The following information is for the use of Emergency Room Physicians, Surgeons, and others seeing our Roux-en-Y gastric bypass (RNY GBP) patients on an urgent basis.

Though the vast majority of patients generally do well after surgery, some will present with serious medical or surgical problems, and even problems functional in origin may ultimately have grave consequences. Abdominal pain, nausea, vomiting, and dehydration occur with a certain frequency following Bariatric Surgery, most often in the first month or two after surgery. Specific approaches to these and other problems will be listed below.

In January 2004 we added the adjustable laparoscopic gastric band placement to our surgical offering. Emergency info regarding this procedure will be added at a later date. For now please call our office for problems with LAP-BAND patients

Treatment includes reassurance, judicious anti-emetics (Phenergan 25 mg po or pr q4-6h, Zofran orally disintegrating tabs 4mg sl q 6h), and gentle attempts at po, starting with small quantities of simple comfort foods that the individual patient tolerates best, such as water, sugar free popcicles, tea, broth, and crackers. Patients may have to stay on this "Beginning" diet for several days, and should continue it for a day after symptoms resolve.

Patients referred to the ER for IV hydration are best treated with at least 2 liters of fluid, a vitamin cocktail, and Phenergan IV or IM. Encourage patients to try to control episodes on their own by avoiding irritating foods or eating behaviors, and by learning to switch to the "Beginning" diet at the first signs of trouble.

Patients present with emesis, pain, and with relatively sudden inability to keep anything down. Patients should be asked if they have actually tried to take meats or other solid foods in the first days or weeks after surgery. Emesis may be persistently dark colored, stained by the impacted material. Initial evaluation includes UGI, which will reveal a complete obstruction at the gastrojejunostomy. Treatment includes referral for endoscopic disimpaction versus a trial of Adolph’s or other meat tenderizer, one tbsp. in a glass of water. Judgement is necessary in this regard as there is concern for tenderizer induced esophageal injury.

It may be associated with emesis, though not usually fevers. It may be of relatively sudden onset, and quite severe. We have seen relatively few obstructions or abscesses as confirmed causes of our patients presenting with abdominal pain, and when they occurred they were for the most part were readily apparent.

Postulated etiologies for idiopathic episodes of abdominal pain include atony of the bypassed stomach, spasm of the Roux limb, traction of the tube gastrostomy site against the abdominal wall, and renal stones. The latter may be a frequent cause of lower abdominal or flank type pain.

Two frequently presenting known causes, Ulcers/NSAID Use, and Costochondritis, are discussed in following sections. Abdominal pain has also been a chief complaint of patients presenting in emotional collapse after trying to deal with the many changes required after Bariatric Surgery. This is usually elucidated by a thorough and prolonged visit and a judicious work-up, and is well treated with much reassurance that the patient is actually on tract (is not having an unexpected amount of difficulty with the postoperative recovery and adaptation to the postoperative lifestyle), and with a subsequent support group meeting.

Patients presenting with significant abdominal pain should be evaluated as indicated with CBC, CMP, and radiologic studies. To date CT with oral and IV contrast seems to be the best study, and will render information regarding leaks, abscess formation, distention of the bypassed stomach and/or biliary limb, obstruction, or kidney stone (see emergency section). UGI is helpful, though it will not shed information on obstruction of the afferent limb, or on gastric atony. In the majority of cases no cause will be determined for the pain, and it will not recur, though it may have initially been quite severe and have prompted a 24 hour admission for observation and pain relief. Judicious narcotics and anti-emetics usually are very helpful while waiting for the pain to resolve. Patients presenting with a deep aching LUQ abdominal pain may have atony of the bypassed stomach, and a few have responded remarkably well to Reglan.

The following information is presented to help surgeons preparing to operate, either emergently or electively, on patients who have undergone Roux-en-Y Gastric Bypass (RNY GBP) at our Center. References will be made to our experiences operating on patients who received Bariatric surgery elsewhere and who have returned to Alaska. Other than abdominal wall hernias, our patients have only infrequently required re-exploration for problems specifically related to the index RNY GBP, and fewer than 10 of our first 300 patients required subsequent surgery.

