In today’s instantaneous, technologically enabled society, people expect instant gratification while searching for solutions to their issues. These days, many people choose to have their hotel, restaurant, cafeteria, or supermarket deliver their food to them. As a result, they often eat fast food and other calorie-laden treats like soda and candy bars. Less time spent in the kitchen means more indulging in buttered snacks and pastries. Because of this, they frequently use far more energy than is required. The prevalence of obesity among the population has therefore exploded.

This is a global problem, not simply an Indian one. Worldwide, 13% or more of adults are overweight, with 11% or more of men and 15% or more of women classified as obese by the World Health Organization. Moreover, the prevalence of obesity throughout the world doubled between 1975 and 2016, according to the World Health Organization. Things have been getting worse since 2022.

A dangerous and excessive body fat accumulation is what we mean when discussing obesity. According to the World Health Organization (WHO), the body mass index (BMI) is the parameter used to determine obesity. The body mass index, often known as BMI, is a quick and easy technique to compare the weight of one person to another based on their height. A person’s body mass index (BMI) may be calculated by taking their weight in kilograms and dividing that number by the square of their height in meters. According to the World Health Organization (WHO), underweight is a body mass index (BMI) of less than 18.5. In contrast, the definition of average weight is a BMI that falls anywhere between 18.5 and 24.9. Therefore, if your body mass index (BMI) is between 25 and 29.9, you are regarded to have a healthy weight; however, if it is over 30.0, you are obese. There are three basic types of obesity, each of which may be determined by one’s body mass index. An individual is considered to have class 1 obesity if their body mass index (BMI) is between 30.0 and 34.9, class 2 obesity when their BMI is between 35.0 and 39.9, and hazardous class 3 obesity when their BMI is greater than or equal to 40.0.

Consuming a diet rich in calories and fat consistently is the primary contributor to obesity. These eating habits result in an imbalance between calorie intake and calories burned. It is wishful thinking to believe that consuming foods heavy in fat and sugar is the only way to satiate one’s hunger. They find that foods with excess sugar left as table sugar have a flavor that appeals to them. Many processed foods, morning cereals, and flavored yogurts include extra free sugars. Some examples of these foods include You shouldn’t eat them despite having a delicious flavor. Honey, syrups, and fruit juices are all naturally occurring foods containing this potentially hazardous type of sugar. As a result, we should reduce the amount of these things we consume. One of the primary causes of the current epidemic of obesity is the widespread practice of doing nothing but sitting about all day. People are becoming increasingly reliant on machines to carry out their day-to-day activities. Because of this, they need to be more energized to put in any genuine effort when working. The idea of breaking a sweat is less tempting than the possibility of eating some sweets, so I’ll take the candy. The proliferation of different modes of transportation, the changing nature of work due to advances in technology, and the growth of urban areas are some factors that have contributed to an increase in the amount of fat stored excessively throughout the human body. Other factors contributing to this phenomenon include the expansion of metropolitan areas. The systemic effects of obesity include cardiovascular diseases such as heart disease, hypertension, and stroke, among others. It is also known to cause cancer of the bowels. Obesity of the Class 3 kind is associated with many unfavorable effects, such as a shorter life expectancy, lower vigor, increased weakness, an unpleasant body odor, and a diminished willingness to engage in sexual activity. There are approximately 2.8 million fatalities that can be attributable to morbid obesity every single year. The prevalence of obesity is a significant health concern in India.

There has been a recent uptick in the popularity of bariatric surgery due to the limited long-term efficacy of behavioral and pharmaceutical therapy in treating extreme obesity. Patients are more likely to have a positive outcome after bariatric surgery if they are evaluated, treated, monitored, and assessed by a team of professionals before and after the procedure. The assumption that obese people may lose weight by “eating less and exercising more” is unfounded and unsupported by the scientific literature, yet it is widely believed. Therefore, patients at high risk of morbidity and death due to the consequences of obesity and who have not lost enough weight after lifestyle and medicinal therapy should be evaluated for bariatric surgery. Assessment, treatment, monitoring, and evaluation by a multidisciplinary team of healthcare professionals before and during bariatric surgery increases the likelihood of positive outcomes. Family doctors should consult with the other members of the patient’s interdisciplinary care team to improve and monitor the health of patients who have undergone bariatric surgery.

Count on the best: You only have one life.
Going under the knife is certainly not a walk in the park. Bariatric procedures are more complicated than they are commonly perceived. In addition, each bariatric procedure is different and may not bode well with every patient.
The most popular bariatric procedures are Sleep Gastrectomy and Gastric Bypass. Sleeve gastrectomy is less invasive than other weight loss surgeries since just the stomach is altered. Stomach reduction surgery entails cutting off some of the guts to get this effect.
During gastric bypass, the stomach is disconnected from the esophagus, and the small intestine is linked directly. This means that the stomach is no longer receiving food but rather is linked to the gut to secrete digestive juices for the intestine. The kind of bariatric procedures that patients go through must align well with their lifestyle and other associated factors.

Antrang to the rescue
If you are thinking of bariatric procedures and breakthrough the shackles of obesity, who better consult with the practitioners and surgeons at Antrang Hospital – the only Gastroenterology specialty Hospital in Maharashtra?
The Symbiosis of different specialist practitioners at the hospital work to give their patients the best treatment via state-of-the-art technology and ensure their optimum recovery with 360 care.

