Welcome to the August 2010 issue of Bariatric Times! Two very interesting articles, a difficult case presentation, and the 2010 Buyers Guide are the core contents of this month’s issue.
First, I’d like to comment on an excellent review article on bariatric surgery in adolescents presented by Dr. Daniel DeUgarte. I respectfully disagree with some of the comments made by the author regarding patient and procedure selection. I personally do not follow the revised National Institutes of Health (NIH) adult guidelines when performing bariatric surgery in adolescents. I follow the American College of Surgeons (ACS) guidelines instead, which state that body mass index (BMI) must be greater than 50kg/m2 with serious comorbidities. Although morbid obesity is a disease that will result in long-term, severe morbidity and mortality, in my opinion, the early presentation of the disease does not require a surgical approach. In fact, surgery should be last on our list.
Main concerns and questions I try to address with the parents when choosing the type of procedure include the following:
1. Has this child achieved bone maturity?
2. How serious are the comorbidities?
3. Do the parents have morbid obesity as well?
4. Why has the child decided to consider surgery?
5. Is this a parent-driven choice?
As far as procedure choice, adjustable gastric banding continues to be my first choice in the early stages of adolescence and I tend to recommend gastric bypass or sleeve gastrectomy in late stages, such as 17 or 18 years of age. Why? Besides the previously mentioned issue of bone maturity and ability of the child to make lifestyle changes, I worry about dealing with parents and an adolescent patient if the patient develops a serious complication, such as a leak, stricture, marginal ulceration, or chronic abdominal pain following a procedure like a sleeve gastrectomy or gastric bypass.
The youngest child I operated on was a 12-year-old boy with a BMI of 56kg/m2, arterial hypertension, osteoarthritis, and depression. Two years after a “gorgeous” sleeve gastrectomy, this child had regained 60 percent of the weight loss and his mother (a former bariatric patient) was requesting a gastric bypass. I declined to pursue with a second approach until the child reached adulthood when I felt he would be more likely to adhere to lifestyle changes and understand the risks and benefits of further surgery.
Dr. DeUgarte makes a very important comment in his article that I strongly support. He says that it is often the perception of patients and insurance carriers that bands are “less invasive” and “reversible.” I question those who market this procedure as such knowing that reversibility will invariably result in nearly complete weight regain and recurrence of comorbidity and that such a pathway requires two surgeries, which will leave scars and anatomical changes in the gastroesophageal junction that are difficult and dangerous to deal with when attempting a conversion.
Also in this issue, Dr. Holly Thompson presents an interesting and controversial topic—the routine performance of a postoperative upper gastrointestinal (UGI) series in patients undergoing gastric bypass. In this article, the main concern is detection of anastomotic leaks. The conclusion is that a prospective, randomized study comparing routine and selective UGI is needed to better answer this dilemma. We perform UGI series routinely on postoperative Day 1 in all patients after bariatric surgery regardless of the procedure—bands, sleeves, or bypasses. The detection of leaks is last on my list since they are extremely rare (less than 1%) and, as Dr. Thompson says, the clinical signs and symptoms should guide us, not whether the UGI is positive or negative for a leak. Why do we perform routine UGIs? We document the size of the sleeve, the size of the gastric pouch, and the position of the band; we mobilize patients out of bed early on by sending them down to radiology (prevention of deep venous thrombosis [(DVT)] and atelectasis); and, there is no better laxative than a swallow of gastrografin!
Finally, I’d like to make a brief comment on this month’s case in our column Ask the Experts: Dilemmas in Bariatric Surgery, with expert commentary by Dr. Gregg Jossart. One month ago I was consulted from an overseas colleague with this case and I felt since it is so complex I should share it with you. A 42-year-old man with morbid obesity and portal hypertension underwent a sleeve gastrectomy. He presented to the office eight weeks postoperatively with back and left shoulder pain that was treated with nonsteroidal anti-inflammatory drugs (NSAIDS). He underwent a computed tomography (CT) scan of the abdomen that showed two major staple line disruptions and corresponding cavities behind those leaks. He also presented with concomitant bleeding of a varicose vein in the gastric sleeve into one of the cavities. Clinically, he was compensated. The gastroenterologists could not place any kind of stent and they were not able to place a band over the bleeding vein.
Several issues have to be addressed in this case: 1) indications for bariatric surgery in cirrhotic patients, 2) the choice of a sleeve gastrectomy as a treatment option, 3) the management of staple line disruptions, and 4) the treatment of concomitant variceal bleeding from portal hypertension.
I encourage you to read Dr. Jossart’s approach to this conundrum as well as a follow up to what the surgeon did in this situation.
I hope you find the 2010 Buyers Guide to be a valuable tool over the next year and I hope you enjoy the articles in this issue as well!
Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times