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Bariatric patients in an emergency setting

How surgeons treat bariatric patients in an emergency setting

The majority of patients had received a sleeve gastrectomy (38.5%; 45/117), and 31.6% (37/117) a laparoscopic Roux-en-Y gastric bypass

Emergency surgeons have a crucial role in the management of bariatric patients admitted in the emergency department for acute abdominal pain, yet no consensus or guidelines about the emergency management of long-term complications following bariatric surgery are currently available, according to a study written on behalf of the OBA trial supporters.

The paper, ‘The Operative management in Bariatric Acute abdomen (OBA) Survey: long-term complications of bariatric surgery and the emergency surgeon’s point of view’, published in the World Journal of Emergency Surgery, sought to investigate via a web survey how emergency surgeons approach this unique group of patients in an emergency medical scenario and to report their personal experience. The paper also reported the epidemiological characteristics and clinical-pathological features about this population of patients and highlighted life-threatening complications and outcomes of bariatric surgery.

The questionnaire survey included 26 (multiple choice and open) questions and was sent to 197 members of the World Society of Emergency Surgery (WSES). In total, 117 international emergency surgeons joined the project and answered the web survey (response rate of 59.39%).

The majority of emergency surgeons (64%; 61/95) worked in a university hospital, 26.31% (25/95) in a public hospital, 16.8% (16/95) in a private hospital and 13.6% (13/95) in a trauma centre level I, 7.4% (7/95) in a trauma centre level II, 2.1% (2/95) in a trauma centre level III. Most (51.8.%; 68/117) had over ten years of surgical experience and 25.6% (30/117) have surgical experience of five to ten years.

Most (55.6%; 65/117) work in a hospital with a bariatric unit and almost all (97.4%; 114/117) in a hospital with an intensive care unit (ICU). Nearly two-thirds of responders (59.5%;69/117) had no experience in bariatric procedures, but almost all (98.3%; 115/117) have been called to evaluate an acute abdominal pain after bariatric surgery in an emergency department. Most reported to have managed less than ten bariatric patients (52%; 61/117), 24% (29/117) between ten and 20 bariatric patients, and 23% (27/117) more than 20 patients.

Most patients (36.8%; 43/117) presented with acute abdominal pain after less than four weeks after their bariatric surgical procedure, 22.2% (26/117) between four weeks and six months, 16.2% (19/117) between six months and one year, and 25% (29/117) after over one year following bariatric surgery. The majority of patients were female (76.7%; 91/117) over 40 years old (59.8%; 70/117), and capable of reporting their surgical history and specific type of bariatric surgical procedure previously performed (77%; 91/117).

The majority of patients had received a sleeve gastrectomy (38.5%; 45/117), and 31.6% (37/117) a laparoscopic Roux-en-Y gastric bypass (Table 1).

Table 1: Type of bariatric surgery previously undergone by patient presenting with acute abdominal pain

In evaluating the patients, 37.6% (44/117) of emergency surgeons asked for the following diagnostic laboratory exams,: complete blood count (CBC), dosage of electrolytes, protein C-reactive (PCR), and/or procalcitonin (PCT). Eighty-seven/117 (74.4%) of surgeons reported that laboratory exams were a useful diagnostic tool, and 30/117 (25.6%) reported that they were not.

Radiological exams performed to aid in diagnosis included plain abdominal radiography and enhanced computed tomography (CT) in 41.9% of responses (49/117), abdominal CT with intestinal opacification in 41.9% of responses (49/117), and plain abdominal radiography in standing position and abdominal US, in 13.7% of responses (16/117). Radiological exam results were useful in the decision-making of 109/117 ES (93.2%).

The most common complaint (Figure 1) was generalised abdominal pain (65%; 76/117), followed by vomiting (52%; 61/117) and localized abdominal pain (40.2%; 47/117). Sixty-two/117 (53%) surgeons took patients to the operating room because of a clear diagnosis, 60/117 (51.3%) because of worsening abdominal pain and 31/117 (26.5%) for inconclusive findings.

Figure 1: Most common symptoms presented by bariatric patients admitted in emergency department

Timing for surgery was between 12 and 24 hours in 51/117 responses (43.5%), <12 hours for 41.9% (49/117) of responses, > 24 hours for 12.8% (15/117) of responses, variable according to diagnosis for 2/117 (1.7%) of responses.

Surgical exploration was performed by laparoscopy in more than 50% of bariatric patients for 57/117 of ES (48.7%), by laparoscopy in less than 50% of cases for 24/117 (20.5%), by laparotomy in more than 50% of cases for 19/117 (16.2%), by laparotomy in all cases for 16/117 surgeons (13.7%), by laparotomy in less than 50% of cases for 1/117 ES (0.9%).

The most common intra-operative finding (Table 2) was Internal hernia (49.5%), followed by adhesions (41.8%), anastomotic stenosis (12.8%) and intussusception (7.6%).

Table 2: Common intra-operative findings in bariatric patients

In-hospital mortality rate reported was <10% in 69.2% (81/117) of answers, between 10 and 50% for 19/117 (16.2%) of responders, “low” for one surgeon (0.9%) and unknown for 16/117 (13.7%) of responders. Fifty-six/117 (47.9%) reported that their patients required admission to the ICU after surgery; 15/117 (12.8%) reported that theirs did not; and 46/117 (39.3%) answered ‘maybe’.

Most (95.7%; 112/117) reported that their patients were discharged alive and 72.6% (85/117) declared to be worried about bariatric patients presenting with acute abdominal pain.

“Emergency surgeons must be mindful of postoperative bariatric surgery complications. CT scan with oral intestinal opacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeon,” the authors cautioned. “In the case of inconclusive clinical and radiological findings, when symptoms fail to improve, early surgical exploration, by laparoscopy if expertise is available, is mandatory in the first 12–24 hours, to have good outcomes and decrease morbidity rate.”

To access this paper, please click here

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