Today on the podcast, we discuss how to handle emergencies in patients who have undergone a Bariatric Operation. These patients can create anxiety if you don't have a pre-planned paradigm or don't understand the differences between the various procedures.
The Guest
Matthew J. Martin, MD FACS is a trauma, acute care, and bariatric surgeon from the Division of Trauma and Surgical Critical Care, Los Angeles County + USC Medical Center, University of Southern California
The Paper
Common postbariatric surgery emergencies for the acute care surgeon: What you need to know. Journal of Trauma and Acute Care Surgery 95(6):p 817-831, December 2023. | DOI: 10.1097/TA.0000000000004125
Top 10 Principles for Bariatric Emergencies
- There is nothing unique about abdominal emergencies in the bariatric patient versus other patients who have undergone prior foregut surgery, but there are specific additional considerations and triggers for interventions of which the acute care surgeon should be aware. Bariatric patients still develop appendicitis, gallstone disease, etc., so work up the common problems.
- A bariatric history is critical! Establish exactly what procedure the patient had done (many times they will all be labeled as having a “prior gastric bypass”), when and where it was done, open versus laparoscopic, and any immediate postoperative complications or problems. Contacting the original bariatric surgeon can provide critical information or advice.
- In the early postoperative period (i.e., 1–4 weeks). any significant abdominal complaints should be assumed to be a leak (anastomotic or staple line) until proven otherwise.
- Leaks can present insidiously with minimal abdominal complaints. Relatable early signs are fever, tachycardia, or unexplained elevation of the white blood cell count. However, each of these findings lacks specificity.
- Many abdominal emergencies present with associated pulmonary symptoms, and pulmonary emboli can present similar to a leak. Both should be considered and ruled out, usually by CT imaging combined with clinical assessment.
- Postoperative bowel obstructions after a gastric bypass are due to an internal hernia until proven otherwise. Computed tomography scan can provide evidence of an internal hernia, but no imaging study is reliable enough to rule out an internal hernia. This “proof” usually requires surgical exploration done in a timely fashion to avoid catastrophic small bowel strangulation or blowout of a proximal staple line.
- The SG is the fastest growing bariatric procedure being performed, so be familiar with the anatomy and the common emergencies with this procedure. Although touted as a “safer and less invasive” option than gastric bypass, the leak rate is similar (or higher) and more difficult to manage.
- Many acute abdominal complaints with the adjustable gastric band can be relieved by complete band deflation (i.e., can be done at bedside), turning an urgent issue into an elective one. Although now rarely performed as a primary bariatric operation, there are many patients who have a gastric band and who may present with some acute complication that requires urgent bedside or surgical intervention.
- Upper gastrointestinal fluoroscopy studies alone will miss a significant number of leaks. Following the UGI study with a CT scan (i.e., combined CT/swallow protocol) will greatly improve detection of leaks and evaluate for most other emergent abdominal pathologies.
- The acutely decompensating patient belongs in the operating room as soon as possible. The stable patient with persistent and unexplained abdominal pain after complete radiologic evaluation usually warrants endoscopy and/or laparoscopic surgical exploration.
LEAKS CAN PRESENT WITH PULMONARY SYMPTOMS!!!
H/P
History
- What operation was performed? When?
- Open or laparoscopic (also see examination)?
- Any subsequent operations or revisions?
- Location and name of the hospitals and the surgeons?
- How long was your hospital stay after the bariatric surgery?
- Any complications related to the surgery?
- Any endoscopy performed since the surgery? Any other imaging studies?
- How much weight did you lose? Regained?
- Current smoking or tobacco use?
- All medications, including over-the-counter meds, herbs, supplements
Physical Exam
- Current vital signs, temperature, Any tachycardia?
- Subjective abdominal pain, nausea, other complaints before examination
- Tenderness location, referred pain, rebound, guarding
- Location and size of scars (consistent with the given surgical history?)
- lncisional or groin hernias
- Pleuritic chest pain/tenderness
- WBC, CMP, lipase
Initial Imaging
CT Abd with IV and Oral Contrast (1 dose)
- SG – swig and scan minutes afterward
- Gastric Bypass – drink 1 full dose and image ~1 hour later if the pt is not obviously peritoneal
The Operations
Sleeve Gastrectomy
Most commonly performed in the USA as of 2023
Leak
Uncommon, but possible
Abd pain, Pulmonary Symptoms,
Bleeding
From staple line
Obstruction
Can be a technical error early or a stricture later
Persistent vomiting is a sign of badness (1 or 2 episodes immediately afterwards, maybe, but after that there is a problem until proven otherwise
This may require a swallow or EGD to evaluate, but the Bariatric Surgeon can make that call
Gastric Bypass
Early Complications
Make the stomach smaller and reroute the small intestine
Leak
Contrast will not extravasate from the excluded stomach
Bleed
Late Complications
Small Bowel Obstruction
Not a watch and wait situation b/c it is an internal hernia until proven otherwise–waiting can result in dead bowel
Strictures
Persistent Vomiting
Marginal Ulcers
At the junction of stomach and small intestine, Can cause a microperf. They look bad and this may prompt an open operation, but they can be easily handled by a Lap Op.
Choledocolithiasis
More of a problem of what to do with them after identification
Get an MRCP after initial suspicion from CT or UTS
In a bypass patient, MRCP is the test of choice
Lap Band
Historic, but a bunch of these pts are still out there
Obstruction
Usually means the band has slipped
Can perforate if left too long
Abdominal Xray can answer if it has slipped
Can access the Port and suck out all the fluid–can completely solve the issue in the short term
Use a port access needle (non-coring 20G or 22G)
NGT Tubes
After 1-2 weeks, probably ok, but worth just checking with the surgeon
Additional Resources
- MBSAQIP program website
- Listing of all accredited bariatric centers (searchable)
- Overview of currently performed bariatric procedures
- ASMBS “Clinical Pearls for Emergency Care of the Bariatric Surgery Patient” poster (downloadable)”
Additional New Information
More on EMCrit
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
excellent.. despite the number of times I study this, the bariatric surgery patient always worries me. and whenever I do have a bariatric surgery patient with a problem, even if its 12 years prior that they had surgery, the general surgeons in our busy but rural community hospital are, possibly rightfully so, hesitant to get very involved, and most require transfer.
but this podcast with dr. Matt Martin (whose shop is just a few hours south of me) was exceedingly clear, concise, and wonderfully helpful to me. exceedingly so. thank you both.
tom fiero
ed , merced, ca.
word games are games that is not difficult. But it’s not easy either, It’s better when you play it with your friend. You’ll see an incredible level of word search. Puzzles will be solved twice as fast as usual that is not difficult. But it’s not easy either, It’s better when you play it with your friend. You’ll see an incredible level of word search. Puzzles will be solved twice as fast as usual wordle unlimited