The Operative management in Bariatric ... - BioMed Central

RESEARCH ARTICLE Open Access

The Operative management in BariatricAcute abdomen (OBA) Survey long-termcomplications of bariatric surgery and theemergency surgeonrsquos point of viewBelinda De Simone1 Luca Ansaloni2 Massimo Sartelli3 Yoram Kluger4 Fikri M Abu-Zidan5 Walter L Biffl6Arianna Heyer7 Federico Coccolini8 Gian Luca Baiocchi9 the OBA trial supporters and Fausto Catena10

Abstract

Background The number of bariatric procedures is increasing worldwide No consensus or guidelines about theemergency management of long-term complications following bariatric surgery are currently available The aim ofthis study is to investigate by a web survey how an emergency surgeon approaches this unique group of patientsin an emergency medical scenario and to report their personal experience

Method An international web survey was sent to 197 emergency surgeons with the aim to collect data aboutemergency surgeonsrsquo experience in the management of patients admitted in the emergency department for acuteabdominal pain after bariatric surgery The survey was conceived as a questionnaire composed by 26 (multiplechoice and open) questions and approved by a steering committee

Results One hundred seventeen international emergency surgeons decided to join the project and answered tothe web survey with a response rate of 5939

Conclusions The aim of this WSES web survey was to highlight the current management of patients previouslysubmitted to bariatric surgical procedures by ESEmergency surgeons must be mindful of postoperative bariatric surgery complications CT scan with oral intestinalopacification may be useful in making a diagnosis if carefully interpreted by the radiologist and the surgeonIn case of inconclusive clinical and radiological findings when symptoms fail to improve surgical exploration forbariatric patients presenting acute abdominal pain by laparoscopy if expertise is available is mandatory in the first12ndash24 h to have good outcomes and decrease morbidity rate

Keywords Complication bariatric surgery Outcome bariatric surgery Emergency surgery Acute abdomen Abdominalpain after bariatric surgery

BackgroundThe World Health Organization (WHO) reported that theworldwide prevalence of obesity nearly tripled between1975 and 2016 There are 340 million children and adoles-cents (age 5ndash19) who are overweight or obese In 2016more than 19 billion adults aged 18 years and older wereoverweight Of these over 650 million adults were obese

Overall about 13 of the worldrsquos adult population (11 ofmen and 15 of women) were obese in 2016 [1]Morbid obesity occurs in 2ndash5 of the Western popu-

lation and is associated with a high incidence of multiplepreventable co-morbidities such as diabetes cancer andcardiovascular disease Morbid obesity increases the riskof mortality [1]Bariatric surgery is the only method that has been

shown to achieve long term weight loss and treat co-morbidities [2]

copy The Author(s) 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 40International License (httpcreativecommonsorglicensesby40) which permits unrestricted use distribution andreproduction in any medium provided you give appropriate credit to the original author(s) and the source provide a link tothe Creative Commons license and indicate if changes were made The Creative Commons Public Domain Dedication waiver(httpcreativecommonsorgpublicdomainzero10) applies to the data made available in this article unless otherwise stated

Correspondence desimonebelindagmailcom1Department of General and Emergency Surgery Azienda Usl Reggio EmiliaIRCCS Reggio Emilia ItalyFull list of author information is available at the end of the article

De Simone et al World Journal of Emergency Surgery (2020) 152 httpsdoiorg101186s13017-019-0281-y

The number of bariatric procedures performed by bar-iatric surgeons is increasing in specialist centers andabroad due to the phenomenon of health tourism [2ndash3]The most recent International Federation for the Surgeryof Obesity and metabolic Disorders (IFSO) WorldwideSurvey [3] reported that 634897 bariatric operations wereperformed worldwide in 2016The IFSO worldwide survey 2014 reported that the

current most commonly performed bariatric proceduresare the sleeve gastrectomy (SG) Roux en-Y gastric by-pass (RYGB) and laparoscopic adjustable gastric band(LAGB) These procedures represent respectively 459396 and 74 of all bariatric procedures performedworldwide RYGB is the most common bariatric surgeryin the UK followed by SG although the latter has beengaining in popularity and is now the most common bar-iatric surgery in countries where most bariatric surgeriesare performed such as other European and NorthAmerican countries A total of 6391 bariatric surgicalprocedures were performed in the UK in 2014 comparedwith 191920 in the USA and 46960 in France [3ndash4]The number of bariatric procedures performed is in-

creasing leading to more post-operative bariatric patientsthat will present with an acute abdomen in the emergencydepartmentPatients with early postoperative complications may be

managed in specialist centers by the bariatric surgeonduring the hospital stay but patients with acute abdom-inal pain that occurs after months or years post-operatively may present for assessment and managementin the local emergency unitsComplications following surgical treatment of severe

obesity vary based upon the procedure performed andcan be as high as 40 [4] Due to the wide variety of sur-gical bariatric techniques the functional outcomes andlate or long-term complications (those that occur after 1month after surgery) from bariatric surgery remain notcompletely known or well understoodNo consensus or guidelines about the emergency man-

agement of long-term complications following bariatricsurgery are currently availableThe aim of this study is to investigate by a web survey

how an emergency surgeon approaches this uniquegroup of patients in an emergency medical scenario andto report their experience

