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Why obesity is every surgeon's nightmare


Obesity: Every surgeon's nightmare

With obesity rates going up globally, surgeries on such patients will continue to present a risk

The study of medicine is not short of surprises. Just when you think you have seen it all as a medical student, a new surprise crops up that throws you off your feet.
One of the highlights of our undergraduate training was a six-week rotation in hospitals in the developed world to give us exposure to first world medicine. We had a chance to see medical conditions unique to different populations, healthcare systems we did not have back home, advanced diagnostic and treatment options that we had only read about in the books and unlimited access to online study material we could only dream of back home.
My rotation was in a hospital that, by the American standards, was regarded as very small. Despite the size, it boasted a wide array of services that were very well supported to ensure patients received the best of care.
One Wednesday morning, we did rounds with the exchange programme director. On these mornings, he dedicated his time to just the two of us who were on rotation from Kenya. He took us into the cardiac intensive care unit and our first stop was at the bedside of Marlene*. Marlene was a 42-year-old lady who had been in the unit for 67 days.

She had walked into the hospital one winter morning, referred by her primary care physician for further evaluation and treatment. After a battery of tests, she was confirmed to have a tumour that was localised to the lower lobe of her right lung. Since it had not spread, she was deemed eligible for surgery to remove the affected lobe and, thereafter, undergo chemotherapy.

FAT LAYERS
However, Marlene presented a challenge. She weighed a whopping 138kg! She barely stood at five feet, three inches. Due to the nature of her illness, Marlene did not have the luxury of postponing surgery to deal with the weight. She went under the cardiothoracic surgeon’s knife and the team successfully managed to remove the entire offending lobe.
Despite a successful surgery, it was not a walk in the park. The surgery entails opening up the chest wall (thoracotomy) to access the underlying lung tissue and removing the diseased lobe. In this instance, the procedure was greatly prolonged as the surgeon had to deal with excessive fat layers during dissection and during closure of the wound.
Though Marlene handled the operation well, she did not recover well from anaesthesia. She was admitted to the cardiac intensive care unit for observation and post-operative care. What was expected to be a short transition period in intensive care turned into 67 days.
Although Marlene received appropriate antibiotics from the outset to help prevent infection, this did not stop the bugs from causing a riot. Week after week, Marlene suffered from swinging fevers. Instead of her wound healing, it broke down and tissue would die off in patches. She kept being shuttled to and from the operating room to clean out the dead tissue so as to contain the infection.
Despite the best efforts, Marlene’s body wouldn’t co-operate and by the time I met her, she was quite a sight. Fifty per cent of her chest wall was missing! There was an open gaping hole where the central part of her breasts should have been. She was covered in a clear polythene bandage through which we could see her wound.

NO COMMUNICATION
Because of the open wound, Marlene could only be nursed while lying on her back. This presented an obvious risk for deep vein thrombosis, pressure sores on the body parts in contact with the bed, including the soles of her feet. All manner of fancy gadgets were deployed to prevent the sores from happening, but this battle was rapidly being lost.
I looked at Marlene lying there and I wondered about the quality of life she had. She was mostly unconscious, septic, immobilised and in pain. She was fed through tubes and a machine breathed for her. She had never been able to communicate with anyone since she went to the operating room. Her family could only visit her for a few minutes at a time and they had no way of communicating their concerns and well wishes to her. The pain of a mother not being able to hug her daughter and reassure her that it was going to be OK is unimaginable.
All these complications arose from her obesity. The excessive fat made the surgery more difficult, hence time-consuming. The prolonged operating time increased the risk for anaesthetic complications and exposure to germs. The fat tissue has very poor blood supply, resulting in poor healing and difficulty in clearing infections once they set in. Marlene gave us nine more days before she passed away.
At this point, it did not matter that the cancer had been successfully treated. Marlene did not succumb to cancer, she succumbed to post-operative complications. The morbid obesity denied her a chance to survive the cancer.

DELAY SURGERY
With worldwide obesity (body mass index above 30) rate going over 10 per cent, surgical treatment for these patients will continue to present an increasingly higher risk for surgical and post-surgical complications. This is no longer a problem of the developed world, it is our problem now too.
Weighing our options reveals we do not have adequate resources to comprehensively address this menace. We may easily advise our patients to delay surgery and work on losing the weight as a form of reducing the anticipated complications. However, obesity does not preclude need for emergency surgery and the attendant complications.
No one plans for medical emergencies. Our best chance at surviving this, is to prevent obesity in the first instance.