In a series of interviews, we will be previewing this year’s ACPGBI annual meeting in Bournemouth, 3-5 July. We talked to Mr Ahmed Ahmed, Consultant Bariatric Surgeon St Mary’s Hospital, Imperial College NHS Trust, UK, who discussed some of the unique issues faced by a surgeon when performing abdominal surgery on obese (BMI>25) patients.
“Obesity is associated with a number of intra-abdominal conditions such as non-alcoholic steatohepatitis (NASH), gallstones, pancreatitis, as well as some types of female cancers (endometrial),” began Mr Ahmed. “We also recognise that obese patients are more likely to suffer from gastro-oesophageal reflux disease (GERD), and Barrett’s oesophagus. This might also help explain the increasing incidence of oesophageal adenocarcinoma. There are conflicting reports surrounding colorectal cancer, it is generally accepted that obesity is associated with a higher risk of colon cancer but a recent paper has noted a higher risk of colorectal cancer in patients who have undergone previous gastric bypass surgery!
Obesity is a surrogate marker for several other conditions such as type 2 diabetes, hypertension, heart disease, sleep apnoea, poor mobility etc., so the obese patient must be carefully assessed pre-operatively so any ‘silent’ illnesses can be identified and optimised before the patient has surgery.”
He said that from a technical viewpoint, there are several considerations surgical teams must take into account when treating an obese patient namely, anaesthetic and surgical aspects.
When operating on the obese patients, he said that access to the abdomen can be particularly challenging and most surgeons will agree that performing open surgery in obese patients is fraught with more bleeding, a higher risk of injuring other organs during surgery from difficult exposure, as well as increasing the likelihood of post-operative wound infections and incisional hernias. He added “My personal preference is where possible, to carry out laparoscopic surgery as opposed to open surgery because in my experience it is usually better for obese patients.”
Mr Ahmed explained that laparoscopic surgery in obese patients can also be challenging particularly when it comes to instruments as standard laparoscopic instruments may be too short and also because of the increased torque on these instruments from the thick abdominal wall, which not only makes the operation more demanding and tiring for the surgeon but also increases the risk of the instruments potentially bending or breaking during surgery.
From a medication standpoint, he explained that the obese patient is at a higher risk of developing venous thrombo-embolism (VTE) such as deep vein thrombosis or pulmonary embolism.
“Therefore, during surgery we must ensure obese patients receive adequate prophylaxis such as low-molecular weight heparin and mechanical compression devices. Furthermore, following discharge, most bariatric surgeons will prescribe low-molecular weight heparin for patient self–administration to reduce VTE risk. In addition, whilst obese patients are recovering in hospital it is important to be aware of the risk of pressure ulcers and make sure they do not spend too long in bed and try to encourage mobility from the day of operation.”
He added that his bariatric team are given training and courses on how to manage obese patients, however, he was not aware that other surgical teams are given such training and believes as the population as a whole is becoming more obese, extra training and guidance should be provided so all surgical teams may provide the optimal care for these patients.
“My presentation at this year’s ACPGBI meeting will be in two parts. In the first part, I will provide my colorectal colleagues some technical tricks that bariatric surgeons use to improve access when operating on the obese patient.
In the second part of my presentation, I will highlight to colorectal surgeons what they should look out for when operating on patients who have previously had bariatric surgery. Specifically, to make them aware that they will be operating on a patient with altered anatomy. Such information can be crucial if they are operating on a patient who has colon cancer.”