Surgery M and M

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Surgery M and M

• Rummana Aslam, MD
• 08/12/08

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• 53 y/o AA woman
• PMHx thyroid disease, NIDDM, GERD, bronchitis,
  DVT, hypertension, morbid obesity, epidural
  abscess, osteomyelitis, MRSA, smoking
• PSHx tonsillectomy,appendectomy, hysterectomy,
  thyroid surgery, numerous back surgeries, Lap
  Roux- en-y gastric bypass 12/2006, bowel
  resection a month prior to this admission

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• No allergies
• Continues to smoke, no drugs, no alcohol
• Medications verapamil, synthroid, fentanyl,
  naprosyn, per patient
• 8/2/08 presented to Sinai ER with sudden onset
  of sharp epigastric pain. Left AMA
• 8/3/08 presented to Northwest Hospital.
  Worsening abdominal pain described as constant,
  causing shortness of breath, now generalized,
  made worse by movement, alleviated by sitting up

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• VS 36.5 122 135/86 100 RA
• PE Alert, moderate distress, lungs clear,
  tachycardic, abdomen rigid with clear peritoneal
  signs and guarding, rectal exam showed gross
  blood, extremities 1 edema, clearly
  malnourished
• Laboratory data WBC 1.9 ( previous 7-10), H/H
  8.5/26.6, platelets 800,000, sodium 142,
  potassium 3.5, chloride 107, bicarb 24,
  BUN/creatinine 15/0.6, glucose 100, alk phos 134,
  amylase 101, lipase 187, coagulation profile
  normal, drug screen negative

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• CT scan revealed pneumoperitoneum and large
  amount of fluid in upper abdomen
• 8/4/08 Resuscitation with IVF, IV antibiotics
  and transferred to Sinai. On arrival to Sinai
  patient was in moderate to severe distress,
  central venous access, pain control, aggressive
  fluid resuscitaion, blood transfusion, patient
  consented and emergently taken to the OR

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• 8/04/08 Exp laparoscopy, repair of gastrojejunal
  ulcer, open washout, gastrostomy tube placement,
  2 JP drains, wound VAC
• ICU intubated, sedated, requiring vasopressor
  support, fluid resuscitation, low urine output,
  on empiric broad coverage antibiotics
• 8/06/08 OR for washout, subdiaphragmatic fluid
  collection drained, omental patch of
  gastrojejunal ulcer, JP drains and modified wound
  VAC
• ICU tolerated aggressive diuresis, started on
  definitive antibiotic therapy

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• 8/8/08 brought back to the OR for washout and
  closure
• Doing well, on CPAP, hemodynamically stable,
  tolerating initial G-tube feeding

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• Complications of bariatric surgery
• Lee, Calvin et al. Current Opinion in Internal
  Medicine. 2008
• Gastrointestinal complications of bariatric
  surgery
• Abel, Thomas et al. The American Journal of
  Medical Science. 2006

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• Complications from post surgical weight loss, not
  the surgery
• Gallstones
• Gastrointestinal complications
• Dumping
• Occurs more commonly with combined procedures
• Can occur early ( 10-30 min after eating) or late
  (2-3 hrs after eating)
• Early rapid and directpassage of hyperosmolar
  chyme into the small intestine bloating,
  cramping abdominal pain, darrhea
• Late presentation and rapid absorption of high
  carbohydrate load from small intestine with
  resultant hyperglycemia and a rapid systemic
  insulin response symptoms of hypoglycemia,
  flushing, weakness, diaphoresis, dizziness

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• Therapy for early and late Dietary modification,
  octreotide
• Vitamin and mineral deficiencies
• More common with combined restrictive and
  malabsorptive
• Most common reported deficiencies are B12, vit D,
  calcium
• Vomiting
• More often with restrictive
• More often due to increased intake
• May be due to decreased potassium and magnesium
• Treatment usually promethazine or odansteron

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• Anastomotic leak
• Tachycardia, fever, leukocytosis treatment
  primarily surgical
• Large case series (63 patients) reported that
  leaks after RYGBP most often are not detected by
  CT imaging, most required surgery 63 morbidity
  53, mortality 10
• Stenosis
• SBO
• Usually at site of anastomosis
• Endoscopic balloon dilation or surgical revision
• Stenosis that occur after 2 months usually due to
  marginal ulceration
• Ulceration
• Manifests with pain, vomiting or bleeding,
  requires endoscopy or imaging for confirmation
• Treatment is usually medical including carafate
  or anti-acid drugs- eradication of H pylori
• Complications gastro-gastric fistula, perforation
• If ulcer refractory to medical treatment
  surgery considered, options include ulcer
  resection with revision of the pouch or staple
  line

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