Emergency Department Management of Patients With Complications of Bariatric Surgery

Table of Contents

 

Bariatric surgery has shown evidence of being a means of achieving sustainable weight loss, along with improvement in the comorbidities associated with obesity, such as hypertension, diabetes, and dyslipidemia. Though relatively safe, these patients do frequently present to the ED with complications, and proper management depends on emergency clinicians’ swift recognition and treatment.

What are the most common types of surgical procedures? Which ones have the highest likelihood of complications?

What is the difference between restrictive and malabsorptive procedures and how does this affect the type of complications seen?

Each procedure has common “early” and “late” complications; how can you quickly tell what the complication might be, based on the time post surgery?

Which laboratory tests can point to obstruction, gallbladder disease, or sepsis?

What are the conditions plain x-rays can show? What complications are evident on upper GI series with oral contrast?

CT imaging can show hernias, leaks, perforations, and erosions; what are the signs to look out for?

When should you admit, and when does the bariatric surgeon need to be consulted?

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Epidemiology and Etiology
   1. Overview of Bariatric Procedures
      1. Laparoscopic Gastric Sleeve (Sleeve Gastrectomy)
      2. Laparoscopic Adjustable Gastric Banding
      3. Roux-en-Y Gastric Bypass
      4. Other Bariatric Procedures
6. Pathophysiology
   1. Nonsurgical/General Complications
   2. Surgical Complications
      1. Nutritional Deficiencies
      2. Complications of Sleeve Gastrectomy
         • Early Complications of Sleeve Gastrectomy
         • Late Complications of Sleeve Gastrectomy
      3. Complications of Roux-en-Y Gastric Bypass
         • Early Complications of Roux-en-Y Gastric Bypass
         • Late Complications of Roux-en-Y Gastric Bypass
      4. Laparoscopic Adjustable Gastric Band Complications
         • Early Complications of Adjustable Gastric Band Surgery
         • Late Complications of Laparoscopic Adjustable Gastric Band Surgery
      5. Rare Complications
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. Initial Stabilization
      1. Airway Management
      2. Breathing
      3. Circulation
   2. History
   3. Physical Examination
10. Diagnostic Studies
    1. Laboratory and Diagnostic Testing
    2. Imaging Studies
       1. Plain Radiographs
       2. Upper Gastrointestinal Series With Oral Contrast
       3. Computed Tomography
       4. Endoscopy
       5. Ultrasound
11. Treatment
12. Special Populations
    1. Pediatric Patients
    2. Considerations for Women of Childbearing Age/Pregnancy
13. Controversies and Cutting Edge
    1. Endoscopic Procedures
    2. Aspiration Techniques
14. Disposition
    1. Admission
    2. Discharge
15. Summary
16. Risk Management Pitfalls in Managing Patients With Bariatric Surgery Complications
17. Case Conclusions
18. Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications
19. Tables and Figures
    1. Table 1. Indications for Bariatric Surgery Procedures
    2. Table 2. Complications of Bariatric Procedures
    3. Table 3. Treatment of Bariatric Surgery Complications
    4. Table 4. Indications for Bariatric Surgery Procedures in Adolescents
    5. Figure 1. Gastric Sleeve
    6. Figure 2. Adjustable Gastric Band
    7. Figure 3. Roux-en-Y Gastric Bypass
    8. Figure 4. Vertical Banded Gastroplasty
    9. Figure 5. Biliopancreatic Diversion
    10. Figure 6. Potential Spaces for Internal Herniation Following a Retrocolic Roux-en-Y Gastric Bypass
    11. Figure 7. Normally Positioned Gastric Band on X-Ray
    12. Figure 8. Slipped Gastric Band on X-Ray
    13. Figure 9. Obstruction of the Biliopancreatic Limb Following Roux-en-Y Gastric Bypass
    14. Figure 10. Gastro-Jejunal Anastomotic Leak Following Open Roux-en-Y Gastric Bypass
    15. Figure 11. CT Image of the Mesenteric Swirl Sign With a Small-Bowel Obstruction
20. References

Abstract

As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively. The most common complaints in these patients are abdominal pain, nausea, and vomiting, though each of the surgical procedures will present with specific complications, and management will vary according to the surgical procedure performed. Computed tomography is often the primary imaging modality, though it has it limits, and plain film imaging is appropriate in some cases. This review presents an overview of the various bariatric procedures, highlighting the potential complications of each, both surgical and nonsurgical, and provides evidence-based recommendations regarding patient management and disposition.

