Be alert to the silent but serious comorbidities of obesity

| January 21, 2010

Dear Readers:

In this issue of Bariatric Times, we present three articles that discuss frequent medical conditions that relate to the obesity disease and bariatric surgery. These conditions are osteoarthritis (OA), fatty liver infiltration/nonalcoholic steato-hepatitis (NASH), and marginal ulcerations (MUs).

First, OA is probably present in close to 100 percent of our patients. Symptomatic OA, however, is not as prevalent. Patients develop chronic inflammatory changes of weight-bearing joints, such as hips, knees, and lumbar spine, and are often self referred to our consultations because orthopedic surgeons are reluctant to operate on them in the presence of morbid obesity.
A common phrase that we hear from our patients is, “My doctor says I need to lose 50 pounds if I want to get my hip replaced.” Well, that is like telling me that they expect me to grow five inches! I wish it was that easy.

Bariatric surgery plays a key role in the population of patients in need of joint replacement who also suffer from overweight or morbid obesity. Along with rapid weight loss and resolution of major comorbid illnesses, such as diabetes and hypertension, bariatric surgery enables patients to proceed with their joint replacement. Several issues among others type of surgery, such as vitamin D and calcium supplementation, also need to be taken into consideration when performing bariatric surgery to pave the way for a second nonbariatric procedure like joint replacement.

Next, considered the number one cause of primary biliary cirrhosis worldwide, NASH is another silent, serious, and prevalent condition that affects our patients due to fatty infiltration of the liver. As a surgeon, I am often asked if I routinely perform liver biopsy in my patients. I have all patients consented for possible liver biopsy, but only perform it selectively in those patients with macroscopic signs of cirrhosis. Those of us who work in the field of bariatric surgery are well aware that rapid weight loss results in resolution of NASH; however, what we do not know is the degree of cirrhosis in those patients that have a combination of both. A clinical case that helped us understand the seriousness of this comorbid condition was that of a 58-year-old woman who had an uneventful Roux-en-Y gastric bypass (RYGB) with an incidental intraoperative finding of macro nodular cirrhosis. Six months postoperatively, after resolution of most comorbid conditions, the patient developed jaundice and rapid progressive liver failure without being able to make it to a transplantation list. The lesson to us was, if you discover cirrhosis intraoperatively as an incidental finding, you want to at least know the stage and severity of it and have the patient see an hepatologist to better assess the prognosis.

Finally, marginal ulcers are a real problem for patients and bariatric surgeons. Some causes of marginal ulcer formation include the use of nonsteroidal anti-inflammatory drugs (NSAIDS), presence of foreign bodies (sutures and staples), and gastro-gastric fistulas, but probably the number one cause, which should raise a red flag, is cigarette smoking. It raises a red flag because, in the era of sleeve gastrectomy, it is preventable. More and more, often I recommend a laparoscopic sleeve gastrectomy to a patient that is a smoker because of the possibility of having to deal with a stricture, ulcer, bleeding, and perforations in other procedures. Is a promise made verbally in the office to cease smoking good enough for us to proceed with an ulcerogenic procedure such as the RYGB in patients that are addicted to cigarettes? My answer is no.

I am sure you will enjoy this issue of BT and the topics discussed in our outstanding articles.

On a happier note, I was glad to read in a recent installment of the New York Times health section that the obesity epidemic in the United States has stopped climbing. According to government data from 2007 to 2008, the obesity rate has held steady for about five years, reflecting earlier signs it had stalled after steadily increasing. But the latest numbers still show that more than two-thirds of adults and almost one-third of children in the United States are overweight, with no sign of improvement. The key question to ask is if the glass is half full or half empty. My interpretation is that we cannot get any more obese than we are! In my opinion, patients who only lose enough weight to control one comorbidty, like diabetes, will see other silent but serious comorbidities like osteoarthritis and NASH result in potential for serious complications.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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