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Bariatric Surgery - Obesity Algorithm 2024

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16 Bariatric Surgery   ➤ Leak or perforation (RNY, sleeve gastrectomy, BPD/DS) • Can lead to acute peritonitis. • Technical failure within the f irst 72 hours (with ischemia can occur up to 14 days post-op). • Can also occur at any time due to ulcer perforation (avoid nonsteroidal anti-inflammatory drugs [NSAIDS], steroids, nicotine, caffeine, alcohol). • Often with acute and severe abdominal pain (may NOT have peritonitis symptoms if on steroids). • Fever, tachycardia, abdominal or back pain, and leukocytosis. • Urgent surgical exploration may be required but can sometimes be managed with endoscopic stent and drain (in selected cases) • Imaging not always diagnostic but when performed, water soluble contrast preferred (abdominal CT or upper GI). • Immediate surgical consultation is critical for suspected leak or perforation EVEN if imaging is negative. Late (>30 Days)   ➤ Gastro-gastric fistula (RNY) • Results in increased capacity to ingest food and/or increased passing of food into the gastric remnant (where it is more completely digested and absorbed). • Possible contributing factor to suboptimal weight loss/weight regain and recurrence of metabolic disease. • A non-healing ulcer might raise concern for a gastro-gastric fistula.   ➤ Band erosion through gastric wall into the lumen (LAGB) • Suspect if band is full but patient perceives no restriction or obstructive symptoms with empty or minimally filled band. • Can also present as infection with pain, fevers, leukocytosis. • Pain/infection may or may not be present. • Diagnose with esophagogastroduodenoscopy (EGD). Surgical consult for removal is required for eroded band.   ➤ Incisional hernias (more common with open procedures) • Pain at one of the incisional sites. • Maybe be palpable defect but due to body habitus this may be difficult to ascertain on exam. CT or US is needed to confirm. • Repair usually postponed until significant weight loss unless signs of bowel incarceration/strangulation (bowel obstruction).

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