Morbid Obesity is a disabling and sometimes life-threatening medical condition.
There are generally accepted indications and contraindications for the two effective surgical procedures currently recommended. Serious complications of these operations are well-recognised and only partially preventable in the present state of knowledge.
Medically, overweight is a Body Mass (BMI) of 25-30 kilograms per metre height squared (kg/m2 = weight in pounds x 700 divided by the square of the height in inches). Beyond 30 kg/m2 is considered obese.
Morbid Obesity is defined as a BMI of more than 40 kg/m2. Mortality rates are up to 12 times normal 1 and disease risks are increased, notably for diabetes, high cholesterol, high blood pressure, gall-stones, heart disease, lung diseases, sleep apnea, and osteoarthritis2.
Practice PointMorbid
Obesity is a disabling medical condition with a considerably reduced life-expectancy |
There are generally accepted indications and contraindications for the two effective surgical procedures currently recommended. Medical treatment3 -diet, behaviour modification and exercise - is frequently ineffective4, and the last decade has seen increasing professional acceptance of bariatric surgery as a legitimate alternative approach to the problem5, 6.
Practice PointSubstandard
patient selection and inadequate disclosure should be considered for litigation
strategy |
The International Federation for the Surgery of Obesity in 1997 published7 patient selection guidelines that are generally adopted in North America8. There are also generally accepted contraindications3 to bariatric surgery.
Practice PointContraindications
to bariatric surgery |
Of the two currently recommended operations9, the Vertical Banded Gastroplasty (VBG) consists of an upper stapled stomach pouch with the capacity of only a tablespoon, to limit the amount of food that can be taken, and a 1 cm banded outlet to the rest of the stomach, to delay emptying of the pouch10.
The Roux-en-Y Gastric Bypass (RGB) additionally includes a bypass of the stomach, the duodenum, and the first portion of the jejunum, to restrict absorption of food10.
On average, patients lose 40% (VGB) to 60% (RGB) of excess weight and more than two-thirds maintain significant loss10. For the majority of patients who sustain weight loss for 5 years, the medical conditions previously noted are materially improved3.
Serious complications of these operations are well-recognised and only partially preventable in the present state of knowledge.The relatively high complication rates for these uncommonly performed surgical procedures result in disproportionately frequent malpractice enquiries. Both leakage from the staple-line11 and venous thromboembolism12 may be lethal, and overall mortality of bariatric surgery approaches 2%3.
Wound infection is commoner following surgery in the morbidly obese and higher doses of routine prophylactic antibiotics have been recommended12a.
Vomiting following bariatric surgery may accompany weight loss that is poor, exemplary12b or excessive12c []. In 1-2% of well-selected patients, vomiting with excessive weight loss is not relieved by standard routines12c [] and surgical reversal must be considered.
Practice PointPrejudice
and psychiatric problems commonly interfere with medicolegal assessment and prosecution
of litigation |
As many as 25% of patients who undergo VBG for morbid obesity have an unsatisfactory outcome12d.
Patients and their families often have unrealistic expectations of the surgery13. Binge-eating and decreased rates of metabolism contribute to the surgical failures, and psychiatric accompaniments of the physical condition may not be adequately addressed for a variety of reasons10.
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