MethodThis study reports data collected by an internationalweb survey carried out with the aim to collect dataabout emergency surgeonsrsquo experience in the manage-ment of patients admitted in the emergency departmentfor acute abdominal pain (AA) after bariatric surgeryThe survey was conceived as a questionnaire com-

posed by 26 (multiple choice and open) questions and

was sent on January 28 2018 via Google Forms afterthe approval of the World Society of Emergency Surgery(WSES) project steering committee represented byFausto Catena (Parma Trauma Center Italy) Luca Ansa-loni (Cesena Trauma Center Italy) Yoram Kluger (Ram-bam Health Care Center Israel) and Walter L Biffl(Scripps Clinic San Diego USA) to the mailing list ofthe WSES membersThe deadline to participate was March 28 2018The projectrsquos main objectives were the following1) To extrapolate epidemiological characteristics and

clinical-pathological features about this population ofpatients admitted to the emergency department foracute abdominal pain2) To highlight life-threatening complications and out-

comes of bariatric surgery3) To analyze the decision-making algorithms of the

emergency surgeons in the management of AA in pa-tients previously treated with bariatric surgical proce-dures to determine best practices for early diagnosisand best operative and non-operative treatments to de-crease morbidity and in-hospital mortality rates

ResultsThe invitation to participate in the web survey was sentto 197 surgeonsOne hundred seventeen international emergency sur-

geons (ES) decided to join the project and answered tothe web survey with a response rate of 5939Sixty-four percent (6195) of ES worked in a university

hospital 2631 (2595) in a public hospital 168 (1695) in a private hospital and 136 (1395) in a traumacenter level I 74 (795) in a trauma center level II 21(295) in a trauma center level III as summarized in Fig 1Most participants (518 68117 ES) declared to have

over 10 years of surgical experience and 256 (30117)have surgical experience of 5 to 10 yearsThe majority of ES (556 65117) work in a hospital

with a bariatric unit and almost all (974 114117 ES)in a hospital with an intensive care unit (ICU) 595 ofresponders (69117) declared to have no experience inbariatric procedures but almost all surgeons (983115117) have been called to evaluate an AA after bariat-ric surgery in an emergency department (ED) The ma-jority of ES reported to have managed less than 10bariatric patients in their experience (52 61117) 24(29117) between 10 and 20 bariatric patients and 23(27117) more than 20 patientsAccording to the answers 368 (43117) of bariatric

patients examined presented with AA after less than 4weeks from the bariatric surgical procedure 222 (26117) between 4 weeks and 6 months 162 (19117) be-tween 6 months and 1 year and 25 (29117) after over1 year following bariatric surgery The majority of

De Simone et al World Journal of Emergency Surgery (2020) 152 Page 2 of 9

patients were female (767 91117) over 40 years old(598 70117) and capable of reporting their surgicalhistory and specific type of bariatric surgical procedurepreviously performed (77 91117)Most of the examined patients (44117 376) had

been operated on in the same hospital as that of the ESon call while 325 (38117) were operated in a privatehospital 28 (33117) in another public hospital and17 (2117) were operated on in a different countryThe majority of patients had received a sleeve gastrec-

tomy (385 45117) and 316 (37117) a laparoscopicRoux-en-Y gastric bypass as summarized in Table 1The most common complaint was generalized abdom-

inal pain (65 76117) followed by vomiting (52 61117) and localized abdominal pain (402 47117) assummarized in Fig 2In evaluating the patients 376 (44117) of the ES

asked for the following diagnostic laboratory exams assummarized in Table 2 complete blood count (CBC)dosage of electrolytes protein C-reactive (PCR) andorprocalcitonin (PCT)Eighty-seven117 (744) of ES reported that labora-

tory exams were a useful diagnostic tool and 30117(256) of ES reported that they were notRadiological exams performed to aid in diagnosis in-

cluded plain abdominal radiography and enhanced com-puted tomography (CT) in 419 of responses (49117)

abdominal CT with intestinal opacification in 419 ofresponses (49117) and plain abdominal radiography instanding position and abdominal US in 137 of re-sponses (16117) as summarized in Table 3Radiological exam results were useful in the decision-

making of 109117 ES (932)62117 (53) of ES took patients to the operating

room because of a clear diagnosis 60117 (513) of ESbecause of worsening abdominal pain and 31117(265) of ES for inconclusive findings as summarized inFig 3Timing for surgery was between 12 and 24 h in 51117

responses (435) lt 12 h for 419 (49117) of re-sponses gt 24 h for 128 (15117) of responses variableaccording to diagnosis for 2117 (17) of responses assummarized in Table 4Surgical exploration was performed by laparoscopy in

more than 50 of bariatric patients for 57117 of ES (487)by laparoscopy in less than 50 of cases for 24117 (205)of ES by laparotomy in more than 50 of cases for 19117(162) of ES by laparotomy in all cases for 16117 surgeons(137) by laparotomy in less than 50 of cases for 1117ES (09) as summarized in Table 5Intra-operative findings reported were summarized in

