A 65 y.o. woman with cardiomyopathy is sp a Roux-en-Y gastric bypass one year earlier.
She comes in with epigastric pain and vomiting. What could be wrong?
Hint: the short arrow shows the gastrojejunal anastomosis. The long arrows on the L show the problem. The gastric remnant is on the R.
Our patient had a marginal ulcer at the GJ anastomosis with a stricture at the anastomosis. A marginal ulcer is frequent with gastric bypass occurring in up to 15% of patients in the first year after surgery. . The native pancreatic and duodenal wall protect against ulceration. The ulcerogenic hydrogen cation H+ stimulates the release of secretion in the duodenum which releases bicarbonate HCO 3- released from the pancreatic duct buffering the effects of acid.
There are other complications of a Roux-en-Y gastric bypass with the most common being an anastomotic leak which is associated with a 50% mortality. Complications are divided into early (within two weeks) and late( anything later). Since most leaks occur at the GJ anastomosis, bariatric surgeons test the integrity of the anastomosis with either methylene blue instilled through an NG or air insufflation with the anastomosis submerged.
The most common long term complication is an internal hernia. This is because a number of colonic mesenteric defects are created in the course of the procedure. Ironically, weight loss leads to an increase incidence of hernia risk. There are pathognomonic findings on CT for internal hernias including whirling of the mesentery , and all the small bowel on one side of the abdomen but often the CT is normal and the patient simply presents with episodic pain. Strictures, anastomotic ulcers , fistulae, and nutritional deficiencies are all late complications.
So why get surgery when you can just take a GLP-1 agonist?
More weight can be lost with surgery- Both gastric sleeve surgery and Roux-en –Y result in 3 times the weight loss of ozempic. The average weight loss with ozempic is 14 lbs over 30-56 weeks. If you weigh 250 lbs 90% of patients can lose 25 lbs with medical treatment which is nowhere near the 60-70 lbs you can lose with surgery.
Insurance coverage: Wegovy is covered for a BMI of 27 or above. If there is no insurance coverage the medication cost $1,300 per month. Bariatric surgery is only covered by insurance if your BMI is 35 or greater.
Complications of Ozempic: Recent reports suggest stopping ozempic one week before any major surgery because of multiple cases of vomiting during anesthesia induction. Since the drug causes delayed gastric emptying nausea and reflux are frequent side effects.
If Ozempic is stopped, weight is easily regained. Ozempic has been reported to cause hypoglycemia, pancreatitis and a risk of thyroid cancer. It is not recommended for patients with multiple endocrine neoplasia type 2.
A Florida man Jeancarlo Danies at age 39 weighed 431 lbs. after weigh loss surgery he decided to become a body builder.
A QUICK REVIEW OF DRUGS AVAILABLE FOLLOWS:
Binenbaum S, Dressner R, Borao F. Journal of the society of laparoendoscopic surgeons/society of lararoendoscopic surgeons 2007 Jul-Sept.
Papasavas PK, Caushaj PF, McCormick JT, et al. Laparoscopic management of complications following laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2003;17:610–4.
Can J Surg. 2012 Oct; 55(5): 329–336.
doi: 10.1503/cjs.002011