Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION II. Clinical Cases

CASE 48

A 38-year-old morbidly obese woman presents to the clinic for evaluation and management of venous insufficiency in the lower extremities. During your conversation with the patient, she tells you that she has been extremely overweight ever since childhood. She has tried many different dietary modifications, hypnosis, and medications but has not been able to achieve sustained weight loss. She is concerned about her health status because of a recent diagnosis of type 2 diabetes mellitus and a history of coronary artery disease in several immediate family members. The patient is married and without children. She works as a computer programmer. She does not consume tobacco or alcohol. Her current medications are an oral hypoglycemic agent and neutral protamine Hagedorn (NPH) insulin. On examination, she is found to be 5 ft 3 in and weighs 280 lb. Her body mass index (BMI) is 47 kg/m2. Her pulse rate is 95 beats/min and her blood pressure is 158/86 mm Hg. The findings from her cardiopulmonary examination and abdominal examination are unremarkable. Examination of the lower extremities reveals mild edema, diffuse varicosity, and venous stasis dermatitis bilaterally. The patient indicates that she is not interested in surgical therapy for her venous disease but would like your opinion regarding operative intervention for management of her obesity.

Images Is surgical therapy a reasonable treatment option in this patient?

Images What are the complications associated with morbid obesity?

ANSWERS TO CASE 48: Obesity (Morbid)

Summary: A 38-year-old morbidly obese woman (BMI 47 kg/m2) with obesity-associated complications (diabetes and venous stasis) is inquiring about the surgical treatment of obesity.

• Surgical therapy: Surgical therapy is a reasonable option in this patient.

• Complications associated with morbid obesity: Diabetes mellitus, hypertension, hyperlipidemia, atherosclerosis, cardiomyopathy, sleep apnea syndrome, gallstones, arthritis, and infertility are disease processes associated with morbid obesity.

ANALYSIS

Objectives

1. Become familiar with the complications associated with morbid obesity and the effectiveness of bariatric operations on these complications.

2. Become familiar with the short- and long-term outcomes in weight reduction achieved with operative treatment.

Considerations

This patient falls within the National Institutes of Health (NIH) class III (Table 48–1) category of clinically severe obesity and on the basis of weight-to-height ratio alone is a candidate for surgical therapy. Her comorbidities, diabetes and venous stasis, add further evidence of the advanced nature of her disease. Her blood glucose level should be carefully monitored during the postoperative period, and the venous disease in her lower extremities should be treated prophylactically during surgery with miniheparin and sequential compression stockings.

Table 48–1 • NIH CLASSIFICATION OF OBESITY (REVISED)

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APPROACH TO: Surgical Treatment of Morbid Obesity

DEFINITIONS

BODY MASS INDEX: The ratio of weight in kilograms (kg) to height in meters squared (m2). It is calculated by dividing the weight (in kg) by the height (in m2) or by multiplying the weight in pounds (lb) by 704 and dividing by the height in inches squared (in2).

CLINICALLY SEVERE OBESITY: BMI greater than 40 kg/m2.

OBESITY-RELATED COMORBIDITIES: Various diseases are considered to be caused by obesity: hypertension, diabetes, coronary and hypertrophic heart disease, gallstones, gastroesophageal reflux disease (GERD), sleep apnea, asthma, reactive pulmonary disease, osteoarthritis, lumbosacral disk disease, urinary incontinence, infertility, polycystic ovarian syndrome, and cancer. This list attests to the serious nature of this problem.

GASTRIC RESTRICTIVE PROCEDURES: Operations which involve the creation of a small pouch at the upper end of the stomach that communicates directly with the intestine or the stomach.

MALABSORPTIVE PROCEDURES: Surgeries that decrease the contact of food with the digestive juices and the absorptive surface of the small intestine.

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING: This procedure (Lap-Band) was approved by the Food and Drug Administration (FDA) for application in the United States in 2001. It involves the placement of a Silastic band around the proximal stomach at approximately 1 cm below the GE junction. The band is attached to a subcutaneous port that may be injected with saline to adjust the gastric luminal opening (Figure 48–1).

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Figure 48–1. Adjustable gastric band. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Dunn DL, et al, eds. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1004.)

METABOLIC SYNDROME: Metabolic syndrome puts the patient at risk for cardiovascular disease.

CLINICAL APPROACH

Obesity is increasing in epidemic proportions and qualifies as one of the leading medical problems among Americans. The adverse health effects associated with obesity may reduce patient quality of life and longevity. Because of concerns about the prevalence of obesity and its associated health problems, two NIH consensus conferences have taken place to address the surgical treatment of morbid obesity. At the 1991 conference, Roux-en-Y gastric bypass (RYGB) (Figure 48–2) and vertical banded gastroplasty (VBG) (Figure 48–3) were recommended for appropriately selected patients. Based on more current results, an updated statement indicates a preference for RYGB compared to VBG because the latter does not result in adequate sustained weight loss and is associated with complications. The treatment goals of any patient with morbid obesity should be focused on weight loss as well as on the reduction in comorbidities (Tables 48–2 to 48–4). It is important for the patient and the physician to have realistic expectations about surgical treatment outcome; most successfully treated patients achieve a reduction in weight that is frequently sustainable; however, patients rarely achieve the ideal body weightproscribed in standard height-weight tables. Most patients experience an improvement in obesity-related complications following successful surgery; however, increased longevity has not been demonstrated. The success and the patient satisfaction associated with surgical therapy are further augmented when patients receive proper preoperative counseling and undergo modifications in dietary habits and lifestyle.