Table 6In-hospital mortality rate reported was lt 10 in 692

(81117) of answers between 10 and 50 for 19117(162) of ES ldquolowrdquo for 1 surgeon (09) and unknownfor 16117 (137) of ESFifty-six117 (479) of ES reported that their patients

required admission to the ICU after surgery 15117(128) of ES reported that theirs did not and 46117(393) of ES answered ldquomayberdquoMost ES 112117 (957) reported that their patients

were discharged alive726 (85117) of ES declared to be worried about bar-

iatric patients presenting with AA

Fig 1 Participantsrsquo affiliations

Table 1 Type of bariatric surgery previously undergone bypatient presenting with acute abdominal pain

Type of bariatric surgery Number of answers

Sleeve gastrectomy 45117 385

Laparoscopic Roux en Y gastric bypass 37117 316

Open Roux en Y gastric bypass 4117 34

Unknown 9117 77

Laparoscopic adjustable gastric binding 22117 188


DiscussionThe present international survey was conceived to assessknowledge and clinical practice about the managementof AA in patients previously submitted to bariatric sur-gery in an emergency setting 593 of invited ES de-cided to join the project confirming the increasinginterest to explore this topic especially in light of thecurrent lack of consensus and guidelinesThe quality of data collected by this questionnaire de-

rives from the seniority (518 of respondents declaredto have a surgical practice of more than 10 years) andthe internationality of the respondentsThe survey reported that not all ES have experience

in bariatric surgery and not all hospitals have a bar-iatric surgery unit consequently bariatric patientsneeding re-intervention for acute abdomen were man-aged by the ES on callLate complications following bariatric surgery have

been poorly analyzed and their management is notclearly assessed in the emergency settingCollected data showed that most of the bariatric pa-

tients (BP) admitted in the ED were female mean age ofgreater than 40 years and presenting with acute

generalized abdominal pain (65 of answers) and vomit-ing (521 of answers) within 4 weeks after the surgicalinterventionThe survey showed that SG was the most commonly

reported surgical procedure (385) followed by LRYGB(316)Clinical signs and physical examination of BP present-

ing with AA can be atypical insidious often resulting indelayed management due to inconclusive clinical andradiological findings with poor outcomes and high mor-bidity rate Tachycardia is considered the alarm sign forall bariatric surgeons in the early postoperative timeLate complications can be revealed by hemodynamic in-stability respiratory failure or renal dysfunction How-ever these are not always presentSeveral studies confirmed that abdominal pain is one

of the most common and sometimes frustrating prob-lems after bariatric surgery and some authors affirmedthat anywhere from 15 to 30 of patients will visit theemergency room or require admission within 3 years ofgastric bypass [5ndash8]In particular Saunders et al [7] reported that the overall

1-year readmission rate for abdominal pain in a high vol-ume bariatric center was 188 and that most of the pa-tients were re-admitted after LRYGB (242) whereasLAGB showed the lowest readmission rate of 1269Another study confirmed this data showing that the le

90-day all-cause postoperative ED visit rate was 18(65361 BP) in a bariatric center [6]The most common postoperative complications of

bariatric procedures described in literature are summa-rized in Table 7 [9ndash16]

Fig 2 Most common symptoms presented by bariatric patients admitted in emergency department

Table 2 Common laboratory tests requested at admission ofbariatric patients

Laboratory tests requested Number ofanswers

CBC dosage electrolytes dosage CPR andor PCT 45117 384

CBC blood gas analysis lactates CPR andor PCT 39117 3333

CBC liver function tests dosage lipase dosagetroponin dosage CPR andor PCT

33117 282


Complication rates are reported higher after LRYGBbut we cannot confirm that most surgeons reportedevaluating patients presenting with abdominal pain afterSG [11ndash14]In agreement with available studies [17ndash23] the WSES

survey reported that ES used enhanced abdominal com-puted tomography (CT) with oral intestinal opacificationto make a diagnosis in BP even if only 53 of ES de-clared that diagnosis after radiological exams was clearDiagnostic value of imaging in BP depends on the

careful interpretation of the new anatomical landmarksand on the knowledge of the potential complications fol-lowing bariatric surgerySeveral studies described the new radiological anatomy

after bariatric surgery at CT scan The administration oforal and intravenous contrast is fundamental to find land-marks for the interpretation of images [19ndash23] For ex-ample after gastric bypass the identification of the gastricpouch gastrojejunal anastomosis jejunal Roux limb jeju-nojejunal anastomosis and biliopancreatic limb on CT is

essential for detecting potential complications such as in-ternal hernias and small bowel obstruction (SBO) Positiveoral contrast material administered just prior to image ac-quisition helps differentiate the gastric pouch and Rouxlimb from the excluded stomach and biliopancreatic limbwhich are not opacified The Roux limb should befollowed along its antecolic or retrocolic course to thejejunojejunal anastomosis typically in the left mid-abdomen The excluded stomach should be visualized onCT images and is normally collapsed [19 20]According to CT scan findings SBO following RYGB

is classified on the features of the Roux-alimentary limbbilio-pancreatic limb and distal common channel in-volvement [18]After SG CT scan is the right radiological exam to as-

sess for abscesses perforation staple line dehiscenceand other complications such as splenic injury or infarc-tion [19 20]Our survey reported that internal hernia (496 of an-

swers) and adhesions (419 of answers) were commonintraoperative findings at surgical exploration (Table 6)suggesting that SBO is the leading cause of abdominalpain after bariatric surgerySBO occurs in approximately 5 of cases after gastric

bypass and is due frequently to adhesions or to internalherniation Other causes of SBO are incisional herniathrough a trocar opening or intussusception of the smallbowel [21]Internal herniation occurs in approximately 6 of

patients after gastric bypass or biliary pancreaticshunting and it can be a potentially fatal complication[22 23]

