ASMBS Guidelines for General Surgeons: Bariatric Emergency Management

Metabolic and bariatric surgeries (MBS) have become a prevalent global practice for effectively treating obesity and metabolic diseases. The rising demand for MBS due to the worldwide obesity epidemic has increased the incidence of post-surgical emergencies. The most common MBS procedures are Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), known for their minimally invasive approach and reduced mortality. However, the growing number of MBS cases has led to an increase in short- and long-term complications, necessitating attention from emergency room physicians, regardless of their expertise in MBS. The American Society for Metabolic and Bariatric Surgery (ASMBS) has developed clinical recommendations to address this issue, providing guidance on handling common bariatric emergencies and their management. The guideline emphasizes the importance of individual assessment and prompt consultation or referral to an MBS surgeon.¹

Figure 1: Frequently conducted bariatric surgeries include procedures: A) Roux-en-Y gastric bypass. (B) Laparoscopic adjustable gastric band. (C) Sleeve gastrectomy. (D) Duodenal switch.¹

Recommendations for Managing Gastrointestinal Complications after Bariatric Surgery¹

Gastrointestinal Leak

• Gastrointestinal (GI) leaks have significant consequences, leading to considerable morbidity and contributing to postoperative mortality. The leak’s timing after surgery can offer insights into the severity of symptoms and how they progress.
• It is crucial to avoid delays in diagnosing GI leaks, as doing so can worsen patient outcomes. To achieve better results, a high level of suspicion, timely detection, and early intervention are essential in minimizing morbidity and mortality.
• In hemodynamically stable patients, computed tomography (CT) imaging with intravenous (IV) and oral contrast can aid in diagnosing and locating the leak. However, it is important to note that a negative imaging result does not rule out the possibility of a leak, especially in patients with a high index of suspicion. In such cases, unexplained persistent tachycardia might necessitate surgical exploration.
• For clinically stable patients, nonoperative management options include antibiotics, image-guided percutaneous drainage, endoscopic therapy, and nutritional support.
• When definitive surgical planning becomes necessary, it should be undertaken in collaboration or consultation with a metabolic bariatric surgeon, if available. This step should occur after the patient is stabilized and the leak site has been identified and controlled during the initial phase of treatment.

Marginal Ulcer (MU)

• Recognize that urgent intervention for MU is uncommon, except in cases of perforation or significant bleeding.
• Use upright chest x-ray, upper GI series, or CT scans to diagnose perforated MU in patients with sepsis symptoms.
• After resuscitation and broad-spectrum antibiotics, opt for operative repair with an omental patch and appropriate drainage to treat perforated MU.
• Upper endoscopy can be diagnostic and therapeutic in cases of significant upper GI bleeding due to MU, with symptoms like hematemesis, melena, and hemorrhagic shock. Surgical exploration is rarely required but may be considered if other modalities fail.

Gastric Band Complications

• Medical professionals, especially general surgeons, must be well-versed in the placement procedure and potential complications associated with Adjustable Gastric Band (AGB) in patients. Despite the significant number of patients with gastric bands, it is essential to be prepared to address any urgent complications that may arise.
• Although urgent complications related to the adjustable gastric band (AGB) are infrequent, they may involve band slippage and erosion, leading to perforation.
• In cases of band slippage, the initial approach involves aspirating band fluid. If decompression does not resolve the issue, surgical intervention becomes necessary for band removal.
• By staying informed about the AGB placement procedure and its potential complications, general surgeons can provide optimal care to patients with gastric bands, ensuring their safety and well-being.

Bowel Obstruction

• Understand that all bariatric procedures carry the risk of adhesive bowel obstruction, while those involving intestines have additional risks such as internal hernia, closed-loop obstruction, and intussusception.
• Consider a CT scan to aid in diagnosing internal hernias, but maintain a high index of suspicion, as a negative study does not exclude it.
• In cases of intussusception involving the jejunojejunal (JJ) in RYGB patients, early surgical exploration should be considered, even if a CT scan appears normal.
• When managing intussusception involving the JJ, consider revision of the anastomosis as the most common surgical procedure with the lowest recurrence rate.

Biliary Disease after Roux-en-Y gastric bypass (RYGB) and Portomesenteric Vein Thrombosis (PVT)

• Be aware that transoral endoscopic retrograde cholangiopancreatography (ERCP) may not be feasible in patients who underwent MBS involving GI bypass.
• Laparoscopic-assisted ERCP through the remnant stomach is often the preferred approach to the papilla in the emergent setting for biliary disease after RYGB.
• Consider abdominal CT scan for patients with suspected PVT presenting with abdominal pain, nausea, and intermittent emesis.
• Administer rehydration and anticoagulation for PVT treatment, and reserve surgical exploration for cases with suspected bowel ischemia.

Other Considerations¹

Emergencies can be clinically challenging for individuals undergoing bariatric surgery (MBS) due to potential medication interactions and nutritional deficiencies. One critical complication is thiamine (vitamin B1) deficiency, which can lead to severe and permanent side effects. Patients with protracted nausea and vomiting should be evaluated for thiamine deficiency. The deficiency can cause acute cardiac and neurologic symptoms, often mistaken for dehydration or hypoglycemia. IV thiamine supplementation should be given alongside IV rehydration to prevent this. Additionally, MBS patients on sodium-glucose cotransporter-2 (SGLT2) inhibitors may be at risk of euglycemic diabetic ketoacidosis, necessitating discontinuation before surgery.

Conclusion¹

Complications after MBS can pose a significant risk to a patient’s health, especially in geographically dispersed cases where immediate bariatric surgical expertise may be difficult to access. General surgeons on call should be knowledgeable in identifying and managing common complications proactively. Early diagnosis and timely treatment are vital to prevent severe morbidity and mortality. Consulting a bariatric surgeon early, and collaborating with gastroenterologists and interventional radiologists, can enhance effective diagnosis and treatment.

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References

1. Altieri MS, Rogers A, Afaneh C, et al. Bariatric emergencies for the general surgeon. Surg Obes Relat Dis 2023; 19(5): 421-433. DOI: 10.1016/j.soard.2023.02.007