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Out patient diagnosis and preoperative therapy

A final indication requires certain examinations which cannot be performed during regular obesity consultation hours. In order to recognise treatable secondary diseases and deficiencies, most of the diagnosis is made as outpatient treatment. This reduces the length of the hospital stay, and thus effectively the cost while improving patient comfort.

Secondary diseases must be treated before the operation, in order to minimise risks of the intervention. For example, hypertension must be medicated, sleep apnoea must be recognised, and controlled and uncontrolled diabetes needs to be treated. In a difficult psycho-social environment all contacts such as the general practitioner, psychiatrist or social-psychiatric services should create a network of support after surgery.

If problems in compliance are identified, indication for surgery must be reassessed. Regardless of the chosen interventional technique, reflux conditions of the oesophagus should be treated with acid inhibitors before operation and therapy success verified via gastroscopy. Iron deficiency is very common in morbid obese patients and will be detected in a first blood analysis; it should be levelled out before intervention. If insufficient chewing occurs due to dental conditions, dental reconstruction is essential.

The goal of the first consultation is to determine the appropriate surgical technique or to initiate further diagnostics in order to assess the information needed to select the final procedure. After receiving extensive information the patient must be able to evaluate the surgical interventions.

Stages of information are shown in Table 19. In particular, diseases of the upper abdominal tract must be ruled out and the patient’s general condition regarding currently manifest secondary diseases must be documented in order to assess the surgical risk and to introduce therapeutic measures.

Surgery can only be scheduled if formal approval from the relevant insurance carrier has been issued. Thus, only examinations necessary for general preparation of surgery are initiated before a formal approval is issued.

After a first and second adiposity consultation the surgery indication will be issued and the technique will be selected, the formal approval will be issued and the patient will be informed to the fullest extent.

  1. First obesity consultation:
    – clinical examination (weight, blood pressure, pulse)
    - evaluation protocol
    - nutritional protocol, "standard" eating habits over 2 weeks
  2. When weight criteria and conditions according to KLV are met:
    – information brochure
    - patient information on surgical techniques (form)
    - nutritional consultation (2nd nutritional anamneses)
    - request for meeting the costs
  3. After formal permission from the insurer is issued:
    gastroscopy (possibly oesophagus assessment)
  4. Second consultation
    - final choice of intervention
    - final explanation of surgical technique
    - evaluation of the basal metabolic rate and the body composition (fat mass, cell mass, liquid)
    - ultrasound: performing gastric banding in the presence of gall stones; gall bladder is removed as usual in bypass surgery.
    – photo documentation (whole body)
  5. Diagnosis during the day before surgery
    (in case it has not been done before)
    - ECG (during stress), blood pressure daily profile
    - X-ray of thorax
    - blood analysis
    - lung function, respiratory exercise

 
Tab.18: course of examinations