I don’t see that many of these procedures coming back to our ED. A lot are done privately and even overseas. The overseas ones can be particularly challenging as the paperwork is often not in English and often the patient doesn’t really know what was done. Given the costs associated with travelling for surgery people often leave earlier than they might otherwise and some of the earlier complications might end up in your ED.
Either way there’s lots to learn from what is a really important and really effective surgical procedure (over 50% gaining significant weight loss post procedure)
This is all from a paper by Ellison and Ellison in JEM in 2008 – one EP and one surgeon, I bet they’re married…
Ellison SR, Ellison SD. Bariatric Surgery: A Review of the Available Procedures and Complications for the Emergency Physician. J Emerg Med. 2008 Jan;34(1):21–32. PMID 17976781
There’s lots of pearls and some nice diagrams of the procedures available.
- a third develop gallstones in the 6 months following a roux-en-y; some places even prophylactically take the GB out
- vomiting after the procedure is not normal – it may turn out to be benign but usually needs a work up
- gastric obstruction reasonably common in all of the procedures. most of it is proximal but you can also get “internal hernias” when sections of the bowel herniated through defects in the mesentery created during the procedure
- GI bleeding can be reasonably late as patients develop “marginal ulcers” or even erosion from lap bands into the stomach lumen
- lap bands usually have a sub cut balloon that can be inflated/deflated with saline to adjust size. Authors point out that we should not be fiddling with these even if the surgeon asks you to over the phone!
- the bands can also slip in position creating a large reservoir of stomach above the band leading to lots of vomiting.
- given the complexity of the procedures and the obesity of the patients simple clinical exam is tricky here and imaging or scopes are frequently needed.
- always remember the “medical” complications. particularly VTE – the paper quotes a rate of 10% in bariatric procedures.
- thiamine loss and even wernicke’s can occur in gastric bypass patients so remember your thiamine – it’s not just for the drinkers.