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Morbid Obesity
Diagnosis/Definition
- Morbid Obesity is obesity which creates major existing or threatened secondary effects on the patient’s health and well being.
- The usual threshold for diagnosis of this condition is 100 pounds over ideal body weight, as determined by standard height/weight charts.
- Examples of obesity-aggravated secondary health problems are arthritic symptoms on weight-bearing joints, adult-onset diabetes, sleep apnea/severe snoring, hygiene problems related to skin folds, and depression/low self-esteem.
Initial Diagnosis and Management
- Establish diagnosis based on existing patient weight compared to ideal body weight.
- Establish reasonable history of failed attempts at weight control through diet and exercise.
- Establish degree of secondary weight-aggravated co-morbidity.
Ongoing Management and Objectives
- The objective of surgical weight-control is to sufficiently decrease the degree of obesity in order to diminish the secondary co-morbidities, and improve the patient’s self-esteem and ability to function.
- Current surgical options usually do not bring about total correction of obesity.
- Patients who are poorly motivated to make a post-operative effort to begin an increased level of exercise and to correct past poor dietary habits (snacking, use of junk food, etc.) are less likely to achieve a major benefit from surgery.
Indications for Specialty Care Referral
Morbidly obese patients who are attempting to lose weight, but have failed non-operative (dietary) management should be referred for surgical consideration. There is no set time-frame nor number of dietary failures to be considered for surgery provided that: the patient is morbidly obese; is not content to accept his/her obesity as a chronic condition; and is willing to accept the small but unavoidable peri-operative risks of major weight-control surgery. The estimated 30-day surgical mortality after this surgery is approximately 1-2 %. The average hospitalization time is 7 days. The average time for at-home convalescence prior to return to work or full resumption of homemaker responsibilities is 4-6 weeks.
Though not absolute, patients referred for surgery should usually be between the ages of 18 and 60 years.
The best current surgical options for weight reduction involve surgery to create a major reduction in gastric capacity, either by various “stapling” techniques, or by partial gastrectomy. All involve major open abdominal surgery. Exclusion criteria for this surgery include:
Patients with obvious severe cardiac or other co-morbidity, which would make their operative risks prohibitive. They should not be referred unless the co-morbidity can first be corrected or improved. Patients with such a co-morbidity that is borderline or difficult to assess should be referred to General Surgery for specialty-level assessment of their operative risk and suitability for surgery.
Patients with major inflammatory GI disease, such as, ulcerative colitis or regional enteritis. Past history of ulcer disease, or reflux (GERD) disease is NOT a contraindication for surgical consideration.
Patients with major psychoses are poor candidates, however, depression, flat affect, and lack of motivation do not contraindicate referral as they may reflect secondary changes from the severely obese condition.
Patients who are profoundly retarded are poor candidates for weight-control surgery. Borderline retardation is NOT a contraindication for consideration of surgical therapy.
Laparoscopic weight-control surgery is considered experimental and unproven, and is presently unavailable at this institution.
The present waiting time is approximately 1 year from the time the patient is accepted to the waiting list after initial assessment in the General Surgery Clinic.
Criteria for Return to Primary Care
Patients post-op from surgery for morbid obesity should be followed in General Surgery Clinic for the first year after their surgery, on an every three month basis. After that time, they should be followed indefinitely by their primary care manager, with the following long-term recommendations:
Annual CBC. If abnormal, serum iron, and B-12/folate should be checked.
Patients should also have their weight checked annually.
