Bariatric Emergencies for the General Surgeon

  • Richard M. Peterson
  • Pedro Pablo Gomez
  • Patrick Nguyen


Between 2011 and 2015, nearly one million bariatric surgeries were performed in the United States. With around 200,000 weight loss operations being performed annually in the United States, general surgeons face a growing number of bariatric surgical emergencies. This chapter deals with the most common surgical emergencies following the three most common bariatric surgeries being done currently and the best way in which to deal with them. The principles of rescue therapy and damage control are as applicable to the bariatric surgery patient as they are to trauma and general surgery patients. There are specific maneuvers for some of these emergencies, but in general, good surgical technique and judgment of the surgeon will prevail. In this chapter, we will discuss the algorithm of evaluating the emergent patient and approaches to diagnosis and treatment. Emergencies may be surgical in nature but may also be related to nutritional deficiencies. We will discuss how to assess for these nutritional deficiencies and best treatment options.


Emergency Bariatric surgery General surgeon Gastric bypass Sleeve gastrectomy Laparoscopic adjustable gastric band Nutrition emergencies 


  1. 1.
    Ponce J, Nguyen NT, Hutter M, Sudan R, Morton JM. American society for metabolic and bariatric surgery estimation of bariatric surgery procedures in the United States, 2011–2014. Surg Obes Relat Dis. 2015;11:1199–200.CrossRefPubMedGoogle Scholar
  2. 2.
    American College of Surgeons. Listing of MBSAQIP accredited bariatric surgery centers. Date Accessed 20 May 2017.
  3. 3.
    American Hospital Associations. Fast facts on U.S. hospitals. Date Accessed 20 May 2017.
  4. 4.
    Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: conservative vs. surgical management. Dis Colon Rectum. 2005;48(6):1140.CrossRefPubMedGoogle Scholar
  5. 5.
    Aquina CT, Becerra AZ, Probst CP, Xu Z, Hensley BJ, Iannuzzi JC, et al. Patients with adhesive small bowel obstruction should be primarily managed by a surgical team. Ann Surg. 2016;264:437–47.CrossRefPubMedGoogle Scholar
  6. 6.
    Monkhouse S, Morgan J, Norton S. Complications of bariatric surgery: presentation and emergency management – a review. Ann R Coll Surg Engl. 2009;91:280–6.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Ahmed AR, Rickards G, Husain S, Johnson J, Boss T, O’Malley W. Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:1563–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Rogula T, Yenumula PR, Schauer PR. A complication of Roux-en-Y gastric bypass: intestinal obstruction. Surg Endosc. 2007;21:1914–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Elms L, Moon RC, Varnadore S, Teixeira AF, Jawad MA. Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution. Surg Endosc. 2014;28:1624–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Obeid A, Mcneal S, Breland M, Stahl R, Clements RH, Grams J. Internal hernia after laparoscopic Roux-en-Y gastric bypass. J Gastrointest Surg. 2013;18:250–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Capella R, Iannace V, Capella J. Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg. 2006;203:328–35.CrossRefPubMedGoogle Scholar
  12. 12.
    Zak Y, Petrusa E, Gee DW. Laparoscopic Roux-en-Y gastric bypass patients have an increased lifetime risk of repeat operations when compared to laparoscopic sleeve gastrectomy patients. Surg Endosc. 2015;30:1833–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Harakeh ABA, Kallies KJ, Borgert AJ, Kothari SN. Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis. Surg Obes Relat Dis. 2016;12:194–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Paroz A, Calmes J, Giusti V, Suter M. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery. Obes Surg. 2006;16:1482–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Karila-Cohen P, Cuccioli F, Tammaro P, Pelletier A-L, Gero D, Marmuse J-P, et al. Contribution of computed tomographic imaging to the management of acute abdominal pain after gastric bypass: correlation between radiological and surgical findings. Obes Surg. 2017;27(8):1961–72.CrossRefPubMedGoogle Scholar
  16. 16.
