Sunday, September 1, 2013

Minimally Invasive Surgery

      For the past month, I have been the intern on minimally invasive surgery.The surgeries that are done on the service are mostly bariatric surgeries, which include both gastric bypass aka the Roux-en-Y and the gastric sleeve. In order to qualify for bariatric surgery, a person's BMI must exceed 40 OR be over 35 with associated co-morbidities (health problems related to the obesity, which can include anything from diabetes to hypertension to sleep apnea, and so on). The patient is referred to the surgeons at this particular hospital by their primary care physicians, and they are required to attend an information session about the surgeries and the lifestyle changes the surgeries require before they even meet with the surgeon.
      Once the patient meets with the surgeon and the surgeon determines that they are a good candidate for bariatric surgery, the patient must decide what kind of bariatric surgery they desire. A majority of patients choose either the Roux- en- Y or the gastric sleeve, and there are differences between the two (the gastric band is hardly used anymore at this hospital because the weight loss is not as effective, and there are a lot of complications associated with it). There are two mechanisms by which people lose weight after bariatric surgery, restriction and malabsorption. The gastric bypass incorporates both of these components while the gastric sleeve and the gastric band incorporate only the restrictive component for weight loss.
      Restrictive procedures limit caloric intake by reducing the stomach's resovoir capacity. Malabsorptive procedures decrease the effectiveness of nutrient absorption by shortening the length of the functional small intestine. Although malabsorptive procedures cause profound weight loss, they also frequently cause protein deficiencies and vitamin malabsorption. The goal of bariatric surgery in general, is to reduce the morbidity and mortality associated with obesity, and improve organ function.
      Both the gastric sleeve and the Roux-en-Y can be done laparoscopically (or as a minimally invasive technique, which means reduced blood loss, lower incidence of incisional hernia, lower incidence of wound infection, faster recovery, and a shorter hospital stay ). In layman's terms, a Roux-en-Y entails decreasing the size of the stomach, and then dividing (the Y part) and reconnecting one part of the small intestine to the new smaller stomach and the other to an area closer to the area where the bigger leftover part of the stomach, pancreas, and liver drain. The small stomach that is left over can only hold about an ounce of food (eventually it stretches to hold a cup) and this causes early feelings of fullness and satiety. Additionally, less calories are consumed because food bypasses most of the stomach and the upper small intestine. This also causes improved metabolism by changing the release of different hormones that influence fullness and digestion.
      The gastric sleeve is formed by removing part of the stomach and re-shaping the remaining portion into a banana shape.This prevents the stomach from being able to stretch and eliminates most of the area where ghrelin (the hormone that causes hunger) resides. While the gastric sleeve is considered a safer operation than the gastric bypass because it is only restrictive as opposed to both restrictive and malabsorptive, it is also an irreversible procedure as opposed to a gastric bypass, which can be reversed if necessary.
      The big moral of the story is that obesity is a huge problem in our country and America spends around $100 billion dollars annually to treat it and its associated co-morbidities. While both of these procedures are done frequently, they are not operations that should be taken lightly, especially because there are many potential complications associated with them. Complications can occur for no reason, but some depend on how complaint the patient is with the pre-op and post-op protocols. In the hospital that I work in, the patient is required to meet with a nutritionist (for up to 6 months depending on the patient's insurance), get medical clearance from an internist, undergo a psychiatry clearance, attend 2 support groups at minimum, +/- other necessary hoops they must jump through in order to even be considered for the procedure. They must follow a high protein diet in order to shrink their liver pre-operatively (because many of them have fatty livers that will get in the surgeon's way in the OR), and are on a clear liquid diet for at least 2 weeks post-operatively before moving on to purees for an unset amount of time. Eventually, they will be able to eat real food, but only a few spoonfuls at a time.
     I think you would agree that given all of this information on bariatric surgery, I would be a little shocked by the following patient encounter that occurred last week:  I walk into one of my patient's rooms (a patient who had gastric bypass surgery the day before) just in time to see her taking a big bite of a Burger King whopper and then reaching for a milkshake to wash it down with.

            Me: "What is going on here? What are you doing? How did you get that?"
           Patient: "My boyfriend brought it for me."
           Me: "But why are you eating, you know you can't eat, you are supposed to be on clear liquids for 2 weeks."
           Patient (shrugging): "I know, but I got hungry."

      And this is what is wrong with society everybody. People believe they can have a drastic surgery and then resort right back to their old habits. Personally, if I were so concerned about my weight and obesity that I was going to have surgery to combat it (and have Medicaid pay for it I might add), I would at least follow the diet that goes along with it for the first DAY after surgery. But that is just me. I think I am becoming jaded.........especially because of the conversation I had shortly after that incident with my attending."

      Me: "Can you believe it? I just can't believe she would do this, I mean she was cleared by psych, she went to the education sessions and was deemed fit for the surgery. Clearly she wasn't fit."
     Attending (who is not half as shocked as I am): "I guess you just missed the girl who had Chinese food delivered to the hospital for herself last month and then complained she was too full to eat the whole thing."

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