Management of the Patient with a History of Bariatric Surgery and Abdominal Pain in the Emergency Department

Fig. 5.1

(a, b) Easily seen radiographic findings that may indicate the presence of a slipped band include the presence of an “O” sign (the circular ring of the band easily visible), an air-fluid level in the proximal stomach, or the location of the band greater than 3 cm below from the diaphragm

While the basic abdominal radiograph is a good initial study, an upper GI series will give the same information plus the real-time movement of material through the stomach. This modality can help diagnose a stricture/overtightening, gastric perforation, as well as issues related to delayed gastric emptying. However, due to the “real-time” nature of the study, an upper GI series is dependent on the skill of the radiologist performing and interpreting the study.

Computed tomography is rapidly gaining favor in most institutions as a quick and reliable diagnostic modality. With the addition of oral contrast, a CT scan may obtain much of the same information as an upper GI series, as well as three-dimensional visualization of the abdominal viscera and any fluid collections or signs of inflammation. It does, however, miss the motility issues demonstrated on upper GI. CT should also be reserved for patients who are hemodynamically and clinically stable.

Using the described diagnostic modalities, a definitive diagnosis should be obtained. Should the source of the patient’s symptoms be due to obstruction at the band, the treatment is simply deflation of the gastric cuff via the subcutaneous port, as mentioned above. Evaluation of the patient post-intervention can then be pursued by clinical resolution or radiographic means. If the patient’s pain resolves there is no need to emergently remove the band; the patient can be safely discharged with referral to their original bariatric surgeon or a local bariatric specialist. If there is concern for ischemia, foreign body, or device erosion, however, an upper endoscopy should be obtained to definitively diagnose and possibly treat the pathology. Emergent surgery is rarely required for a band erosion; the erosive process is typically progressive over weeks or months, giving ample time to contain any perforation. In an unstable patient, however, band removal with extensive drainage should stabilize a patient for transfer to a bariatric center. Urgent surgical intervention on gastric bands should be reserved for persistent symptoms/obstruction, as well as adequate clinical suspicion for bowel ischemia or necrosis. It is also appropriate if band removal for complications is desired. Further, a surgical consultation and evaluation should always be obtained, even if the patient does not require emergent surgical intervention.

5.2 Laparoscopic Sleeve Gastrectomy

The laparoscopic sleeve gastrectomy has increased in popularity in recent years owing to its efficacy (average 60 % EBW loss), relative ease, and rapid postoperative recovery [7]. The procedure was first described by Marceau in 1993 as the first stage of a biliopancreatic diversion [8]. In super-obese individuals, the diversion was performed as a two-stage procedure, with the sleeve gastrectomy portion first. Patients experienced such significant weight loss prior to the second stage that many surgeons began performing the sleeve gastrectomy as a stand-alone procedure. Since 2010, laparoscopic sleeve gastrectomy has become the bariatric procedure of choice in many high-volume centers [2].

The effectiveness of sleeve gastrectomy is attributed to both a restrictive effect from removal of significant gastric reservoir and decreasing the hunger stimulus by reducing the secretion of ghrelin [9]. Normally, ghrelin levels rise prior to a meal and subsequently fall; this cycle does not occur after sleeve gastrectomy, thereby inhibiting a key stimulus of hunger. This can help explain how the procedure produces outcomes superior to the Lap Band [9]. However, despite greater efficacy, the procedure does carry its own set of complications. These patients may present postoperatively with intraabdominal or intragastric bleeding, gastric stricture, gastric volvulus, or leak from the gastric staple line.

Upon presentation to the emergency department, postoperative sleeve gastrectomy patients should be evaluated in a manner similar to gastric band patients, the key difference being the absence of an implanted foreign body and its potential complications. As always, a thorough history and physical should be performed, taking great care to elucidate the nature and timing of the abdominal pain, as well as the patient’s ability to tolerate liquids or solids [10]. The progression of radiographic studies mirrors the workup of the gastric band patient, with any ominous findings indicating free perforation or bowel ischemia prompting urgent surgical exploration.

The treatment of many post-sleeve complications is a rapidly changing algorithm, the cause of which is the rapid advancement of endoscopic and “interventionalist” techniques and the skill of those who perform them. Endoscopic intervention can successfully treat many post-sleeve complications. Paradoxically, leak may present early or late after sleeve gastrectomy (Fig. 5.2). A number of endoscopic devices, including over-the-scope clips, fibrin sealant, and endoscopic suturing, have been moderately successful in promoting closure of the perforation [11, 12]. Additionally, the placement of covered stents over the site of perforation can help to decrease the extravasation of gastric contents through the perforation, thereby promoting healing. Should these efforts remain unsuccessful, the patient may be placed on prolonged oral restriction with parenteral nutritional support [13]. For these patients, surgical management may be necessary. Endoscopy is also the first-line therapy for endoluminal bleeding, which can be controlled by electrocautery or endoscopic clips in a similar fashion as the treatment of bleeding peptic ulcers.

Fig. 5.2

Leak may present early or late after sleeve gastrectomy

If a patient presents with signs of sepsis and a fluid collection observed on imaging (Fig. 5.3), a drainage procedure is required in addition to antibiotic therapy. If the collection is accessible via the skin, a percutaneous drainage procedure may be performed. However, in the event a drainage window cannot be obtained, operative drainage is required. Patients should be widely drained. Fistulas from the leak may be controlled with a t-tube or urinary catheter to facilitate transfer to a bariatric center. Similarly, a patient who presents with an intraperitoneal hematoma from the gastric staple line may require operative exploration if they are hemodynamically unstable or show continuing signs of bleeding.