Morbid Obesity

Morbid Obesity

One in three Americans is 20% or more over his or her ideal body weight (U.S. Department of Health and Human Services, 2001). Morbid obesity is the term applied to people who are more than two times their ideal body weight or whose body mass index (BMI) exceeds 30 kg/m².

Another definition of morbid obesity is body weight that is more than 100 pounds greater than the ideal body weight (Monteforte & Turkelson, 2000). Patients with morbid obesity are at higher risk for health complications, such as cardiovascular disease, arthritis, asthma, bronchitis, and diabetes. They fre-quently suffer from low self-esteem, impaired body image, and depression.

Medical Management

Conservative management consists of placing the person on a weight loss diet in conjunction with behavioral modification and exercise; however, diet therapy is usually unsuccessful. There is a belief that depression may be a contributing factor to weight gain, and treatment of the depression with bupropion hydrochloride (Wellbutrin) may be helpful (Wangsness, 2000). Some physicians recommend acupuncture and hypnosis before recommending surgery.

PHARMACOLOGIC MANAGEMENT

Several medications have recently been approved for obesity. They include sibutramine HCl (Meridia) and orlistat (Xenical). By inhibiting the reuptake of serotonin and norepinephrine, sibutramine decreases appetite. Orlistat reduces caloric intake by binding to gastric and pancreatic lipase to prevent digestion of fats. Both medications require a physician’s prescription. Sibutramine may increase blood pressure and should not be taken by people with a history of coronary artery disease, angina pectoris, dysrhythmias, or kidney disease; by those taking antidepressants or monoamine oxidase inhibitors; or by pregnant or nursing women. Side effects may include dry mouth, insomnia, headache, increased sweating, and increased heart rate. Side effects of orlistat may include in-creased bowel movements, gas with oily discharge, decreased food absorption, decreased bile flow, and decreased absorption of some vitamins. A multivitamin is usually recommended for patients taking orlistat. Women who are pregnant or nursing should not take orlistat (Hussar, 2000).

SURGICAL MANAGEMENT

Bariatric surgery, or surgery for morbid obesity, is performed only after other nonsurgical attempts at weight control have failed. The first surgical procedure to treat morbid obesity was the je-junoileal bypass. This procedure, which resulted in significant complications, has been largely replaced by gastric restriction pro-cedures. Gastric bypass and vertical banded gastroplasty are the current operations of choice. These procedures may be performed laparoscopically or by an open surgical technique.

In gastric bypass surgery, the proximal segment of the stomach is transected to form a small pouch with a small gastroenterostomy stoma. The Roux-en-Y gastric bypass is the recommended proce-dure for long-term weight loss. In this procedure, a horizontal row of staples creates a stomach pouch with a 1-cm stoma that is anas-tomosed with a portion of distal jejunum, creating a gastro-enterostomy. The transected proximal portion of the jejunum is anastomosed to the distal jejunum (Fig. 37-3A).

In vertical banded gastroplasty, a double row of staples is ap-plied vertically along the lesser curvature of the stomach, begin-ning at the angle of His. A small stoma is created at the end of the staples by adding a circle of staples or a band of polypropylene mesh or silicone tubing (see Fig. 37-3B).

After weight loss, the patient may need surgical intervention for body contouring. This may include lipoplasty to remove fat deposits or a panniculectomy to remove excess abdominal skinfolds.

Nursing Management

Nursing management focuses on care of the patient after surgery. General postoperative nursing care is similar to that for a patient recovering from a gastric resection, but with attention given to the risks of complications associated with morbid obesity. Complica-tions that may occur in the immediate postoperative period in-clude peritonitis, stomal obstruction, stomal ulcers, atelectasis and pneumonia, thromboembolism, and metabolic imbalances result-ing from prolonged vomiting and diarrhea. After bowel sounds have returned and oral intake is resumed, the nurse provides six Small feedings consisting of a total of 600 to 800 calories per day and encourages fluid intake to prevent dehydration.

Patients are usually discharged in 4 to 5 days with detailed di-etary instructions. The nurse instructs patients to report excessive thirst or concentrated urine, both of which are indications of de-hydration. Psychosocial interventions are also essential for these pa-tients. Efforts are directed toward helping them modify their eating behaviors and cope with changes in body image. The nurse explains that noncompliance by eating too much or too fast or eating high-calorie liquid and soft foods results in vomiting and painful esophageal distention. The nurse discusses dietary instructions be-fore discharge and schedules monthly outpatient visits. Long-term side effects may include increased risk of gallstones, nutritional de-ficiencies, and potential to regain weight.