Patient selection, education and preparation
Patients will be assessed during two appointments approx. one month apart. The first consultation (one hour) includes clinical assessment, completion of a standardised questionnaire with specific data concerning the anamneses of obesity:
- Weight anamneses
evaluation of the “weight-career”, duration and extent of obesity
- Eating habits
eating behaviour and previous diets
By analysing eating habits, quality of food, size of portions, daytimes of food intake and feelings of hunger or repletion, specific anamneses in terms of eating disorders and malnutrition is collected. Furthermore, a personal "eating record" showing the patient’s eating habits in terms of quality and quantity over a period of 2 weeks, will be analysed. After assessment by the physician, a nutritional counsellor will analyse the data collected.
- Compliance
Evaluation of the patient’s capability to cooperate and of risk behaviours (e.g. alcohol consumption) will be given special consideration. This will include the patient’s environment.
- Secondary diseases
Associated and secondary diseases can generally be limited by carrying out physical checkups and checking the patient’s medical history.
The assessing physician will need previous external anamneses, thus contact to the general practitioner and evaluation of his reports is very important. In addition to the complex medical situation (secondary diseases), the patient’s psycho-social situation must be evaluated as well, in regard to indication. Aside from good communication with the general practitioner (providing background information and playing a major role in follow-ups), interdisciplinary cooperation with other departments such as gastroenterology, pneumonology, cardiology, psychiatry, and with the anaesthetist and IC-physicians is of utmost importance.
Patients will be informed extensively about the techniques available (e.g. gastric banding), required diagnostics, surgical techniques, possible complications and postoperative follow-up. Aside from this they will receive a brochure and the comprehensive patient information sheet on the surgical procedure.
After evaluating the results of the additional outpatient examinations, and issuance of a formal permission by the insuring company, a second conversation eventually clarifies the indication for surgery and the choice of the interventional technique. This decision should be made in solid agreement with the patient, who will now have had sufficient time to consider the planned measure extensively. Experience has shown such a second consultation to be useful because patients sometimes tend to change their mind even after previously agreeing to surgery.
Not all morbid obese patients (BMI >40) are suitable for surgical treatment. Often evaluation is only possible after all corresponding diagnostics and treatments have been performed. Usually approximately 50% of the evaluated patients will actually have surgery.
Common reasons for exclusion are a lack of cooperation, severe malnutrition and eating disorders (appearing untreatable at times), addictions like alcohol abuse (or failed antabuse therapy of at least 1 year and monitored by a physician), non-guaranteed follow-ups after surgery. Less common are somatic (physical) and mental illnesses.
Despite strict selection criteria and continuous monitoring, in some patients dysfunctions will not be noticed until after surgery. Patients are mainly concerned with insufficient weight reduction. For example eating disorders like excessive "sweet-eating" may be concerned, where the corresponding conservative therapy (diet counselling, mental care) fails. There are a variety of problems threatening weight reduction success after surgical intervention. In another example after gastric band insertion, patients use fatty gravies as lubricant to facilitate passage through the gastric band, thus increasing calorie intake.
Essential prerequisites are: extensive and frank information (including complications), confidence of the patient, explanation of severe changes in eating habits after surgery, details about the follow-up, and discussion of possible causes for therapy failure.
In general a psychiatrist familiar with massive overweight should assess patients. Previous reluctance often vanishes after a good conversation and precise information. However, the need for a psychiatric assessment could not be verified yet. The indication to operate will eventually be made by the surgeon himself.