Risks and benefits of gastric bypass in morbidly obese patients with severe venous stasis disease

Abstract

Objective: To determine the risks and benefits of gastric bypass-induced weight loss on severe venous stasis disease in morbid obesity.

Summary background data: Severe obesity is associated with a risk of lower extremity venous stasis disease, pretibial ulceration, cellulitis, and bronze edema.

Methods: The GBP database was queried for venous stasis disease including pretibial venous stasis ulcers, bronze edema, and cellulitis.

Results: Of 1,976 patients undergoing GBP, 64 (45% female) met the criteria. Mean age was 44 +/- 10 years. Thirty-seven patients had pretibial venous stasis ulcers, 4 had bronze edema, 23 had both, and 17 had recurrent cellulitis. All had 2 to 4+ pitting pretibial edema. Mean preoperative body mass index (BMI) was 61 +/- 12 kg/m(2) and weight was 179 +/- 39 kg (270 +/- 51% ideal body weight), significantly greater than in patients who underwent GBP without venous stasis disease. Two patients had a pulmonary embolus and four had Greenfield filters in the remote past. Additional comorbidities included obesity hypoventilation syndrome, sleep apnea syndrome, hypertension, gastroesophageal reflux, degenerative joint disease symptoms, type 2 diabetes mellitus, pseudotumor cerebri, and urinary incontinence. Comorbidities were significantly more frequent in the patients with venous stasis disease than for those without. At 3.9 +/- 4 years after surgery, patients lost 55 +/- 21 % of excess weight, 62 +/- 33 kg, reaching 40 +/- 9 kg/m(2) BMI or 176 +/- 41% ideal body weight. Venous stasis ulcers resolved in all but three patients. Complications included anastomotic leaks with peritonitis and death, fatal pulmonary embolism, fatal respiratory arrest, wound infections or seromas, staple line disruptions, marginal ulcerations treated with acid suppression, stomal stenoses treated with endoscopic dilatation, late small bowel obstructions, and incisional hernias. There were six other late deaths.

Conclusions: Severe venous stasis disease was associated with a significantly greater weight, BMI, male sex, age, comorbidity, and surgical risk (pulmonary embolus, leak, death, incisional hernia) than in other patients who underwent GBP. Surgically induced weight loss corrected the venous stasis disease in almost all patients as well as their other obesity-related problems.

Figures

Figure 1. Pretibial venous stasis ulcers before gastric bypass-induced weight loss in a severely obese 40-year-old woman weighing 175 kg, body mass index 68 kg/m2, 310% ideal body weight (Reprinted with permission from Sugerman HJ. Obesity. In: Wilmore DW, ed. Care of the surgical patient. Vol. 2, Elective care. Section VII, Special problems. 1st ed. New York: Scientific American; 1994:1–13).

Figure 2. Healed venous stasis ulcers 1 year after the loss of 66 kg with gastric bypass-induced weight loss. Ulcers remained healed for 13 years when she died of metastatic colon adenocarcinoma (Reprinted with permission from Kellum JM, DeMaria EJ, Sugerman HJ. The surgical treatment of morbid obesity. Curr Probl Surg 1998; 35:791–858).

Figure 3. Anterior and posterior views of venous stasis ulcers and bronze edema before long-limb gastric bypass in a 30-year-old man weighing 203 kg, body mass index 75 kg/m2, 310% ideal body weight.

Figure 4. Healed venous stasis ulcers and improved bronze edema at 3 years after the loss of 110 kg with long-limb gastric bypass surgery.