Cath Lab Digest

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Index: Ostomy Wound Manage. 2008;54(1):20-32.

  A recent a random-digit telephone survey of US households by Sturm¹ (N = approximately 250,000) reported that the prevalence of morbid obesity as indicated by body mass index (BMI) >40 and >50 rose by 50% and 75%, respectively, between 2000 and 2005. This increase in the population of morbidly obese individuals is far greater than the 24% concurrently reported for the person classified as obese (BMI 30 to 40).¹ Patients presenting to the authors’ clinic reflect this trend, one with major implications for healthcare.

  Obesity increases body size. Limbs enlarge and redundant skin folds develop. Additional adipose tissue can interfere with the lymphatic system, exacerbating existing secondary lymphedema² or triggering it. In addition, patients with lipedema (a genetically linked disease that involves the pathological accumulation of fat on the lower body, most commonly observed in women^3,4 will eventually develop secondary lymphedema as fatty tissue occludes lymphatic channels.

Also, an overhanging pannus can worsen pre-existing venous insufficiency. Irregularly shaped extremities and the reality that obese patients are usually unable to don and doff garments unaided (even if they can be fitted properly) preclude compression garment use and reduced mobility further contributes to dependent fluid collection. The net result of all these factors is the increasing enlargement of the extremities of the obese individual, with varying degrees of lymphedema and venous insufficiency. Interestingly, the association between limb enlargement and excess weight has not previously been reported in the literature.

  Obesity is a known risk factor for many diseases; the importance of abdominal adiposity as a cause of metabolic syndrome and cardiovascular problems also has been recognized.^5,6 However, the unique issues related to obesity that affect the skin in general and the lower extremities in particular are rarely addressed from a medical or therapeutic standpoint. The purpose of this article is to review common concerns related to morbid obesity and interrelated lower extremity complications. Clinical presentations of lower extremity problems regularly encountered among morbidly obese patients illustrate the challenges of managing these conditions. It must be emphasized that in this particular population it is especially important that healthcare processes are patient-centered. In the authors’ experience, treating disease symptoms and complications separately does not yield positive outcomes.

Wound and Skin Infection

  Diabetes and bacteria. Morbidly obese patients have a 20% incidence of type 2 diabetes,^7-9 which, in addition to the difficulty of maintaining adequate hygiene, increases the likelihood of bacterial and fungal infection.^10-12 Because bacteria are known to contribute to the inflammatory process, excessive bioburden (organisms contaminating a wound, even in the absence of frank infection) can slow or prevent wound healing.^13,14 Figure 1 shows the neon green drainage characteristic of Pseudomonas, which can be challenging to eradicate in heavily draining wounds. Figure 2 shows a morbidly obese patient with secondary lymphedema and a large pyogenic granuloma on the posterior calf.