Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery

Complications from bariatric medical tourism: Lessons for the emergency physician from selected case reports

BACKGROUND

Each year, increasing numbers of Americans travel abroad to undergo bariatric surgery. When postoperative complications arise, these patients often present to domestic emergency departments for care.

CASE REPORTS

We present three patients who experienced severe postoperative complications after bariatric surgery in Mexico and subsequently sought emergency medical care at an under-resourced, rural community hospital in Southern California, just north of the US-Mexico border.

SIGNIFICANCE

The presentation of patients with complications from bariatric surgery abroad at emergency departments, particularly those located near ports of entry, is likely to become more frequent. Emergency physicians should familiarize themselves with the clinical and operational challenges they may face when caring for this population.

High risk and low incidence diseases: Bariatric surgery complications

INTRODUCTION

Bariatric surgery complications carry a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of bariatric surgery complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Bariatric surgeries include restrictive procedures (e.g., adjustable gastric banding, endoscopic gastric balloon insertion, and sleeve gastrectomy) and mixed restrictive and malabsorptive procedures (e.g., roux-en-y gastric bypass and duodenal switch-biliopancreatic diversion). Several complications may occur, which may be associated with severe morbidity and mortality. These complications include anastomotic/staple line leaks, small bowel obstruction and internal hernia, marginal ulceration, biliary disease, and device-specific issues. History concerning the type of surgery, when and where it was performed, prior complications, changes in weight, and systemic symptoms is essential. Many signs and symptoms are subtle, but fever, tachycardia, and persistent vomiting are concerning for a severe complication. If there is concern for a complication, emergent consultation with the bariatric surgeon is recommended (preferably the patient's surgeon). Imaging studies can assist in the evaluation, including computed tomography with oral and intravenous contrast. Resuscitation in the ED and early intervention by a bariatric surgeon provide the best opportunity to reduce morbidity and mortality for patients with intra-abdominal pathology.

CONCLUSION

Understanding bariatric surgery complications can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Evaluating the Impact of Source-specific Order Sets for Sepsis on Empiric Antibiotic Selection in the Emergency Department

This retrospective cohort study found that implementing source-specific antibiotic order sets for sepsis in the emergency department increased appropriate empiric antibiotic selection from 51% to 74% (P = .01).

Anastomotic leak test using indocyanine green during laparoscopic Roux-en-Y gastric bypass: A cohort study

BACKGROUND

Indocyanine green (ICG) can be injected into the human bloodstream and it allows us to show stomach vascularity in real time. The aim of our study is to observe the preliminary results of the application of indocyanine green fluorescence (IGF) during laparoscopic Roux-en-Y Gastric Bypass (RYGB in our center and how the perfusion of the gastro-jejunal anastomosis affects the onset of fistula.

MATERIALS AND METHODS

30 consecutive patients underwent RYGB with ICG fluorescence angiography at our center from January 2020 to December 2021.5 ml of ICG were then injected intravenously to identify the blood supply of the stomach and the gastro-jejunal anastomosis. The UIN for ClinicalTrial.gov Protocol Registration and Results System is: NCT05476159 for the Organization UFoggia.

RESULTS

In the RYGB tested with ICG, we all have adequate perfusion but despite this a methylene blue test was positive and allowed us to reinforce the suture of the gastro-jejunal anastomosis.

CONCLUSION

Intraoperative ICG testing during laparoscopic RYGB may be helpful in determining which patients are at an increased risk for leakage but multiple factors concur to the pathophysiology and the incidence of gastric fistula not only the perfusion.

The incremental value of multislice CT in diagnosis of late bariatric surgery complications

Background

Bariatric surgery has become a widely accepted treatment option among the population for obesity management. Nevertheless, different complications may still be encountered during the late post-operative period. Our prospective cross-sectional study aimed to show the incremental value of multislice CT for diagnosis of such complications.

Results

Within the included twenty patients who underwent multislice CT of upper abdomen, gastric pouch dilatation causing recurrent weight gain was the commonest complication detected in 70% of the studied patients and was found mainly after sleeve gastrectomy in whom mean gastric pouch volume was 248.4 ml. Gastric stricture, gastric herniation through plication suture, hiatus hernia and incisional hernia were less commonly encountered complications.

Conclusion

Multislice CT is a useful non-invasive imaging modality for detection of late bariatric surgery complications.

Assessing Criteria for a Safe Early Discharge After Laparoscopic Colorectal Surgery

Importance

Early discharge after colorectal surgery has been advocated. However, there is little research evaluating clinical and/or laboratory criteria to determine who can be safely discharged early.

Objective

To evaluate the diagnostic performance of a C-reactive protein (CRP) level combined with 4 clinical criteria in ruling out an anastomotic leak and therefore allowing an early discharge on postoperative day 2 or 3.

Design, Setting, and Participants

This prospective, single-center cohort study was performed between February 2012 and July 2017. All consecutive adult patients undergoing laparoscopic colorectal surgery were included. All patients were followed up for 30 days postoperatively. Data analysis was performed in May 2021.

