Bariatric patients arrive in the emergency room with a number of surgical complications.The most common case seen is peritonitis from an anastomotic breakdown.Usually seen within 10 days after surgery, the incidence of post operative leak after Roux en Y gastric bypass ranges from 1-6 %, more after laparoscopic than open cases. The classic peritoneal signs are not always present post operatively and the ER team should be aware of subtle signs and symptoms that may point to this diagnosis, requiring early surgical consultation. These signs include fever, increasing abdominal pain, back pain, pelvic pressure. hiccups, unexplained tachycardia. (a pulse rate >120/min has been associated with gastric dilatation and leak with peritonitis).Given the seriousness of the complication and the vague nature of the presenting symptoms , suspicion of this diagnosis should lead to early surgical consultation. Upper GI series is essential to aid in the diagnosis, although, this can be non diagnostic in some cases and are not extremely sensitive for anastomotic leak. Depending on the severity of the symptoms, a re- exploration in the operating room may be needed.
Acute gastric distention is another complication after a laparoscopic Roux en Y.This seems to be due to edema or obstruction at the entero enterostomy site developing within first several days post op. The client presents with nausea, vomiting(dry heaves), left upper quadrant bloating and hiccups.Severe distention can create problems with staple line and anastomosis.Plain radiograph may demonstrate significant gastric distention with air-fluid levels. There is a controversy as to whether a nasogastric decompression can be done , should distention of the proximal pouch or small bowel obstruction be found. A distended remnant stomach will not be decompressed by a nasogastric tube.Percutaneous decompression has been successful in some, whereas others require reoperation with gastrostomy tube placement. It is prudent to discuss this intervention with a consulting surgeon before NG tube placement in the ED due to the potential risk of puncturing suture lines.
Stomal stenosis occurs in upto 12% of both gastric bypass and vertical banded gastroplasty and typically occurs 1 or more than a month after surgery.The gastric outlet of both procedures is typically designed to be 1 cm in diameter.Stenosis of the outlet can lead to symptoms of post prandial epigastric pain and vomiting.Treatment involves endoscopy with balloon dilatation.Some patients require multiple dilatations.
Band erosion into the stomach after gastric banding has been reported in 0.3-1.9% of patients.Patients with this complication may present with progressive left upper quadrant pain or pain in the left lower chest that can mimic complaints of angina.Outlet obstruction can also lead to severe gastroesophageal reflux and esophagitis.Conversion to gastric bypass may be required in some to resolve this complication.
Bariatric patients also arrive in the emergency department with other surgical complications such as small bowel obstruction,( due to adhesions, hernias and intussuception), incisional and internal hernias, staple line disruptions etc.