Letter re: Elective Operations in Class III Obese Patients

Dear Editor

My comments were stimulated by the article recently published in The American Surgeon “Morbid Obesity is Not a Risk for Serious Complications Following Outpatient Surgery” by Tumminello et al ¹ In their paper, the authors show that patients with class III obesity should not be precluded from undergoing outpatient surgical procedures such as inguinal hernias and elective cholecystectomies. I congratulate the authors of this article as it continues to show the necessity to perform elective operations in patients with class III obesity.

In a previous study, 200 patients were not offered elective ventral hernia repairs because of obesity and were asked to lose weight prior to the operation. After 2.3 years, 75% of patients had not been offered an operation because of an inability to lose weight. Only 36 patients were able to undergo elective ventral hernia repair. During the same period, fourteen patients had to undergo emergent operative intervention. The average BMI of patients with emergent hernia repairs was 40.6 ± 8.2 kg/m². Compared to patients in the elective setting, emergent repairs were more likely to need a bowel resection (2.8% vs 21.4%; P = .03), had trend toward a higher risk surgical site infections (13.9 vs 21.4%; P = .51), had a higher hospital length of stay (2.2 vs 6.9 days; P < .01), and had a much higher rate of recurrence (5.6% vs 35.7%; P < .01). ²

As the prevalence of obesity continues to increase, it is likely that more patients with class III obesity will present for elective operations. It is unlikely that patients with a BMI >40.0 Kg/m² will lose substantial weight by dietary interventions alone before they can be offered elective operations. In parallel with the findings of Tumminello ¹ and James, ² we have previously shown that obesity does not affect 30-day morbidity in patients undergoing inguinal hernia repair. The rate of recurrence and inguinodynia was also similar between obese and nonobese patients. ³ In another of our analyses, examining outcomes in patients undergoing umbilical hernia repair, we found a similar rate of 30-day complications and recurrence in class III obese patients compared to the nonobese cohort. ⁴ Added to this list are now patients undergoing elective cholecystectomies as Tumminello’s group has shown. ¹

An aggressive trial of weight loss is reasonable to request for class III obese patients planning to undergo elective operations. However, substantial weight loss is unlikely for most of these patients. Thus, elective operations should be offered to class III obese patients after a short, attempted period of weight loss. These operations can be performed in the outpatient setting. Delaying operative intervention in class III obese patients might lead to emergent intervention rising the rate of complications quite substantially.