When a 44-year-old man from Kolkata arrived at CK Birla Hospitals, CMRI, he weighed 190 kilograms and had a body mass index of 64. He was managing type 2 diabetes, hypertension, and high cholesterol. He had severe obstructive sleep apnoea. His legs were significantly swollen. And he was breathless in ways he had attributed to his weight without fully understanding why.
What his clinical evaluation at CMRI revealed was that the breathlessness had a more specific cause. He had right heart failure and pulmonary hypertension, conditions that had not been previously diagnosed and that made the prospect of bariatric surgery considerably more complex than it would otherwise have been. He also had an umbilical hernia. Previous attempts to manage his weight through medication had not produced meaningful results. Surgery was the appropriate path forward, but it could not happen immediately.
The team at CMRI, led by Dr Sarfaraz J Baig, Senior Consultant, GI Surgery, made the decision to admit the patient for a structured one-week preoperative optimisation protocol before any surgical intervention was attempted. Continuous positive airway pressure therapy was initiated for the sleep apnoea. Diuretics and sildenafil were prescribed to address the right heart failure and pulmonary hypertension. A low-calorie, high-protein diet was started with the specific aim of reducing liver volume, improving metabolic parameters, and improving the conditions under which surgery would take place. The patient’s cardiopulmonary status was monitored closely throughout, with input from a critical care specialist, the pulmonary team, and a dietitian working alongside the bariatric team. By the end of the week, his respiratory status and pulmonary function had improved sufficiently to proceed.
The procedure — a laparoscopic sleeve gastrectomy, the most commonly performed bariatric surgery — was carried out with careful attention to the specific technical challenges the patient presented. His extreme obesity meant a large, thickened stomach and significant hepatomegaly that restricted access and operative exposure. The swelling in his lower abdomen and the umbilical hernia required particular care during port placement. All ports were inserted under direct vision. Despite these difficulties, the procedure was completed laparoscopically in one hour.
The patient was monitored in the intensive care unit for 24 hours following surgery and was discharged home on the second postoperative day in stable condition. Ten days after his surgery, he had already lost 15 kilograms. His breathing had improved. The oedema in his legs was reducing. He described himself as feeling great.
Dr Sarfaraz J Baig, Senior Consultant, GI Surgery, CK Birla Hospitals, CMRI, said, “This case required careful thought before we could even consider taking the patient to the operating room. The right heart failure and pulmonary hypertension had not been identified before he came to us, and operating without addressing those first would have carried a risk that was not justified. The optimisation protocol was as important as the surgery itself. The technical challenges intraoperatively were significant — his anatomy made access difficult and the operative field restricted. The fact that we were able to complete the procedure laparoscopically in an hour reflects what a coordinated, prepared team can achieve in a complex case.”
The patient’s weight loss journey is ongoing. Bariatric surgery is the beginning of a long-term process that requires dietary adjustment, follow-up, and sustained multidisciplinary support. He has spoken about his goal of returning to the active, sporty life he had before his weight became a clinical problem. That goal now has a realistic path toward it.
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