Pre-operative Assessment and Questions

 Indication for surgery — are you within the criteria

– BMI 40 and over

– BMI between 35 – 40 with metabolic syndrome or obesity related morbidities (type II diabetes, insulin resistance, obstructive sleep apnea, infertility, polycystic ovarian syndrome, high blood pressure — etc. )

– BMI under 35 could be indicated in special circumstances

1- Diabetes / poorly controlled
2- Asian patient, we need to adjust the BMI criteria.
3- Patient able to stay under BMI under 35 with intensive diet / medication / exercise with recurrent rebound of weight.
4- Other circumstances, e.g. joint surgery refused until patient loses weight.

  Age criteria, deciding to operate at both extreme is difficult decision

1- Under age, under 15 male and under 13 female (before reaching puberty) — patient and family should show that they made enough effort to lose weight by other non-surgical options. We will need clear evidence that they been to obesity clinic in pediatric hospital, and or endocrinologist.
2- Age over 65, or over 70 or over 75 —- the older the patient possibly the less overall benefit from surgery, and sometime could cause harm, basically depends on individual patients circumstances and health. The patient should have realist goals and expectations.

  Suitability for anesthetic will be assessed during consultation and if deemed high risk for anesthetic then will arrange review by our anesthetist and other specialist if needed.
 Surgical Suitability

Previous abdominal surgery including obesity surgery

  Patient compliance with pre-operative diet.

Some patient might not need any pre-operative diet at all but on the other end some patient will need substantial weight loss before surgery could be offered. Majority of patients are some were in between the two extreme, meaning weight loss between 5 – 10 kg before surgery is quite sufficient. The main idea from diet again is to make surgery safer by softening the liver and allowing bigger space during surgery.

  Routine investigation

routine and specific blood test, ECG when indicated, review by other specialist again when indicated

 Psychological suitability

good number of obese patient suffers from depression / anxiety. I think it is due to the ignorance of general public and most of the medical professional of obesity and blaming the patient. Obesity not like other disease that you could hide it. Otherwise the rest of other psychological and psychiatric conditions are no different from non-obese patients. I don’t believe of routine pre-operative psychologist review, it is not practical and demands extra-time from patient to provide, away from work or family commitments. Patient with recognized psychiatric condition will be asked to provide most recent letter from psychiatrist or might need review and supporting letter before surgery.

  Medical morbidity assessment and medication adjustment

Thorough assessment of all the medical conditions and medications pre-surgery. Some patients are very organized and they bring with them printed copy of all medications and of any allergies.

Medical morbidities
1- Diabetes, type I and II— we need to plan the medication, usually we need to half the medication during the pre-operative dieting. Will need to stop it on the day of the surgery. Following surgery will plan your medication depending on sugar level during the two days post surgery.
2- Obstructive sleep apnea—- we have to stop you using CPAP machine at least in the first 3 weeks post-surgery. Hopefully with enough weight loss you might not need it at all.
3- Osteoarthritis, we have to stop the medications few days before surgery and only restart if needed when full diet recommenced 4 – 6 weeks post surgery.
4- Cardiac medication, we will try to not interrupt these medication, you could even have them at the same day of surgery
5- Lung and respiratory conditions, chest x-ray and spirometry might be needed. Oral steroids should be stopped otherwise we should post-pond surgery if patient suffers from acute exacerbation.
6- Blood pressure, you could have you medication at day of surgery and we will monitor the pressure during the hospital stay and recommenced them back depending on the situation.
7- Fatty liver, we need to check the liver if we suspect liver cirrhosis, but early stages of cirrhosis is very hard to detect pre-operatively and we come across the dilemma of what to do if we are not sure at the time of surgery — meaning in patient with severe fatty changes, it is very hard with our bare eyes to differentiate between severe fatty changes and early cirrhosis. The good news is, there is good evidence that early cirrhosis could be reversed by removing the cause, like obesity.
8- Acid reflux, this area will need good understanding and the patient should understand the effect of surgery on their pre-existing reflux. Good number of patient will lose their reflux and if they had hiatus hernia we will repair during surgery unless techniquelly very difficult or not safe.

  Deciding on type of surgery and timing + other logistics.

Over the years the trend kept on changing from one type of surgery to other. But at different pace at different continents. Currently sleeve is the most common surgical procedure in Australia, over 90% of the procedures performed. While band dropped out of favor, coming down to few % from 85% few years ago.

Three main considerations to think about while deciding to choose the surgical procedure

1- Effectiveness and longevity of weight loss.
2- Life style post surgery.
3- Complication rate.

I am sure every individual patient will have some other additional factors in choosing the type of surgery they like to have.

Sleeve tends to suit most of the comers, with few exceptions

1- Esophageal dilatation or stretching from previous lap band surgery.
2- Esophageal motility problems
3- Acid reflux and hiatus hernia, might be considered by some surgeons as contra-indication. We have successfully treated hiatus hernia and performed sleeve with good outcome.
4- Eating habit, frequent grazers and excess sweet eaters might struggle to reach their goals.

Gastric bypass have possibly slight advantage over the sleeve in regard to diabetes resolution, although some studies proves the opposite. Bypass not suitable for:

1- Smokers, unless patient stops smoking, they should avoid bypass as smoking predisposes the patient to the risk of severe bleeding from the gastric pouch.
2- Alcohol, bypass might predispose the patient to alcohol dependence for unknown reasons.
3- Severe adhesion, scaring or previous complex abdominal surgeries.

Gastric band surgery, this surgery I think should be abandoned, although it is the simplest of all and ? Reversal with less complication to start with, but in the long term it carries significant risk of ruining your esophagus, eroding into the stomach or slipping. All in addition to poor life style and higher risks of failure.