Table 3 Common radiological exams requested to evaluateacute abdomen in bariatric patients

Radiological exams requested Number ofanswers

Abdominal CT scan with oralintestinal opacification

49117 419

Plain XR enhanced CT scan 49117 419

Plain XR US 16117 136

Plain XR 1117 085

UGI CT 1117 085

Fig 3 Why emergency surgeons decide to take the bariatric patient into the operating room


It is promoted by massive weight loss and by charac-teristic mesenteric defects that develop after LRYGB thatare in the transverse mesocolon for a retrocolic Rouxlimb a mesenteric defect near the jejunojejunal anasto-mosis and a defect posterior to the Roux limb (iePetersenrsquos defect)Internal hernias are very difficult to reveal clinical

inquiry and from radiological investigations and requiresa high index of suspicion The sensitivity of CT scan inidentifying the ldquomesenteric swirl signrdquo the most sensitiveCT scan sign suggestive of internal hernia has been re-ported to be between 68 and 89 [17]Anastomotic stenosis can cause an obstruction and it

usually involves the gastrojejunal anastomosis It occursin approximately 12 of patients after bypass and typic-ally develops a month or more after surgery with a peakoccurring 50 days after gastric bypass [16 17]Patients presenting with bariatric surgery complica-

tions in an emergency setting have a poor outcomelargely related to delayed diagnosis and re-operation butno data are availableOur survey showed that in-hospital mortality related

to re-operated BP is lt 10 for 692 of ES and that themajority of patients were discharged alive (957 ofanswers)Diminishing the delay in surgery is crucial to avoid

catastrophic scenarios such as generalized peritonitisdue to intestinal perforation or massive bowel ischemiaOur survey reported that the majority of ES do not

wait for more than 24 h to decide in favor of surgical ex-ploration if the patient presents with worsening

abdominal pain and inconclusive radiological findings(Fig 3)Our data showed that surgical exploration was made

by laparoscopy for the majority of ES in more than 50of BPThis is in accordance with several available studies that

investigated the role of explorative laparoscopy to assesschronic abdominal pain after bariatric surgery Thesestudies demonstrated that the laparoscopic approach issafe and feasible in BP presenting with abdominal painof unknown etiology [24 25]

Table 4 Delay from admission to operating room

Delay Number of answers

lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085

Variable according to diagnosis 2117 17

UGI upper gastrointestinal series CT abdominal computed tomography USultrasonography XR X-ray

Table 5 Technique for surgical emergency exploration inpatients presenting acute abdomen previously submitted tobariatric surgery

Technique for surgical emergencyexploration

Number ofanswers

Laparoscopy in lt 50 of cases 24117 205

Laparoscopy in gt 50 of cases 57117 487

Laparotomy in all cases 16117 137

Laparotomy in lt 50 of cases 1117 085

Laparotomy in gt 50 of cases 19117 162

Table 6 Common intra-operative findings in bariatric patients

Intraoperative findings Number of answers

Internal hernia 58117 495

Adhesions 49117 418

Anastomotic stenosis 15117 128

Intussusception 9117 76

Volvulus 9117 76

Leak 5117 42

Complications of gastric band 4117 34

Gastric perforation 1117 085

Hemorrhagic ulcer in esclude stomach 1117 085

Peritonitis 3117 25

Leaking stapler line 1117 085

Cholecystitis 1117 085

Bleeding abscesses 1117 085

Perforation 1117 085

Bleeding mesenteric thrombosis 1117 085

Table 7 Common complications following bariatric surgery

Bariatric surgicalprocedures

Early complications Late complications

Sleevegastrectomy

Leakfistula Gastroesophageal reflux

stricture

hemorrhage

Gastric bypass Leakfistula Anastomotic ulcer(bleeding perforation)

obstructionanastomotic

stricture bowel obstruction(internal hernia)

hemorrhage

Adjustablegastric binding

Esophageal andorgastric perforation

Infection

connector tubing rupture

acute dilatation of thegastric pouch

gastric pouch dilatation andslippage of the AGB

erosion and intragastricmigration

esophageal dilatation


All of these studies express concerns regarding chronicpain in BP and the diagnostic value of explorative lapar-oscopy Other (case reports and retrospective studies)authors reported data about the management of AAafter bariatric surgery by laparoscopy confirming thatlaparoscopy is feasible and safe even in the emergencysetting if expertise is available and the patient ishemodynamically stable [26ndash28]Despite a good correspondence between the data result-

ing from our survey and the current data available in litera-ture about the management of acute abdomen in bariatricpatients 85117 (726) of ES declared to be worried whenasked to manage acute abdomen in patients with a previoushistory of bariatric surgery This indicates the ESrsquo desire tobe familiar with the various types of bariatric surgery tounderstand the new anatomy radiological findings andlong-term bariatric complications to be able to appropri-ately manage them in the emergency settingWe acknowledge the limitations of the present study

some due to the intrinsic nature of surveys (answers maynot be honest and accurate responders represent an in-trinsic selection bias because non-responders may answerdifferently answer options may be interpreted differentlyby different responders) and some related to the nature ofour data not linked to a population of patients but to thepersonal experience and opinion of 117 international ES

