Be Fast without Hurrying Up

| October 14, 2011

Dear friends and colleagues:

I am happy to report that the American Society for Metabolic and Bariatric Surgery (ASMBS) second annual Fall Educational Event, September 23–24, 2011, in Chicago, Illinois, was a great success. I foresee this meeting gaining popularity in years to come as we move the annual ASMBS conference to the month of November starting in 2013, joining The Obesity Society (TOS) meeting, which will take place in Atlanta, Georgia.

We are already feeling the effects of “Hurricane Robin,” as she directs ASMBS efforts to improve access for our patients. Also on her agenda is establishing a unified strategy between the Surgical Review Corporation (SRC) and American College of Surgeons (ACS) to develop a more inclusive policy for the Centers of Excellence accreditation process, maintaining the highest standards in bariatric care. Read this month’s ASMBS News and Update for the latest information.

In this issue of Bariatric Times, we present a review by Kim Delamont entitled, “Clinical considerations and recommendations for pregnancy after bariatric surgery.” As surgeons and allied professionals in the bariatric field, we have seen a number of patients become pregnant after bariatric procedures, despite warnings about the potential negative impact of pregnancy on weight loss and resolution of comorbidities. In my opinion (with no scientific evidence to support it), it does not make sense for a patient to become pregnant shortly after having bariatric surgery while she is losing weight. There have been little scientific data published regarding this topic, and when I discussed it with the gynecologists/endocrinologists at my facility, they could not list a good explanation for the lack of study. This is indeed a topic to explore and research since we are all aware of the benefits of bariatric surgery enabling patients with polycystic ovarian syndrome to resume their regular periods and become fertile. Increased libido due to rapid weight loss after bariatric surgery might also be influencing the incidence of pregnancy in this patient population.

During Digestive Disease Week (DDW), May 7–10, 2011, in Chicago, Illinois, Dr. Michael Sarr mentioned to me that he had an interesting case of noninsulinoma pancreatogenous hypoglycemia (NIPH) after Roux-en-Y gastric bypass (RYGB) and that he performed an unusual reconstruction of the gastrointestinal (GI) tract. I thought it was a terrific idea to make a difficult procedure, such as a reversal, into a simple one for this kind of complex situation. In this month’s installment of “Surgical Pearls: Techniques in Bariatric Surgery,” Dr. Sarr shares his technique. Management of hypoglycemia can become a nightmare for the bariatric surgeon “on call.” Causes include NIPH and dumping syndrome in patients who are both adherent and nonadherent to their diet restrictions after bariatric surgery. My strategy is to first admit the patient into the hospital and then monitor his or her blood sugarwhile encouraging the patient to eat the prescribed diet in the hospital. This approach works in a handful of cases because it allows you to observe whether a patient is adhering to the diet. If this does not work, my colleagues and I recommend placing a G Tube into the gastric remnant and feeding the patient through it. If this maneuver resolves the episodes of hypoglycemia, then the procedure Dr. Sarr describes or complete reversal is indicated. It is important to remember that hypoglycemia can become a life-threatening situation if not properly managed.

I am excited to welcome a new column to Bariatric Times edited by Dr. Stephanie Jones entitled “Anesthetic Aspects of Bariatric Surgery.” The first installment is a report on the anesthesia session at the XVI World Congress of The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), August 31 to September 3, 2011, in Hamburg, Germany. I personally do not believe in fast-track medicine nor do I believe that patients should be sent home the day after undergoing a gastric bypass. My professor in Germany used to say, “Be fast without hurrying up.” This instruction should apply not only during operating, but also when discharging patients. In an article recently published in Obesity Surgery, my colleagues and I documented that tachycardia related to bleeding starts eight hours after a procedure, while the tachycardia related to leaks starts, on average, 20 hours after surgery. This tells us that the trouble can start after the patients are sent home.

In this month’s installment of “The Hole in the Wall,” Drs. Kligman and Lo Menzo present a nice review on ventral hernias in bariatric patients. In their conclusion, Kligman and Lo Menzo state, “the lowest recurrence and complication rates will be achieved if the hernia repair can be deferred until the patient reaches a stable weight.” I would like to add to this conclusion: When it comes to ventral hernias, “size matters.” We can watch and defer when a patient has a large ventral hernia, but little ventral hernias, including umbilical hernias, must be repaired at the time of surgery. Bowel obstruction and “blow out” of anastomosis can be a dreadful complication if not repaired. Two of my worse complications in bariatric surgery were due to a loop of bowel that herniated in a trocar site and in an umbilical hernia that was not repaired.

Finally, I express sincere condolences to the family of Dr. Alex McGregor, the 10th past president of the ASMBS, who passed on September 11, 2011, at his home in Gainsville, Florida. Dr. McGregor was originally from Dundeee, Scotland, and had been an Associate Professor of Surgery, Shands HealthCare, University of Florida Health Science Center, Gainesville, Florida, since 1971. Besides his passion for surgery and his family, he enjoyed sports, music, sailing, photography, and raising orchids. Dr. McGregor’s contributions to medicine and surgery can be highlighted in some of the comments made by his peers and friends

“Alex made many contributions to the founding of bariatric surgery as we know it today. He not only was a great surgeon and a mentor, but taught us all what it meant to be a gentleman. He will be missed by all.” -Dr. Neil Hutcher

“We shared many grand times together. Alex’s devotion to helping our patients solve their problems never ceased and will continue to benefit millions of lives. We did not know when we began how great the need would be. Thank you, Alex, Christine, family, and team. Love to all who shared and continue to share Alex’s life.” -Dr. Ed Mason.

I hope you enjoy this issue of Bariatric Times. I look forward to seeing you at the 97th annual ACS Clinical Congress, October 23 to 27, 2011 in San Francisco, California.

Sincerely,

Raul J. Rosenthal, MD, FACS
Editor, Bariatric Times

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