Morbid obesity is a growing health problem that results in many health risks, besides the decrease in life expectancy. People who have morbid obesity may develop several cardiovascular complications besides metabolic, respiratory, endocrinological, and surgical ones, among others.

The fat distribution also has an important role in the increase of diseases, in particular:
- Central or abdominal obesity increases the risk of coronary diseases, cerebral vascular accidents, systemic arterial hypertension, non-insulin dependent mellitus diabetes, and premature death.
- Visceral obesity has been correlated with increase in cancer risk in the breast, cervix, ovary endometrium, rectal colon, (low fiber content and high rate of animal fat diet and prostrate).

Cardiovascular Diseases

Obese patients are subject to not only structural but also functional cardiac abnormalities. The most frequent are coronary alterations, arterial hypertension and VE mass increase (eccentric hypertrophy). The high mass rate is correlated to increase in VE mass, even when adjusted to the age and arterial pressure.

The obese cardiopathy is characterized by:
1. Increase in cardiac effort
2. Increase in ventricular volume
3. Left ventricle hypertrophy (eccentric or concentric)

We point out that homodynamic disorders, cardiac effort, oxygen consumption and blood volume directly increase weight gain. The increase in diastolic pressure in VE and the obese hypoventilation syndrome can cause pulmonary hypertension.
The relation between obesity and coronary arterial disease is not very clear, even though studies, such as Framingham’s, point to obesity as risk factor to it, independent of other supporting factors (arterial hypertension, hyperlipidemia, non-insulin dependent mellitus diabetes).

The risk of systemic arterial hypertension development in previously normal blood pressure people is proportional to the weight gain. With the increase in the arterial pressure the VE hypertrophy development can happen with consequent cardiac insufficiency.

The association between hypercholesterolemia and CAD (coronary arterial disease) is well known, and is an evidence that it is a little smaller between these factors, and obesity also exists. Besides being modest, the increase in cholesterol LDL with weight gain, hypertrigliceridemia and VLDL metabolism alterations appear frequently.
Hyperinsulinemia also contributes to hepatic growth of the lipoprotein synthesis, resulting in a decrease in HDL cholesterol (good) and consequently increase in CAD risk.

Respiratory complications happen as consequence of increased respiratory effort and decrease in the functional reservation capacity. The fat accumulation in the thoracic trunk and abdominal wall reduces the total respiratory capacity in 60%, but ventilation/minute, Oxygen consumption and carbon dioxide production are increased.

When subjected to spirometry, the pulmonary total and vital capacity are frequently reduced as well as the expiratory reservation volume.

Sleep apnea when present may be of obstructive, central or mixed origin. An increase in the pharynx larynx muscles relaxation and/or abnormalities in the respiratory control can be found in these patients. Hyper somnolence is a morbid obese characteristic and it is frequently associated with apnea during sleep (PICKWICK SINDROME), which can become a medical emergency.

Obese patients correspond to 80% of patients with non-insulin dependent mellitus diabetes. The increase in fat cells expresses decrease of insulin receptors in the cell’s surface, which associated with an abnormality of post receptors that is manifested with altered glucose utilization, results in an insulin resistance or hiperinsulinemia. The obesity rate correlates directly to the risk to develop non-insulin dependent mellitus diabetes. Overweight patients have twice as much risk to develop NIDMD while overweight patients (BMI>40) ten times as much.

Other abnormalities include: decrease in estradiol and estrogen levels in obese women, excretion of increased urinary hydroxicorticoid 17, plasmatic levels of cortisol decreased or increased, with possible development of the Cushing disease, and decreased secretion of growth hormone.

EHepatic Steatosis (fat deposit in the liver) is present in 60% to 90% of obese patients, and the hepatic fibrosis occurs in a small percentage, showing that the hepatic function is usually normal.
An increased lipid production associated with a biliary secretion increase is responsible for the biliary lithiasis formation situation in 30% of patients.

Renal diseases (nephropathies) accompanied by proteinuria, menstrual abnormalities with anovulatory cycles, metrorrhagy (dysfunctional uterine bleeding), hirsurtism (abnormal growth of faneros-hair), infertility and precocious menopause are observed in obese women. Also in these is the increased risk of eclampsia, pre-eclampsia, gestational diabetes, and cesarean necessity.

Arthralgia and arthritis are frequently found (known risk of knee arthritis). It is not uncommon to find abnormalities in the lumbar column, as well as lordosis, scoliosis and kyphosis.
The incidence of hyperurecemia and gout also increase with weight gain.
Peripheral vascular insufficiency appears in 1/3 of patients represented by varicose and okra dermatitis. Leg ulcers and the development of DVT (deep vein thrombosis) also have their risk increased.

Obese patients have an increased risk of secondary post surgical complications, which are divided into anesthetic, intra surgical and post surgical.

The cardiac function compromised by obesity, added to the surgical stress, anesthesia, and increased respiratory effort or chronic pulmonary disease, contributes to an increase in surgical mortality in patients subjected to bariatric surgery.

Prospective studies have found strong association between obesity and post surgical pulmonary complications, in particular TEP risks, infection risk, wall dehiscence and incision hernias.

MANY MEDICAL COMPLICATIONS GET BETTER OR EVEN DISAPPEAR WITH APPROPRIATE WEIGHT LOSS AFTER bariatric SURGERY, BESIDES THE ADDITIONAL BENEFIT IN THE PSYCHOLOGICAL AND SOCIAL ASPECTS.

From the cardiovascular point of view, the weight reduction through surgery is associated to improvement in the cardiac systolic function, a decrease in the width of the walls with improvement in the ejective volume. There is also reduction in the arterial levels and lipids.

Patients with intolerance to carbohydrates or DMNID end up reversing the abnormalities in 86% of patients after gastric bypass.
Pulmonary hypertension, sleep apnea and total respiratory volume also have great improvement. Hepatic Steatosis, infertility and stress, urinary incontinence in women also recede after significant weight loss.

Important improvement in the quality of life of obese patients after bariatric procedures happens and by itself justifies surgery.