Emergency Surgical Intervention in the Post Bariatric Surgery Patient: Can Anyone Do It?

Cheickna Diarra, Jennifer Sasaki, MD, Shaukat Gulfaraz, MD, Leah Bess, MS, Eric M Pauli, MD, Ann M Rogers, MD, Randy S Haluck, MD, Jerome R Lyn-sue, MD. Penn State Hershey Medical Center

Background: Patients may have multiple Emergency Room (ER) visits following a Bariatric procedure, which may range from non-specific abdominal complaints requiring conservative management to an abdominal emergency which may require immediate surgical intervention. Following Bariatric surgery, the abdominal anatomy is often variable and complex. Frequently, surgeons with little or no bariatric expertise may feel uncomfortable taking care of these patients. We looked at our experience over a 5-year period in managing this unique, but ever increasing patient population.

Methods: A retrospective chart review was done for the patients who were admitted from our emergency department with abdominal complaints and a history of having a bariatric procedure. All patient visits between January 2009 and January 2014 were reviewed for type of primary bariatric procedure, time from procedure, weight loss, diagnosis and management of the problem.

Results: 222 patients met the inclusion criteria, resulting in a combined total admission of 282. 97% of patients were following Roux- En-Y gastric bypass. The time range from primary procedure was 2 days to 19 years. The mean weight loss after primary intervention was 36kg (SD 1.74). The mean weight at emergency presentation was 90.14kg (SD 1.64). The most common complaint was abdominal pain (80%). Nausea and vomiting was seen in 12.4% of patients. Other complaints included dysphagia and hematemesis. 94% (264/282) of visits needed some form of intervention such as diagnostic or therapeutic upper endoscopy, diagnostic laparoscopy, exploratory laparotomy, adhesiolysis, reduction and repair of internal hernia, and revision of gastro-jejunostomy. The most common diagnoses were stricture 16.6% (47/282), bowel obstruction due to adhesions 16.3% (46/282), internal hernia 15.6% (44/282), gastro-jejunostomy perforation 8.5% (24/282), cholecystitis 6.7% (19/282), and volvulus or intussusception at the jejuno-jejunostomy 5.3% (15/282).

Patients that required endoscopic interventions were on average 30 months from their primary operation, while patients requiring surgical interventions for obstruction were on average 62 months from their primary intervention p=0.0006. There was no statistical significance between patients who required endoscopic intervention and surgical intervention in regards to weight loss and weight at time of emergency intervention, p=0.2 and p=0.18 respectively. There was no mortality in this series.

Conclusion: After bariatric surgery, abdominal pain was found to be the main presenting complaint among patients that presented to the ER. A variety of diagnoses can be responsible for this pain. Our data showed that these symptoms required some form of intervention in more than 90% of the cases. Due to varied anatomy and unique pathophysiology associated with post bariatric surgery patients, surgeons who have the experience and necessary skills in bariatric surgery would be better equipped to deal with these complications. Skills needed would include comprehensive knowledge of bariatric surgical procedures and advanced interventional endoscopy.

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