Exposures

Whether the 5 discharge criteria were fulfilled on postoperative day 3 (or day 2 for patients discharged on day 2). Fulfillment was defined as a CRP level less than 150 mg/dL on the day of discharge, a return of bowel function, tolerance of a diet, pain less than 5 of 10 on a visual analog scale, and being afebrile during the entire stay.

Main Outcomes and Measures

The primary outcome measurement was the diagnostic performance of the 5 discharge criteria in anticipating anastomotic leak development. The diagnostic performance of CRP level alone and 4 clinical criteria alone was also evaluated. Secondary measures were anastomotic leaks and mortality rates up to postoperative day 30. A discharge was successful if the patient left the hospital on postoperative day 2 or 3 without any complications or readmissions.

Results

A total of 287 patients were included (median [IQR] age, 58 [20] years; 141 men [49%] and 146 women [51%]). Mortality was 0%. There were 17 anastomotic leaks, of which 2 were on day 1 and were excluded. A total of 128 patients fulfilled all criteria, and 125 did not, including 34 for whom data were missing. Two leaks occurred in patients who had fulfilled all criteria vs 13 leaks in patients who did not (hazard ratio, 0.15 [95% CI, 0.03-0.69]; P = .01). Seventy-six of 128 patients (59.4%) were discharged successfully by postoperative day 3. The negative predictive value in ruling out an anastomotic leak was at least 96.9% for CRP alone (96.9% [95% CI, 93.3%-98.8%]), the 4 clinical criteria (98.4% [95% CI, 95.3%-99.7%]), and all 5 criteria combined (98.4% [95% CI, 94.5%-99.8%]). False-negative rates were 40% (95% CI, 16.3%-67.7%) for CRP level alone, 20% (95% CI, 4.3%-48.1%) for the other 4 criteria, and 13.3% (95% CI, 0%-40.5%) for all 5 criteria.

Conclusions and Relevance

These 5 criteria have a high negative predictive value and the lowest false-negative rate, indicating they have the potential to allow for safe early discharge after laparoscopic colorectal surgery.

IS BODY MASS INDEX AND OBESITY SURGERY MORTALITY SCORE IMPORTANT IN PERIOPERATIVE COMPLICATIONS OF LAPAROSCOPIC SLEEVE GASTRECTOMY BEFORE DISCHARGE?

BACKGROUND

Morbid obesity surgery and related complications have increased with time.

AIM

To evaluate the relationship between perioperative complications before discharge and preoperative body mass index and obesity surgery mortality score in laparoscopic sleeve gastrectomy.

METHOD

1617 patients who met the inclusion criteria were evaluated retrospectively. The patients were examined in terms of demographic data, presence of comorbidities, whether there were complications or not, type of complications and obesity surgery mortality score.

RESULTS

Complications were seen in 40 patients (2.5%) and mortality wasn't seen in the early postoperative period before discharge. The mean age of patients with complications was 36.3±10.02 years (19-57) and without complications 34.12±9.54 (15-64) years. The preoperative mean BMI values of patients with and without complications were 45.05±3.93 (40-57) kg/m2 and 44.8±3.49 (35-67) kg/m2 respectively. According to BMI groups 40-45 kg/m2, 45-50 kg/m2 and 50 and over, there was not any statistical significance seen in three groups in terms of complication positivity and major-minor complication rates. There was not any statistical significance seen between the patients with and without major-minor complications and obesity surgery mortality score.

CONCLUSION

There was not any relation between perioperative laparoscopic sleeve gastrectomy complication rates before discharge and BMI and obesity surgery mortality scores.

Postoperative sepsis after primary bariatric surgery: an analysis of MBSAQIP

BACKGROUND

Identifying patients at higher risk of postoperative sepsis (PS) may help to prevent this life-threatening complication.

OBJECTIVES

This study aimed to identify the rate and predictors of PS after primary bariatric surgery.

SETTING

An analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015-2017.

METHODS

Patients undergoing elective sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were included. Exclusion criteria were revisional, endoscopic, and uncommon, or investigational procedures. Patients were stratified by the presence or absence of organ/space surgical site infection (OS-SSI), and patients who developed sepsis were compared with patients who did not develop sepsis in each cohort. Logistic regression was used to identify independent predictors of PS.

RESULTS

In total, 438,752 patients were included (79.4% female, mean age 44.6±12 years). Of those, 661 patients (.2%) developed PS of which 245 (37.1%) developed septic shock. Out of 892 patients with organ/space surgical site infections (OS-SSI), 298 (45.1%) developed sepsis (P <.001). Patients who developed PS had higher mortality (8.8% versus .1%, P < .001), and this was highest in patients without OS-SSI (11.8% versus 5%, P = .002). The main infectious complications associated with PS in patients without OS-SSI were pneumonia and urinary tract infection. Independent predictors of PS in OS-SSI included RYGB versus SG (OR, 1.8), and age ≥50 years (OR, 1.4). Independent predictors of PS in patients without OS-SSI were conversion to other approaches (OR, 6), operation length >2 hours (OR, 5.7), preoperative dialysis (OR, 4.1), preoperative therapeutic anticoagulation (OR, 2.8), limited ambulation most or all of the time (OR, 2.4), preoperative venous stasis (OR, 2.4), previous nonbariatric foregut surgery (OR, 2), RYGB versus SG (OR, 2), hypertension on medication (OR, 1.5), body mass index ≥50 kg/m²(OR, 1.4), age ≥50 years (OR, 1.3), obstructive sleep apnea (OR, 1.3).

