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Abdominoplasty on the Persistently Obese Patient Following Gastric Bypass Surgery
Adam J. Nadelson, M.D., Teresa Benacquista, MD.
Montfiore Medical Center, Bronx, NY, USA.
Purpose: To assess complication rates in post gastric bypass surgery patients undergoing abdominoplasty; stratifying by body mass index (BMI), and to compare complication rates of patients below and above the obesity and morbidly obese cut-offs at the time of surgery.
Methods: This is a retrospective study conducted at Montefiore Medical Center, the University Hospital for Albert Einstein College of Medicine. The charts of a single surgeon’s experience between 2004-2011 of consecutive abdominoplasty procedures performed on patients who had a prior gastric bypass were reviewed. Patients were stratified retrospectively into three groups according to their BMI at time of abdominoplasty (Group1 BMI<30kg/m2, Group2 BMI=30kg/m2-34kg/m2, and Group3 BMI>35kg/m2). Complications were graded using the Clavien-Dindo Classification Scale for Surgical Complications. We describe our preoperative selection and optimization, operative technique, postoperative care, management of complications, and provide a thorough literature review. Data were analyzed using Chi-Square and Fisher’s Exact tests for categorical variables and t-tests and ANOVA for continuous variables.
Results: 134 consecutive abdominoplasty procedures were performed on patients who had a previous gastric bypass procedure. The overall complication rate was 28%. No significant association was observed between the presence of complications and: BMI groups, max BMI, ΔBMI, age, gender, diabetes, smoking history, ASA class, specimen weight, and hernia repair(Table1). When examining complication Grade: GradeI complications were observed in 11 patients (25%) in Group1, 8 patients (17%) in Group2, and 4 patients (9%) in Group3. GradeII complications were observed in 12 patients (9%) and were equally distributed among all three Groups examined. GradeIIIb complications occurred in only 2 patients (2%)--one among Group2 and one in Group3 (Table2).
Conclusion: With the epidemic of obesity in the U.S. there has been a rapid rise in gastric bypass procedures performed. After considerable weight loss, a majority of these patients continue to have BMI that are above the obesity level of 30kg/m2 at the time of consultation for abdominoplasty. These post-gastric bypass patients are predisposed to complications with their new malabsorptive anatomy causing poor mobility, redundant skin, and higher likelihood of infections underneath their skin folds. Many of these patients benefit from post-bariatric body contouring surgery to improve their activities of daily living. Patient selection for abdominoplasty is thought to be critical to its success. Historically patients are selected based on several factors including a BMI<30kg/m2. These data provide no evidence of an increase in complications among obese and morbidly obese patients who underwent abdominoplasty after gastric bypass procedure. These data support that an abdominoplasty may be performed safely on a selected group of morbidly obese patients and that patient selection should not be based solely on BMI.
Table 1 - Demographic Data and Complication:
|Demographic data||Complication||No Complication||P value|
|BMI Group 1||15/44 (34%)||29/44 (66%)||0.39|
|BMI Group 2||13/47 (28%)||34/47 (72%)|
|BMI Group 3||9/43 (21%)||34/43 (79%)|
|Max BMI||52.7kg/m2±6.7||53.1 kg/m2±9.5||0.86|
|Female||35/123 (28%)||88/123 (82%)||0.73|
|Male||2/11 (18%)||9/11 (82%)|
|No history of smoking||27/106 (25%)||79/106 (75%)||0.34|
|History of smoking||10/28 (36%)||18/28 (64%)|
|ASA class 1||6/21 (29%)||15/21 (71%)||0.14|
|ASA class 2||24/71 (34%)||47/71 (66%)|
|ASA class 3||7/42 (17%)||35/42 (83%)|
|No hernia repair||23/87 (26%)||64/87 (74%)||0.69|
|Hernia repair||14/47 (30%)||33/47 (70%)|
Table 2 - Classification of Surgical Complications
|Grade I||Any deviation from normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions|
Allowed therapeutic regimens are: drugs as antiemetics, antipyretics, analgesics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside
[skin dehiscence, necrosis, seroma, hematoma, hypertrophic scar]
|Grade II||Requiring pharmacological treatment with drugs other than such allowed for grade I complications|
Blood transfusions and total parenteral nutrition are also included
[Cellulitis, other infections requiring antibiotics, anemia requiring transfusion, DVT]
|Grade IIIa||Requiring surgical, endoscopic or radiologic intervention not under general anaesthesia||0|
|Grade IIIb||Requiring surgical, endoscopic or radiologic intervention under general anaesthesia|
[Reoperation under anaesthesia for enlarging hematoma and wound infection]
|Grade IV||Life-threatening complication (single/multi-organ dysfunction)||0|
|Grade V||Death of a patient||0|
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