Apollo Hospital

The Apollo Hospitals, Center for Gastroenterology & Hepatology performs Bariatric surgery as a specialized treatment for obesity. Bariatric surgery is performed if other forms of fat reduction methods like exercise or diet control do not produce the desired results. Bariatric surgery involves reducing the size of the stomach, leading to lesser food intake and gradual weight loss.

• First successful:

1. Pediatric liver transplant in India
2. Adult liver transplant in India
3. Cadaver liver transplant in India
4. Transplant in acute liver failure in India
5. Liver-kidney transplant in India

• Fastest growing Liver Transplant program in India with the biggest cadaver program for liver.
• Over 400 Liver Transplants performed with a success rate of 90%.
• Multi-organ Transplant Program at Apollo Hospitals New Delhi performed as many as 250 Liver and Kidney transplants in the year 2009.
• First of its kind Comprehensive Organ Transplant program being commenced at Apollo Hospitals Chennai.
• One of the country's busiest and rapidly growing Pediatric Liver transplant programs at Apollo Hospitals New Delhi

• Upper GI Endoscopy
• Capsule Endoscopy
• Enteroscopy
• Colonoscopy
• E R C P
• Endoscopic Ultrasonography

Upper GI endoscopy is a procedure that uses a flexible endoscope to visualize the upper GI tract. The upper GI tract includes the oesophagus, stomach, and duodenum - the first part of the small intestine.

• Treating diffused mucosal bleed with Argon plasma coagulation (APC)
• Dilation of narrowed food pipe (Balloon dilation of stricture and achalasia cardia)
• Metallic stenting of narrowed segments of food pipe or stomach
• Removal of polyps (polypectomy)
• Creating alternative pathway for feeding directly to stomach (PEG) or small intestine (PEG-J)
• Draining fluid collections though stomach (Cystogastrostomy) in patients with pancreatitis

1. How is upper GI endoscopy performed?

During the procedure, patients lie on their back or side on an examination table. An endoscope is carefully fed down the oesophagus and into the stomach and duodenum. A small camera mounted on the endoscope transmits a video image to a video monitor, allowing close examination of the intestinal lining. Air is pumped through the endoscope to inflate the stomach and duodenum, making them easier to see. Special tools that slide through the endoscope allow the doctor to perform biopsies, stop bleeding, and remove abnormal growths.

2. What problems can upper GI endoscopy detect?

Upper GI endoscopy can be used to determine the cause of

• Abdominal pain
• Nausea
• Nomiting
• Swallowing difficulties
• Gastric reflux
• Unexplained weight loss
• Anaemia
• Bleeding in the upper GI tract
It is used for both diagnostic and therapeutic procedures.

Diagnostic upper GI endoscopy is done to detect:

• Ulcers
• Abnormal growths
• Obstruction
• Inflammation
• Hiatal hernia
- source of bleeding
- tissue samples (biopsy) are also taken during endoscopy and sent for pathological examination to confirm the diagnosis.

The following therapeutic (treatment) procedures are also performed through upper GI endoscopy:

• Foreign body removal
• Treat bleeding ulcers by
   - Injection of medication (injection therapy)
   - Application of heat (coagulation) or
   - Application of clips (hemoclips) to the bleeding vessel
• Treat bleeding varices (engorged veins in liver disease) by applying plastic rings (EVL)
• Glue injection for gastric varix

Colonoscopy is a procedure used to see inside the colon and rectum.

1. What problems can colonoscopy detect?

Colonoscopy is a procedure used to see inside the colon and rectum.

Colonoscopy can help doctors diagnose the reasons for

• Unexplained changes in bowel habits
• Abdominal pain
• Bleeding from the anus
• Unexplained weight loss

Colonoscopy can also detect inflamed tissue, ulcers, and abnormal growths.

The procedure is used to look for early signs of colorectal cancer. The doctor can also take samples from abnormal-looking tissues during colonoscopy. The procedure, called a biopsy, allows the doctor to later look at the tissue with a microscope for signs of disease. The doctor removes polyps and takes biopsy tissue using tiny tools passed through the scope. If bleeding occurs, the doctor can usually stop it with an electrical probe or special medications passed through the scope. Tissue removal and the treatments to stop bleeding are usually painless.

2. Colonoscopy can be used to:

• Remove polyps (polypectomy)
• Dilate narrowed segments (stricture dilation) of large intestine and place metallic stents across them (colonic stenting)
• Banding for haemorrhoids (piles banding)

3. How is colonoscopy performed?

During colonoscopy, patients lie on their left side on an examination table. The doctor inserts a long, flexible, lighted tube called a colonoscope, into the anus and slowly guides it through the rectum and into the colon. The scope inflates the large intestine with carbon dioxide gas to give the doctor a better view. A small camera mounted on the scope transmits a video image from inside the large intestine to a computer screen, allowing the doctor to carefully examine the intestinal lining. The doctor may ask the patient to move periodically so the scope can be adjusted for better viewing.

Once the scope has reached the opening to the small intestine, it is slowly withdrawn and the lining of the large intestine is carefully examined again. Bleeding and puncture of the large intestine are possible but they are uncommon complications during colonoscopy.

1. What is morbid obesity?

Obesity is a condition in which one has too much body fat (adipose tissue). Obesity is determined by calculating the Body Mass Index (BMI), which measures weight for height and is stated in numbers.

