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HISTORY OF PRESENT ILLNESS: In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. He is also an ex-smoker. He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on.

PHYSICAL EXAMINATION: On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. His pulse is 78, temperature is 97.5, blood pressure is 132/74. Lungs are clear. He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. Abdomen is soft, nontender. No incisions. No umbilical hernia, no groin hernia, has a large abdominal pannus. No hepatosplenomegaly. Lower extremities; no pedal edema. No calf tenderness. Deep tendon reflexes are normal. Lungs are clear. S1, S2 is heard. Regular rate and rhythm.

DISCUSSION: I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed.

All these are going to be at high risk for this patient secondary to his supermorbid obese condition.

I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period.

Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient. The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. He will be seen by cardiologist, pulmonologist. He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities. He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success.

Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox. He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so. All these were discussed with the patient. The patient understands. He wants to go to surgery. All questions were answered. I will see him in few weeks before the planned date of surgery.

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