ConclusionsBariatric procedures are increasing and this results in anincreased number of bariatric patients admitted in theED for AA ES have a crucial role in the management ofthis group of patients and no consensus or guidelinesare availableThe aim of this WSES web survey was to highlight the

current management of bariatric patients in the ED by ESEmergency surgeons must be mindful of postoperative

bariatric surgery complications CT scan with oral intes-tinal opacification may be useful in making a diagnosis ifcarefully interpreted by the radiologist and the surgeonIn the case of inconclusive clinical and radiological

findings when symptoms fail to improve early surgicalexploration by laparoscopy if expertise is available ismandatory in the first 12ndash24 h to have good outcomesand decrease morbidity rate

AbbreviationsAA Acute abdomen BP Bariatric patient(s) CT Abdominal computedtomography ED Emergency department ES Emergency surgeon(s)LAGB Laparoscopic adjustable gastric binding RYGB Roux en Y gastricbypass SBO Small bowel obstruction SG Sleeve gastrectomy

AcknowledgementsWe like to knowledge contributors from WSES the OBA Trial supporters)The OBA trial supporters1 Fabio Cesare Campanile campanilesurgicalnet2 Dente Mario Clinique Bonnefon France mdenteclinique-bonnefonfr3 Asnat Raziel doctorasnatrazielcom

4 Alberto Zaccaroni department of endocrine and general surgery ForligraveHospital albertozaccaroniauslromagnait5 Antonio Tarasconi Emergency Surgery Department Parma UniversityHospital Parma Italy atarasconigmailcom6 Alessandro Dazzi Italy Italy alled78yahooit7 Konstantinos Lasithiotakisi Department of Surgery University Hospital ofHeraklion GR kwstaslasithgmailcom8 Stefano Maccatrozzo Istituto Beato Matteo-Vigevano Paviastefanomaccamecom9 Orestis Ioannidis 4th Surgical Department Medical School AristotleUniversity of Thessaloniki Thessaloniki telonakoshotmailcom10 Francesco Pata Surgical Department SantrsquoAntonio Abate HospitalGallarate Italy francescopatagmailcom11 Maciej Walędziak Department of General Oncological Metabolic andThoracic Surgery Military Institute of Medicine Warsaw Polandmaciejwaledziakgmailcom12 Agron Dogjani University Hospital of Trauma Albaniaagrondogjaniyahoocom13 Affirul Chairil Ariffin Universiti Sains Islam Malaysiaaffirulgmailcom14 Vladimir Khokha Mozyr City hospital Belarus vladimirkhokhagmailcom15 Ling Kho Pennine acute NHS Trust United Kingdomlingkho9gmailcom16 Boris Kessel Hillel Yaffe Medical Center Israel bkkessel01gmailcom17 Ionut Negoi General Surgery Department Emergency Hospital ofBucharest Carol Davila University of Medicine and Pharmacy BucharestRomania negoiionutgmailcom18 Eftychios Lostoridis 1st Department of Surgery Kavala General HospitalKavala Greece elostoridisgmailcom19 Luigi Conti Azienda Ospedaliera G Da Saliceto Piacenzadrluigicontigmailcom20 Luca Ponchietti Torrevieja University Hospital Spainlponchiettigmailcom21 Francesco Saverio Papadia Ospedale Policlinico San Martino GenovaItaly francescopapadiaunigeit22 Giorgio Ghilardi Universitagrave degli Studi di Milano - DiSS Italygiorgioghilardiunimiit23 Valentin Calu Elias Emergency Hospital University of Medicine andPharmacy ldquoCarol Davilardquo Bucharest Romania drcalugmailcom24 Tuna Bilecik Adana City Training and Research Hospital Turkeytbilecikyahoocom25 Berhanu N Alemu Ethiopia b_negayahoocom26 Martin Reichert Department of General Visceral Thoracic Transplant andPediatric Surgery University Hospital of Giessen Germanymartinreichertchirumeduni-giessende27 Martin Hutan Surgical department Landesklinikum Hainburg Austriamartinhutanyahoocom28 Charalampos Seretis George Eliot Hospital NHS Trust West MidlandsUnited Kingdom babismedgmailcom29 MOLDOVANU Radu Department of Surgery Clinique Ste Marie CambraiFrance rmoldovanugmailcom30 Carlos Augusto Gomes Hospital Terezinha de Jesus Faculdade deCiecircncias Meacutedicas e da Sauacutede de Juiz de Fora (Suprema) Brazilcaxiaogomesgmailcom31 Faruk Karateke Health Sciences University Adana City HospitalDepartment of General Surgery Turkey karatekefarukhotmailcom32 Vinicius Cordeiro da Fonseca Hospital ViValle Brazildrviniciuscirurgiaicloudcom33 Arda Isik pittsburgh university magee womens hospital USAkarardayahoocom34 Ioannis Nikolopoulos Lewisham amp Greenwich NHS Trust UKinikolopoulosgmailcom35 Anfrii Fomin Ukraine tryshlandiagmailcom36 Wagih Ghnnam Mansoura faculty of medicine General surgerydepartment Egypt wghnnamgmailcom37 Ruslan Sydorchuk General Surgery Department Bukovinian State MedicalUniversity Ukraine rsydorchukbsmueduua38 Ciro Paolillo Emergency Department Spedali Civili di Brescia Brescia Italyciropaolillogmailcom39 Andrea Sagnotta Azienda Ospedaliera Santa Maria Terni Italyandreasagnottagmailcom


