By: Verne Maree
Appropriately prescribed and holistically managed, bariatric or weight-loss surgery is a powerful tool that saves lives – particularly in treating early Type 2 diabetes. On a more banal note, could it also be used to get a bride super-slim for her wedding day? Verne Maree finds out more from Dr Ganesh Ramalingam – a specialist in general surgery, bariatric and advanced laparoscopic surgery, endoscopy and trauma.
What got you into the field of weight-management surgery?
Not only do I have ten years in advanced laparoscopy (or keyhole) surgery, but I also helped to set up the Alexandra Hospital weight-management centre in 2001, and the one at Khoo Teck Puat Hospital in 2010. I’m a founding member of the national committee for obesity – the OMSSS (Obesity and Metabolic Surgery Society of Singapore).
Actually, it was my sportiness – I represented Singapore in football at the junior levels, and still play regularly – that made me choose the more active and demanding route of practising surgery rather than going down the medical path. I’m part of the national soccer team’s medical committee, by the way, and I’m usually the national team physician for games played in Singapore.
How prevalent is obesity in Singapore?
The Singapore consensus in 2010 estimated the prevalence of obesity at more than 10 percent of the population; that’s more than half a million people. Severe obesity or morbid obesity is likely to be about 1.5 percent – this, for Asians, means a BMI of more than 32.5.
BMI testing is a very blunt tool, right?
Yes, BMI is a crude estimate, but it remains the commonest counter used. Other ways of measuring include looking at waist circumference, waist-to-hip ratio and skin-fold thicknesses. You’ll also have seen those machines at the gym that use bioelectrical impedance to give an approximate assessment of the percentage of fat in the body. More sophisticated methods include magnetic resonance imaging and dual energy x-ray absorptiometry.
In any case, BMI is just one of many multi-factorial criteria that we look at. Human beings are complex creatures, and the ratio of their height to their weight is just one aspect. That’s why any weight management programme needs to be tailored to the whole individual.
In my work, I tend to look at the patient as a whole: their appearance, their diet, how active they are, the onset and progression of their obesity, their past efforts to lose weight, and so on.
Explain your holistic approach.
I start by assessing how being overweight affects the patient – not only physically and medically, but also from the mental, emotional and spiritual perspectives. There are many criteria to consider, and I have rejected many patients who do not qualify for surgery and do not need it.
Importantly, I emphasise that there’s no quick or easy fix. My programme is a long, hard road that requires commitment and self-control and encompasses a permanent lifestyle change with regard to diet and exercise – and that’s true whether you’re a morbidly obese patient undergoing major gastric bypass surgery, or the less overweight recipient of a minimally invasive gastric balloon.
Diet-wise, I recommend small amounts of high-quality, nutrient-rich foods; with supplements where necessary. Exercise-wise, I will guide and support you for the duration of your time under my care, but I will push you and push you, and it won’t be easy.
To demonstrate their commitment to the process, I ask prospective surgery candidates to start by showing me that they can lose 5 to 10 percent of their bodyweight over a period of months, while I support and monitor their progress.
What are the various procedures that you perform?
For the overweight person who wants to lose a few kilograms over a short period of time – a maximum of six months – the only procedure available is the intra-gastric balloon. With the patient under sedation, the balloon is inserted and positioned endoscopically (through the mouth and down the oesophagus), and then filled with water; six months later, it’s removed in the same way. While it’s in position, the patient feels full all the time, and can only eat slowly and small amounts. Weight is lost and the patient gets used to eating smaller, healthier portions.
Multiple surgeries are available for the morbidly obese. That group includes Caucasians with a BMI of over 40 (or 35 with medical complications), and Asians with a BMI of 37.5 (or 32.5 with medical complications).
A laparoscopic sleeve gastrectomy involves removing about 60 percent of the stomach longtitudinally (making it look like the sleeve of a shirt), thus reducing the volume of food that can be present in the stomach at one time.
A laparoscopic gastric band (or lap-band) is an inflatable and adjustable silicon device placed around the top part of the stomach to form a small pouch, restricting food intake by drastically slowing the rate of entry into the stomach to a slow trickle. It can be removed or replaced laparascopically, too.
With a laparoscopic gastric bypass, the small bowel is brought up to the stomach: the food from the stomach is thereby rerouted directly into the small intestine, bypassing the liver-pancreas complex. When this weight-management procedure is used as treatment for Type 2 diabetes, it is known as metabolic surgery.
Entirely bypassing the stomach would seriously affect digestion and the absorption of nutrients, surely?
The body adapts to digesting the food lower down the intestinal tract, but because the absorption capacity of the small bowel is not as good as that of the stomach, digestion is undeniably limited. Not only are you eating less, but you’re absorbing less of what you eat. We’re still discovering the hormonal changes this procedure causes in the body, too,
Would you explain how a laparoscopic gastric bypass “cures metabolic syndrome: the evil trio of diabetes, high blood pressure and high cholesterol?
Diabetes is essentially your pancreas burning out and no longer being able to supply sufficient insulin to control blood sugar levels. Bypassing the liver-pancreas complex relieves the stress on the pancreas and reverses the diabetes immediately, without the need for weight loss. In fact, the BMI criterion no longer applies. So effective is this surgery that the International Diabetics Federation recommends it for the management of early Type 2 diabetes.
Though medical insurance does not generally pay for weight loss surgery, some of the major companies are starting to do so. The cost of this surgery may be high, but it can save on the enormous long-term medical cost of diabetes and its complications.
What do you enjoy most about your work?
Seeing people’s lives transformed is incredibly rewarding. A number of people that I’ve given gastric balloons to, for example, have taken up the challenge to start exercising, making friends at the gym, buying clothes from regular stores, and even dating for the first time in their lives.
And yes, I do also share the happiness of a slim bride in her gorgeous wedding dress – as long as her wedding commitment goes hand in hand with the resolution to live, eat and exercise healthily for the rest of her life.
Dr Ganesh Ramalingam, PanAsia Surgery, 3 Mount Elizabeth, #11-13/14 Mt Elizabeth Medical Centre | 6737 8538
This story first appeared in Expat Living’s August 2015 issue.