Perioperative Care of
the Bariatric Patient
Mark Kadowaki, MD, FACS
Wellmont Surgical Services
Kingsport, Tenessee
Objectives

Be familiar with the perioperative concerns that
face the bariatric patient

Be aware of the signs of complications after
bariatric surgery

Plan for initial management and stabilization of
the patient suffering postoperative
complications
Bariatric Procedures

WWW.ASMBS.ORG

Bariatric Surgery: Postoperative Concerns
http://s3.amazonaws.com/publicASMBS/GuidelinesStateme
nts/Guidelines/asbs_bspc.pdf

Emergency Care of the Bariatric Patient
http://s3.amazonaws.com/publicASMBS/ASMBS_Store/
ASMBS_ER_Poster9-20-10.pdf
Download the poster for your Emergency Department or
Acute Care Clinic

Pre-Surgical Psychological Assessment


Perioperative Nutritional, Metabolic, and Nonsurgical
Support of the Bariatric Surgery Patient


http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guideli
nes/PsychPreSurgicalAssessment.pdf
http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guideli
nes/aace-tos-asmbs.pdf
ASMBS Allied Health Nutritional Guidelines for the
Surgical Weight Loss Patient

http://s3.amazonaws.com/publicASMBS/GuidelinesStatements/Guideli
nes/bgs_final.pdf
Non-Emergent
Concerns
RNY Gastric Bypass and Dumping
Syndrome

Common “side effect” (85%)
Essentially a known result of the anatomic changes
associated with the surgery
 Can range from mild to severe
 Rapid emptying of the gastric pouch of refined
sugars (HFCS) or other high glycemic carbohydrates
or other osmotically concentrated foods, such as
dairy products and some fats such as fried foods

“Benefit” of Dumping Syndrome

Negative feedback

Causative foods will interfere with success of
long-term weight loss

Patient is less likely to eat the same foods again
Bad effects of Dumping

Symptomatically uncomfortable

Confusion with other etiologies

Can be difficult to manage

May have short-term physiological consequences
Two Types of Dumping

Early:
30-60 minutes
 Duration up to 60 minutes
 Osmotic symptoms:

sweating, flushing, lightheadedness, tachycardia,
palpitations, desire to lay down, upper abdominal fullness,
nausea, diarrhea, cramping, active, audible bowel sounds
 Caused by release of gut hormones with vasoactive effects

Two Types of Dumping

Late:

1-3 hours after eating

Reactive hypoglycemia symptoms:
Sweating, shakiness, loss of concentration, hunger,
fainting and passing out
 Related to insulin surge overshooting glucose levels

Diagnosis of Dumping Syndrome

History:

Classic symptoms related to food intake
Management of Dumping Syndrome

Early


Dietary compliance with an appropriate diet
Late
Dietary compliance
 Intake of a small amount of sugar (1/2 glass juice) 1
hour after a meal
 Acarbose or Somastostatin in resistant cases
 Rule out rare causes such as insulinoma

Bowel Function after Bariatric
Surgery

Diarrhea
Most common with Duodenal Switch procedures
 Less common with RNY gastric bypass
 Uncommon with Sleeve gastrectomy or Gastric
banding
 Caused by FAs, undigested foods and Sorbitol
(occurs naturally in fruits)

Management of Diarrhea

Dietary:
Avoidance of fats
 Identify other trigger foods
 Evaluate for previously unmasked lactose
intolerance: eliminate dairy completely


Medical:
Imodium or Lomotil
 Probiotics
 Cholestyramine to bind bile salts

C diff Colitis





Can occur up to 3 months after surgery
Severe cramping, especially watery diarrhea,
extremely foul flatus
Treat with Flagyl
Relapses common
Follow up with probiotics
Constipation


Common after bariatric surgery
Causes:






Insufficient intake of water
Insufficient intake of fiber
Diuretics (caffeine?)
Nutritional supplements with Calcium and Iron
Narcotics
Management:


Increased water and fiber intake
Avoidance of aggravating agents
Bowel Changes after Bariatric
Surgery

Caveat:
 Don’t
assume that all bowel function
problems are related to bariatric surgery

Recent changes in a previously stable patient
Postoperative Dysphagia



Most commonly associated with restriction procedures
Symptoms: chest pressure or tightness in the throat
May be functional:




Eating too fast
Eating too much
Not chewing well enough
Tough foods


Breads, rice and pastas
Overcooked steak or dry chicken breast
Postoperative Dysphagia

Treatment


Better eating habits
Failure to respond or severe symptoms

Band adjustment (loosening) or endoscopic dilation
Postoperative Nutrition

Purely restrictive procedures



Gastric Banding, Sleeve Gastrectomy, Vertical
Banded Gastroplasty
Daily multivitamin
Monitor protein intake

1 gm protein/kg ideal body weight/day
Postoperative Nutrition

Primarily Restrictive with some malabsorption



Gastric Bypass
Calcium, Iron and B-complex vitamins
supplemented at higher than daily recommended
levels
Prioritize protein intake
Postoperative Nutrition

Primarily Malabsorptive Procedures

BPD +/- DS

Calcium, Iron
Protein
Fat Soluble Vitamins (A, D, E, K)
Hydration

Deficiencies can be resistant to therapy!