40 Leonardo Solaini General and Oncologic Surgery Morgagni-PierantoniHospital Forligrave Italy leonardosolaini2unboit41 Robert G Sawyer Western Michigan University USA rws2kvirginiaedu42 David A Spain Stanford University USA dspainstanfordedu43 Michael McFarlane Department of Surgery Radiology Anaesthesia andIntensive Care University of the West Indies MonaJamaicamichaelm500yahoocom44 Catherine ARVIEUX Clinique universitaire de chirurgie Digestive et de lurgenceGRENOBLE-ALPES UNIVERSITY HOSPITAL France carvieuxchu-grenoblefr45 Andrey Litvin Immanuel Kant Baltic Federal University Regional ClinicalHospital Kaliningrad Russia aalitvingmailcom46 Bruno M Pereira Vassouras University Brazil drbrunompereiragmailcom47 Teresa Gimeacutenez Maurel Hospital Universitario Miguel Servet Zaragozateresagm87gmailcom48 Andrea Barberis EO Ospedali Galliera Genova Italyandreabarberisgallierait49 Mahir Gachabayov Vladimir City Clinical Hospital of Emergency MedicineRussia gachabayovmahirgmailcom50 Donal B OrsquoConnor Tallaght Hospital Trinity College Dublin Irelandoconnd15tcdie51 Daniel Rios Cruz HOSPITAL CENTER VISTA HERMOSA Mexicodr_rioscruzoutlookcom52 Elif Colak University of Health Sciences Samsun Training and ResearchHospital turkey elifmangancolakhotmailcom53 Cristian Mesina Emergency County Hospital of Craiova Romaniamesinacristiandoctorcom54 Ramiro Manzano-Nunez Fundacion Valle del LiliColombiaramiromanzanocorreounivalleeduco55 abdelkarim Jordan university of Science and technology Jordan Omariakomarijustedujo56 Tadeja Pintar UMC Ljubljana Slovenia tadejapintarkcljsi57 Renol Koshy UHCW Coventry UK renolkoshygmailcom58 Georgios Triantos Rhodes General Hospital - 1st Surgical DepartmentRhodes Greece geotriantosgmailcom59Subash Gautam fujairah hospital UAE scgautamgmailcom60 Ali GUNER Karadeniz Technical University TrabzonTurkeydraliguneryahoocom61 Zaza Demetrashvili Georgia zdemetryahoocom62 Carlos A Ordontildeez Division of Trauma and Acute Care SurgeryDepartment of Surgery Fundacioacuten Valle del Lili Colombiaordonezcarlosagmailcom63 Dimitrios K Manatakis Department of Surgery Athens Naval andVeterans Hospital Athens Greece dmanatakyahoogr64 Massimo Chiarugi University of Pisa Medical School -Emergency SurgeryUnit Italy massimochiarugimedunipiit65 Luis BUONOMO Argentina lbuonomogmailcom66 Piotr Major 2nd Department of General Surgery Jagiellonian UniversityMedical College Poland majorpiotrgmailcom67 Hecker AndreasDept of General amp Thoracic Surgery University Hospitalof Gieszligen Germany andreasheckerchirumeduni-giessende68 Derek J Roberts University of Calgary Canadaderekroberts01gmailcom69 Jill R Cherry-Bukowiec University of MichiganUSA jillcherumichedu70 Koray Das Adana City Education and Research Hospital Turkeykoraydasyahoocom71 Andrea Costanzi Ospedale di Desio Italy acostanziasst-monzait72 Harry van Goor Radboud University Medical CenterNijmegen TheNetherlands harryvangoorradboudumcnl73 Kenneth Y Y Kok Jerudong Park Medical Center Brunei kokybrunetbn74 Aleix Martiacutenez-Peacuterez Department of General and Digestive SurgeryHospital Universitario Doctor Peset Valencia Spainaleixmartinezperezgmailcom75 Roberta Villa Policlinico San Marco Italy robevillatiscaliit76 luca fattori HS Gerardo Italy lucafattorifastwebnetit77 Gabriela Elisa Nita Ausl Reggio Emilia Italy nitagabriela2001yahoocom78 Dimitrios Damaskos Ηνωμένο Βασίλειο dimitrisdamaskosgmailcom79 KUO-CHING YUAN Taipei Medical University Hospital Taiwantraumayuangmailcom80 Aintzane Lizarazu Spain aintzanelizarazuhotmailcom81 michael denis kelly Albury Hospital Australia mkmdkellycom82 Isidoro DI CARLO University of Catania Italy idicarlounictit