    Spector D, Perry Z, Shah S, Kim JJ, Tarnoff ME, Shikora SA. Roux-en-Y gastric bypass: hyperamylasemia is associated with small bowel obstruction. Surg Obes Relat Dis. 2015;11:38–43.CrossRefPubMedGoogle Scholar
  17. 17.
    Stephenson D, Moon RC, Teixeira AF, Jawad MA. Intussusception after Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2014;10:666–70.CrossRefPubMedGoogle Scholar
  18. 18.
    Cusati D, Sarr M, Kendrick M, Que F, Swain JM. Refractory strictures after Roux-en-Y gastric bypass: operative management. Surg Obes Relat Dis. 2011;7:165–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Qureshi A, Podolsky D, Cumella L, Abbas M, Choi J, Vemulapalli P, et al. Comparison of stricture rates using three different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass. Surg Endosc. 2014;29:1737–40.CrossRefPubMedGoogle Scholar
  20. 20.
    Ukleja A, Afonso BB, Pimentel R, Szomstein S, Rosenthal R. Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass. Surg Endosc. 2008;22:1746–50.CrossRefPubMedGoogle Scholar
  21. 21.
    Yimcharoen P, Heneghan H, Chand B, Talarico JA, Tariq N, Kroh M, et al. Successful management of gastrojejunal strictures after gastric bypass: is timing important? Surg Obes Relat Dis. 2012;8:151–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Varban OA, Cassidy RB, Sheetz KH, Cain-Nielsen A, Carlin AM, Schram JL, et al. Technique or technology? Evaluating leaks after gastric bypass. Surg Obes Relat Dis. 2016;12:264–72.CrossRefPubMedGoogle Scholar
  23. 23.
    Spaniolas K, Kasten KR, Sippey ME, Pender JR, Chapman WH, Pories WJ. Pulmonary embolism and gastrointestinal leak following bariatric surgery: when do major complications occur? Surg Obes Relat Dis. 2016;12:379–83.CrossRefPubMedGoogle Scholar
  24. 24.
    Kim J, Azagury D, Eisenberg D, Demaria E, Campos GM. ASMBS position statement on prevention, detection, and treatment of gastrointestinal leak after gastric bypass and sleeve gastrectomy, including the roles of imaging, surgical exploration, and nonoperative management. Surg Obes Relat Dis. 2015;11:739–48.CrossRefPubMedGoogle Scholar
  25. 25.
    Augustin T, Aminian A, Romero-Talamás H, Rogula T, Schauer PR, Brethauer SA. Reoperative surgery for management of early complications after gastric bypass. Obes Surg. 2015;26:345–9.CrossRefGoogle Scholar
  26. 26.
    Puli SR, Spofford IS, Thompson CC. Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc. 2012;75:287–93.CrossRefPubMedGoogle Scholar
  27. 27.
    Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, Sugerman H, et al. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg. 2007;11:708–13.CrossRefPubMedGoogle Scholar
  28. 28.
    Fringeli Y, Worreth M, Langer I. Gastrojejunal anastomosis complications and their management after laparoscopic Roux-en-Y gastric bypass. J Obes. 2015;2015:1–6.CrossRefGoogle Scholar
  29. 29.
    Lublin M, Mccoy M, Waldrep DJ. Perforating marginal ulcers after laparoscopic gastric bypass. Surg Endosc. 2005;20:51–4.CrossRefPubMedGoogle Scholar
  30. 30.
    Felix EL, Kettelle J, Mobley E, Swartz D. Perforated marginal ulcers after laparoscopic gastric bypass. Surg Endosc. 2008;22:2128–32.CrossRefPubMedGoogle Scholar
  31. 31.
    Wendling MR, Linn JG, Keplinger KM, Mikami DJ, Perry KA, Melvin WS, et al. Omental patch repair effectively treats perforated marginal ulcer following Roux-en-Y gastric bypass. Surg Endosc. 2012;27:384–9.CrossRefPubMedGoogle Scholar
  32. 32.
