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A Challenging Laparoscopic Gastric Bypass Case

Tue, 05/24/2011 - 5:36am
Twelve years of doing laparoscopic weight loss surgery permits a surgeon to have a robust series of memorable cases. The challenge of performing complex digestive surgery through tiny holes in very big patients never really gets old.

By Alfons Pomp, MD, FACS, FRCSC
Leon C. Hirsch Professor,
Vice Chairman, Department of Surgery,
Chief, Section of Laparoscopic and Bariatric Surgery                                    
Weill Medical College of Cornell University
New York Presbyterian Hospital

May 23, 2011

Twelve years of doing laparoscopic weight loss surgery permits a surgeon to have a robust series of memorable cases. The challenge of performing complex digestive surgery through tiny holes in very big patients never really gets old.

One case that I recall for a number of reasons happened a few years ago but taught me several lessons. “Mike” came to see me with his wife who was morbidly obese; she had done a great deal of online research and was considering the laparoscopic adjustable band and he had decided to have surgery before her. The family business was wholesale ice cream distributing and we had some fun together discussing just how much of their products they were actually sampling; we then decided on a laparoscopic gastric bypass in spite of the higher risk, given this might have a better effect on weight loss because of the unpleasant side effects (“dumping”) bypass can provoke when patients consume foods with high sugar or fat contents like ice cream.

The initial surgery was uneventful and on his 4 week post-operative visit I was rewarded with some Ben and Jerry’s and Mike with a 25 pound weight loss. One week later, however, he presented to the emergency room with an acute onset of bloody vomiting. Endoscopy showed a very large ulcer in the small gastric pouch. In spite of optimal medical treatment, a few days later while still in the hospital, he had a massive re-bleed. I remember pushing his bed up to surgery leaving his tearful wife behind in the ICU waiting room.  In the operating room I had no other choice but to redo the entire proximal part of the surgery in an unstable patient. With great help from my residents, anesthesia and the nurses I was able to do this laparoscopically.

The next few days were dicey, to say the least, and only Mike’s wife spent more time in the hospital than I did. More than once she alluded to the fact that had he had “band surgery” things would have been better, but that she herself would never, ever, have weight loss surgery of any kind. Fortunately things turned out for the best and Mike’s weight loss after his discharge was substantial, more than 100 pounds. As an added bonus he had complete remission of his diabetes, high blood pressure and cholesterol problems. I was surprised however when his wife requested that I do her laparoscopic gastric bypass a year later. I asked her why and she responded “Mike may have risked a great deal when he decided to have the surgery, but now he is reaping the rewards; more importantly when things went bad you were always there. I know that you are a good surgeon, but I also know that should things not go well you will be there to fix them”. Not without some trepidation I brought her to surgery.

Fortunately things did go well, her post-operative course was uneventful and weight loss substantial. From Mike and his wife I learned a great deal about how patient’s perception is colored not only the final results of surgery but by how his surgeon reacts to bumps on the road. Being available and honest interaction with the patient (and their family) is truly the best medicine. Being part of a great team in the operating room and elsewhere in the hospital can truly save lives, especially when things take a turn for the worse.

Bariatric surgery is unique for the long term interaction we have with our patients. I have seen obese diabetics trim down to run the New York Marathon. A corpulent chartered accountant took a huge pay cut to fulfill a lifelong dream of becoming an EMS now that she could fit in the ambulance (and this just before 9/11…did she get her money’s worth!).

Curiously there are many, many, heavy moms who are ecstatic that they could finally ride the roller coasters in theme parks with their kids instead of being forced to wait outside. Hundreds of my patients have resolved thousands of their illnesses with their weight loss and are enjoying life with the overriding theme of “I never knew just how ill I was until now I am healthy again”. 

When they thank me I usually repeat what I believe; “I gave you the tools and the raw materials; but you took the chance, made the effort and built the house”. The technical challenge of these operations is certainly enjoyable, but seeing patients during office hours never fails to remind me why I do this kind of surgery.

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