Evolution of Bariatric & Metabolic Surgery in India (1999-2014)
Massive obesity was well known in ancient India , particularly abdominal obesity, seen in depiction of images of Gods and mighty bodies of demons. It was not until recently , it was seen as a problem, infact the myth of “Obesity being a sign of Prosperity” was well rehearsed in the Indian psyche.
Only at the end of 20 th century, in last decade or so , some medical practitioners (I know of DrVinod Durandar in Mumbai) took initiatives from his own examples, started practicing weight loss medicines and therapies.
The concept for a surgical treatment of obesity was developed from observing the significant postoperative weight loss developed in patients that had large portions of their stomachs or small intestines removed VictorHenrikson (1952),Varco (1953),Kremen and Linner(1954), Payne (1963) Sherman (1965). This led to the development of different bariatric surgery procedures that can be categorized into three approaches including restrictive, E Mason (1971), M Long (1978), Paul (1979), Wilkinson (1980), Kuzmac (1986), Marceau (1993) and combined mal-absorptive and restrictive, Mason (1966), Griffen (1977), Torres (1983), Fobi (1988) & solely malabsorptive procedures (Scopinaro (1976), Hess & Hess (1986) .
It was in December 1997 during ASICON Bangalore, that I heard a talk on Bariatric Surgery by Andrew Jemieson from Melbourne, Australia. I remembered reading a footnote in Bailey’s Text book of Surgery on weight loss surgery. I was impressed with the results of bariatric surgery for weight loss for morbidly obese patients. Though it was not considered necessary in India, in my practice I had come across few morbidly obese patients who had tried all means but were not able to loose weight. Unfortunately, at that time no one was doing bariatric surgery in the country. I co-ordinated& visited Andrew Jemiesonat in Melbourne in August 1998 for training in Bariatric Surgery. Andrew was performing only open VBG & RYGB at the time. During the same visit I also attended the Laparoscopic Adjustable Gastric Banding (SAGB) workshop at Adelaide.
After much persuasion and many counseling sessions with obese patients I did India's first Open VBG in January 1999 in Pune. After 3-4 surgeries the word spread quickly and by end of May 1999, I had performed more than 20 surgeries. The outcomes were presented at the ICS Conference in Maldives/Mysore during the same year. Subsequently, I conducted the first Live Bariatric Surgery Workshop in Pune, in September 1999, where 3 open VBG Surgeries were demonstrated by Andrew Jemiesson (Australia) &Harold Engler (USA).
Since the end of the 1980s, laparoscopic techniques have revolutionized general surgery. Though in the beginning bariatric surgeons were reluctant to perform laparoscopic bariatric surgery, introduction of gastric bands made it easier to adapt this approach. International pioneers in this field were M Belachew (Belgium) and P Forsell (Sweden)(1991). Subsequently Wittgrove(1993) performed RYGB laparoscopically.
By the end of year 2000, laparoscopic bariatric surgery was well established and proved to be better for early post op recovery. The adaptation of conventional VBG to laparoscopy was difficult & studies showed higher rate of complications.
I traveled for Laparoscopic Gastric Banding Training &Proctorship with Prof. C.Klaiber&R.Stephen in Bern in December 2000 and attended Laparoscopic Gastric Banding Workshop at Lyon, France with Gerome Dargent. Ramen Goel and I attempted the first Laparoscopic Gastric Banding procedure in August 2001 but converted to open due to technical difficulties.
Subsequently, Laparoscopic Gastric Banding was successfully done by me in September 2001 in Pune. The International Federation for the Surgery of Obesity (IFSO) was formed at Stockholm in 1995. The first International Congress of IFSO was held in Prague in 1996, followed by Cancun in 1997, Bruges in 1998, Salzburg in 1999, Genoa in 2000 and Chania, Greece in 2001. I attended the IFSO 2001 at Chania, Greece with Dr Raman Goel for the first time, though he had become individual member of IFSO since 1998. I started open RYGB in December 2001 after returning from IFSO.I attended laparoscopic RYGB workshop with P. Schaeur in March2002but did not do it until DrMuffazzalLakdawala in Mumbai performed the first laparoscopic RYGB in 2004.
In September 2002 Obesity Surgery Society of India(OSSI) was founded by us including Ramen Goel(Mumbai), Sanjay Borude(Mumbai), MahendraNarwaria (Ahmedabad) , P.K.Chowbe, (New Delhi), VP Shanugsundram(Coimbatore ), Sanjay Deshmukh(Pune), Krishna Y.R (Bilaspur) & S Ashok(Chennai). OSSI was registered with IFSO (International Federation for Surgery of Obesity ) in January 2003 & confirmed during IFSO Congress in Salamanca, Spain in September 2003. I must mention, for formation of OSSI, the great help came from Andrew Jemison, AnicetoBaltasar& Nicola Scopinaro.