Nutritional Deficiencies

Protein:


Calcium


Fatigue
Zinc


Bone pain
Iron


Hair loss, Fatigue, Leg swelling
Brittle nails
Vit A

Decreased night vision
Nutritional Deficiencies

Vit E


Vit K


Easy bruising
Vit B1 (thiamine)


Poor wound healing
Numbness and tingling in hands and feet
Vit B12 (Methylcobalamin)

fatigue
Exercise





IMPERATIVE
Weight loss will not occur without it
40 minutes per day, 6 days per week, strenuous
enough to breathe deeply but still able to
converse
Light resistance training a benefit
Some patients may be “exercise naïve” or even
“alienated”
Emergent Concerns
Emergency Presentations

Unstable Vital Signs:
Fever > 102 F
 Hypotension


Remember incidence of hypertension
Tachycardia >120 bpm X 4 hours
 Tachypnea
 Hypoxia
 Decreased urinary output

Emergency Presentations

Bleeding




Per mouth or rectum or drainage
Abdominal pain or colic > 4 hours
Nausea + Emesis > 4 hours
Emesis + Abdominal pain
Principles of Management

Critical Time Frames:



Diagnosis within 6 hours
To OR in 12-24 hours
Critical Warnings
 Alert





Bariatric Surgeon
Patients typically have less physiologic reserve
Avoid blind placement NG tube
Avoid NSAIDs, ASA, Plavix, Steroids
Use PPIs routinely
Be mindful of small volume of gastric pouch
Initial Assessment


Serial PE and Vitals
Labs:


CBC, CMP, Amylase
Imaging:
Chest Xray
 CT of Chest
 CT of Abdomen
 Upper GI

Initial Management:
FAST HUG




Food: establish nutritional support early
Analgesia
Sedation: if on ventilator
Thrombo-embolism prophylaxis




Mechanical and Medical
Head of Bed: elevated 30 deg (aspiration)
Ulcer Prophylaxis: PPIs
Glucose Control: <150
Bleeding





< 48 hours: staple line
> 48 hours: marginal ulcer
Oral: gastric pouch
Melena or rectal blood: duodenal ulcer, bypassed
stomach or bowel source
EGD: consider GA in OR

Increased risk of perforation with intervention
Leaks and Sepsis




Presentation: unstable VSs within 72 hours of
bariatric surgery
Persistent or progressive tachycardia is most
sensitive
Similar presentation to PE
Imaging can be negative
Obstruction

Presentation:



Do NOT place NG tube
Diagnostics:



Abdominal pain > 4 hours associated with vomiting
CT abdo with contrast or UGI
Increased risk for aspiration due to small volume of
stomach
Consider EGD prior to anesthesia to R/O GOO and
empty contrast material to decrease risk of aspiration
Obstruction

Special Concerns:

Acute bleed causing obstruction secondary to clots
Internal hernias after gastric bypass
Evaluation/imaging / PE may be negative






Dilated distal stomach or contrast in remnant
High risk for closed loop obstruction
Bowel ischemic necrosis within 6 hours
Immediate surgical exploration
Internal hernias

A. Transverse
Mesocolon

B. Petersen Hernia:


Beneath Roux limb
C. Mesentery defect
created by
jejunojejonostomy
Pulmonary Embolism




Extremely high risk patients
Unstable vitals associated with chest pain and
tachypnea
Evaluation with Chest CT
Can mimic acute intra-abdominal complication
Vomiting + Abdominal Pain
 Gastric
Banding
 AXR:
assess orientation of band
 Deflate band
 Huber
needle
 Similar to a Portacath
 Reassess

Does not usually require surgery
Adjustable Gastric Band

Normal Band orientation


2:00-8:00
Normal orientation but
too tight
Adjustable Gastric Band Slips

Anterior Slip:


Band rotated
counterclockwise
Posterior Slip:


Band rotated clockwise
Note: enlarged pouch
flopping over slip
Vomiting + Abdominal Pain

Unstable:


Immediate surgical exploration
Stable:
Evaluate per obstruction
 Barium swallow most useful

Abdominal Compartment Syndrome

Respiratory failure
Renal failure
Other end organ failure
Elevated bladder pressure (> 25 mmHG)

Emergent abdominal decompression



“George, how often do you have a
leak?



“Never had one”
“In how many cases?”
“Oh, I’ve never done one . . . . .”

Surgery for Obesity and Related Diseases 7 (2011) 668
Summary






Complications are unavoidable but disasters are often
avoidable
Be familiar with the perioperative concerns that face
the bariatric patient
Be aware of the signs of complications after bariatric
surgery
Plan for initial management and stabilization of the
patient facing postoperative complications
Early involvement of a Bariatric Surgeon
Work with a certified Center of Excellence

ASMBS or ACS