Staging and combining procedures

Published on 23/05/2015 by admin

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Last modified 23/05/2015

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Chapter 55 Staging and combining procedures

Preoperative Evaluation of the Massive Weight Loss Patient

Evaluation begins with a detailed history. In particular, it is important to obtain a thorough weight loss history. The method of weight loss and type of bariatric procedure provide important data on the potential for nutritional deficiencies, amount of expected weight loss, and time to plateau. Other relevant information includes date of bariatric surgery, maximum BMI, current BMI and change in weight over the past 3 months. This information can aid in determining if the patient has weight stabilized and is a good candidate to proceed with body contouring surgery.

A relevant nutritional history should be obtained. The majority of weight loss patients will have adequate intake for the unstressed state. Major surgery, however, can increase the body’s nutritional requirements by 25% and many weight loss patients may have physical impedance to increasing oral intake.1 Please see Chapter 54 for further details.

One area that may be overlooked in the preoperative evaluation, which is essential to the postoperative recovery, is the patient’s social support network. It is necessary to define who will be available to help take care of the patient at home in the initial postoperative period, especially if multiple combined procedures are contemplated.

Patient Selection

Patient selection must be focused on maximizing safety and minimizing complications. With that goal in mind, the following criteria are desirable: (1) the patient should be weight stable for at least 3 months; (2) BMI should be favorable; (3) good nutritional status confirmed; (4) medical and psychosocial stability determined; and (5) reasonable goals and expectations communicated.

Favorable BMI

A high BMI is associated with increased wound healing complications.4,5 As the patient’s BMI decreases, we are able to offer more safe surgical options and expect better esthetic outcomes.6 The best candidates have a BMI of 28 kg/m2 or less. We are more cautious in our level of intervention with patients who have a BMI between 29 and 32 kg/m2. Patients with a BMI between 32 and 35 kg/m2 should be selected with great care. If a patient in a high BMI range desires significant contouring, we recommend delaying the operation until further weight loss can be achieved. We work on a weight loss plan with the patient and nutritionist and schedule a 2–3 month follow up appointment. This way the patient will remain under your care and not feel abandoned; moreover, you are able to serve as a motivating force. Some patients in a high BMI range may benefit from a first stage breast reduction or simple panniculectomy if such a procedure would improve their ability to exercise and progress with further weight loss. For patients with a BMI greater than 35 kg/m2, our practice in most cases is to defer operations because of increased risk of complications and less potential for satisfying esthetic results.5,7 Patients in this BMI range may be offered a functional panniculectomy, with strict indications of severe panniculitis or a profoundly disabling pannus.

Nutritional Status

The importance of the nutritional status of the post-bariatric patient cannot be over-stressed.811 If the patient has symptoms of persistent nausea and vomiting, have them see their bariatric surgeon to rule out a stricture or a treatable cause. Because gastric bypass patients have altered gastrointestinal physiology and subsequent dietary issues, nutritional deficiencies are not uncommon.12 In our center, we require patients take at least 75–100 g of protein per day before elective body contouring surgery. A patient who is incapable of consuming 75 g of protein per day is often not a good surgical candidate and dietary modification is essential. Please see Chapter 54 on nutritional assessment.

Overview of Staging Strategies

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