Most patients received a hand sewn gastrojejunostomy anastomosis (g-j) with a 6 cm, green #5 Ethibond band placed over the lower 3rd of the pouch, and a stapled jejunojejunostomy anastomosis (j-j). 3 patients operated on or before January 2001 received a short pouch with a stapled anastomosis, and no band. After June of 2002 the vast majority of our open RNY GBP patients have had their Roux limbs passed in an antecolic/antegastric fashion. Approximately 6 patients have not been given a tube gastrostomy, principally for anatomic reasons. As of June 2003 we also began to perform laparoscopic RNY GBP’s. These patients have for the most part an antecolic/antegastric configuration, stapled g-j and j-j anastomoses, and Roux and biliary limbs of 80-100 and 40-50 cm, respectively.

At the time of exploration, should the g-j anastomosis need to be evaluated, consider placing a light source in the pouch itself, to help localize it in the dense adhesions encountered. In our patients the green Ethibond band around the lower 3rd of the pouch is a useful landmark, and the anastomosis can be palpated just distal to it.

Revision bypass surgery is demanding to those experienced in the field, and even more so to the non-bariatric general surgeon tasked to care for these patients on an emergency basis. Avoid it when possible. Bowel may appear compromised, only to revive when given the time to do so after the obstruction is relieved or the hernia reduced. Give the bowel sufficient time (15 to 30 minutes?) to regain color. When bowel viability is still in question, strongly consider closing and returning in 24 to 48 hours to see if the bowel has recovered, and then only excise the minimal length required. The above is especially true when dealing with problems of the Roux limb. Whenever possible, avoid revising the entire Roux limb, as dissecting out and revising the g-j can be difficult. Again, relieve the obstruction or reduce the limb, and later excise only what definitely appears non-viable.

Patients post RNY GBP are often in a delicate nutritional balance, and resection of any appreciable length of bowel may leave them with inadequate digestive capability. If for any reason, such as an Oncologic procedure, vascular accident, or obstruction in the pelvis from adhesions due to GYN surgery, should there be a need for excision of much of the common channel (small bowel below the j-j), consider shortening the Roux limb at the same time by relocating the j-j more proximally on the Roux limb. This will place more bowel in the common channel, which carries both ingested nutrients and digestive juices from the liver and pancreas, and is the segment where most absorption of nutrients may occur. Use care not to shorten the Roux limb to less than 30 cm, and not less than 50 cm if possible, as shorter lengths may lead to bile reflux into the gastric pouch.

Whenever our patients are seriously ill or may shortly become seriously ill and are planned to undergo surgery, strongly consider placing a g-tube for postoperative nutrition. Their ability to regain weight by eating is limited in the best of circumstances, and may be very difficult for them to achieve when debilitated. Do not feed via the g-tube for at least the first 3 days following surgery, as the tract may take several days to seal adequately from the peritoneal cavity. A g-tube tube, along with a carefully placed NG tube directed through the g-j anastomoses and 10 to 15 cm into the Roux limb, may be critical in decompressing the GI tract of RNY GBP patients who undergo subsequent surgery, and who may then have a prolonged postoperative ileus.

When evaluating patients for suspected obstructions CT with IV and oral contrast is often the best study to obtain, as it will give information on obstruction of the Roux limb and common channel as well as the bypassed, afferent limb. UGI may be used to evaluate the Roux limb and common channel, with ultrasound then done to evaluate for a distended, bypassed stomach.

Obstructions may be difficult to diagnose. Incomplete obstructions may cause venous congestion to the point of bowel compromise, but without obstructing the bowel lumen or flow of contrast flow. Obstructions involving all or parts of the bypassed limb are difficult to evaluate, as they do not involve the alimentary stream, and thereby are not elucidated with oral contrast studies per se. Diagnosis is made more difficult by the not infrequent presentation of RNY GBP patients with nonsurgical abdominal pain, or by the chronic and recurrent nature of symptoms in patients who present with internal hernias that may incarcerate intermittently and reduce spontaneously. Patients presenting with pain out of proportion to presentation not relieved with time or medication should be considered for exploratory surgery.