    American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011–2015. Date Accessed 20 May 2017.
  33. 33.
    Hutter MM, Schirmer BD, Jones DB, Ko CY, Cohen ME, Merkow RP, et al. First report from the American College of Surgeons Bariatric Surgery Center Network. Ann Surg. 2011;254:410–22.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Gagner M, Deitel M, Erickson AL, Crosby RD. Survey on laparoscopic sleeve gastrectomy (LSG) at the Fourth International Consensus Summit on sleeve gastrectomy. Obes Surg. 2013;23:2013–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Benedix F, Poranzke O, Adolf D, Wolff S, Lippert H, Arend J, et al. Staple line leak after primary sleeve gastrectomy—Risk factors and mid-term results: do patients still benefit from the weight loss procedure? Obes Surg. 2017 Jul;27(7):1780–8.CrossRefPubMedGoogle Scholar
  36. 36.
    Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients. Surg Endosc. 2011;26:1509–15.CrossRefPubMedGoogle Scholar
  37. 37.
    Gonzalez R, Sarr MG, Smith CD, Baghai M, Kendrick M, Szomstein S, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204:47–55.CrossRefPubMedGoogle Scholar
  38. 38.
    Sakran N, Goitein D, Raziel A, Keidar A, Beglaibter N, Grinbaum R, et al. Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients. Surg Endosc. 2012;27:240–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Campanile FC, Boru CE, Rizzello M, Puzziello A, Copaescu C, Cavallaro G, et al. Acute complications after laparoscopic bariatric procedures: update for the general surgeon. Langenbecks Arch Surg. 2013;398:669–86.CrossRefPubMedGoogle Scholar
  40. 40.
    Nguyen NT, Nguyen X-MT, Dholakia C. The use of endoscopic stent in management of leaks after sleeve gastrectomy. Obes Surg. 2010;20:1289–92.CrossRefPubMedGoogle Scholar
  41. 41.
    Parikh A, Alley JB, Peterson RM, Harnisch MC, Pfluke JM, Tapper DM, et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc. 2011;26:738–46.CrossRefPubMedGoogle Scholar
  42. 42.
    Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg. 2013;23:1481–6.CrossRefPubMedGoogle Scholar
  43. 43.
    American society for metabolic and bariatric surgery position statement on emergency care of patients with complications related to bariatric surgery. Surg Obes Relat Dis. 2010;6:115–7.Google Scholar
  44. 44.
    Snyder B, Worley T, Aluka KJ, Robinson EL, Bajwa K, Mehta S, et al. Past, present, and future: critical analysis of use of gastric bands in obese patients. Diabetes Metab Syndr Obes. 2010;3:55–65.CrossRefPubMedPubMedCentralGoogle Scholar
  45. 45.
    Brown WA, Egberts KJ, Franke-Richard D, Thodiyil P, Anderson ML, Oʼbrien PE. Erosions after laparoscopic adjustable gastric banding. Ann Surg. 2013;257:1047–52.CrossRefPubMedGoogle Scholar
  46. 46.
    Thodiyil P, Petros Benias P. Band erosion: surgical and endoscopic management. In: Bariatric surgery complications and emergencies. New York: Springer Science; 2016. p. 215–22.CrossRefGoogle Scholar
  47. 47.
    Eid I, Birch DW, Sharma AM, Sherman V, Karmali S. Complications associated with adjustable gastric banding for morbid obesity: a surgeons guide. Can J Surg. 2011;54:61–6.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Hamdan K, Somers S, Chand M. Management of late postoperative complications of bariatric surgery. Br J Surg. 2011;98:1345–55.CrossRefPubMedGoogle Scholar
  49. 49.
    Keidar A, Carmon E, Szold A, Abu-Abeid S. Port complications following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg. 2005;15:361–5.CrossRefPubMedGoogle Scholar
  50. 50.
    Speybrouck S, Aelvoet C, Tollens T, Vanrykel JP. Use of gentamicin in the treatment of access-port infections. Obes Surg. 2005;15:1278–81.CrossRefPubMedGoogle Scholar
  51. 51.