BMI	Weight (in kg)
	Height (in m)

BMI STATUS
Below 18.5	Underweight
18.5 - 24.9	Normal
25 - 29.9	Overweight
30 - 34.9	Obese
35 - 39.9	Severe Obesity
> 40	Morbid Obesity
> 50	Super morbid Obesity

2. Health Hazards of Morbid Obesity

Severe obesity damages the body by its mechanical, metabolic and physiological adverse effects on normal body functioning. These "co-morbidities" affect nearly every organ in the body in some way, and produce serious secondary illnesses, which may also be life threatening. The cumulative effect of these co-morbidities can interfere with a normal and productive life and can shorten life as well. The risk of developing these medical problems is proportional to the degree of obesity.

• People who are obese do not live for as long as those who are not obese and the earlier a person become obese; the more years of life are lost.
• Heart Disease- Severely obese persons are approximately 6 times as likely to develop heart disease as those who are of normal weight. Heart disease is the leading cause of death today and obese persons tend to develop it earlier in life.
• High Blood Pressure- Hypertension is much more common in obese persons and leads to development of heart disease, and damage to the blood vessels throughout the body, causing susceptibility to strokes, kidney damage, and hardening of the arteries.
• Diabetes Mellitus- Overweight persons are 40 times as likely to develop Type 2, Adult-onset diabetes. Once diabetes occurs, it becomes even harder to lose weight, because of hormone changes which causes higher fat accumulation in the body.
• Sleep Apnea Syndrome- Sleep apnea – the stoppage of breathing during sleep – is commonly caused in the obese, by compression of the neck, closing the air passage to the lungs.
• Respiratory Insufficiency
• Heartburn - Reflux Disease and Reflux Nocturnal Aspiration
• Asthma and Bronchitis
• Gallbladder Disease -Gallbladder disease occurs more frequently in the obese, in part due to repeated efforts at dieting, which predispose one to this problem.
• Stress Urinary Incontinence.
• Degenerative Disease of Lumbo-Sacral Spine (Backbone)
• Degenerative Arthritis of weight bearing joints like knee and hip
• Venous Stasis Disease in the lower extremities.
• Emotional/Psychological Illness- Extremely overweight persons face constant challenges to their emotions: repeated failure with dieting, disapproval from family and friends, and remarks from strangers. They often experience discrimination at work. Stereotypes of obese people – such as that they are lazy – may result in lower self esteem and poor body image.
• Social Effects- Severely obese persons suffer inability to qualify for many types of employment and there tends to be a higher rate of unemployment among them. There is a general societal belief that obesity is a consequence of a lack of self-discipline, or moral weakness.

3. Surgical options for treating Morbid Obesity

The morbidly obese have to seriously consider surgery for reducing weight to avoid its ill effects. Surgery for Morbid Obesity is for the following situations:

• The person's BMI is over 40, or is 35 or higher and a serious medical problem (hypertension, diabetes, heart disease, joint problems, reflux) that is made worse by obesity is present
• If it has not been possible to reduce or maintain weight under a medically supervised program
• If the person has been obese for at least 5 years

4. Surgical Treatment options available are :

• An Inflatable Gastric Band is used, thus creating an Hourglass structure to the Stomach.
• This procedure may lead to about 39% of the excess weight being reduced within 18 months after the surgery.
• This procedure needs a high level of compliance from patient regards lifestyle and diet post surgery.
• There is always a risk of the Band eroding into the stomach, slipping out of place, and can also produce vomiting, development of GERD or sometimes the device can also fail to function.

• Laparoscopic Sleeve Gastrectomy is safer than other procedures.
• In this procedure, 80% of the stomach is stapled and removed which induces weight loss by restriction in food intake and early satiety, due to loss of hunger producing hormones.
• Digestion and absorption is normal.
• By eating less the body draws the required energy from its own fat stores and thus you lose weight.

• In this procedure, a small, 15 to 20 cc, pouch is created at the top of the stomach.
• The small bowel is divided. The bilio-pancreatic limb is reattached to the small bowel and the other end is connected to the pouch, creating the Roux limb.
• The small pouch releases food slowly, causing a sensation of fullness with very little food intake.
• The bilio-pancreatic limb preserves the action of the digestive tract.

• In this procedure, greater weight loss can happen with less dietary compliance from the patient.
• There may be an increased risk of malnutrition and vitamin deficiency and intermittent diarrhea can also occur.
• Constant follow-up is needed for this procedure in order to monitor for complications.

Dr. S. T. Gopal

MBBS, MRCP, CCST (Gastroenterology)

Consultant, Dept of Medical Gastro-enterology

Dr. Siddapura T Gopal is a consultant in the department of Hepatology and liver transplant. He is professionally trained from reputed hospitals of India. He has more than 8 years of experience. His special interest lies in Surgical Treatment of Solid Organ Malignancies(Head & Neck, Breast, Thoracic, Gastrointestinal, Gynecological cancers.

Dr. V. Bhaskaran

MBBS, MS, PhD, FACS, FICS, FIAGE

Senior Consultant, Surgical Gastroenterology

Dr. V. Baskaran, is a dynamic gastrointestinal, bariatric and advanced laparoscopic surgeon, with an immense body of surgical skills and academic credentials. Having more than 25 years of rich experience, he is an asset to the Apollo Hospital Bangalore. He has had 18 years of experience in Surgical gastroenterology and 15 years of experience in laproscopy. He is an acclaimed Gastro intestinal surgeon and a laparoscopic surgeon. Apart from this many surgical students have benefitted from his excellent teaching skills.