Case Presentations

You are in the middle of a busy shift, during which you have seen several patients with abdominal pain, vomiting, and diarrhea. Your next patient is a 54-year-old woman who also presents for abdominal pain. She is 2 weeks out from a Roux-en-Y gastric bypass procedure and reports that her pain is diffuse and severe. She is ill-appearing, with vital signs notable for tachycardia, hypotension, and a low-grade fever. Her abdomen is diffusely tender and peritonitic. You immediately initiate resuscitation with IV fluids and broad-spectrum antibiotics and obtain laboratory studies and cultures. You have limited experience with such patients, but you realize that she will require advanced imaging to determine the diagnosis. You wonder what diagnostic tests to order and what treatment, if any, you should start…

You are later called to the bedside of another patient who presents for nausea and vomiting. He is a 38-year-old man who is 2 weeks out from the placement of a laparoscopic adjustable gastric band. He reports that he had an acute onset of nausea and vomiting this evening. He is actively vomiting on presentation and complains of diffuse abdominal pain, but is hemodynamically stable. While attempting to contact his surgeon, you wonder what the best imaging modality is to make the diagnosis….

Your final patient of the evening is a 63-year-old woman who presents for chest and upper abdominal pain as well as shortness of breath. She was discharged home 2 days ago after undergoing a gastric sleeve procedure. She appears uncomfortable and is tachycardic and hypoxic on evaluation. In the process of completing your evaluation, you wonder how this presentation could be related to her bariatric procedure . . .

Introduction

Obesity, defined as a body mass index (BMI) of > 30 kg/m², is a significant public health concern because it affects a large proportion of the population, both in the United States and worldwide. It is associated with an increased risk of developing chronic diseases such as type 2 diabetes mellitus, hypertension, and hyperlipidemia. This rise in the prevalence of obesity and its related comorbidities has resulted in a concurrent increase in the number of bariatric procedures performed, because this is the only (evidence-based) means of achieving sustainable weight loss.^1,2

Bariatric procedures can be classified as restrictive, malabsorptive, or a combination of both. The 3 most commonly performed procedures in the United States are: (1) laparoscopic sleeve gastrectomy, (2) the Roux-en-Y gastric bypass (performed either laparoscopically or open), and (3) laparoscopic adjustable gastric banding. Each has specific complications that are due largely to postoperative anatomic changes.

Many of these patients will present to the emergency department (ED) postoperatively. A retrospective study looking at 38,776 patients over a 3-year period showed a 30-day unplanned ED utilization rate of 11.3%, with a 30-day hospital readmission rate of 5.3%.³ Similar trends have been noted in other studies. One study showed that approximately 14.6% of patients had a postoperative ED visit (not resulting in an admission) in the 2 years reviewed.⁴ In another study, 31.1% of patients had an ED admission following laparoscopic Roux-en-Y gastric bypass surgery, with most presenting within 1 year of the procedure.⁵ Other studies have estimated that up to 25% of these patients will require admission within the first 2 years of the procedure, with a 30-day admission rate of around 5%.⁶ Many of the patients described in these studies had multiple ED/hospital visits, generally for abdominal pain, nausea, vomiting, and dehydration.^4,5,7 This issue of Emergency Medicine Practice reviews common ED presentations of patients with postoperative bariatric surgery complications, with recommendations on imaging and management, based on the type of surgery performed.

Critical Appraisal of the Literature

A literature search was performed on PubMed, using the search terms bariatric, emergency, diagnosis, management, and complications. The reference section of each article was reviewed for additional articles. A search was also performed using the Cochrane Database of Systematic Reviews and Ovid MEDLINE^®, but yielded very limited information. The American Society for Metabolic and Bariatric Surgery (ASMBS) guidelines were reviewed. These searches highlighted the fact that the bulk of available research on complications of bariatric procedures is primarily from the surgical literature, with limited studies in the emergency medicine sphere. In addition, many of the available articles were review articles, retrospective cohort studies, or meta-analyses, with very few prospective randomized controlled trials.

Risk Management Pitfalls in Managing Patients With Bariatric Surgery Complications

5. “I thought he was tachycardic because he was in pain, so I discharged him home when his vital signs normalized after pain control.”

Tachycardia and tachypnea may be the initial signs of significant intra-abdominal pathology (such as anastomotic leaks) in postoperative bariatric patients, so close attention should be paid to all vital signs. Both can also be seen in patients with pulmonary emboli, which are an important cause of morbidity and mortality in these patients.

6. “The abdominal examination was benign, so I didn’t think she needed a CT.”

Findings on abdominal examination may be subtle in bariatric patients due to the modified anatomy and the amount of adipose tissue, so a benign examination may not be indicative of a lack of significant pathology.

10. “I couldn’t figure out why she kept coming back for persistent diarrhea.”

Dumping syndrome results from a high osmotic load in gastric bypass patients, which causes diarrhea. Patients should be cautioned about dietary modifications to prevent this from occurring.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

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