With the widespread use of semaglutide injections for weight loss, especially in Kenya, bariatric surgery has somewhat taken a back seat. Yet the real question isn’t which option wins, but who needs what and when.
Dr Prabu Kathiresan, a consultant laparoscopic bariatric surgeon at Aga Khan University Hospital, states that semaglutide injections can be safely combined with bariatric surgery.
“For example, if we combine a sleeve gastrectomy, which is a restrictive procedure for a morbidly obese patient, with semaglutide, the results are much better,” he explains.
“If the patient is in a wheelchair because of obesity and has arthritis, we can start with semaglutide, help them lose some weight through passive exercises, and after some time, they will be safe enough to undergo surgery.”
He explains that semaglutide works by mimicking a natural gut hormone that reduces hunger and helps patients feel full sooner.
However, once the injections are stopped, the effect diminishes. Since the anatomy isn’t altered, appetite can return to previous levels, and many patients start eating more again.
Obesity is a disease that affects more women in urban areas than men.
In a typical month, Dr Kathiresan sees six to seven patients seeking bariatric surgery. But before any intervention, he first checks whether they have followed standard weight loss protocols and examines what truly drives their weight gain. “What is the weight problem? Is it hormonal issues, depressive or psychiatric issues?”
For instance, if a patient has hypothyroidism and is gaining weight because of it, that must be addressed first. If it is the only cause, the patient often responds well once the thyroid issue is managed. The next step, he says, is to motivate the patient to make lifestyle and diet changes.
For bariatric surgery, surgeons either bypass the normal food pathway or restrict how much a person can eat, which naturally reduces calorie intake.
“In restriction, we remove around 75 to 80 percent of the stomach from the body. In bypassing, we create a small pouch in the stomach and connect it directly to the small intestine. So, malabsorption will occur, and nutrients won’t be absorbed like in a normal person,” he says.
Which procedure is more common?
According to Dr Kathiresan, the choice depends on the patient’s needs and profile. “For example, if a young woman wants to lose weight so she can conceive, we prefer a restrictive procedure because we cannot risk significant malabsorption. She will need those nutrients for a healthy pregnancy,” he explains.
For sustained weight loss, bariatric surgery still requires patient commitment. “If patients revert to their previous eating habits, they will regain the weight,” he says.
Success in bariatric surgery is gradual. Dr Kathiresan mentions that, for instance, if a patient is 160 centimetres tall and their ideal weight is 60 kilogrammes, weighing 110 kilogrammes means they have 50 kilogrammes of excess weight. “By doing surgery, after a year or two, they can lose up to 50 percent of that excess weight,” he says.
Who should consider bariatric surgery?
The current guidance from the American Society for Metabolic and Bariatric Surgery states that anyone with a body mass index (BMI) over 35 may be considered for surgery, especially if they also have obesity-related conditions such as diabetes, hypertension, or sleep apnoea.
However, before surgery, patients are encouraged to start some form of physical activity so that movement becomes part of their routine by the time they reach the theatre.
“As a surgeon and as an anaesthetist, we’re happy when we see a patient lose around 10 percent of their body weight before surgery,” Dr Kathiresan says.
After an uncomplicated bariatric procedure, patients can usually start consuming small amounts of liquid food on day one or two. They then gradually transition to puréed foods, semi-solids, and then solid foods.
Dr Kathiresan warns that if a patient regularly consumes large amounts of junk food, like chocolate every few hours, they will gain weight again.
“The stomach has the capacity to stretch. Even if only 20 percent of it is left, it can still stretch to accommodate the food volume you put in,” he explains.
Can one get pregnant after surgery? “Yes, but preferably after a year or two,” he says. “Pregnancy is physiologically demanding, so it’s better to wait until the body has adjusted.”
