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Extreme obesity adds extra level of danger to surgery

At 650 pounds, Michael "Big Mike" Barbetta feared he wouldn't live to see his 40th birthday. After more conservative weight loss measures failed, the 31-year-old St. Petersburg lawyer hoped the lap band surgical procedure to limit his stomach's capacity would be the answer.

But shortly after the surgery, he developed an infection, friends said. He died Oct. 11 before leaving Palms of Pasadena Hospital.

His surgeon did not return calls for comment. But doctors who treat obese patients (although not Barbetta) say his end is a sad reminder of the risks that extremely obese patients face when undergoing any kind of surgical procedure.

"Everything you do in these patients is different and more difficult," said Dr. Alexander Rosemurgy, who performed more than 1,000 weight loss surgeries in 10 years at Tampa General Hospital.

"People who are heavy have a whole different set of potential problems," compared to normal-weight patients, he said.

While any surgery carries risk, the danger increases substantially in the obese, particularly those who are more than 100 pounds above ideal weight.

"Morbid obesity triples the risk of dying from any procedure," said Dr. Dany Sayad, a cardiologist with the Florida Cardiovascular Institute Heart Center in Tampa.

"I have a lot of patients who need a catheterization (to open blocked vessels) or a pacemaker or defibrillator," said Sayad, "I tell them to lose at least 20 pounds before surgery because of all the risks."

The chief risk is — as in Barbetta's case — infection. "It's harder for fatty tissue to heal because it doesn't have the same blood supply," said Rosemurgy. With blood circulation impaired, the immune system can't fight off infection as well, giving bacteria a better chance to invade.

Extremely heavy people are also more likely to develop blood clots that can cause heart attacks and strokes. One reason: It's hard for them to get out of bed and get moving soon after surgery, which is recommended to prevent clots.

Another hazard: Medications are metabolized differently in the obese. Certain drugs linger in fat, meaning their effects can last longer. Other drugs need to be increased as body weight rises. Finding the right dose can be tricky, particularly with anesthesia and medications for pain.

"They may wake up from surgery much more slowly because the drug is released from the fatty tissue for a longer period of time," said Rosemurgy. "As a surgeon, you walk a tightrope with medications and must monitor these patients closely for a long time."

Additional flesh can make it more difficult to insert a breathing tube. Further, obese patients are more likely to aspirate stomach fluid into their lungs, which can lead to pneumonia.

Put all of these issues together, and even simple problems can snowball, Sayad said. "That's why some surgeons don't like to take big patients. These patients can quickly spiral down."

When possible, doctors like Sayad insist on pre-procedure weight loss both due to the risks, and also so patients will get some benefit from the surgery.

"Patients going for back surgery or hip surgery, if they don't lose weight, it doesn't matter what you do for them, they will break their hip again or re-injure their back,'' Sayad said.

Sometimes even a small loss, say 20 to 25 pounds, can make a big difference because it can improve diabetes, high blood pressure and sleep apnea, which can complicate recovery.

Although Rosemurgy now specializes in pancreatic cancer surgery, many colleagues send him their obese patients, because of his background in bariatic surgery. He understands the reluctance of some doctors to do this work.

"It really is hard,'' he said. "It takes experience working with heavy people before you have a comfort level.''

Irene Maher can be reached at imaher@sptimes.com.

Extreme obesity adds extra level of danger to surgery 11/09/11 [Last modified: Wednesday, November 9, 2011 9:04pm]
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