    Ulmer TF, Ambe P, Alizai HP, Lambertz A, Rheinwald K, Plamper A, et al. Major esophageal dilation after laparoscopic adjustable gastric banding in symptomatic patients: does it prevent effective weight loss and how should it be treated? World J Surg. 2015;39:2000–5.CrossRefPubMedGoogle Scholar
  52. 52.
    Molloy D, Kaloo PD, Cooper M, Nguyen TV. Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry. Aust N Z J Obstet Gynaecol. 2002;42:246–54.CrossRefPubMedGoogle Scholar
  53. 53.
    Helgstrand F, Rosenberg J, Bisgaard T. Trocar site hernia after laparoscopic surgery: a qualitative systematic review. Hernia. 2010;15:113–21.CrossRefPubMedGoogle Scholar
  54. 54.
    Coblijn UK, de Raaff CA, van Wagensveld BA, van Tets WF, de Castro SM. Trocar port hernias after bariatric surgery. Obes Surg. 2016;26:546–51.CrossRefPubMedGoogle Scholar
  55. 55.
    Pilone V, Micco RD, Hasani A, Celentano G, Monda A, Vitiello A, et al. Trocar site hernia after bariatric surgery: our experience without fascial closure. Int J Surg. 2014;12:S83–6.CrossRefPubMedGoogle Scholar
  56. 56.
    Young MT, Gebhart A, Phelan MJ, Nguyen NT. Use and outcomes of laparoscopic sleeve gastrectomy vs laparoscopic gastric bypass: analysis of the American College of Surgeons NSQIP. J Am Coll Surg. 2015;220(5):880.CrossRefPubMedGoogle Scholar
  57. 57.
    Stein PD, Matta F. Pulmonary embolism and deep venous thrombosis following bariatric surgery. Obes Surg. 2013;23:663–8.CrossRefPubMedGoogle Scholar
  58. 58.
    Jamal MH, Corcelles R, Shimizu H, Kroh M, Safdie FM, Rosenthal R, et al. Thromboembolic events in bariatric surgery: a large multi-institutional referral center experience. Surg Endosc. 2014;29:376–80.CrossRefPubMedGoogle Scholar
  59. 59.
    Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: chest guideline and expert panel report. Chest. 2016;149(2):315–52.CrossRefPubMedGoogle Scholar
  60. 60.
    Carrodeguas L, Kaidar-Person O, Szomstein S, Antozzi P, Rosenthal R. Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery. Surg Obes Relat Dis. 2005;1:517–22.CrossRefPubMedGoogle Scholar
  61. 61.
    Flancbaum L, Belsley S, Drake V, Colarusso T, Tayler E. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg. 2006;10:1033–7.CrossRefPubMedGoogle Scholar
  62. 62.
    Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American society for metabolic and bariatric surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727–41.CrossRefPubMedGoogle Scholar
  63. 63.
    Aasheim ET, Johnson LK, Hofsø D, Bøhmer T, Hjelmesæth J. Vitamin status after gastric bypass and lifestyle intervention: a comparative prospective study. Surg Obes Relat Dis. 2012;8:169–75.CrossRefPubMedGoogle Scholar
  64. 64.
    Majumder S, Soriano J, Cruz AL, Dasanu CA. Vitamin B12 deficiency in patients undergoing bariatric surgery: preventive strategies and key recommendations. Surg Obes Relat Dis. 2013;9:1013–9.CrossRefPubMedGoogle Scholar
  65. 65.
    Szomstein S, Nguyen DM. Nutritional complications and emergencies. In: Bariatric surgery complications and emergencies. Cham: Springer Science; 2016. p. 269–82.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Richard M. Peterson
    • 1
  • Pedro Pablo Gomez
    • 1
  • Patrick Nguyen
    • 1
  1. 1.Department of SurgeryUniversity of Texas Health San AntonioSan AntonioUSA

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