General Surgeons are from Mars, Bariatric Surgeons are from Venus

samir-johna Article by – SAMIR JOHNA
MD, MACM, FACS, FICS

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The latest US presidential elections taught us many things. Among others, it showed the role that the media plays in every aspect of life. It seems to me that “being impartial” in media reportage is far-fetched, and bias a universal language. The role of media coverage in medicine, including scientific publications in respected journals, is no different. Often, medical news reports or publications only depict the excellent prospects, and vouch for a new medicine or a new surgical technique. I daresay that this holds truefor bariatric surgery, where the downsides seem to be underplayed.

Over the past couple of decades, bariatric surgery had become the panacea for all ailments that afflict the fluffy (one can’t call anyone fat these days!) patients. These procedures take away not just your breath, but also your high blood pressure, high sugar levels, your risk of heart attacks, and even your risk of strokes! As an icing on the cake, you do not have to worry about your spine and your knees. This really sounds a great bargain, in this era of economic decline. Nothing out there in the market today brings you as much dividends for your buck(if you are fluffy)as bariatric surgery!

As a general surgeon who can be considered a rebel, I would like to shed some light into the darker aspects of bariatric surgery. I have the luxury of working in a large department of surgery for one of the major HMOs in the United States. Within our department of general surgery, we have two full-time, highly qualified and trained bariatric surgeons with a case log of around 1,500 cases a year. The most commonly performed surgery is Roux-en-Y Gastric Bypass, and gastric sleeve. Because they are so busy, we often help them in taking care of some of their patients when the latter bounce back to the hospital. As such, I feel qualified to render an opinion about what happens to some bariatric patients, all said and done.

Over the past 6 weeks, I have seen more anastomotic ulcers, some with mini-perforations than I have seen in years. I thought ulcer disease was a thing of the past, after PPIs were introduced. While some of them we managed non-operatively, a couple needed a return to the OR because of free perforation or bleeding. Recurrent vague abdominal pains, abdominal pains secondary to Petersen’s hernias, and partial small bowel obstruction are vouchers that feed the “frequent flier” mileage for every bariatric patient. We are not even going to tap into the aftermath of successful bariatric surgeries. Plastic surgeons are all too familiar with the tsunamis of “Pannus” and what patients now call “batwings” that dangle from the back aspect of everyone’s arms these days.

One case in particular haunted me and will leave a long lasting impact, a lady in her forties who became pregnant after she had her bariatric surgery. Near her expected due date, she developed crampy abdominal pain. Patient was in labor and managed to give birth to a healthy child. However, her abdominal pain refused to settle. Upon exploration in the same admission, she was found to have dead bowel secondary to a delayed diagnosis of Petersen’s hernia! She lost a significant length of her small bowel. Her course was complicated by development of enterocutaneous fistula and further complications that required more surgeries down the road.

Stories like this one make me think twice, as they should, before considering bariatric surgery. I would rather live fluffy and happy than thin and depressed. Let alone using abdominal surgery to treat a hypothalamic lesion.


Samir Johna
MD, MACM, FACS, FICS
Clinical Professor of Surgery
Loma Linda University School of Medicine
Staff Surgeon, SCPMG

  • Sergio Santoro

    I think you are right when you think of restriction and Malabsorption. But…
    What if….the hypothalamic malfunction is caused by receiving poor signals from the gut, and these may be well fixed by purely metabolic interventions. The article right above this seem to have the same vision, which is correct for past procedures but may not be for new ones. As I suggested to Dr Schein above, please access:

    Santoro S. From bariatric to pure metabolic surgery: new concepts

    on the rise. Ann Surg 2015;262:e79–80.

    Let me have a chance of changing your mind

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