Laparoscopic Procedures for Morbid Obesity

Procedure Type: Laparoscopic Gastric Bypass with Roux en Y Reconstruction (Short Limb)

Surgeon: Philippe J. Quilici, MD, FACS

Definition

This procedure is a bariatric-advanced laparoscopic surgical procedure or a surgical procedure performed via keyhole incisions designed to promote weight loss and reduce the complications associated with morbid obesity. This procedure will transect (cut) your stomach, surgically create a small stomach, recreate a new outlet for your stomach and bypass a portion (75cm) of your small intestine.

Indications – Understanding the Process of Becoming a Surgical Candidate

Becoming a surgical candidate for this procedure is a rigorous process, which you need to comprehend fully. This office has strict guidelines that comply with the guidelines of the American Society for Bariatric Surgery, the American College of Surgeons and the Society of American Gastro-intestinal Endoscopic Surgeons.

Initially, you have been fully evaluated by a nutritionist and an approved psychologist-psychiatrist. You have undergone a complete evaluation by your primary care physician and an independent internist-pulmonary care physician. All your surgical risk factors or co-morbid factors (if any) were identified, explained in detail to you, and are currently well controlled.

You have undergone two successive consultations with your surgeon, Dr. P. Quilici, and his office staff. Our bariatric clinical coordinator has met with you.

The following parameters have been met for you to qualify as a surgical candidate for the Laparoscopic Gastric Bypass with Roux en Y Reconstruction (Short Limb):

Risks of the Defined Surgical Procedure

All the risks of this procedure (as set forth in the following document) as well as the impact of this procedure on your future life style have been explained to you by your surgeon. All your questions have been answered to your satisfaction.

Please, read the following very carefully. It summarizes some of the most common risks associated with this procedure.

·        The Issue of Conversion

This procedure is performed via laparoscopy, i.e. via small puncture type incisions. This will allow you to recover quicker than with conventional surgery, where an incision is made. In some cases, the laparoscopic procedure will have to be converted, meaning an incision will be made to continue and safely complete the procedure. Although this is a rare occurrence, your surgeon may decide to do so if he foresees too many technical complications, or if he cannot complete the procedure safely. If the laparoscopic procedure is converted, it will lengthen you hospital stay on the average by three days.

·        Surgical Risks Associated with the Surgical Procedure

 These risks are rare but do occur. The most significant are as follows:

1. Breakdown of a Gastro-Intestinal Anastomosis: The small bowel and the stomach are usually re-attached or put back together (an anastomosis) using sophisticated surgical instruments (i.e. stapling devices and laparoscopic stapling devices). Occasionally, this “attachment” does not heal well and will breakdown generating a sequence of complications that may lengthen you hospital stay. And in some instances you may have to undergo an additional surgical procedure.
2. Injuries to Other Intra-Abdominal Organs: As with all surgical procedures, injuries to other intra-abdominal organs could occur. Your surgeon will attend to them as needed.
3. Bleeding: Bleeding may occur during the procedure or in the early post-operative period. You may require the transfusion of blood products as needed. Your surgeon has explained the risks of such transfusions.

·        Surgical Risks Increased by the Condition of Morbid Obesity

Morbid obesity will increase the frequency and incidence of certain complications. This surgical team is dedicated to the utilization of all surgical means to decrease it. However, some of these complications remain severe and can still occur in spite of the best preventive measures:

1. Deep Vein Thrombosis and Pulmonary Embolus: This is a rare but dangerous complication. A blot clot could form in you leg or in your pelvic veins and could travel to your lungs, endangering your life. To prevent this you should carefully follow the surgical instructions given by your surgical team. It is crucial you ambulate (walk) after surgery as much and as frequently as you can.
2. Heart Problems: Severe cardiac problems can occur. This office has made every effort to assess your cardiac condition prior to the surgical procedure. You must have received cardiac clearance before undergoing this procedure.
3. Lung Problems: Respiratory insufficiency or problems may occur after the surgery necessitating the use of a ventilator. This potentially would lengthen your hospital stay and your recovery.

