Vivek Saxena, 32, has just begun to savour life and emerge out of his shell. He loves songs from the 1990s, especially those from the Bobby Deol film ‘Soldier’, and now wants a future that once seemed impossibly far away: finishing his graduation, getting into an LLB programme and becoming a corporate lawyer. For now, though, even ordinary things require patience. He is recovering from a life-altering surgery at AIIMS Delhi, the one that got him down from 209 kg to almost 160 kg.For much of his adult life, his world had grown smaller as his body grew heavier. He could not move easily, stand for long or breathe without difficulty. His abdomen measured nearly two metres around. Severe sleep apnoea had compromised his breathing so badly that even a CPAP device support was no longer enough to ease his breath at night. Eventually, he needed a tracheostomy — a tube insertion through a small opening in his neck and into his windpipe — for prolonged respiratory support just to stay alive. He needed bariatric surgery.When surgery was the toughest challengeVivek lost his mother when he was six and was overweight since childhood. He did well academically but rarely participated in class or mingled with other children. At 19, just after his Class XII examinations — in which he scored a first division — Vivek was diagnosed with depression. The anti-anxiety medication he was prescribed changed something in him. “I started eating a lot and sleeping most of the time,” he says.His weight, around 120 kg in 2013, began to climb steadily. Over the next decade, it reached 200 kg as he tried herbal concoctions and fad diets.When Vivek arrived at AIIMS on June 16, his BMI was 74 kg/m². He had hypertension, prediabetes, high cholesterol, acid reflux, severe obstructive sleep apnoea and pain in both knees. “He was in an inoperable condition,” says Dr Manjunath Maruti Pol, Professor of Surgery in the Surgical Disciplines Department at AIIMS Delhi and part of the multidisciplinary team that treated him. The team was concerned if they could make him fit enough to survive the operation.Also Read | Why Chandipura virus returns every monsoon and why children face the highest riskAn elaborate pre-surgery protocolWhat followed over the next several weeks was less a single surgical procedure than a carefully choreographed protocol, involving anaesthesia, critical care, physicians, infection control, dietetics and surgery. His breathing had to be stabilised. His infection had to be managed. His body had to be brought down to a size at which doctors could safely position him on an operating table. And the team had to wait for a narrow window in which his respiratory condition was stable enough to withstand the operation.For 32 days, Vivek was kept on a medically supervised very-low-calorie diet. His weight fell from 209 kg to 172 kg. His abdominal girth shrank from 198 cm to 178 cm.Story continues below this adOnly then could the operation be attempted. Even the tracheostomy presented a logistical challenge. “Because of his size, the procedure itself had to be performed on his own bed inside the operating theatre — he could not be safely placed on a standard operating table,” Dr Manjunath says.On July 24, Vivek underwent bariatric surgery. The challenges during the surgery were airway stabilisation and respiration. “We needed him stable for at least two hours before the operation could even be considered,” he adds. The procedure took two hours and ten minutes. By the 13th day after surgery, he was talking, walking and passing urine on his own. When he was discharged on August 6, he weighed 160 kg — nearly 50 kg less than when he had first arrived.Also Read | Scientists discover 14 new gut bacteria species in Indian tribal communitiesWhy is the surgery significant?An internal AIIMS case summary described the approach as a “multidisciplinary rescue strategy” that converted an almost inoperable patient into an operable candidate.The significance was not simply that bariatric surgery had been successfully performed in a patient with extremely morbid obesity. Rather, it was the way preoperative optimisation — particularly airway stabilisation, respiratory optimisation and a very-low-calorie diet — had made the surgery possible. It showed that extreme body weight is not a contraindication to bariatric surgery when a patient is managed by an experienced multidisciplinary team.Story continues below this ad“Obesity is not merely excess weight, it is excess risk,” says Dr Manjunath, noting that Indians tend to develop metabolic complications at a lower BMI and younger age than Western populations. Citing ICMR-INDIAB data, he says over 250 million Indians have generalised obesity, and more than 350 million suffer from abdominal obesity.Explaining why weight loss isn’t simply a matter of willpower, Dr Manjunath says, “Once excess fat accumulates, adipose tissue behaves like an active endocrine organ — it releases hormones and inflammatory signals that affect appetite, insulin sensitivity and metabolism. As obesity progresses, the body actively defends the higher weight, making sustained loss harder. Telling every patient to just ‘eat less and exercise more’ is often inadequate — this is a disease involving biology, behaviour and environment, not a failure of discipline.”There is a very large population that may qualify for medical or surgical treatment — particularly those with severe obesity or conditions like uncontrolled diabetes, hypertension, sleep apnoea or fatty liver disease. “But India performs only around 20,000 bariatric procedures a year, a fraction of the actual need, largely due to lack of awareness, fear, and misconceptions. The goal of metabolic surgery isn’t to make someone thinner. It’s to make them healthier, and reduce the burden of obesity-related disease,” says Dr Manjunath.Teach the body to recoverThe operation was not the end of the process. After surgery, Vivek was placed on a recovery diet and lifestyle management and his weight continued to fall. He is still on a liquid diet, drinking around four litres of water a day and having dal. Because of the tube in his neck, he cannot yet eat solid food. “I have a follow-up with the doctor next Friday — they will decide then whether I can start on solids,” he says, pausing for a deep breath.Story continues below this adIn between, Vivek is preparing for B.Com Honours from Delhi University’s School of Open Learning. Then he wants to do an LLB. The surgery has changed his body. For the first time in years, Vivek is thinking less about how much his body weighs and more about where his life might go next. “I am no longer breathless,” he says.