CONCLUSION

Development of OS-SSI after primary bariatric surgery is associated with sepsis and increased 30-day mortality. Patients without OS-SSI who develop PS have a significantly higher mortality rate compared with patients with OS-SSI who develop PS. Early identification and intervention in patients with PS, including those without OS-SSI, may improve survival in this high-risk group.

Alveolar recruitment manoeuvre results in improved pulmonary function in obese patients undergoing bariatric surgery: a randomised trial

Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p =  0.043) and 77% versus 88% at postoperative day 1 (p =  0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

Bariatric surgery prior to living donor nephrectomy: a solution to expand the living donor kidney pool - a retrospective study

Most transplant centers decline morbidly obese people for living kidney donation. Their inclusion in the living donor pool after weight loss and reversal of comorbidities by bariatric surgery could reverse the downward living donation trend. We investigated whether bariatric surgery in the morbidly obese altered their candidacy for donation, complicated their subsequent donor nephrectomy, and impacted their early postoperative outcomes in a series of 22 donors who had bariatric surgery 0.7-22 years prior to laparoscopic living donor nephrectomy. Eighteen would have been excluded from donation prior to bariatric surgery based on a body mass index (BMI) > 40. Seventeen reached a BMI < 35 after bariatric surgery. One had hypertension that resolved after bariatric surgery. Prior bariatric surgery did not influence port placement and laterality of donor nephrectomy. None required open conversion or blood transfusion. In an exploratory comparison with 37 donors with a BMI 35-40, length of stay and warm ischemic time were shorter, blood loss and postoperative complications were similar, and operative time was longer. We therefore advocate the consideration of bariatric surgery in preparation for donation in morbidly obese people since it positively alters their candidacy without major impact on the subsequent living donor nephrectomy and early outcomes.

A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology

The critical nature of the microbiology laboratory in infectious disease diagnosis calls for a close, positive working relationship between the physician/advanced practice provider and the microbiologists who provide enormous value to the healthcare team. This document, developed by experts in laboratory and adult and pediatric clinical medicine, provides information on which tests are valuable and in which contexts, and on tests that add little or no value for diagnostic decisions. This document presents a system-based approach rather than specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes, and blood and tissue parasite infections. Each section contains introductory concepts, a summary of key points, and detailed tables that list suspected agents; the most reliable tests to order; the samples (and volumes) to collect in order of preference; specimen transport devices, procedures, times, and temperatures; and detailed notes on specific issues regarding the test methods, such as when tests are likely to require a specialized laboratory or have prolonged turnaround times. In addition, the pediatric needs of specimen management are also emphasized. There is intentional redundancy among the tables and sections, as many agents and assay choices overlap. The document is intended to serve as a guidance for physicians in choosing tests that will aid them to quickly and accurately diagnose infectious diseases in their patients.

Cost-effectiveness analysis of stent type in endoscopic treatment of gastric leak after laparoscopic sleeve gastrectomy

Background

Gastric leak is the most feared surgical postoperative complication after sleeve gastrectomy. An endoscopic procedure is usually required to treat the leak. No data are available on the cost-effectiveness of different stent types in this procedure.

Methods

Between April 2005 and July 2016, patients with a confirmed gastric leak undergoing endoscopic treatment using a covered stent (CS) or double-pigtail stent (DPS) were included. The primary objective of the study was to assess overall costs of the stent types after primary sleeve gastrectomy. Secondary objectives were the cost-effectiveness of each stent type expressed as an incremental cost-effectiveness ratio (ICER); the incremental net benefit; the probability of efficiency, defined as the probability of being cost-effective at a threshold of €30 000, and identification of the key drivers of ICER derived from a multivariable analysis.

Results

One hundred and twelve patients were enrolled. The overall mean costs of gastric leak were €22 470; the mean(s.d.) cost was €24 916(12 212) in the CS arm and €20 024(3352) in the DPS arm (P = 0·018). DPS was more cost-effective than CS (ICER €4743 per endoscopic procedure avoided), with an incremental net benefit of €25 257 and a 27 per cent probability of efficiency. Key drivers of the ICER were the inpatient ward after diagnosis of gastric leak (surgery versus internal medicine), type of institution (private versus public) and duration of hospital stay per endoscopic procedure.

Conclusion

DPS for the treatment of gastric leak is more cost-effective than CS and should be proposed as the standard regimen whenever possible.