26yr old female presented with cholangitis. She had underwent choledochojejunostomy at 16yrs of age for choledochal cyst. On CT she had developed anastomotic stricture with dilated CHD and IHBR with multiple stones. We attempted a spiral enteroscopy but couldn’t reach the stricture due to acute bend. She underwent PTBD to relive her cholangitis. She was explained regarding Sx hepaticojejunostomy or to get subcutaneous access biliary limb for recurrent stricture dilatation. But patient did not want any surgical intervention, so after detailed counselling and informed consent we did a EUS guided duodenojejunostomy (but placing a 20mm x 10mm Hot Axios stent to create an anastomosis between 1st part of duodenum and the biliary jejunal limb). Pt had no complications post procedure and was started on oral feeds liquids followed by solids 6hrs post procedure and was discharged next day. She was called after 2 weeks, we could reach the strictured choledochojejunostomy site through the duodenojejunstomy stent with a normal gastroscope. PTBD stent was removed. We dilated the stricture up to 8mm with a CRE balloon, and removed multiple stones and put a plastic stent.
Now we have access to the strictured choledochojejunostomy site and can dilate it as and when it’s required and can be done under short GA on OPD basis.
We attempted ERCP and we were successful in placing stent across the cystic cavity from the papilla upto the tail of the pancreas. Presently we have keep the gastrocystostomy stent and the PD stent in Situ and will plan to remove both the stents if the Disconnect pancreatic duct heals ,so that there is no recurrence of the pseudocyst due to persisting pancreatic ductal leak.
Discussion
Rupture of WOPN is a rare condition.WOPN can rupture into the gastrointestinal lumen or in the peritoneal cavity. The rupture of WOPN into the peritoneal cavity is difficult to treat and has dilemmas in management approach. It can leads to high possibilities of infections, pancreatic fistulas and carries high mortality. We present a case series of 8 patients of acute necrotizing pancreatitis with disconnected pancreatic duct syndrome (DPDS) and walled off pancreatic necrosis (WOPN) with spontaneous rupture. Two patients had rupture into the GI tract (1 in the antrum and 1 in 1st part of duodeum). 2 plastic stents were placed through the luminal opening into the pseudocyst cavity to create an internal fistula and later underwent ERCP with pancreatic duct (PD) stenting. 6 patient had a rupture in the perinoteal cavity causing pancreatic peritonitis. Ascitis was aspirated for diagnosis with ascitic amylase ranging from 8945 to 25768 U/L. All patients presented with high grade fever and systemic inflammatory response syndrome (SIRS).

The average size of the WOPN was 8 cms with wall thickness of 4 mm. Surgical gastrocystostomy was not possible. 5 patients underwent endoscopic ultrasound guided gastrocystostomy with lumen opposing metal stent (LAMS) to drain the WOPN and create an internal fistula, followed by ERCP with PD stenting. 3 patients had clear ascitic fluid so were drained by percutaneous pigtail drainage. 2 patients had multiple internal septations in the ascitic fluid, hence were later subjected to a laparotomy with peritoneal lavage and external drain placement. One patient had a complete rupture of the WOPN with no residual collection, hence only PD stent followed by peritoneal lavage was done. All patients were on broad spectrum antibiotics and nasojejunal feeds. None of patients required endoscopic pancreatic necrosectomy. There was no mortality, no external pancreatic fistula and the average hospital stay was 10 days. This is the first case series of 8 patients with partially ruptured WOPN managed successfully.

A 13 year old girl presented with Pain, fever & jaundice off & on for 6 months. She was operated for possible choledochal cyst with hepaticoduodenostomy at the age of 3 years. She had jaundice, leukocytosis & significantly dilated Intrahepatic biliary radicles studded with thousands of tiny stones. We could not visualize or locate hepaticoduodenostomy stoma on upper GI scopy. Percutaneous transhepatic cholangiography was done which revealed significantly dilated IHBR more severe dilatation on left side with total block at the level of confluence. The biliary radicles were full of tiny stones.
Interventional radiologist could pass guide wire across the block into duodenum through stenosed stoma. The stoma was dilated by 6mm balloon dilator by transhepatic route. After dilatation bile with numerous small stones were seen flowing out. An interno-external plastic stent was placed. For 1 week patient had relief from jaundice, fever & pain.
She was advised to undergo ROUX-EN-Y hepaticojejunostomy. The relatives refused 1 more surgery. The interno-external stent was removed. A Lumen Apposing Metallic Stent ( LAMS ) of 1cm diameter was placed across the stoma. At the end of 15 days patient is totally asymptomatic. We planned to remove LAMS at the end of 3 months by which we expect good dilatation of stoma.

A 73yr old gentleman presented with recurrent episodes of pain abdomen since last 2years. He was admitted elsewhere with Jaundice and Fever. His LFT was deranged. His USG abdomen showed post cholecystectomy status and CBD (Common Bile Duct) was normal. He was suspected to have biliary colic and hence a specialized method MRCP ( MRI evaluation to assess bile and pancreatic duct) was advised. MRCP showed a stone in common bile duct (CBD)causing obstruction. He was resuscitated initially and taken up for ERCP (an endoscopic procedure to clear bile duct blockage). His cholangiogram showed dilated CBD due to obstruction by a large stone with narrow distal CBD .On attempted stone clearance, it was found that stone was getting impacted in narrow distal CBD.

A specialised method called Through the Scope Mechanical Lithotripsy was used to crush the stone. This procedure involves passing a basket attached to a metal wire through the scope into CBD. Once stone is grasped in the basket, stone gets stuck between two metal sides and by applying mechanical pressure it gets mechanically crushed into pieces. CBD clearance was achieved in this patient and plastic stent was placed in CBD for short duration.

He was discharged from hospital on day 2. One week on follow up his LFT was normal and he was pain free. This technique helped us to avoid a major surgery of CBD exploration which would have required prolonged hospital stay and risk of general anaesthesia.