Interesting Cases Encountered During Fellowship

| March 1, 2015

This column aims to educate individuals and organizations about the importance of the work that the Foundation for Surgical Fellowships is doing to ensure the funding that leads to the innovative training for surgeons to apply the principles of advanced surgical techniques in patient care.

This month:
by Matthew O. Hubbard, MD, MS, and Caitlin Halbert, DO, MS

Dr. Matthew Hubbard is currently working to complete a Bariatric Fellowship under the direction of Ronald H. Clements, MD, at Vanderbilt University in Nashville, Tennessee. Dr. Halbert is currently working to complete a Bariatric Fellowship under the direction of Aurora D. Pryor, MD, at Stony Brook University Medical Center, Stony Brook, New York.

Bariatric Times. 2015;12(3):18–19.

Entry #1:
Matthew O. Hubbard, MD, MS
As a bariatric fellow most of my days are routine. Two or three surgeries are performed, perhaps a few gastric bypasses or sleeve gastrectomies. On other days I may see patients in an outpatient setting, either in an endoscopy suite or the clinic. The treatment of my patients and surgeries I perform have standard protocols. Having respect for each patient’s unique personality and journey to bariatric surgery is important, but for the most part the actual surgical decision-making follows a well-worn path.

We all occasionally come across a patient who tests our mettle with respect to surgical planning, diagnostic acumen, and bedside manner. A patient such as this can be upsetting for any number of reasons. First of all, treading outside of your comfort zone in the clinic or the operating room can be stressful. Secondly, this patient likely has been passed around the local medical community because his or her problem is challenging to most practitioners, which probably has led to a general frustration with the medical community from the patient’s point of view. Lastly, the challenging patient often comes to an academic surgery program for treatment because he or she needs re-operative surgery, a challenge that no surgeon takes lightly.

Recently, a middle-aged man presented to our clinic for evaluation for revision of his sleeve gastrectomy, which was performed many years ago. He had been suffering for a few years with dysphagia that had progressed to regurgitation and subsequent weight loss. This patient consulted with multiple surgeons who all offered him different surgical plans. He also went to multiple gastroenterologists, some who dilated his gastroesophageal (GE) junction, but none of whom could offer a solution to his problem.

When we first saw this patient, we could not quite understand what was going on. After performing an esophagram we were able to make the diagnosis of achalasia. Achalasiaa is a disorder in which the lower esophageal sphincter (LES) fails to relax properly, making it difficult for food and liquids to reach the stomach.

Unfortunately, our patient’s esophagus had become quite dilated and aperistaltic. We offered him a conversion to a Roux-en-Y gastric bypass (RYGB) and concomitant Heller myotomy, a surgical procedure in which the muscles of the cardia (lower esophageal sphincter) are cut, allowing food and liquids to pass to the stomach., which he accepted. After a short resolution of his symptoms, the nausea and regurgitation resumed. While his LES was patent on endoscopy, his esophagus had become non-functional. Currently, he is awaiting an esophageal replacement procedure (likely with colon interposition), and is being fed via a jejunal feeding tube. It’s interesting that this patient who has had two separate bariatric surgical procedures is likely going to have a hard time meeting his nutritional requirements enterally for the rest of his life.
We can never be sure about whether this patient’s achalasia developed because of a high-pressure zone distal to the LES from the sleeve gastrectomy anatomy, or was a de novo presentation of latent achalasia that was not yet symptomatic when he had his original sleeve gastrectomy.  A case like this, which makes one wonder if all of the surgeons who tried to help this patient did him any good, can be frustrating; however, a case like this can also provide inspiration. When faced with a difficult case, it’s important to pause and consider how you can learn from the experience. Most patients’ cases don’t offer you a chance to critically examine the thought process, work-up, surgical procedure, or recovery. When, despite our best efforts, a failure occurs, an opportunity is created for us to identify areas of physiology with which we aren’t familiar, improve surgical techniques, and discover new and better ways to educate our patients.

Perhaps the most rewarding thing I learned from this patient came from our interactions postoperatively. One might think that this patient would have developed a distrustful attitude toward surgeons, and who could blame him? Yet every day he greeted me with a smile, a handshake, or a hug. He appreciated the fact that we were honest with him regarding our difficulty in making the proper diagnosis, and he appreciated our concern that, despite a revisional surgery, his symptoms might not resolve. We didn’t always know what was right or best for this patient, but we gained his respect and trust by being honest about our failures, and by letting him know that we would support him through his entire journey.

Entry #2: Caitlin A. Halbert, DO, MS
After reaching the halfway mark of my Bariatric/MIS fellowship in January 2015, I am thankful for the variety of procedures and patients to which I have been exposed. While my confidence is growing, there are still those cases that intimidate me. It is not entirely the technical aspect that is so humbling, but rather the patients behind the operation. Their stories and struggles are what truly make this profession both interesting and rewarding. For this entry, I wanted to share the case of one patient whom I was fortunate to take care of alongside Dr. Pryor.

I met this young woman a few months previously who was just on the eve of her 21st birthday. She had struggled with her weight for her entire life, leading her to undergo laparoscopic sleeve gastrectomy at another institution about a year before I met her. She was a thin, pale ghost of her former self. Her hair was falling out and her skin was dry and scaly. She was scared of doctors and hospitals, and for good reason. Her original surgery was complicated by a gastric leak that went undiagnosed for weeks. She spent the following months in and out of the hospital. At one point, she was in the intensive care unit when she developed sepsis from a peripherally inserted central catheter (PICC) line infection. She came to us after developing a significant stricture from an esophageal stent. We could immediately see that she was desperate to feel better and to rejoin her life. After a series of pneumatic dilations, her esophageal stricture became widely patent.

To our dismay, her symptoms did not resolve. On esophagogastroduodenoscopy (EGD), we found that she had a significantly narrowed sleeve at roughly the incisura angularis, possibly a finding that contributed to her leak. We had a long discussion with the patient and her family recommending revisional surgery to gastric bypass. The day of her surgery quickly came. She cried as she fell asleep on the table, fearful of undergoing yet another procedure, but hopeful that this would be her last. I felt a huge responsibility for this young girl.

During surgery we stayed calm and focused on the task at hand, and though challenging, the surgery was technically successful. I was, however, anxious to start our patient on her diet.
On postoperative Day 2, I visited her, and she was beaming—she could drink without pain and without nausea or vomiting! It was then that I realized the surgery was truly successful, beyond the technical achievement.

The case of this young woman piqued my interest in revisional bariatric surgery. The stories are compelling. For example, consider the patient whose bypass procedure has herniated into her mediastinum or the patient who develops significant stricture after a vertical banded gastroplasty. Cases such as these are challenging and stressful to the bariatric team and patient, and the risks are high. But to be able to successfully help a patient regain his or her health and quality of life is a tremendous reward that is afforded to those in this specialty.

Funding: No funding was provided for this article.

Financial disclosures: The authors report no conflicts of interest relevant to the content of this article.

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Category: Past Articles, Spotlight on Surgical Fellowships

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