Arquivos Diários: 2 janeiro, 2015

Complications of Bariatric Surgery presenting to the GENERAL SURGEON

Over the past decade, following the publication of several long-term outcome studies that showed a significant improvement in cardiovascular risk and mortality after bariatric surgery, the number of bariatric procedures being carried out annually in the UK has grown exponentially. Surgery remains the only way to produce significant, sustainable weight loss and resolution of comorbidities. Nevertheless, relatively few surgeons have developed an interest in this field. Most bariatric surgery is now performed in centres staffed by surgeons with a bariatric interest, usually as part of a multidisciplinary team.

The commonest weight loss procedures performed around the world at present are the gastric band, the gastric bypass and the sleeve gastrectomy. In very obese patients, an alternative operation is the duodenal switch, while the new ileal transposition procedure represents one of the few purely metabolic operations designed specifically for the treatment of type II diabetes. Older operations such as vertical banded gastroplasty and jejuno-ileal bypass are now obsolete, although patients who have undergone such procedures in the distant past may still present to hospital with complications. The main endoscopic option at present is insertion of a gastric balloon, with newer procedures like the endoscopic duodenojejunal barrier and gastric plication on the horizon. Implantable neuroregulatory devices (gastric ‘pacemakers’) represent a new direction for surgical weight control by harnessing neural feedback signals to help control eating.

It should be within the capability of any abdominal surgeon to manage the general complications of bariatric surgery, which include pulmonary atelectasis/pneumonia, intra-abdominal bleeding, anastomotic or staple-line leak with or without abscess formation, deep vein thrombosis (DVT)/pulmonary embolus and superficial wound infections. Patients may be expected to present with malaise, pallor, features of sepsis or obvious wound problems. However, clinical features may be difficult to recognise owing to body habitus. Abdominal distension, tenderness and guarding may be impossible to determine clinically due to the patient’s obesity. Pallor is non-specific. Fever and leucocytosis may be absent. Wound collections may be very deep. These complications in a bariatric patient should be actively sought with appropriate investigations. In particular, it is vital for life-threatening complications such as bleeding, sepsis and bowel obstruction to be recognised promptly and treated appropriately. A persistent tachycardia may be the only sign heralding significant complications and should always be taken seriously. It is useful to classify complications as ‘early’, ‘medium’ and ‘late’ because, from the receiving clinician’s point of view, the differential diagnosis will differ accordingly.

Complications of bariatric surgery presenting to the GENERAL SURGEON


Reassuring Worried MotherWhat is a Surgical Profession?

The professions are the means by which the complex services needed by society are organized. A profession has been defined by the American College of Surgeons as: an occupation whose core element is work that is based upon the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning, or the practice of an art founded upon it, is used in the service of others. Its members are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism and to the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which, in turn, grants the profession a monopoly over the use of its knowledge base, the right to considerable autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society.

1. What are the core elements of a profession? All professions are characterized by four core elements: (1) a monopoly over the use of specialized knowledge; (2) in return for that monopoly that we enjoy, relative autonomy in practice and the responsibility of self-regulation; (3) altruistic service to individuals and society; and (4) responsibility for maintaining and expanding professional knowledge and skills.

3.What is professionalism? Professionalism describes the cognitive, moral, and collegial attributes of a professional. Ultimately, it is all the reasons that your mother is proud to say that you are a doctor and a surgeon.

4. Why do physicians need a code of professional conduct? Trust is integral to the practice of surgery. The Code of Professional Conduct clarifies the relationship between the surgical profession and the society it serves. This is often referred to as a social contract. For patients the code of professional conduct crystallizes the commitment of the surgical community toward individual patients and their communities. Trust is built brick by brick.

5. What is the Code of Professional Conduct ? The Code of Professional Conduct takes the general principles of professionalism and applies them to surgical practice. The code is the foundation on which we earn our professional privileges and the trust of patients and the public. It is our job description. During the continuum of the preoperative, intraoperative, and postoperative care surgeons have the responsibility to:

5.1 Serve as effective advocates for our patients’ needs.

5.2 Disclose therapeutic options including their risks and benefits.

5.3 Disclose and resolve any conflict of interest that might influence the decisions of care.

5.4 Be sensitive and respectful of patients, understanding their vulnerability during the perioperative period.

5.5 Fully disclose adverse events and medical errors.

5.6 Acknowledge patients’ psychological, social, cultural and spiritual needs.

5.7 Encompass within our surgical care the special needs of terminally ill patients.

5.8 Acknowledge and support the needs of patients’ families and

5.9 Respect the knowledge, dignity, and perspective of other healthcare professionals.

6. Why do surgeons need their own code of professionalism? A surgical procedure is an extreme experience. We impact our patients physiologically, psychologically, and socially. When patients submit themselves to a surgical experience, they must trust that the surgeon will put their welfare above all other considerations. The written code helps to reinforce these values.

7. What are the fundamental principles of the Code of Professional Conduct and the codes of other professional societies?

7.1 The primacy of patient welfare.

This means that the patient’s interests always come first. Altruism is central to this concept, and it is the surgeon’s altruism that fosters trust in the physician-patient relationship. 

7.2 Patient autonomy.

Patients must understand and make their own informed decisions about their treatment. This is tricky. As physicians we must be honest with our patients so that they make educated decisions. At the same time, we must make sure that their decisions are consistent with ethical practices and do not lead to demands for inappropriate care. 

7.3 Social justice.

As physicians we must advocate for our individual patients while at the same time promoting the health of the healthcare system as a whole. We must balance our patient’s needs (autonomy) and not misdirect scarce resources that benefit society (social justice).

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