The PULSE
Osteopathic Emergency Medicine Quarterly VOLUME XXXI NO. 4
OCTOBER 2006
Featured Article Anita Eisenhart, D.O., FACOEP, FACEP
Emergency Department Presentations Following Weight Loss Surgery Introduction Weight loss surgery, as a class known as bariatric surgery, is becoming increasingly popular as treatment for morbid obesity. According to the American Society for Bariatric Surgery, the number of bariatric surgeries performed in the United States has increased from 16,200 in 1992 to 140,640 in 20041. This trend is expected to continue. With a growing population of bariatric surgery patients, emergency physicians in both bariatric centers and community hospitals must be prepared to evaluate and treat complications. Many patients will travel several counties or even across state lines to have their surgery, then present to their local Emergency Department (ED) for post-operative complications. There are several different types of bariatric procedures. The two most common procedures today are the Roux-en-Y (or gastro-duodenal bypass) and the laparoscopic adjustable gastric banding procedure. This discussion will be limited to general concepts of bariatric patients and problems specific to these two procedures. Morbid Obesity Early Complications Morbidly obese patients (defined as a body mass index (BMI) > 40 kg/m2) carry a significant surgical risk, regardless of the surgical procedure being performed. Many
of these risks are related to their co-morbidities that include, but are not limited to, hypertension, non-insulin dependant diabetes mellitus, coronary artery disease, dyslipidemia, obstructive sleep apnea, asthma, obesity-hypoventilation syndrome, peripheral venous insufficiency, thrombophlebitis2, and sedentary life-styles. A national cohort of over 69,000 bariatric surgical patients revealed the most common comorbidities in post-operative complications were hypertension (45%), diabetes (22%), and chronic lung disease (16%). Other important co-morbid conditions included liver disease, congestive heart failure, and renal failure3. Regardless of the bariatric procedure performed, patients may present to the ED early in the post-operative phase with complications related to obesity and co-morbidities. These include, but are not limited to, pulmonary embolus (1 – 2% cases), deep vein thrombosis, wound infections, fascial dehiscence (1% of cases), incisional hernias (10 – 20% of open cases), seromas (40% of open cases)4, and infarction. These should all be evaluated and treated, as each case deems necessary. A retrospective cross-sectional, coroner based study over 2 years described one county coroner’s office experience with bariatric patient mortalities. Fifteen (0.5%) out of 3097 archival cases died following bariatric surgery
The PULSE OCTOBER 2006
(73% of which died within six months of surgery). 80% of these deaths were natural co-morbidities of obesity: cardiovascular diseases (33%), gastrointestinal diseases (20%), acute pulmonary thromboembolism (13%), and acute bacterial pneumonia (13%). Two decedents (13%) died of direct inadvertent / accidental surgical complications5. Tachycardia Tachycardia in a morbidly obese post-operative bariatric surgical patient should be taken very seriously. The most likely reason for the tachycardia is dehydration and may improve drastically with hydration. However, two other diagnoses must be considered. Pulmonary embolus occurs approximately 1 – 2% of cases, but is responsible for 20 – 30% mortality in bariatric surgical patients4. Evaluation and management is the same as would be for a non-bariatric patient. The other serious consideration in the patient who presents with tachycardia is a leak from either the anastomoses or staple line. A leak represents one of the most serious complications and occurs from 1 – 6% of cases of Roux-en-Y surgical patients and is more common in the laparoscopic approach6. Tachycardia and, variably, signs of sepsis may be the only indication of a leak. This populaComplications of Weight-Loss Surgery, continued on page 8