Tropical Weight Loss
Tropical Weight Loss
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The average weight of the resected pannus was 20.0 kg (range 15.2–36.3).
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Read More »Although giant panniculectomy continues to be an operation with significant risk for complications, we demonstrated in this small subset of patients that this procedure improved global quality of life at long-term follow-up. Patients specifically demonstrated improvements in hygiene, physical activity, and the ability to fit into clothing. Despite stringent preoperative screening, four of seven patients had complications with two requiring re-exploration for hematoma. Safety continues to be paramount in both our preoperative and intraoperative management of these patients. At our institution, several intraoperative steps are performed to minimize fluid shifts and blood loss. There have been many descriptions regarding the use of a suspension system to elevate the pannus and the use of tumescent solution along incision lines [1,2,3]. To minimize blood loss, we inject a freshly prepared epinephrine solution at a concentration of 1:100,000 along all incision lines. We also suspend the pannus using Steinman pins suspended from a Hoyer lift, which allows for the progressive elevation of the pannus during the procedure. This not only allows the surgeon to work expeditiously, but it also minimizes fluid shifts by allowing egress of blood and lymphatic fluid from the pannus as it is elevated prior to final resection. We also use auto-clip ligation on all visible vessels along with suture ligation of the inferior epigastric vessels to minimize bleeding. Venous thromboembolism (VTE) continues to be a significant concern in obese patients. Natural history trials demonstrate a DVT incidence of 1.2–1.6% and a PE incidence of 0.8–3.2% [4]. The American College of Chest Physicians (ACCP) recommendation for VTE prophylaxis for bariatric surgery patients includes pneumatic compression devices in combination with chemoprophylaxis; however, the optimal timing to initiate chemoprophylaxis has not been clearly defined [5]. The American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery (AACE/TOS/ASMBS) have made the recommendations that patients should receive either unfractionated heparin (UF) or LMWH prior to surgery and repeated 8–12 h postoperatively until the patient is ambulatory [6]. Unlike many of our bariatric surgery colleagues that give preoperative chemoprophylaxis, many plastic surgeons (including ourselves) do not give preoperative anticoagulation for the real concern of postoperative hematoma. Although there is minimal undermining performed with little potential dead space, these patients can often lose multiple units of blood prior to any clinical sign of bleeding. Our current VTE protocol includes SCD placement prior to the induction of anesthesia and the initiation of standing 30 mg subcutaneous doses of enoxaparin 6 h postoperatively until the time of discharge. Review of our database of over 500 post-bariatric body contouring patients has demonstrated that this protocol does not increase the risk of hematoma compared to controls that received only SCDs as the only form of VTE prophylaxis. In this small study, we observed two cases of serious hematoma. Given the extent of the panniculectomy performed, we see this as an unavoidable risk despite our meticulous precautions to prevent this complication. The benefits of anticoagulation are readily apparent, however, as none of the patients suffered a DVT or PE, the latter of which is far more devastating than an unexpected re-operation to correct a hematoma.
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Read More »The final element of our blood clot prevention strategy involves IVC filters. The use of IVC filters remains an area in which there is no clear consensus. The literature demonstrates that IVC filters can be safely placed and later removed in patients undergoing bariatric surgery [7,8,9]. However, there were no standard criteria amongst these papers. Currently, the ACCP does not recommend the use of IVC filters for prophylaxis. The AACE/TOS/ASMBS does recommend the use of IVC filters in high-risk patients [6]. This is an area that requires randomized, prospective studies. However, given the low incidence of VTE, demonstration that IVC filters make a statistically significant difference would require a large sample size. We encourage all patients to receive an IVC filter before giant panniculectomy; for those patients with notable risk factors (preoperative BMI > 55 kg/m2, a history of VTE, hereditary thrombophilia, or preoperative immobility), we virtually require their placement. Perhaps most importantly, this study demonstrates that patients suffering from the ill effects of a giant pannus are capable of achieving significant improvements in their health following giant panniculectomy. Prior research has demonstrated that patients generally enjoy increased quality of life and health after aesthetically motivated surgery [10, 11]. More specifically, patients consistently report significant improvements after resection of a smaller pannus, often less than six kilograms [12,13,14,15]. Similar data for patients undergoing the more physiologically demanding resection of a giant pannus are limited to one report by Reichenberger and colleagues, who reported mainly on surgical technique and healing [16]. Our report is the first to specifically address patient-centered outcomes such as quality of life and health. All seven patients in our series were able to consistently perform aspects of basic personal hygiene postoperatively, for example, whereas two-thirds of them were entirely unable to do so before giant panniculectomy. Similarly, there were very impressive improvements in ambulatory metrics such as unassisted walking and climbing a flight of stairs. These data demonstrate that giant panniculectomy, despite certain inherent risks, can have crucial, positive effects on overall health and well-being in these patients, beyond the immediate benefits of panniculectomy itself.
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Read More »Although our postoperative quality of life data are extremely encouraging, the small sample size of this study prohibited us from demonstrating a truly statistically significant improvement. Because this procedure is uncommon, a multicenter study would be necessary to achieve the appropriate sample sizes necessary to conclusively demonstrate the benefits of giant panniculectomy.
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