Thursday, May 15, 2008
Over a 100,000 weight loss operations are performed in the United States every year. It is an operation that is the only proven solution to the complications of refractory morbid obesity, aka the "metabolic syndrome". There are many surgical options including lap bands, laparoscopic roux-enY gastric bypass, duodenal switch, and sleeve gastrectomy.
The most common one performed for morbid obesity is the Roux-en Y, usually performed laparoscopically. As everyone knows, this is a difficult operation and the learning curve is steep. In the wild west early days, the complication rates were astoundingly high. Leak rates of 8-20% were described. Patients died. It was a dangerous endeavor. Nowadays, as residents and fellows are learning the procedure from seasoned specialists, the morbidity of the operation is much more palatable.
But it's still a rather new operation, relatively speaking. Long term complications are still being delineated. I saw a young woman yesterday ER who had a Roux-en-Y done in Oregon exactly one year ago. She presented with an acute onset of severe abdominal pain and nausea. A CT scan suggested free air. I took her for emergent laparotomy and the perforation was at the anterior surface of the gastrojejunostomy. She had formed a "marginal ulcer" after the surgery which, over the subsequent months, ultimately eroded through the full thickness of the jejunal limb. Since the gastric pouch was already so small, I had to simply Graham patch the hole, as if it were a perforated duodenal bulb ulcer. I also placed a gastrostomy tube into the gastric remnant, in case she needs enteral feeding access in the future. Drains were placed in the upper abdomen and I got out. I didn't do it laparoscopically, but I think it was the right thing to do. Long term, she's going to need treatment with proton pump inhibitors and endoscopic surveillance of the ulcer. Stricture is a definite possibility in the future.
Even though most general surgeons do not actually perform weight loss surgery, it's important to be familiar with the anatomic alterations of all the bariatric variations. You never know when someone is going to turn up in your ER with free air.