The Pledge

The Pledge.  Not THE Pledge, but The Pledge to treat Obesity seriously.

This was from a CME activity from the recent Obesity Week conference,  a place where the surgical (ASMBS) met the medical (the Obesity Society) at a recent, first-of-it's kind event.

I suspect you wouldn't be reading this Blog if you didn't take it seriously already, so I am kind of preaching to the choir, but I still thought this was worth putting up today as a gut-check as my Blog post of the week.

Marginal Ulcers: "Aren't Tylenol and Advil the Same Thing?"

Photo of Intraoperative Photo by M Clock

As you may see a recurrent theme in your practice from time to time, we do as well in Bariatric Surgery.  We've had a run on perforated Marginal Ulcers lately.  Three cases in the last few weeks to be exact.

I remember my days of Primary Care, and seeing what seemed like a cluster of Bell's Palsy, or Shingles, or DVT's -  things that you do see from time to time, but over a short interval, interacting with it more frequently than you would ordinarily expect to, given the relative scarcity of it as a common presentation averaged out over the longer haul of regular practice.

Marginal ulcers are not that infrequently seen, but perforated marginal ulcers are certainly less frequently encountered, but the natural end to a smoldering presentation of the former, a logical possible endpoint complicating the run-of-the-mill ulcer or pouch gastritits.

Marginal ulcers are frequently seen in the post Gastric Bypass population, and represent an ulcer of the gastric pouch or more commonly just distal to the gastro-jejunal anastamosis, in the Roux limb (the jejunal limb that connects to the gastric pouch).  The most common presentation is ongoing epigastric abdominal pain, similar to what you may expect for how PUD would present.

The most common risk factors are NSAIDs smoking, and occasionally environmental stressors.

Our patients are repetitively advised to avoid all NSAIDs post op, as they can easily induce an ulcer to form, or rapidly encourage one to go on to perforate, resulting in a trip to the OR for an urgent diagnostic laparoscopy and some form of ulcer repair. We either do a primary closure of the ulcer / perforation, and/or likely a Graham Patch of the area to add further reinforcement to the inflamed and edematous area that perforated.

Often times, when we question patients that either have an ulcer or a perforation, they may admit to getting back to their smoking habit, or (sometimes unknowingly) taking NSAIDs, and that usually cinches the diagnosis, and gets us started with a treatment of Carafate and high-dose BID PPIs.  An EGD may be performed shortly thereafter, if they clinically do not respond as we would expect within a week or two.

I have had patients tell us that they thought Tylenol was the same as the Alleve they have been taking, because they knew that Aspirin and Advil were off limits.  Or patients say that their Orthopedic doctor put them on a 2 week course of a "pain medicine" (an NSAID) even though the patient told them that they had a Gastric Bypass, but they were reassured that it would be OK.

We had a fairly typical recent case of an out-of-towner who had a Bypass at a hospital in Ohio a couple of years earlier and had 8-12 hours of intense epigastric abdominal pain, went to the ER and was found to have free air, and some CT scan findings implicating the G-J region as causative, suspected to be from a perforated MU (Marginal Ulcer).

The picture above is what we saw upon laparoscopy - a classic look at what was expected with a freshly perforated Marginal Ulcer.

The next photo is the start of the primary closure of the ulcer, with stitches placed above and below the ulcer...

Photo of Intraoperative Photo by M Clock

...Which then are tied, leaving their long tails, so as to add some intrabdominal omental fat to be then sewn / tied on top of the primarily closed ulceratous crater, further sealing it, completing the Graham Patch procedure.

Photo of Intraoperative Photo by M Clock

The result is a primary closure, and then a reinforced sealing of the previous site of the ulcer surgically.  Drains were then placed in the upper abdomen, and copious irrigation was performed as to lessen the chemical and inflammatory peritonitis that rapidly ensued when the perforation occurred.

Oh, and her risk factors? Ongoing Alleve for the past few weeks for a musculoskeletal complaint, and resumption of her smoking that she had quit before she had surgery.  

As is often said - "Common things are Common", but it seems that lately, so are somewhat uncommon things, too!

Adolescent Bariatric Surgery: Where Kids Are More Like Adults

Photo by M Clock

When I look each week to do a blog post on a topic of interest from my current Bariatric Surgery experience, there is usually an issue or an idea that stands out and presents itself throughout the course of the preceeding week or so, and this week is no exception.

Adolescent Bariatric surgery has been in the news, my emails, and on TV all week since a study published this past week in JAMA Pediatrics.  The ASMBS  recently commented in the issue as well, and Medscape Surgery also acutely chimed in.