·        Known Late Complications Inherent to this Surgical Procedure

The American Medical literature reports that certain complications may occur after this procedure has been performed (months or years later). The most significant are as follows:

1. Gastro-Enterostomy Stenosis: The “attachment” of the stomach to the bowel is made a certain size to restrict the rapid emptying of your new stomach. In some patients, scarring does occur at this site and will shrink this opening further. The patient will start vomiting. This complication is classified as a gastro-enterostomy stenosis and is managed by performing an endoscopic dilatation (enlarging the opening via an upper GI endoscopy).
2. Internal Hernias: These complications are decreasing as we have modified our surgical techniques accordingly. If they do occur, you may require a surgical intervention to correct it.
3. Specific Malabsorption: As you know, this procedure creates a selective malabsorption of the food and nutrients you eat (Vitamin B6, B12, Iron, folate, etc.). Certain vitamins may not be absorbed well enough for you to meet the recommended US daily requirements. For this reason, we recommend you take a multivitamin (with minerals) daily and a dose of Vitamin B12 sublingual twice a month for the rest of your life.
4. Symptomatic Dumping Syndrome: This syndrome (early and late)has been reported by patients after this procedure. Although not dangerous it is frightening to the uneducated patient. Short period of dizziness, fatigue and hypoglycemia can occur. Prospective patients should read all the education material provided regarding this problem.
5. Diarrhea: Diarrhea can occur immediately after surgery but usually subsides. Chronic diarrhea is not a common side effect of this procedure.
6. Hair Loss: Some patients report some form of temporary hair loss, which is believed to be due to a reduced and insufficient post-operative intake of protein. Again, patients need to follow post-operative instructions meticulously.
7. Renal Problems. Although rare with this procedure, kidney stones can occur.
8. Gastric Pouch - Gastric Body Fistulaes: Abnormal Connections from the gastric pouch to the gastric body can form and create significant late problems, such as chronic bleeding, nausea, poor weight loss, etc.

·        Future, Altered Psycho-social Interactions:

This procedure and the outcome of this surgical procedure may strain the pshycho-social interactions of the patients with his or her family.

·        Published Surgical Performance Data

Surgical procedures are associated with an average rate of complications or morbidity and an average mortality rate or overall rate of death within thirty days after these procedures. These statistics are published in the American Medical literature and can be easily verified. For the laparoscopic gastric bypass with Roux en Y Reconstruction, the morbidity rate is averaging 3.3% (major) and the mortality rate is averaging 0.1 to 0.4%.

Realistic Expectations for Patients Undergoing the Laparoscopic Gastric Bypass with Roux en Y Reconstruction

You must understand that by undergoing this procedure, it will not solve all your problems but will help you lose weight and maintain it. In addition, it may correct or improve some of the medical problems (diabetes, hypertension, etc.) or help your physicians manage them. Statistically, patients who undergo this procedure will lose on the average 75 % of their excess weight and will sustain it.

Post-operatively your eating habits will change as described in the provided education package. You will need to comply to the monitoring schedule proposed by your bariatric specialists.

You have read the PATIENT’S DISCLOSURE DOCUMENTS provided by our office and the section entitled “realistic expectations after bariatric surgery”.

Financial aspects of This Surgical Procedure

The financial aspects of the proposed surgical procedure have been fully explained to you.

Access to our On-Line Website and Technical Description of the Proposed Surgical Procedure

You have been given the URL address of our surgical website, The Online Laparoscopic Technical Manual, or http://www.laparoscopy.net . You can access our online chapter on Laparoscopic Bariatric Procedures. You can view all the technical data and aspects of this procedure online, including online videos. If you do not have online access, our office has printed you a copy of the Laparoscopic Bariatric Surgery Section.

Access to your Patient Education Package and Booklets

You have been given by our office the following educational documents and books:

1.      This document,

2.      Patient disclosure documents,

3.      Operative and post-operative instructions booklet.

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