First Obesity Surgery Congress of Obesity Surgery Society of India (OSSICON) was organized at TajMahal Hotel, Mumbai in March 2003. The international faculty included Andrew Jemiesson, (Australia) Martin Fried(Czech Republic), Luigi Angrisani, (Italy) Anna Maria Wolf (Germany) amongst others. T.E Udwadia was the organizing chairman & I was the organizing secretary.
The 2NDOSSICON was held by Dr P K Chowbey in Delhi in 2004 at Gangaram Hospital.
By this time Laparoscopic surgeons, Ramen Goel, M. Lakdawala, S.Borude, M.Narwaria, P K.Chowbe, Dr.AjayKriplani, Rajesh Khullar, AashishVashistha, PK Reddy,J.S. Rajkumar, C.Palanivellu, Balashanmugam, Sunil Sharma, Shashank Shah were not only performing but also organizing meetings & workshops on bariatric surgery. In January 2005 Dr Michel Gagner demonstrated the first laparoscopic sleeve gastrectomy (Coimbatore). Nicola Scopinaro demonstrated the laparoscopic BPD in Pune (2005).Balashanmugam performed the first laparoscopic sleeve gastrectomy in February 2005.
3rdOSSICON was held by Dr M Narwaria in Ahmedabad in 2005, 4thOSSICON was held in Pune in 2006 by me, while the 5thOSSICON was held by Dr J S Rajkumar in Chennai in 2007.
K S Kular (Ludhiana) started MGB in 2007, which was followed by OmTantia, Arun Prasad , Atul Peters, MohitBhandari , Muhammad Ismail and many others.
6thOSSICON was held in Kolkata in 2008 by VK Bharatia.
During this period, worldwide bariatric surgery was getting recognized for effects beyond weight loss for metabolic effects since 2004. The procedures like Duodeno-Jejunal Bypass by F. Rubino, Ileal Interposition by AureodePaula were introduced.
In India MuffazzalLakdawala did first DJ Bypass with Sleeve gastrectomy in 2008, while Ileal Interposition was started by SurendraUgale in 2008 followed by Ramen Goel, Padmakumar. & Mohammad Ismail.IlealInterposition was not widely accepted by Indian surgeons, may be because of the complexity of procedure and long term results are yet to come. According to some experts lowering of BMI by International Diabetes Federation to 27.5 and reported efficacy of sleeve in glycemic control are the main reasons for reduction in numbers of DJB & SGIT in practice.
7thOSSICON was held in Hyderabad in 2009 by Laxmikumari Kona. MahendraNarwaria started double blind randomised trial comparing comparing Sleeve with Gastric Plication in early 2009. Since results were not so encouraging the trial was abandoned in 2010.
8thOSSICON was held at Jaipur in 2010 by Rajesh Bhojwani, while 9thOSSICON was held at Indore in 2011 by R Shivhare. It was a tribute to the development and widespread acceptance of bariatric surgery in India when the IFSO 2012 was held in India at New Delhi with P K Chowbey being given the honor of becoming the Congress President, he later became the IFSO President in 2013.
Robotic Bariatric Surgery started in India for the first time when laparoscopic gastric sleeve was performed by RajkumarPallaniappan (Chennai) in 2011, followed by Arun Prasad. Slowly Robotic Bariatric surgery found it's way to other procedures too, R Palaniappan, RYGB (2012), MGB (2012) and Gastric Band (2013) followed by MohitBhandari, P.Bhatia et al.
Endoluminal Revision Gastroplasty, Endoluinal Sleeve Gastropexy were performed by R Palaniappan (2012).
When single incision laparoscopy era came in MIS, Muffazzal Lakdawala performed the first Single Incision Sleeve Gastrectomy in India in 2009 while RajkumarPalaniappan performed the first SILS Gastric by-pass in 2011. SADI (Single Anastomosis Duodenal-Ileal Switch) was performed by MohitBhandari (2013) &Arun Prasad (2014).
Notably BPD and BPD-DS is not practiced in India. MahendraNarwaria, Shashank Shah and I performed BPD/BPD-DS in few cases, but no one continued the practice. In my experience both the patient developed severe mal-absorptive symptoms. Though many say, it is due to Indian vegetarian diet but it is difficult to prove.
The development of bariatric surgery has changed the way people look at obesity problem. It has boosted all the other modalities to treat obesity in India and helped the level of understanding of obesity as a serious health problem.
10thOSSICON was held in 2012 in Bangalore by M Ramesh &11thOSSICON was held in Ahmedabad in 2013 by M Narwaria. The 12thOSSICON was held in 2015 in Mumbai by Ramen Goel. The next OSSICON is scheduled to be held in Chandigarh.
As envisaged where ever the OSSICON happened bariatric surgery picked up in that region starting from Mumbai.
Shrihari Dhorepatil,
Founder President, Obesity Surgery Society of India(OSSI)
Life Member, International Federation for Surgery of Obesity (IFSO)
Director: Bariatric & Metabolic Surgery Program, Shree Hospital, Pune.