This JAMA Peds study was a nice foray into the highly controversial subject of adolescent weight loss surgery.  To be honest, I expect there to be a good many Providers who are still not in favor of adults having surgery for obesity, and for those, this topic will likely put them over the proverbial edge.

This highly charged debate stems from many factors, and I really do get it. (We don't do anyone less than 18 years old at our center, and have no plans to do so.)  

Although, to be honest, I am not sure I honestly have a personal stance on the issue, just that it comes up every now and then, and now this hightened increase in publicity has it again at the forefront.  

This is what I can already hear from those concerned about the issue in the health care field...

Why surgery for a "child" with a "behaviorally-induced" malady?  Why not try intensive behavior modification and stick with it instead of surgery?  Can an adolescent really comprehend the nature of their disease, its severity, or the imperative nature of doing something (NOW) to improve their condition?  Aren't there significant psychological and social aspects of morbid obesity in this age group that may not lend itself well to the 'forced' behavior modification that surgery results in?  Is the current disease state of even severe morbid obesity in this age group worth the risk of having surgery for the potential short and  long term benefit?  (These are a few questions that come to my mind as well...)

So, that now that it's out in the open, this study did a go a distance toward addressing some of those questions with it's demographic intake data, and the resultant safety as plotted from its 242 operative cases that were reviewed.  The study was limited to basically perioperative safety and outcomes in its studied adolescent weight loss surgery group.

With the benefit of intake demographic and anthropometric data, one aspect that we wonder about was accurately characterized: Just how sick are these kids?

Of the 242 studied, ranging in age from 13-19 (median age of 17.1), the rate of baseline comorbidites was in fact very similar to a preoperative adult cohort that has been studied many times in the past.  The average BMI was 50.5.

How is this for a hit list?

   *Dyslipidemia     74%   

   *OSA                  57%

   *Joint Pain           46%

   *HTN                  45%

   *Back Pain          45%

   *NASH               37%

   *PCOS                21%

   *Renal Disease    19%

   *DM 2                 14%

Furthermore, this intake data went further to shed light on this population of adolescents that was, on average, 2 fold heavier than ideal weight, in terms of cardiovascular risk factors that we more typically take note of in the adult population.

Nationally representative data demonstrates prevalence rates of HTN, high LDL, and low HDL at 3%, 8%, and 3% respectively in more normal-weighted adolescents.  In this group the numbers were 45%, 9%, and 64% respectively.  

An additional concerning factor was the measurement of C-Reactive Protein, which was abnormally elevated in more than 3/4 of those studied in the surgery group, again showing evidence of systemic inflammation, and all the malady that brings with it.

So, yes, these kids are sick, and even though adolescents are resilient, and usually show a lot of reserve, there is a limit to that physiologic fact of life, and this demonstrates that threshold can be overwhelmed.

And now to safety.  Comparative data for both the adolescents studied and what would be expected in a average adult population of weight loss surgery patients was very similar.  

A study cited by the study from JAMA showed a group of adults who had either Bypass or Sleeve Gastrectomy as experiencing a 30 day complication rate of 27% and 14% respectively.  For the adolescent group, the same surgeries had combined major / minor complication rates of 26% and 16% accordingly.  Essentially the same numbers, as far as safety goes.

So, what is the next logical part of the equation for this issue, an aspect that wasn't a component of this study (yet)?

Yes, the next logical question that will need to be answered is, "So, how did they make out as far as their weight loss and comorbidites?"

The authors write about that portion as to be published later.  But, if you are like me, you need this question answered to clarify a key component (efficacy) of this possible treatment for adolescent super morbid obesity. 

However, so far, maybe so good.  

And for better or for worse, factor this in.  There appears to be no free pass when it comes to the absolutes of some aspects of health and disease.  These kids appear to be more like their adult counterparts than not.

Going against them further is the fact that they have a (hopefully) long road ahead of them jus to get to realize the joys of "true" aging.  Another downside of our accelerated "microwave society"?

Robotic Bariatric Surgery?

From Healthwellnesscolorado.com

Robotic bariatric surgery?

Technically "Robot-Assisted Laparoscopic Bariatric Surgery".

Is it just a trend?  Is there any benefit to this method vs. traditional laparoscopic bariatric surgeries?  Is it available in my area?