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Figure 48–2. Roux-en-Y gastric bypass. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Dunn DL, et al, eds. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1007.)

Images

Figure 48–3. Vertical banded gastroplasty. (Reproduced, with permission, from Brunicardi FC, Andersen DK, Dunn DL, et al, eds. Schwartz’s Principles of Surgery. 8th ed. New York, NY: McGraw-Hill; 2005:1003.)

Table 48–2 • OPERATIONS USED TO TREAT CLINICALLY SEVERE OBESITY

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Table 48–3 • TREATMENT RESULTS AND COMPLICATIONS

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Table 48–4 • EFFECTS OF SURGERY ON OBESITY COMORBIDITY

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PATIENT SELECTION

All patients must have unsuccessfully attempted supervised weight-loss programs by diet, exercise, or medications and fulfill minimum weight criteria that include BMI of 35 to 40 kg/m2 with comorbidity or BMI of greater than 40 kg/m2 without comorbidity. In addition, all patients must be evaluated and considered psychologically stable and are willing to comply with postoperative lifestyle changes and dietary restrictions, exercise, and follow-up programs. Traditionally, bariatric surgery is offered to patients from 18 to 60 years of age; however, more recently, operations have been performed in older patients in some institutions without an increase in morbidity, and appropriately selected adolescents have undergone weight-reduction procedures in some institutions.

COMPREHENSION QUESTIONS

48.1 A 23-year-old woman is referred for an opinion regarding the advisability of surgical treatment for obesity. The patient is 5 ft tall and weighs 210 lb. She has no known comorbidities and is free of symptoms. Which of the following would be your best advice?

A. A small-pouch gastric bypass

B. A VBG

C. A Lap-Band procedure

D. Further efforts at medical therapy

E. Pharmacologic therapy

48.2 A 45-year-old woman, the mother of two adolescents, presents with longstanding, clinically severe obesity (BMI 50 kg/m2) that is refractory to medical therapy. Which of the following surgical procedures is most likely to provide the best chance of long-term weight reduction with the least morbidity?

A. VBG

B. Small-pouch gastric bypass

C. Adjustable Lap-Band

D. Duodenal switch

E. Jejunal-ileal bypass

48.3 By doing which of the following do gastric restrictive procedures lead to weight loss?

A. Increasing the basal metabolic rate

B. Enhancing maldigestion and absorption

C. Producing early satiety

D. Inducing nausea and vomiting

E. Altering glucose metabolism

48.4 Which of the following is the most common, most serious postoperative complication associated with small-pouch gastric bypass?

A. Pneumonia

B. Leakage of intestinal contents from the gastrojejunal anastomosis

C. Intestinal obstruction

D. Pulmonary embolus

E. Insufficient weight loss

48.5 Which of the following do late sequelae from gastric restrictive procedures include?

A. Anemia

B. Osteoporosis

C. Vitamin deficiencies

D. Marginal ulcer

F. All of the above

ANSWERS

48.1 D. The patient is young, free of comorbid medical problems, and has a BMI less than 40. Her BMI is calculated as Images. Further attempts at medical management should be made; however, if significant complications such as hypertension and diabetes are already present, a surgical approach might be appropriate.

48.2 B. This patient has strong indications for a surgical approach (BMI >50, superobese). A small-pouch gastric bypass performed by either an open or a laparoscopic technique will provide the best long-term weight reduction with minimal early and late long-term morbidity.

48.3 C. Gastric restrictive operations help people lose weight by producing early satiety and decreasing their appetite. To be successful, the patient must simultaneously restrict caloric intake.

48.4 B. Leakage from the attachment of the stomach to the intestine can be a devastating complication. It usually is characterized by fever, leukocytosis, and left shoulder pain on postoperative days 3 to 5.

48.5 E. A small-pouch gastric bypass can be accompanied by anemia, osteoporosis, and vitamin deficiencies in view of the marked decrease in food intake. Patients need supplemental vitamins, calcium, and oral iron and vitamin B12following the procedure. In addition, marginal ulcer is a complication that can occur following RYGB procedure, where patients present with epigastric pain that is not affected by eating; the treatment for this complication is proton pump inhibitor administration.

CLINICAL PEARLS

Images The BMI represented in kilograms per meter squared body surface area is a common tool in assessing obesity.

Images Many diseases are considered to be obesity-related comorbidities such as hypertension, diabetes, coronary heart disease, gallstones, and sleep apnea.

Images In general, surgical weight-reduction surgeries should be reserved for severe obesity or those obese individuals with comorbidities.

REFERENCES

Richards WO, Schirmer BD. Morbid obesity. In: Townsend CM Jr, Beauchamp RD, Evers BM, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, PA: Elsevier Saunders; 2008:399-430.

Schirmer BD, Schauer PR. The surgical management of obesity. In: Brunicardi FC, Andersen DK, Dunn DL, et al, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010:949-978.

Scortino C, Schweitzer MA, Magnuson T. Morbid obesity. In Cameron JL, Cameron AM, eds. Current Surgical Therapy. 10th ed. Philadelphia, PA: Elsevier Saunders; 2011:88-92.