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emDOCs Podcast – Episode 144: Post Bariatric Surgery Complications Part 1

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Today on the emDOCs cast with Brit Long (@long_brit), we cover Part 1 on post bariatric surgery complications, with the individual surgeries and an approach. Part 2 will dive into the major complications.

Episode 144: Post Bariatric Surgery Complications Part 1

 

Background:

  • Obesity: defined by the WHO as abnormal or excessive fat accumulation that presents a risk to health. Class I obesity defined as BMI 30-34.9 kg/m2, Class II BMI 35-39.9 kg/m2, Class III (or severe obesity) BMI > 40 kg/m2.
  • Bariatric associated with improved outcomes: reduced overall mortality and significant, sustainable weight loss, partial or total remission of obesity-related comorbidities (diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea).
  • Bariatric surgeries categorized as restrictive procedures that limit food intake, malabsorptive procedures that limit food absorption, or mixed restrictive and malabsorptive procedures that do both.
    • Restrictive procedures: adjustable gastric banding, endoscopic gastric balloon insertion, sleeve gastrectomy.
    • Mixed restrictive and malabsorptive procedures: roux-en-y gastric bypass (RNYGB) and biliopancreatic diversion with or without duodenal switch (BPD-DS).

 

Epidemiology:

  • In 2019, over 256,000 bariatric surgeries were performed in the U.S. Average age of patients undergoing bariatric surgery is in their 40s; majority of patients are female. Most procedures are performed laparoscopically; < 7% are open.
  • In 2006, most common procedure performed was RNYGB. More recently, laparoscopic sleeve gastrectomy (LSG) has become more common.
  • Postoperative mortality from bariatric surgery < 1%. Over half of post bariatric patients visit the ED at least once in the first two years for a bariatric-related complaint. Up to 29% of bariatric surgery patients visit the ED in the first 90 days postoperatively; 10% of visits result in readmission due to surgical complication.

 

Surgeries:

  • LSG: greater curvature of the stomach resected. Reduces volume of the stomach by 80%; limits food intake.
    • Mortality rate associated with this procedure < 1%; the rate of postoperative complications ranges between 2-13%.
    • Complications: hemorrhage, staple line leak, intra-abdominal abscess, but gastric stenosis, nutrient deficiency, GERD often occur beyond the first month post-operatively.
  • Gastric balloon: delivered endoscopically to the stomach to reduce gastric capacity.
    • Complications: balloon intolerance, GERD/esophagitis, gastric ulcer/erosion/perforation, antral impaction, balloon hyperinflation, rarely pancreatitis.
  • Laparoscopic Adjustable Gastric Banding: less commonly performed; involves applying a saline-filled band just below the gastroesophageal junction to leave a gastric pouch sized 50-80 mL. Device is connected to an injection reservoir sutured within the abdominal wall; can be used to adjust the band.
    • Associated with 13% hospital readmission rate and 52% revisional surgery rate.
    • Common late complications: port and tubing problems, GERD, pouch dilation, band slippage, band erosion.
  • RNYGB: second most common bariatric procedure in the U.S. Restrictive and malabsorptive. Surgeon separates small section of the upper stomach from the body of the stomach and creates a limb of proximal jejunum. This is anastomosed to the proximal gastric pouch. Intake restricted by a small gastric pouch, narrow gastrojejunostomy restricts gastric emptying, and food diverted from the duodenum. Causes malabsorption.
    • Mortality rate associated with laparoscopic RNYGB is < 1%; incidence of postoperative complications 1-15%.
    • Complications: PE/DVT, anastomotic/staple line leak, small bowel obstruction/internal hernia, marginal ulceration, gastrointestinal bleeding, dumping syndrome.
  • Biliopancreatic Diversion with or without Duodenal Switch: performed less frequently; combines sleeve gastrectomy with gastrojejunostomy and jejunojejunostomy to create an alimentary limb. Decrease caloric absorption and provides a shorter common channel where food bolus can mix with biliopancreatic juices, resulting in reduced protein and fat absorption. Mildly restrictive and primarily malabsorptive.
    • Complications similar to those following LSG and RNYGB; higher likelihood of malabsorption-related complications like dehydration, protein-calorie malnutrition, vitamin and mineral deficiencies.

surgery types

Approach:

  • Patients present with a variety of signs and symptoms. Having an approach is vital, but consult the bariatric surgery consult early.
  • Clinical signs may be absent or nonspecific; symptoms can be intermittent.

table bariatric

  • Tachycardia or tachypnea in the first month following surgery is concerning: think anastomotic leak and pulmonary embolism.
  • If the patient comes in the first month after surgery with abdominal pain, chest pain, shortness of breath, tachycardia, tachypnea, or fever, assume an anastomotic/staple line leak or PE until proven otherwise. Anastomotic leak may have minimal abdominal pain or tenderness on exam.
  • Abdominal exam in post bariatric patients often nonspecific; patients may have no tenderness.
  • Persistent vomiting following surgery concerning for acute surgical emergency.
  • Intra-abdominal pathology may present with pulmonary symptoms alone or with chest or shoulder pain.
  • If they present following that initial postoperative period with severe vomiting and pain, especially years later and the patient underwent RNYGB, think internal hernia with obstruction.

 

Labs:

  • CBC, electrolytes, renal and liver function, lipase, lactate, urinalysis, c-reactive protein.
  • If bleeding, type and screen. If patient unstable or septic, get cultures.
  • Inflammatory markers are not specific or sensitive.

 

Imaging/General Treatment:

  • Imaging plays key role.
  • Options: Upright KUB, GI fluoroscopy, CT abdomen/pelvis with oral and IV contrast.
  • For most patients, CT of the abdomen pelvis with IV and oral contrast is test of choice.
    • For sleeve gastrectomy, give oral contrast and then patient can undergo the scan some minutes right after.
    • For gastric bypass, the patient should drink 1 full dose and then get the CT about an hour later if the patient is not obviously peritoneal.
    • Oral contrast helps identify the new anatomic landmarks, including the gastric pouch, gastrojejunal anastomosis, jejunal Roux limb, jejunojejunal anastomosis, biliopancreatic limb.
    • If the patient presents within that first month of the surgery, obtain CT chest and abdomen pelvis to evaluate for PE and leak. CT does not have 100% sensitivity for leak, so consult the surgeon.
  • If the patient is acutely decompensating due to an intraabdominal issue, operative intervention necessary.
  • Resuscitate with IV fluids, treat symptoms, administer broad spectrum antibiotics.
  • Caution with placing an NG tube; speak with surgeon first (risk of staple/suture line disruption).

Stay tuned for part 2, where we cover the individual complications in detail!

 

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