83 Marco Ceresoli Department of General Surgery University of Milano-Bicocca Italy marcoceresoli89gmailcom88 Raffaele Galleano sc chirurgia generale ospedale santa corona pietraligure asl 2 savonese Italy raffagalleanotinit85 Herzog St Josef Hospital Bochum Ruhr University Bochum Germanytherzogklinikum-bochumde86 Christos Chatzakis MSc 4th Surgical Department of Aristotle University ofThessaloniki Thessaloniki greececchatzakisgmailcom87 Miklosh Bala Hadassah Hebrew University Medical Center Israelrbalamhadassahorgil88 Frank Piscioneri The Canberra Hospital Australia frankarkpacificcom89 Stefano Bonilauri AUSL Reggio Emilia Italy bonilauristefanoauslreit90 Helmut Alfredo Segovia Lohse Hospital de Clinicas Paraguayhhaassllgmailcom91 Zaza Demetrashvili Surgery Department Tbilisi State Medical UniversityGeorgia zdemetryahoocom (1)92 Dmitry Smirnov South Ural State Medical University Russian Federationsurgeonsmirnovyahoocom93 Dennis Kim Harbor-UCLA Medical Center USA dekimdhslacountygov94 Francesca Martina francescalombardo89gmailcom95 Giovanni Bruni EHS Italy pierogiovannibrunigmailcom96 Giampiero Campanelli EHS Italygiampierocampanelligrupposandonatoit97 Marta Cavalli EHS Italy marta_cavallihotmailit98 VICTOR KONG Department of Surgery University of KwaZulu NatalDurban South Africa victorywkongyahoocom99 Nickos Michalopoulos 3rd Department of Surgery Ahepa UniversityHospital Aristotle University Greece nickosmichalopoulosgmailcom100 Yunfeng Cui Tianjin Nankai Hospital Tianjin Medical University Chinayunfengcuidoctoraliyuncom101 Michele Diana IHU-Strasbourg Institute of Image-Guided SurgeryFrance micheledianaircadfr

Authorsrsquo contributionsBDS and FC conceived the study BDS wrote the questionnaire FC revisedthe questionnaire BDS collected and analyzed data and wrote themanuscript FAZ revised the statistical analysis FC GLB LA MS YK WB andFco read and approved the manuscript All authors read and approved thefinal manuscript

FundingNo funding received for this article

Availability of data and materialsNot applicable

Ethics approval and consent to participateNot applicable

Consent for publicationNot applicable

Competing interestsThe authors declare that they have no competing interests

Author details1Department of General and Emergency Surgery Azienda Usl Reggio EmiliaIRCCS Reggio Emilia Italy 2Department of Emergency and Trauma SurgeryBufalini Hospital Cesena Italy 3Department of General Surgery MaceratarsquosHospital Macerata Italy 4Department of Emergency and Trauma SurgeryRambam Health Campus Haifa Israel 5Department of Surgery College ofMedicine and Health Sciences UAE University Al-Ain United Arab Emirates6Department of Trauma and Acute Care Surgery Scripps Memorial HospitalLa Jolla California USA 7Sidney Kimmel Medical College Thomas JeffersonUniversity Philadelphia Pennsylvania USA 8Department of Surgery PisaUniversity Hospital Pisa Italy 9Department of Surgery University of BresciaBrescia Italy 10Department of Emergency and Trauma Surgery ParmaUniversity Hospital Parma Italy


Received 30 August 2019 Accepted 16 December 2019

References1 Obesity and Overweight Fact Sheet 2018 February 2018 httpwwwwho

intnews-roomfactsheetsdetailobesity-and-overweight (accessed 5 Aug2018 2018]

2 Angrisani L Santonicola A Iovino P et al Bariatric surgery worldwide 2013Obes Surg 2015251822ndash32

3 Angrisani L Santonicola A Iovino P Vitiello A Zundel N Buchwald H et alBariatric surgery and endoluminal procedures IFSO worldwide survey 2014Obes Surg 2017271ndash11 12

4 Ponce J EJ DM Nguyen NT Hutter M Sudan R Morton JM Americansociety for metabolic and bariatric surgery estimation of bariatric surgeryprocedures in 2015 and surgeon workforce in the United States Surg ObesRelat Dis 2016121637ndash9 httpsdoiorg101016jsoard201608488

5 Kellogg TA Swan T Leslie DA Buchwald H Ikramuddin S Patterns ofreadmission and reoperation within 90 days after Roux-en-Y gastric bypassSurg Obes Relat Dis 20095(4)416ndash23

6 Greenstein AJ ORourke RW Abdominal pain after gastric bypass suspectsand solutions Am J Surg 2011201(6)819ndash27 httpsdoiorg101016jamjsurg201005007

7 Saunders J Ballantyne GH Belsley S Stephens DJ Trivedi A Ewing DRIannace VA Capella RF Wasileweski A Moran S Schmidt HJ One-yearreadmission rates in a high volume bariatric surgery center laparoscopicadjustable gastric banding laparoscopic gastric bypass and vertical bandedgastroplasty-Roux-en-Y gastric bypass Obes Surg 200818(10)1233ndash40

