16 Jun

Came for Bariatric Surgery but…

This is a story of a young woman patient who was morbidly obese and came enquiring for a bariatric surgery. But instead underwent 3 other surgeries. Quite strange? Not really. This experience of mine is to tell the world that obesity can often mask serious conditions that might require immediate surgery.

Enquiry for Bariatric Surgery in Chennai

A morbidly obese woman was inquisitive about bariatric surgery and was determined to get the surgery to reduce her weight. She came calling and presented herself for a preliminary physical examination. She was morbidly obese and was indeed an ideal candidate for a bariatric surgery. I suggested her Gastric Bypass Roux-en-Y surgery which is the gold standard surgical type among all the bariatric surgeries.

Preliminary Physical Examination prior to Bariatric Surgery

Much before the physical examination, she told me that she suffers from a severe pain in the right lower abdomen where she has undergone c-section twice. She also informed that she had visited two gynaecologists and the ultrasound reports produced twice suspects that the pain may be due to an incisional hernia. Upon the symptoms she presented, I suspected it should be either an incisional hernia or scar intestinal adhesion before the physical examination.

I then proceeded to do my physical examination. She had pain not only in the right lower abdomen but also in the right upper abdomen. I suspected that she might have gallstones too along with an incisional hernia or scar intestinal adhesions. I recommended strongly to the patient to get a CT scan examination of the full abdomen. She was initially hesitant and said that she has done two ultrasound reports already. I then explained to her with patience that often in obese individuals certain conditions like gallstones might remain asymptomatic. Since women are more likely to have gallstones than menI recommended to her that a full CT abdomen scan would perfectly diagnose if it was indeed present. I also told her that the reason for lower abdominal pain can be accurately diagnosed with a full CT abdomen scan and appropriate treatment can be initiated for the same. The patient saw a reason and felt it was sensible to take a full CT abdomen scan report.

CT Scan Diagnosis

After few days, the patient walked in with her CT scan report. My fear of the presence of gallstones was confirmed. The pain in the lower abdomen was due to a condition called scar endometriosis and not due to an incisional hernia as suspected. This condition was also confirmed in the same CT scan report. Scar endometriosis is a typically rare condition that might occur after a c-section. It typically involves abdominal wall pain at the incision site at the time of menstruation.

The CT scan report went on to drop another bombshell. The scan report also talked about a large stag-horn calculus (stone) completely obstructing the left kidney with no functioning kidney tissues. But a CT scan could not confirm if the left kidney was functional. This was critical to decide the current functional status of the left kidney.

DMSA or Nuclear Scan Report

I explained to the patient that I am surprised that the left kidney has complications. I told her that another test called DMSA scan can confirm if the left kidney is functional / viable or not. She readily agreed to the test due to the seriousness of the underlying surgical condition. DMSA stands for dimercaptosuccinic acid. This scan uses the said acid to determine the functioning of the kidney. The DMSA test confirmed the worst fear that the left kidney is completely dead. It also confirmed that the right kidney was functioning normal

In the event of one kidney becoming completely dead because of obstruction, the second kidney also begins to get affected unless it is removed from the body (nephrectomy). I categorically informed the patient that bariatric surgery can wait but all these 3 conditions are surgical emergencies and have to be performed almost immediately.

The 3 Surgeries – Laparoscopic Cholecystectomy, Excision of Scar Endometriosis and Laparoscopic Nephrectomy

The patient was operated on for three surgeries on the same sitting. First, the the gallbladder removal surgery (Cholecystectomy) was performed. Then the excision of scar endometriosis was performed. Finally, the patient’s damaged left kidney was then removed by laparasocipc nephrectomy with the help of a team of surgeons.

Morbid Obesity Can Mask Anything

The above statement came true for the woman patient. A very serious complication of a dead and infected kidney never gave any pain or indication surprisingly. This is why we say being morbidly obese carries many risks and this is one such risk. The woman was lucky to survive all these issues. The full CT abdomen scan report which I insisted was very timely and it played a role in saving the patient from possible complications.