Sharique Nazir, MD, Laurence Diggs, BA, Alex Bulanov, MS, George Ferzli, MD, FACS. Lutheran Medical Center
Background:
Obesity is associated with serious comorbidities. Only bariatric surgery has been proven to definitively treat this condition. Our focus here is the management of the super-super obese (SSO) whose Body Mass Index (kg/m2) is defined as greater than 60. Bariatric surgery is not commonly undertaken in this group due to perceived increased operative risks including higher incidence of comorbidities and heightened technical challenges such as exposing visceral fat, retracting the fatty liver, strong torque applied to instruments, increased thickness of the abdominal wall and reduced ability to attain adequate peritoneal insufflation. Most sources recommend only bariatric surgeons with at least 50 cases attempt such procedures. Numerous studies report increased rates of complications, OR time and length of stay (LOS) when performing bariatric surgery on the SSO. Our goal was to evaluate the overall outcomes of laparoscopic bariatric surgeries performed on SSO patients at our institution.
Methods:
We selected SSO patients who underwent bariatric surgery between 2004 and 2013 at a 500 bed community hospital. A retrospective chart review was done on a total of 93 patients. We recorded the type of procedure, OR time, peri-operative complications, LOS, weight change and co-morbidity reduction. Success of the surgery was evaluated as the percentage of preoperative excess weight lost (i.e. the post-operative weight change divided by the difference between the preoperative weight and their ideal body weight as defined by a BMI of 22.5).
Results:
40 men and 53 women with mean age of 38 years (18-62yrs) underwent laparoscopic bariatric surgery. 73 of the procedures were Roux-en-Y, 7 were sleeve gastrectomies and 13 were gastric bands. Mean preoperative weight was 188.2kg (141-356kg) with an associated BMI of 64 kg/m2 (60-83 kg/m2) whereas mean postoperative weight was 133.1kg (70-234kg) with an associated BMI of 46.5kg/m2 (26-68kg/m2). Overall mean %EWL at 1 year was 44% (5-100%) with 26% for the lap bands, 38% for sleeve gastrectomy, and 47% for RNY. Mean OR time and LOS were 112 minutes (35-325mins) and 67 hours (23-312hrs). No complications were associated with the surgeries and there were no in-hospital mortalities. We reviewed patient follow-ups at 6 months (42 patients), 12 months (43), 2 years (22), 3 years (11), 4 years (1), 5 years (2) and 6 years (1). Of those who had long-term follow-ups, 37% reported improvement in obstructive sleep apnea, 53% in diabetes mellitus, 50% in GERD, 28% in hypertension, 29% in asthma, 13% in hypercholesterolemia, and 6% in osteoarthritis.
Conclusions:
Laparoscopic bariatric surgery in the SSO is safe and effective when performed by experienced surgeons. It produces excellent outcomes with considerable excess weight loss and improvement of comorbidities with acceptable OR time and LOS. Further research must compare outcomes to those of the morbidly obese patients. For the SSO, medical assistance and life-style modification alone are often ineffective. We recommend that these individuals get a RNY procedure regardless of dietary habits (e.g. sugar intake) as it is more effective. Close follow-up and encouragement have been shown to improve outcomes.
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