1.14.5 Bariatric Surgery Complications

Question 1

Describe post op mgmt for your bariatric surgery patient

Answer 1

• Diabetes
  
  • Improved glycemic control within days
  • Close glucose monitoring
  • Stop oral insulin secretagogues
  • Decrease insulin dose
  • Continue metformin at d/c (may discontinue later with GI)
• Hypertension
  
  • Improvement within 1 week
  • May need to decrease/dc antiHTNives as needed inpatient, or upon d/c
• Ulcers
  
  • Avoid NSAIDs
  • Initiate PPI to decrease ulcer risk
• Maintenance IVF until PO intake is adequate

Question 2

Describe the diet you will order for your post-op bariatric surgery patient

Answer 2

• Clear liquids, 24-48h
  
  • 2L per day, 1/2cup per serving
• Full liquid from Day 3-7
• Pureed foods from 1wk-2wks
• Soft foods at 2wks
• Regular diet at 2months
• Water intake > 1.5L per day
• Macronutrients
  
  • Protein: 1-1.5g/kg of ideal body weight
  • Carbs: 35-50% of calories
    
    • Avoid refined carbs, avoid dumping syndrome
  • Fat: 40% of calories
• Vitamin supplementation
  
  • Multivit
  • Calcium
  • Vit D
  • Vit B12

Question 3

Describe general potential complications for your bariatric surgery post-op patient

Answer 3

• GI bleeding
• Perforation
• Infection
• Leaks
• Intestinal obstruction
• Arrhythmia
• PE
• Hypoglycemia
• Weight gain/weight loss failure (15-35%)
• Anastomotic stenosis
• Cholelithiasis (common)
• Gastric ulcers
• Nutritional deficits
• Abdominal wall hernia, req repair
• GERD/esophagitis
• Dumping syndrome
• Dehydration

Question 4

Describe specific complications of the following bariatric surgery techiques:

• Roux-en-Y
• Laparoscopic Banding
• Sleeve Gastrectomy

Answer 4

• Roux-en-Y
  
  • Maginal Ulcer (Gastro-Jejunal Anastamosis) (16%)
    
    • Any time post-op
    • Epigastric pain, GIB
    • Mgmt: PPI and Carafate
  • Anastomotic Stensosis (GJA) (20%)
    
    • Any time post-op
    • Dysphagia, N/V, malnutrition
    • Mgmt: Endoscopic balloon dilation
  • Surgical Leaks (6%)
    
    • Days to weeks after procedure
    • Tachycardia, leukocytosis, fever, elevated CRP
    • Mgmt: Surgical repair
• Laparoscopic Banding
  
  • Reflux esophagitis (50%)
    
    • Mgmt: PPI/Carafate and band deflation
  • Esophageal dilation (10%)
    
    • Deflate band or surgical revision
  • Band erosion and perforation (7%)
    
    • Weeks to years after surgery
    • Surgical or endoscopic band removal
    • This is why lots of banding folks are getting revisions now
• Sleeve Gastrectomy
  
  • Sleeve Stenosis (4%)
    
    • Sx of obstruction
    • Mgmt: Endoscopic dilation
  • Sleeve leak (5%)
    
    • Mgmt: endoscopy vs surgery

Question 5

Name 4 pearls of mgmt of the post op bariatric surgery patient

Answer 5

1. Tachycardia post op is always a red flag: leak vs sepsis vs PE
2. Classic peritoneal irritation signs may be absent
3. Have a low threshold for imaging: CT abd/pelvis with oral AND IV contrast
4. Low threshold for surgical consult