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Extreme obesity

The management of patients with BMI >60 is a challenge undertaken regularly by few centres worldwide. Literature review reveals a variety of series of such patients with varying degrees of success in technique and outcome. Unfortunately, despite demand for intervention, this patient group is often poorly managed by general healthcare professionals, due to reluctance to intervene, or a belief that they are ‘beyond help’. Ongoing care in the community or hospital setting is extremely costly, and early demise is the norm. 


"Our experience shows that with attention to detail, these patients (heaviest BMI 131) can be safely managed through surgical intervention" Shaw Somers

The complex aetiology of such extreme obesity demands comprehensive multidisciplinary assessment. All patients require the involvement of the extended bariatric team in order to manage the physical and psychological preparation for intervention. Most will require a prolonged period of preparative treatment that might include a temporising weight-loss intervention, such as an intra-gastric balloon.

Co-morbidities are often challenging and sometimes unexpected in nature. Their intensive correction is the cornerstone of safe surgical intervention.Familiarity of the entire Bariatric team with the needs of this patient group is vital. Patient mobilisation and handling protocols are taken to a ‘special level’ in order to ensure patient and staff safety. Infrastructure issues, such as furniture, toileting and operative equipment need to be addressed.


Over the past 12 years, our centre has accumulated experience of surgery in over 300 patients with BMI >60. Our experience shows that with attention to detail, these patients (heaviest BMI 131) can be safely managed through surgical intervention. Application of the same operative decision algorithms can result in similar outcomes of percentage excess weight loss as for standard Bariatric patients. We have undertaken RYBG (open or laparoscopic) in 93%, LAGB in 5% and Sleeve gastrectomy in 2% patients.

Mortality occurred in 3 patients, all secondary to advanced co-morbidity. Complications occurred in 11%, mostly co-morbidity related (cardio-respiratory). Hospital stay was a median of 7 days, but this was skewed due to mobilisation / discharge issues rather than true post surgical recovery. Post discharge, all patients had primary care management plans including prolonged DVT prophylaxis.


Plastic surgery should be considered an essential part of Bariatric management in this group of patients." Shaw Somers

Results at one year (median 48% excess weight loss) might at first seem disappointing. However, in this patient group, this represents a massive amount of weight lost. It does leave a considerable residual excess weight, which many patients wish to lose. The concept of a single operative solution for these patients may not be valid.

Revision or second-hit surgery is becoming more common in this group and can result in further weight loss. In our series, over 10% patients (and rising) return for a second procedure to achieve further weight loss. However, the ability to undertake these secondary procedures is hampered by lack of NHS funding (or understanding) for this approach.


Massive weight loss always results in extreme skin redundancy, which in itself causes morbidity and contributes to residual weight. Plastic surgery should be considered an essential part of Bariatric management in this group of patients.


Our experience has taught us that these patients deserve management by units experienced in their care. The results are cost-effective and life-changing for these utterly debilitated patients.