat takes away your confidence.”

Suraiya*, 49, was teased for being fat through her childhood and when the time came for her to get married, she was rejected several times on account of her weight. “People would come to see me, then say things like ‘Beta, join a gym.’”

She got gastric bypass surgery in April 2011, after being depressed for a long time on account of her weight. At 130 kg, moving was cumbersome and it was difficult for her to accomplish even simple everyday tasks. Since surgery, she has lost 47 kg and, apart from all the medical benefits, she says she feels fabulous. “I can wear jeans now,” she says. “I’ve posted an album on Facebook titled ‘The New Me’ with photos of my new, thinner self.”

Weight loss surgery is distinct from aesthetic procedures, such as an abdominoplasty or ‘tummy tuck’ but doctors find that a lack of awareness results in prospective patients thinking in terms of cosmetic quick-fixes. “I’ve gotten patients with a BMI of over 50 who don’t realise what a dangerous disease they’re carrying. They come to me asking for a liposuction, a mere cosmetic procedure,” says Dr Shahid Rasul, a bariatric surgeon at the NMC. “When I tell them that lipo is for a person closer to their normal weight, they claim that once I take this 7 kg off their tummy, they’ll try to go on a diet to achieve their normal weight.”

While the goal of a thinner self with fewer medical problems is certainly commendable, is surgery the only way to achieve this? Those who have resorted to surgical weight loss disdainfully rattle off a list of the diets and cures, the herbal water and miracle pills, the dieticians and trainers that they tried before making the momentous decision.

“I joined three slimming centres, did yoga, aerobics, electrical body toning, sauna and other exercises,” says Suraiya. “I tried every single diet. I would lose weight rapidly — 5 pounds every week. But I’d always gain it back.”

Every single person I interviewed had more or less the same tale. If you know someone who has lost weight, you know someone who has gained most of it back. Things have never looked so bleak for those who want to not just lose weight but keep it off. The ‘eat less and exercise more’ credo of weight loss experts has turned out to be specious. New research shows that exercise, while it promotes fitness, plays a minimal role in weight loss. Early this year, an NYT article, ‘The Fat Trap’, caused uproar when it claimed that the metabolic changes induced by weight loss make the bodies of dieters act as if they are starving and thus work even harder to regain pounds.

“The curse is hunger,” says Dr Maher. “Any operation which will reduce hunger, reduce the capacity of the stomach, will succeed in weight loss.”

All three options — banding, sleeve and bypass — limit capacity and so control hunger. For the most part, the science behind these procedures is clear yet, for the patients, the decision is fraught with uncertainty: is it better to go for a high-risk bypass surgery that leads to a huge reduction in weight? Or should one go for a minimally invasive band, an almost half-hearted measure for someone who wants to shed a lot of weight?

It is interesting to see how the decision-making process develops at one consultation at the NMC. In theory, this is a combined decision, taken by both the doctor and the patient. In reality, there is a great disparity in the levels of knowledge of the doctor and patient.

At 5’2” and a weight of 130 kg, 40-year-old Sohail Ahmed* has a BMI of 53kg/m2. Two weeks ago, he came to Dr Shahid Rasul specifically requesting a band, and was told to research other options and talk to people who have had bariatric surgery. Now, as he rests his chin on his pudgy fingers, Dr Amir Khan gives him a basic science lesson, making clear sketches of all three procedures with deft, practised strokes: a band, a sleeve, a bypass.

“A sleeve operation will cut away part of the stomach that produces hunger hormones so you will not feel hungry. With a bypass, there’ll be less space for you to fill and the food that you do eat will not all be absorbed. The bypass is more invasive, the sleeve is irreversible.”

Ahmed shifts uneasily. “Bypass seems like a major decision. I had only considered the band when I spoke to Dr Shahid earlier.”

“The band will not work on its own, you can easily beat it if you don’t diet and exercise,” says Dr Khan. “But if you feel that it’s something you can work with, go for the band. With a BMI of 53 though, you’re better off with the bypass or a sleeve.”