Greater sac obstructions or those occurring caudad to the omentum are usually relatively easy to locate and treat by generally accepted techniques. Obstructions may occur at the mesocolic window due to scarring of the mesocolon itself, and are usually diagnosed when a gentle-probing finger cannot be passed through the mesocolic window next to the bowel. These may be difficult to approach from below and easier to approach from the lesser sac. After widely dividing the tight, obstructing sclerotic band usually seen, I chose to suture the edges of the defect down to the bowel serosa to prevent subsequent internal herniation, unless the lesser sac area is so filled with adhesions that no potential cavity exists to herniate into.

Obstructions occurring above the mesocolic defect may occur due to dilatation and elongation of the bowel in the retrogastric tunnel, which then twists on itself, causing a closed loop obstruction. These may be treated by simply reducing the bowel below the mesocolic window, and then fixing it to the mesocolon. Dilatation, elongation, and twisting of the Roux limb may actually be caused by a scarring and obstruction at the mesocolic window, and both sites of obstruction should be sought for and treated.

When treating an obstruction of the bypassed, (biliary, or afferent) limb at the j-j anastomosis, consider simply performing an additional side-to-side anastomosis of the bypassed limb onto the Roux limb or common channel, rather than taking down the j-j and redoing it.

Abscesses are usually associated with leaks. Both occur in a few percent of patients, generally 1 to 2. I suspect they occur more frequently in patients with histories of chronic Prednisone or methotrexate use, or in those with compromised tissues due to collagen vascular disease or advanced age, as these seem to be the patients with the most friable tissue. Leaks and abscesses usually present in the first week after surgery, and as such will usually be cared for by the operative team. We have had one patient present with an abscess and leak 2 weeks after surgery, which may have been related to a fall. We also had one patient present 2 years post op, with a large, perforated g-j stomal ulcer associated with NSAID use.

Infusing the pouch with air or methylene blue at the time of exploration is often helpful for locating leaks, or for assessing the integrity of any repair.

The leaks we have encountered have usually been related to the staple line located at the top corner of the pouch, at what was the angle of His, and are thought to be due to failure of the staple line. If no leak can be identified at the time of exploration, and an abscess has occurred in the area of the pouch, attempt to oversew or staple reinforce this area. Expect the leak to recur, and in all cases widely drain the area. Place a g-tube to be used for postoperative nutrition while waiting for any subsequent leak to close.

Leaks may occur from the g-j. These are best treated with direct closure and advancing the jejunum over the repair. We used this technique for the patient who had the perforated stomal ulcer 2 years postoperatively, and it worked well. Again, expect the leak to recur, though to a lesser degree, and drain and place a g-tube.

This patient went on to develop a subdiaphragmatic abscess. This was well treated with percutaneous drainage rather than open exploration due to dense adhesions in the area.

Troublesome is the posterior anastomotic leak that cannot be readily located or visualized, and that may best be treated with wide drainage and TPN or tube feeds.

Leaks may occur in the bypassed portion of the stomach, around the g-tube, at the j-j anastomosis, and at other sites. General Surgery principles apply to revision and closure techniques. Place a g-tube to decompress and/or feed via the bypassed stomach.

Of note in the morbidly obese patient who has generous subcutaneous tissue is the phenomenon of the persistent seroma. This seems to be caused by apparent liquifaction of adjacent adipose tissue that continues as long as any component of the seroma is present. Keep this phenomenon in mind with any fluid collection or drainage that apparently will not go away, and drain these widely.

We used looped #1 Panacryl for fascial closure until approximately October 2002, at which time it went off the market, and we switched to #1 looped PDS. We appreciated Panacryl for the apparent low incisional hernia rate, which its use seemed to result in (? Less than 5%), but several patients may have reacted to it with chronic stitch granulomas or recurrent abscesses. Consider this when seeing a patient who presents with recurrent wound infections (1 patient), or nodular masses deep to the incision scar (2 patients).

Hernias should not be deferred once they become symptomatic. Be wary of the umbilical hernia that was chronically incarcerated with omentum, and that reduces spontaneously once the patient begins to lose weight, as it may then become incarcerated with bowel. Also be wary of the non-symptomatic hernia that the patient casually says they have had to occasionally reduce without difficulty for years without apparent difficulty, as the behavior of the hernia may change suddenly postoperatively.