I looked into those very questions, as we provide access to Robotic surgery for Bypasses and Sleeves. We don't now perform our surgeries exclusively with the Robot, but patients can generally have their surgery performed that way if they want to.  Our experience is overall quite favorable, in terms of post op pain, length of stay, complications, etc.

We are closing in on our 100th case done this way, but I found an article that was helpful to compare the experiences of another established practice that reviewed the results of their first 100 Robotic-Assisted Gastric Bypass cases, contrasting them with a similar group of 100 patients from their practice done through the traditional laparoscopic approach.

History

Traditionally an open procedure started by Dr. Mason, Gastric Bypass operations started to go to the laparoscopic approach in 1994 as performed by  Dr. Wittgrove and his associates.  Within a relatively short amount of time, the experience proved both beneficial to patients, and morbidity and mortality of this operation have decreased substantially to the current very low levels.

The Da Vinci surgical robotic system has been on the surgical scene for the past 5-10 years, and has  beneficial applications to urologic, gynecological, general, and cardiovascular surgeries to name a few.  DaVinci robotic surgery has the benefits of an enhanced 3-D HD surgeon viewer,  improved wrist articulation (extra-anatomical) interaction with the surgical instruments, as well as a remote-centering of the trocars that enhances the surgery as done laparoscopically,  which can result in less post op pain for most patients.

To be honest, robotic application to some surgical procedures makes a huge difference (such as open vs. staying laparoscopic- ex. uterine myomectomy, radical prostatectomy), and/or enables patients to have less pain (and discharge them sooner), and/or reduce the risk of complications (possibly with the prostatectomy) due to the technology used to do these operations.

However, some procedures are aided by the robotic approach, and are able to be done that way, yet don't offer such an overwhelming advantage that comfortably usurps the tried and true approach of the existing standard of a laparoscopic approach.  Bariatrics, specifically Gastric Bypass, likely falls in to this category.

The Study

The group in the study looked at the first 100 Gastric Bypass Robotic cases, and contrasted them with 100 traditional cases done in the same group, of similar demographic and medical makeup.  They looked at both the progression of their robotic cases in terms of complications and duration of the surgery, and how the overall results of the first 100 cases compared with the latter group of 100 standard laparoscopic cases.

What they found was interesting and mimicked our experiences quite closely.

OR case time decreased over the"learning curve" of the robotic timeline, and approached the time of laparoscopic cases.  Stricture rates were a little higher early in the robotic group, but decreased to below their laparoscopic levels by the second 50 cases.  Mortality was at 0% for both groups.  Two patients returned to the OR within 90 days in the robotic group, and only 1 patient required a transfusion for post op bleeding in the robotic group vs. the lapsaroscopic group (5 pts.).

The biggest difference favoring the robotic group was the length of stay, which showed a significant decrease  vs. the laparoscopic group.  Sixty percent of the robotic patients left the hospital after only a 1 night stay, as compared to 4% o patients in the laparoscopic group.

I have to  imagine this was due to less pain (due to no need for fascial closure, and/or the remote centering trocar movement of the robot that can put less torque on the abdominal wall), and perhaps a more rapid transition to PO diet, and a willingness to send them home earlier than the standard 2 days, as we do in our practice fairly routinely.

The "willingness"  I refer to is the comfort level of sending a patient home that meets a general criteria (PO analgesic pain control, ambulation, urination ability, stable VS, tolerating PO satisfactorily, and absence / or control of significant additional comorbidities) as being able to do so.  Perhaps this was skewed to look more closely at the likelihood to DC a patient POD 1 than their contrasted laparoscopic group, but in any event the readmission rate,  or complication rate did not seem to reveal this as an issue.

The paper does note that the two groups were not equivalent, and that is true.  The traditional laparoscopic group represented 7 years of prior experience, and nearly 800 cases performed.  In the robotic series, it was a fresh 100 cases that implied a learning curve during that time.

However,  in a way, with such similar results among the 2 groups, this may be of even more significance in terms of safety and efficacy vs. the laparoscopic standard.  This also speaks to the Robotic approach as not an entirely new entity, but an "add-on" platform to existing technology that can enhance the already excellent standard of surgical approach to Gastric Bypass in this case.

In a practical sense, that is how we approach it in our practice.  The surgeon is able to offer that technique for a patient's choice of surgery, and it has its benefits as well as its logistic issues (namely access to the robot when needed), but it is a more similar than different surgical approach to a Gastric Bypass than the traditional approach.

Moreover, as with technology in all fields, once further advances are made to the the robotic platform, we are ready to keep pace, especially if there is a marked benefit to our patients and to us in performing the surgery.