Emergencies in Post- Bariatric Surgery Patients

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1 Emergencies in Post- Patients Disclosures Dr. Birnbaumer has no financial disclosures Diane M. Birnbaumer, M.D., FACEP Professor of Medicine University of California, Los Angeles Senior Clinical Educator Department of Emergency Medicine Harbor-UCLA Medical Center You Are Served A letter arrives in your mailbox stating that you are being sued for the wrongful death of a 24-year-old single mother of 2 young children You review the chart and find the following: The Case 24 year old female presents complaining of severe intermittent abdominal cramps off and on for 12 hours. Denies vomiting, fever, diarrhea. Never had this pain before. PMH: None Meds: MVI All: NKDA PSH: Laparoscopic Roux-en-Y gastric bypass 4 months ago 1

2 The Case Afeb / % RA Moderately uncomfortable, nontoxic appearing, morbidly obese WF (170 kg) Exam suboptimal due to patient s body habitus but abdomen nontender Rest of exam normal The Case Workup CBC normal except WBC 14.2, mild left shift Chem-10 normal Abdominal plain films suboptimal, but no evidence of free air or bowel obstruction Abdominal CT with PO and IV contrast read by radiology as s/p Roux-en-Y bypass, no evidence of perforation or abscess The Case Disposition Patient still complaining of abdominal cramping Pain mildly improved with 15 mg morphine, still 5/10 Able to keep down POs Discharged with instructions to see her PCP tomorrow for re-evaluation The Case The denouement Patient complains of increasing abdominal pain at home A friend takes her to another ED 4 hours after discharge Soon after arrival the patient develops severe shock and dies within several hours of presenting to outside ED Autopsy: Necrotic blind loop of bowel 2

3 Obesity in the U.S. is rising dramatically Surgical treatment more and more common and effective Patients with complications of bariatric procedures may come to ED Requires EPs to become familiar with types of procedures and their complications The Procedures Based on two concepts Restricting the size of the stomach Causing intestinal malabsorption Procedures can be done open or laparoscopically Differing complication rates depending on technique 3

4 The Restrictive Procedures Staples Vertical Banding Gastroplasty Band creates a small stomach pouch Band is not adjustable Leads to reduced food intake Not particularly successful Band Small Stomach Pouch Laparoscopic Adjustable Gastric Banding Adjustable silastic band Port implanted in skin Can tighten or loosen the band by injecting or removing liquid from the port Small Stomach Pouch Adjustable Band Laparoscopic Adjustable Gastric Banding May be discharge same day as surgery Band not usually inflated on the first day 4

5 The Malabsorptive Procedures Roux-en-Y Gastric Bypass Most common and successful surgery Restrictive and malabsorptive Restricts stomach Bypasses part of small bowel Roux-en-Y Gastric Bypass Can be performed open or via laparoscope Stomach stump attaches to small bowel Leaves a blind loop Connection to Small Bowel Connection to Small Bowel Stomach Pouch Roux Limb Stomach Stump Blind Loop 5

6 Biliopancreatic Diversion Malabsorptive and restrictive procedure Usually performed via open technique Partial gastrectomy Leaves no defunctionalized bowel The Complications Complications depend on two major factors Procedure performed Time since procedure Early within 30 days Later any time after a month Presentations can be subtle but lifethreatening Can be surgery-related or metabolic The Complications - Early Anastomosis breakdown Most lethal complication up to 6% of cases Usually within 10 days of surgery Presentation may be subtle Fever, unexplained tachycardia, abdominal or back pain, pelvic pressure, hiccoughs, restlessness 6

7 The Complications - Early Anastomosis breakdown Diagnostic studies Upper GI CT with contrast Note! Usual amount of GI contrast not feasible Stomach capacity is only ml Get early surgical consultation unless clearly benign The Complications - Early Acute gastric distention Most common after Roux-en-Y Edema or obstruction of the end of the Roux limb Usually onset few days post-op The Complications - Early Acute gastric distention Nausea, dry heaves, LUQ bloating, hiccoughs Plain films may be helpful CT may be needed The Complications - Early Acute gastric distention Treatment Re-operation or percutanous decompression NO NG TUBE!!! Risk of disruption of staple site May not be effective Highly advisable to consult surgeon before putting down NG tube 7

8 The Complications - Early Proper Placement Acute band migration Can be acute or later Stomach migrates from below to above band Risk for gastric necrosis and perforation Vomiting, upper abdominal pain Plain films may show misplaced band May need swallow study / fluoro Treatment is to deflate the band ASAP Aspirate at least 5 ml to assure deflation Proper placement on AP KUB with oral contrast When in doubt, call the radiologist or the surgeon 8

9 The Complications - Late The Complications - Late Staple line disruption May occur early, but usually > 4 months after surgery Excluded stomach communicates with gastric pouch Not really a complication but rather a failure to achieve goal of weight loss Incisional hernias Seen in 15-20% of patients after open procedures May be hard to palpate depending on patient s body habitus CT scan may be needed to make diagnosis Incarcerated hernias at port sites may also occur; difficult to appreciate on exam The Complications - Late The Complications - Late Stomal stenosis Up to 12% of cases Typically occur more than one month after surgery Present with post-prandial epigastric pain and vomiting, dysphagia Diagnostic studies include UGI, upper endoscopy Treatment is with endoscopic dilatation Band Erosion Occurs in from 0.3 to 1.9% of patients with banding procedures One study quotes 6.8% Band erodes completely through gastric wall Progressive LUQ pain or pain in left lower chest (may mimic angina) 9

10 The Complications - Late The Complications - Late Band Erosion May have intraabdominal sepsis with or without abscess May develop free perforation May develop gastrocutaneous fistulas Surgical consultation, antibiotics Internal Hernia Can occur in up to 6% of patients more frequent with laparoscopic procedures? Present with intermittent, crampy abdominal pain, nausea, vomiting Pain may radiate to back Pain may be out of proportion to exam - highly concerning (bowel ischemia) Exam may be relatively benign The Complications - Late The Complications - Late Internal Hernia Diagnostic studies (CT scan, UGI series) may be nondiagnostic Surgical consultation needed; may need surgical visualization and intervention Resuscitation measures vital Marginal Ulcer Occur in up to 15% Usually present within first 90 days after surgery Present with epigastric abdominal pain, dyspepsia Diagnostic studies is upper endoscopy Treatment - Acid suppression therapy 10

11 The Complications - Late Bleeding from Roux-en-Y Bypass Limb May require aggressive resuscitation Note: Any volume depletion state in postbariatric surgery patients may need significant hydration Decreased oral intake caused by bypass surgery itself may cause volume depletion state The Take Home Points Strongly consider calling a surgeon for post-bariatric surgery patients presenting to the ED Usual imaging studies may not be diagnostic in these patients Volume depletion states may require aggressive fluid resuscitation The Take Home Points Avoid placing an NG tube unless the case is discussed with a surgeon first Patients with inflatable bands with nausea and vomiting or moderate to severe abdominal pain should have the band deflated Thank You For Your Attention!! 11

12 12

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