“The reason I’m going for this in the first place is because I haven’t been able to lose weight through exercise and diet. If I still have to do all of that after surgery — well, I won’t find the time for it.”

At this point, Dr Rasul steps in: “I advised him to go for the sleeve because he wasn’t willing to go far enough for a bypass. He needs a bigger weight loss than the band can give.”

As the doctors concur that the sleeve should be okay for him, Ahmed nods.

Medical guidelines say that before considering surgery, patients should undergo a supervised weight loss programme, failing which they are candidates for bariatric surgery.

“Unfortunately,” says Dr Rasul, “these people are eating away until one fine day they come to me and ask for surgery. I guess we don’t have many supervised weight loss programmes either, so I can’t really send them away and tell them to come in a month’s time.”

Before the surgery, a patient is put on a two-week diet which ‘fixes’ his liver which is often heavy and lying on top of the stomach. The other, more significant reason is to teach the patient that he can actually eat less, so that the extremely small portion sizes that they are able to ingest after surgery aren’t a trauma for them.

So are these surgeries the solution to obesity? One has to be more than just overweight to be eligible for these procedures. Anyone with a BMI over 40 can get surgery to reduce weight, but for a person with a lower BMI, it is justified only if that person has serious medical problems.

It is then something of a surprise that Dr Raheel is a healthy, active 29-year-old who had a BMI of only 32 when he got the sleeve gastrectomy in November 2011.  “People wouldn’t believe that I was 103 kg, because I’m tall,” said the doctor. He did not attempt any sort of diet or exercise regimen to lose weight and was working till the day before his surgery.

“This wasn’t a big deal for me since I’ve seen Dr Maher do it so many times,” he says, shrugging his shoulders.

Planning to go to the US for his residency, he knew he wouldn’t have the time to exercise and with his family history of obesity, hypertension and diabetes, he was likely to get overweight in time. “I used to eat late and go to sleep, I knew this was the easiest way to lose weight, so I went for it.”

Doctors are quick to point out that surgery is merely a tool to lose weight and is far from the easy option. The danger of dying on the table is always present and with an elective operation that is supposed to enhance the quality of life, even a 1% mortality rate is hard to accept. Often, this is not because of the surgery, but the diseases that the patients already had. Malpractice is an issue in this field since bariatric surgery requires specialised equipment, large tables to lift up heavy patients, roomier chairs in the doctor’s office and a different anaesthetic technique.

And not everyone who is obese qualifies as a candidate for weight loss surgery. “I’ve rejected a few patients on the grounds that their life was all about eating,” says Dr Rasul. “If you find their life is food, don’t mess with them.”

Patients sometimes face psychological problems independent of weight and post-surgery the absence of comfort eating can end up exacerbating them. The suicide rate, Dr Rasul points out, is higher in bariatric patients.

Like any major surgery, weight loss surgery comes with its own set of challenges. Suraiya found herself battling not just depression after her surgery but also weakness. Her still plump body craved food but her now much smaller stomach could ingest only tiny portions. She was losing weight drastically and her body was rapidly adjusting to changes. For three months she battled depression and then things settled down. Today, she says, she couldn’t be happier with the decision.

“Some people feel extremely upset in the first month after surgery,” says a dietician who counsels gastric sleeve patients. “But in the long run, no one regrets not being able to eat large quantities.”

“I’m really happy about my divorce with food,” says Anam*, 38, who got a gastric sleeve six months ago and has come down to 83 kg from 107 kg. “It’s not just weight lifted off your body — it’s weight lifted off your mind. I can only eat a quarter of a doughnut now,” she says gleefully.

And if there is one person who is convinced about the work he is doing, it’s Dr Maher. If he were to make the human body all over again, no prizes for guessing which organ he’d change. “If I could, I would give everyone a smaller stomach,” he says with conviction.

*Names have been changed to protect privacy.

Published in The Express Tribune, Sunday Magazine, April 8^th, 2012.