Vital Signs: Why Does Her Belly Hurt?

Complications from surgery provide an important lesson for ER doctors.

By Tony Dajer|Friday, March 10, 2006
RELATED TAGS: OBESITY, SURGERY, GASTRIC BYPASS

Everyone in the emergency room froze. Following the screams, I hurried to a far cubicle.

"Oh, my God," a woman shrieked, clutching her belly. She looked about 40, was noticeably overweight, and was wearing a business suit.

"You OK?" I whispered to the attending physician.

She nodded and said: "She had a gastric bypass two years ago. Sudden onset of severe epigastric pain. Her chest X-ray shows no free air. We're on our way to a CT scan."

Air in the abdomen equals stomach or intestinal perforation, but it doesn't always show up on an X-ray. Although perforation is rare in healthy young women, her bypass for weight loss put her in another category. I tried to think up a list of likely complications, but I couldn't come up with more than a few.

"You'll be OK," I said and grabbed the stretcher railing.

"Ow. Oh, Jesus," she said, gasping as we headed down the hall. "I can't believe this."

The attending physician turned to a nurse: "Six of morphine IV, please."

A half hour later we had a diagnosis.

"The scan shows free air. Her surgeon wants her uptown," the attending physician said. "He did the bypass."

One out of 20 American adults is severely obese, 5 of those 20 are obese, and another 7 are overweight. The categories are not arbitrary. A mathematical computation called the body mass index uses weight and height to calculate risk (see www.cdc.gov/nccdphp/dnpa/bmi/calc-bmi.htm). If your body mass index hits 40, you are severely obese—something like a 5-foot-4-inch woman weighing 230 pounds. Between 1986 and 2000, the percentage of Americans who qualify as severely obese quadrupled. The statistics go on and on: A severely obese 25-year-old will die 12 years earlier than normal; obesity illnesses devour more than 50 billion a year in medical costs in the United States.

Although exercise and diet can clearly control obesity in the vast majority of cases, an increasing number of people are turning to bariatric surgery. In 1998 American doctors performed 13,365 such surgeries. In 2004 the estimate went up to 140,000. For emergency room doctors the numbers are even scarier, because we will see about 40 percent of those patients within three years.

To understand what I was facing, I turned to Howard Beaton, an old friend and chief of surgery at a nearby hospital. Before 9 11, both of us carried some extra pounds. On that terrible day, in our emergency room four blocks from the World Trade Center, he directed surgeons on dozens of trauma cases while I coordinated the rest of the emergency department. The shock of it all set us both on the road to fitness. I started jogging; he ran on a treadmill during nights on call. Four and a half years later he remains slim, almost gaunt.

"I started doing bariatric surgery in 2003," he said as we walked into his operating room. "It is extraordinary. I've had patients who married, who started working again. One became a policeman. When they go for months between visits, you often don't recognize them. A completely unimagined person emerges."

Lying on the table in front of us is a 5-foot-2-inch 220-pound woman. Beaton draws his scalpel from the lower edge of her sternum to a point two inches above her belly button. "I used to make an incision down to here," he says, indicating a spot six inches lower. "Now, this much is plenty. Bariatric surgery has a steep learning curve."

Beaton slices through a hefty layer of globular, canary-yellow fat and enters the peritoneum, the membrane that lines the abdominal cavity. Coils of pink, wormy intestine appear. Beaton uses a modified version of an operation devised by surgeon Cesar Roux a century ago for other conditions. He will divide the stomach, leaving a very small pouch attached to the esophagus and the rest connected to the small intestine.

He severs the intestine below the stomach, then burns a hole in the intestine three feet down. Out come a menacing pair of stapler guns to connect the stomach portion to that opening. The next step is to drastically limit food access to the stomach. He applies his two staple rows across the stomach and cuts between them, dividing the stomach. He has now created a small pouch connected to the esophagus. The bulk of the stomach and duodenum never see food again.

"I tell patients their stomach is now about the size of an egg," he explains.

Finally, to link the newly shrunken stomach to working intestine, he brings up the still-severed section of intestine, makes a hole in the stomach pouch, and zips the two together.

"Amazing," I mutter.

Beaton turns to me and asks, "Aren't those staplers something?"

The first weight-loss operation took place in 1954. Designed to prevent food absorption by connecting the near end of the small intestine to the far, it ultimately caused too much malnutrition and, for reasons unknown, liver cirrhosis. In the 1960s surgeons developed the gastric bypass, which remains the mainstay in the United States. In the 1980s the practice of limiting food capacity by stapling the stomach nearly all the way across became available. Although it seemed like a simple solution, the staple lines tended to come apart.

More recently, in Europe and Australia, stomach banding has gained favor. In that procedure, a saline-filled collar is fastened around the upper stomach and then filled or emptied through tubing connected to a port under the skin. Approved by the FDA in 2001, its attraction is its simplicity, especially if done laparoscopically. Its principal drawback is that patients might lose less weight than with the current standard procedure, known as the Roux-en-Y bypass. That is why American surgeons still perform bypasses in four out of five cases. The largest study to date shows that bariatric surgery reduces excess weight by 61 percent and cures sleep apnea, hypertension, and diabetes in more than two-thirds of patients.

"For diabetics," Beaton says, "the effect is so fast we stop their pills on discharge, or their sugars will bottom out."

A Canadian study of morbidly obese patients found that there were proportionally fewer deaths among patients who had gastric bypass surgery than there were among those who did not: 0.7 percent of the bypass group died within five years, as opposed to 6.2 percent of the control group. Impressive, but there are problems too. Huge battles loom over insurance coverage. Depending on the procedure, it may run up to $30,000 and require a three-day hospital stay.

"Some plans require six months of documented attempts at medically supervised weight loss before approving surgery," says Beaton, shaking his head. "Which means you're taking people who already consider themselves failures and setting them up to fail again."

And experience counts for the surgeon. One study of the banding technique showed that a surgeon's first 30 patients had a 37 percent complication rate, the next 30, only 7 percent.

Constant practice is even more important: Surgeons doing less than one case a month lost one in 20 patients. Their more prolific colleagues lost one in 300.

The overall death rate from the different procedures is 0.1 percent for banding and 0.5 percent for bypass. Darkening that picture is a new study of 16,155 Medicare patients, in which 4.6 percent of patients died within a year of the operation. Medicare patients tend to be older and more disabled, but the results give pause.

"These patients are inherently high risk," Beaton says. "As an ER doctor, you need to know that with post-op complications, your clinical exam is almost worthless. I've seen huge abscesses in patients with no abdominal tenderness or fever. When they present with abdominal pain, they almost always need a CT scan. One pitfall of the Roux-en-Y is that it creates the potential for internal hernias [ruptures] that can trap loops of intestine and cut off blood flow. Then, as opposed to the bowel obstructions that we're used to—where it is reasonable to suction the stomach and wait—you'd better operate immediately."

The list of possible complications is daunting: bleeding, blood clots in the lungs, gastric-pouch rupture, post-op vomiting, infection, scarring that narrows the intestine, ulcers, gallstones, abdominal-wall hernias, and iron and vitamin deficiencies.

Beaton says, "The best rule is, when these patients get sick, diagnose them fast and go right in when necessary."

As for our patient, her surgeon explained that she had developed an opening, or ulcer, where the intestine was stapled to the stomach pouch. "Unusual two years out," he said. "We went in and patched it up. She did fine."

I can't help wondering how many cases like hers are yet to come.


Tony Dajer is acting director of the emergency medicine department at New York University Downtown Hospital in Manhattan. Cases in Vital Signs are true stories, but some details about patients are changed to protect their privacy.
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