Transition of care in a case of obesity with metabolic surgery

The World Health Summit 2011 confirmed the epidemic-like occurrence of diabetes mellitus and obesity. In Germany, 62.7 % and 21.9 % of the population have a BMI of more than 25 kg/m² and more than 30 kg/m², respectively. Currently, 10.5 obese people per 100 000 German inhabitants undergo bariatric surgery, while 86 and 114.8 per 100 000 in France and in Sweden, respectively, favor bariatric surgical interventions.

By means of a scientific case report, the instructive case of a young patient with morbid obesity is illustrated based on 1) selective references from the medical literature and 2) insights from the daily clinical practice in the case-specific medical and perioperative management after successful surgery for malformation in his childhood and, thus, the limited therapeutic options of metabolic surgery.

35-year-old patient with morbid obesity. Medical history: Status after surgical intervention for gastroschisis as a newborn (surgery report not available). Clinical findings: Super obesity characterized by 234 kg and 174 cm (→ BMI: 77.3 kg/m²), hypogonadotrophic hypogonadism. Approach & course: · Initial treatment with gastric balloon followed by a weight reduction of 46 kg within the first 6 months; however, despite weight reduction, development of an insulin-dependent diabetes with insulin resistance from a diet-based diabetes;. · Repeat gastric balloon therapy for "bridging" but with no further weight reduction despite additional administration of GLP-1 analogues.. · Surgical intervention: Removal of the balloon - termination because of excessive adhesions to the liver and spleen as well as filiforme hepatic lesions (histopathology: liver hamartoma). Open surgery: extensive adhesiolysis because of previous pediatric surgery for gastroschisis, including associated non-rotation of the intestine with complete right-sided position of the intestine (left side: colon; right flexure: at infralienal position) prompting single-anastomosis duodeno-ileostomy (SADI)-procedure, leaving the stomach in situ with simultaneous cholecystectomy and herniotomy in sublay technique.. Outcome (early postoperative and mid- to long-term): The patient tolerated the intervention well. Postoperative course was uneventful with regard to mobilization, beginning of oral nutrition, and wound healing; there was a subsequent weight reduction due to a "common channel" of 250 cm.

While the increase of obesity prevalence in adults has currently stopped, incidence in children and teenagers is rapidly rising. The consequence might be that children and young adults who have undergone bariatric surgery in childhood and adolescence can develop complications from these former interventions as adults. Therefore, it is reasonable to recommend follow-up investigations within specialized centers according to well-established standards. On the other hand, the increasing prevalence of obesity in childhood leads to the possibility that adults who underwent pediatric surgery because of embryonal malformations may require an appointment with a bariatric surgeon at some point. For these patients (as a representative example of the transition of care phenomenon), the risk of metabolic surgical intervention is increased; such operations require the appropriate knowledge and expertise of the bariatric surgeon on embryonal malformations and their approach by pediatric surgery.