Acute care surgeons are likely to encounter problems related to bariatric surgery because patients have a lifelong risk of complications, said authors of a single-center retrospective study.
“Internal hernias or obstructive etiologies are the most common presentations, and often require emergent or urgent surgery,” added Dr. Joel F. Bradley of Premier Surgical Associates, Knoxville, Tenn., and his associates at Carolinas Medical Center, a quaternary care hospital in Charlotte, N.C. “We recommend that when diagnosis is unclear for former bariatric surgery patients, diagnostic laparoscopy be performed to answer definitively if a surgical complication is present.”
Bariatric surgeries in the United States have leveled off at about 100,000 per year, but postsurgical complications are rising along with the total patient population. The researchers reviewed all 33 such cases at their acute care surgical service between 2007 and 2013 (Am. J. Surg. 2015;210:456-61).
Most patients were middle-age women with a history of laparoscopic Roux-en-y gastric bypass (RYGB) surgery. Other common index procedures included open RYGB and laparoscopic gastric banding, the researchers said. The most frequent complication was internal hernia, which affected a third of patients, and in two cases involved ischemic bowel. Other complications included adhesive small bowel obstruction, laparoscopic band restriction, and biliary disease. “Of note, all three patients with biliary disease also had internal hernias at Peterson’s defect that were closed at the time of cholecystectomy,” the investigators said. Less-common complications included upper gastrointestinal bleeding or ulcer, perforated ulcer, gastric outlet obstruction, intussusception, and ventral incisional hernia.
About 91% of patients with complications needed surgery, and 43% were open rather than minimally invasive. Laparoscopic and open surgery cases had similar baseline characteristics and outcomes, but open surgery patients averaged 11 days in the hospital, compared with 5 days for laparoscopic cases (P less than .05).
Cases were often emergent (43%) or urgent (20%), the investigators emphasized. All three patients with a previous vertical banded gastroplasty were obstructed at the gastroplasty site and were converted to RYGB. Surgeons managed the single case of intussusception with laparoscopic reduction and colopexy of the proximal and distal bowel to the abdominal wall. All three patients with symptomatic cholelithiasis underwent laparoscopic cholecystectomy. Two patients underwent upper endoscopies for bleeding or ulcer, and one underwent gastric band deflation for obstruction. No patients died.
Patients who have undergone RYGB are at particular risk of obstructive internal hernias, which can be mesenteric, mesojejunal, jejunojejunal, or at the Petersen’s space, the researchers noted. Some bariatric surgeons do not routinely close mesenteric defects, and, even when closed at the index surgery, as many as 83% of patients spontaneously open their jejunojejunostomy mesenteric defect after losing weight, they added (JSLS. 2010 Apr-Jun;14:213-6).
Surgeons should also watch for obstructions secondary to adhesive disease and lap band restriction, they said. “Importantly, patients presenting with bowel obstruction from adhesive disease after RYGB are indiscernible from those with internal herniation, and surgeons must have a low threshold to evaluate these patients with diagnostic laparoscopy,” they added.
Band slippage, the most common complication of gastric banding, can cause dysphagia and gastric outlet obstruction, the investigators noted. Port site infection and band erosion are thought to be rare and can be managed laparoscopically if caught early, they said. “Many general and acute care surgeons may think that these complications are rare, and do not pertain to their practice; however, as bariatric procedures have regionalized, patients’ emergent complications are often seen by the local surgeon, not at the regional center,” they added.
The researchers reported no funding sources and no disclosures.