Obesity affects many people around the world. According to the World Health Organization, obesity is the fifth leading cause of death globally, with more than 2.8 million people dying each year. Morbid obesity as the name implies is a potentially lethal disorder. Many consider bariatric surgery for morbid obesity treatment. While bariatric surgery can reduce certain risks it may also introduce others, making decisions about its use difficult. Decisions are further complicated by the realities of value-based reimbursement and medical malpractice. Medical algorithms can help physicians and patients make better decisions related to morbid obesity and whether to pursue bariatric surgery for treatment. Throughout this article, medical algorithms are suggested that can help provide insight on the many facets of the condition and the best course of action for a morbidly obese patient.
The Curses of Morbid Obesity
Morbid obesity can result in many problems such as:
- Diabetes mellitus
- Metabolic syndrome
- Osteoarthritis
- Bonalcoholic steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma
- Nutritional deficiencies
- Sarcopenia
- Depression and suicide
- Sudden death
- Poor quality of life (QOL)
- Obesity-related cardiomyopathy
- Obstructive sleep apnea
Medical calculators can help physicians diagnose and evaluate risks for morbidly obese patients:
- WHO Definition of Metabolic Syndrome
- HAIR Score for Predicting Nonalcoholic Steatohepatitis in a Severely Obese Patient
- Criteria for Obesity-Related Cardiomyopathy
Hazards of Bariatric Surgery
Many of the problems of morbid obesity can be reduced or eliminated by significant weight loss. While exercise and diet may be tried, for many the only real option is bariatric surgery. Bariatric surgery may be associated with significant morbidity and mortality related to:
- A difficult airway
- Anastomotic leakage
- Post-operative surgical site infections and pressure ulcers
- Deep vein thrombosis and pulmonary embolism
A morbidly obese patient can also be an occupational hazard for healthcare workers and a rehabilitation challenge.
- Nomogram for Predicting Surgical Complications in a Patient Undergoing Bariatric Surgery
- Risk Factors for Anastomotic Leakage After a Gastric Bypass Procedure for Morbid Obesity
Informed Consent
Informed consent is important when offering bariatric surgery to a patient. The key elements are:
- A complete description of the process before and after surgery
- The risks associated with the surgery, including contraindications
- The consequences of not having the surgery
- Alternative therapies
- Honest and complete answers to questions from the patient and family
Many patients want to know what the risks of having surgery are. Many algorithms now exist that can help give a personalized risk assessment.
- Obesity Surgery Mortality Risk Score (OS-MRS) for Mortality Following Gastric Bypass Surgery
- Bariatric Surgery Morbidity Risk Calculator
Risk Reduction
If surgery is decided on, then interventions can be taken that can reduce the risk. This may include smoking cessation and improved aerobic fitness.
- Preparations for Reducing Perioperative Complications in a Patient with Morbid Obesity
- Preoperative Placement of an Airway for a Morbidly Obese Patient
Ongoing Issues
Following successful surgery a number of health problems may improve such as reversal of diabetes. However, some patients may have ongoing problems, such as:
- Arthritis
- Nutritional deficiencies
- Altered drug absorption
Not everyone adapts to the new lifestyle. Some may revert to old habits or start new ones, with weight regain and inactivity.
- Altered Drug Absorption Following Bariatric Surgery
- Arthritis Associated with Intestinal Bypass for Morbid Obesity (Intestinal Bypass Arthritis)
Take Home Message
Morbid obesity can be a major problem for the patient, the family, the clinician and society. Bariatric surgery can be life-changing but is not without risks and challenges that can impact the patient for years to come. Value-based reimbursement will probably result in care being limited to centers of excellence. Medical algorithms can help in the clinical problem-solving that arise during the care of these patients.
