DON’T SUGARCOAT ADIPOSE
Written by Dr. Geeta Sundar
I had a colleague in my undergrad days who paid extreme heightened details to everything she ate. Each morsel was measured. Each bite was only allowed passage into her mouth if she really found it significant. I was amazed at her control, and very keen to know why she did what she did, especially since it was so hard for me to have a figure as hers.
“Thin people hardly suffer, Geeta. Look around you, each comorbid condition we ever know is all related to fat. Hypertension, Diabetes, Osteoporosis, Metabolic Syndrome X, IHD, Hyperlipidemia…”, she rattled the diseases ticking one on each finger. “I can’t be fat. I won’t be fat. I’ll do whatever it takes to maintain my figure and my health.”
It’s been a decade since that conversation, and each time I see obese patients, I think back to what she said, and am amazed to see a new perspective of that sentence which develops in my mind.
From a surgeon’s perspective, fat is never good – those patients are very difficult to shift from one trolley to the other, difficult to intubate, most have OSA, or snoring that causes issues with anesthesia, have lower respiratory drive, restrictive pattern of lung disease, hypoventilation syndromes, often develop atelectasis postoperatively, usually have uncontrolled sugars, need higher insulin doses due to increased resistance, develop seromas and infections at higher rates, mobilize slowly, likely to develop DVT, and many more…
But in neurosurgery, I have seen a whole new scenario, especially when it comes to workup and improvement after surgery. We deal with usually 2 kinds of obese individuals in neurosurgery – the kind that have chronic back aches with some form of compressive myelo/radiculopathy that entails need for surgery or Cushing’s with pituitary adenomas.
A laminectomy, discectomy, or an instrumentation procedure is a surgeon’s joy to perform when the back is devoid of harsh rubbery, stubborn and stiff fat. The dissection planes are cleaner, and normally takes less than 30 minutes to reach the laminae. But the moment the blubbery fat is there, accept that surgery will take at least 2 hours longer. Prone positioning has to be triple careful, to avoid ileus and venous congestion, retraction is tougher, cautery burns at higher rates, and longer times, with hazardous smoke let offs, the fat leaks a lot of oily material when monopolar is used that coats the surfaces and makes nibbling harder, and planes to dissect, place the implants and perform an uneventful surgery gets steeper.
As a lay person who hasn’t entered a neurosurgical operation theatre, you know not of the stress and bullets of sweat that coats a neurosurgeon’s mind, head, arm, palms. You know not of the responsibility he/she carries to ensure nothing happens to that sweet little thecal sac and your spinal roots and nerves. You know nothing of the magnificent task he/she is overtaking so you can wake up in one complete swell piece of adipose and move all the hands, legs, fingers and toes. And whatever money you are paying him/her, trust me, it’s not enough, and will not be enough as he/she puts their reputation, experience, humanity, compassion on the line.
Healing is poor too, the icing on the cake! In patients who are obese, wound leak is a pattern of uniformity, and more so in those where dissection planes were harder to acquire and in whom the surgery lasted far longer than anticipated.
For many Indians, weight is a sensitive topic. And whilst some are very graciously aware of the facts and cons of being fat, and work at maintaining a decorum of a diet and exercise regime, there are many, far many who don’t care about their appearance or the fact that the butter they eat is clogging their arteries, and adding heaps of yellow-orange fat that is really harmful. And it’s the latter who pose the main problem, who give up in seconds when the going gets tough and dieting or exercising is all that’s left. Fat to fit is never easy, anyone will tell you!
I hope not to start a ridicule of a debate where one mentions feminism and shouts in slogans of “love thy body”, “we are beautiful” etc, but I merely wish to emphasize on the gigantic responsibility one entrusts their surgeon with when going under a knife, any knife for that matter. And I also don’t want to support any naysayers who mention that surgeons have to be trained to deal with all shapes and size of patients; coz we are ready and we know how to deal with y’all, however a thinner, lean-built individual has a faster road to recovery.
Its not like being thin doesn’t have its own issues. From a neurosurgical aspect, I have seen patients suffer whiplash, cord injuries, fractures, subarachnoid, vascular malformations, subdural bleeds far more than people whose BMI was higher. I guess it all has to do with one’s center of gravity and how we displace ourselves in momentum, in inertia, in rotational forces and the blood flow dynamics. Maybe physics does have a bigger role to play in trauma dynamics, after all.
Moderate is the best then, BMI bang right in the middle of the range, with enough fat for cushion and insulation, to withstand a high intensity trauma and not so much disastrous fat that a neurosurgeon attacking your pedicle would moan about.
