Stomach-staple surgery raises pregnancy perils

An obese woman and her eight-month-old foetus died of complications 18 months after a stomach-stapling operation – an apparent first that has prompted warnings about the risks of pregnancy soon after such surgery.

The deaths raise concerns because most of the 110,000 people who undergo gastric, or stomach, bypass surgery each year in the United States are women of child-bearing years, say doctors at Brigham and Women’s Hospital in Boston, Massachusetts, who tried to save the mother and baby.

They reported on the case in a letter in the New England Journal of Medicine.

Brigham surgeon Dr Edward Whang cared for the 41-year-old woman nearly two years ago when she was brought to the emergency department after two days at another hospital, where the cause of sudden pain in her upper stomach was misdiagnosed.

“She was nearly dead,” said Whang, who noted that the woman had the gastric bypass and pre-natal care at other hospitals.

After tests and symptoms indicated a massive infection, Whang performed emergency surgery.

He found that most of the woman’s small intestine had slid through a hernia, or tear, in an adjacent membrane, a defect sometimes left after the intestines are rearranged in the bypass operation. The hole choked off blood to the stretch of intestines, and the tissue turned gangrenous.

By then the foetus had died.

Whang repaired the intestine, but the woman died within a few hours. She still weighed more than 31st but her original weight was not available.

“This is a tragic case, but you need to look at the overall risk-benefit of the surgery,” said Dr Harvey Sugerman, president of the American Society for Bariatric Surgery, an educational group for obesity surgeons.

Sugerman said three studies show extremely obese patients have death rates as much as four or five times lower if they undergo gastric bypass surgery, compared with those who don’t. Other research shows lower rates of pregnancy complications after the weight-loss surgery.

Sugerman estimates that more than 110,000 gastric bypasses will be carried out in the United States this year. Complications strike as many as one in five patients, and it is believed that, for every 200 patients, between one and four will die.

Sugerman and other doctors said they knew of no other mother-baby deaths after the operation.

Whang, however, said about 85% of gastric bypasses were performed on women, most of childbearing age and advised any pregnant patients with sudden pain to see a bypass expert quickly.

“Most doctors recommend contraceptives for two years after the surgery" to avoid pregnancy until the woman’s weight stabilises, said Dr Sattar Hadi, who runs the high-risk obesity clinic at Vanderbilt University’s Centre for Human Nutrition.

Hadi said it was unclear whether the Massachusetts woman’s hernia was due solely to the surgery “or the foetus pushing onto the intestines”.

Dr Mark Tucker, director of bariatric surgery at the University of Medicine and Dentistry of New Jersey in Stratford, said such hernias were not uncommon and could happen up to five years after the surgery.

Because fertility increases with major weight loss, he said, reports of pregnancies within a year of surgery are becoming more common.