8 Chen J Mackenzie J Zhai Y OLoughlin J Kholer R Morrow E Glasgow RVolckmann E Ibele A Preventing Returns to the Emergency DepartmentFollowingBariatric Surgery Obes Surg 2017 Aug27(8)1986ndash92 httpsdoiorg101007s11695-017-2624-7

9 Healy P et al Complications of bariatric surgery ndash What the generalsurgeon needs to know Surgeon 14(2)91ndash8

10 Radwan Kassir Tarek Debs Pierre Blanc Jean Gugenheim Imed Ben AmorClaire Boutet Olivier Tiffet Complications of bariatric surgery Presentationand emergency management International Journal of Surgery Volume 272016 Pages 77-81 ISSN 1743-9191 httpsdoiorghttpsdoiorg101016jijsu201601067

11 Joel F Bradley Samuel W Ross Ashley Britton Christmas Peter E FischerGaurav Sachdev Brant Todd Heniford Ronald F Sing Complications ofbariatric surgery the acute care surgeonrsquos experience The American Journalof Surgery Volume 210 Issue 3 2015 Pages 456-461 ISSN 0002-9610httpsdoiorghttpsdoiorg101016jamjsurg201503004

12 Wernick B Jansen M Noria S Stawicki S P amp El Chaar M (2015)Essential bariatric emergencies for the acute care surgeon European Journalof Trauma and Emergency Surgery 42(5) 571ndash584 doihttpsdoiorg101007s00068-015-0621-x

13 Kligman MD Acute care surgery for bariatric surgery emergencies InKhwaja K Diaz J editors Minimally Invasive Acute Care Surgery ChamSpringer 2018

14 Walsh C Karmali S Endoscopic management of bariatric complications areview and update World J Gastrointest Endosc 2015 7(5) 518-523 httpsdxdoiorghttpsdoiorg104253wjgev7i5518

15 Schulman AR Thompson CC Complications of bariatric surgery what youcan expect to see in your GI practice Am J Gastroenterol 2017 Nov112(11)1640-1655 doi httpsdoiorg101038ajg2017241 Epub 2017 Aug 15Review

16 Kassir R Debs T Blanc P Gugenheim J Ben Amor I Boutet C Tiffet OComplications of bariatric surgery presentation and emergencymanagement Int J Surg 2016 Mar2777-81 doi httpsdoiorg101016jijsu201601067 Epub 2016 Jan 22

17 Goudsmedt F Deylgat B Coenegrachts K et al Internal hernia afterlaparoscopic Roux-en-Y gastric bypass a correlation between radiologicaland operative findings Obes Surg 201525622ndash7

18 Tucker ON Escalante-Tattersfield T Szomstein S et al The ABC system asimplified classification system for small bowel obstruction afterlaparoscopic roux-en-Y gastric bypass Obes Surg (2007) 17 1549 httpsdoiorghttpsdoiorg101007s11695-007-9273-1

19 Carucci LR Turner MA Yu J Imaging evaluation following Roux-en-Y gastricbypass surgery for morbid obesity Radiol Clin North Am 200745(2)247ndash60

20 Carucci LR Imaging obese patients problems and solutions AbdomImaging 201338(4)630ndash46

21 Yu J Turner MA Cho SR et al Normal anatomy and complications aftergastric bypass surgery helical CT findings Radiology 2004231(3)753ndash60

22 Levine MS Laura R Carucci imaging of bariatric surgery normal anatomyand postoperative complications Radiology 2014270(2)327ndash41

23 Clayton RD Caress LR Imaging following bariatric surgery roux-en-Y gastricbypass laparoscopic adjustable gastric banding and sleeve gastrectomy BrJ Radiol 2018911089

24 Alsulaimy M Punchai S Ali FA et al The utility of diagnostic laparoscopyin post-bariatric surgery patients with chronic abdominal pain of unknownEtiologyObes Surg (2017) 27 1924 httpsdoiorghttpsdoiorg101007s11695-017-2590-0

25 Pitt T Brethauer S Sherman V et al Diagnostic laparoscopy for chronicabdominal pain after gastric bypass Surg Obes Relat Dis 20084394ndash8

26 Descloux A Basilicata G Nocito A Omental torsion after laparoscopic roux-en-Y gastric bypass mimicking appendicitis a case report and review of theliterature Case Rep Surg 201620167985795 httpsdoiorg10115520167985795

27 Kalaiselvan Ramya et al Incidence of perforated gastrojejunal anastomoticulcers after laparoscopic gastric bypass for morbid obesity and role oflaparoscopy in their management Surg Obes Relat Dis 20128(4)423-8httpsdoiorg101016jsoard201106008 Epub 2011 Jun 24

28 Fringeli Y Worreth M Langer I Gastrojejunal anastomosis complicationsand their management after laparoscopic roux-en-Y gastric bypass J Obes20152015698425 httpsdoiorg1011552015698425]

Publisherrsquos NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations


Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements

Authorsrsquo contributions

Funding

Availability of data and materials

Ethics approval and consent to participate

Consent for publication

Competing interests

Author details

References

Publisherrsquos Note

The number of bariatric procedures performed by bar-iatric surgeons is increasing in specialist centers andabroad due to the phenomenon of health tourism [2ndash3]The most recent International Federation for the Surgeryof Obesity and metabolic Disorders (IFSO) WorldwideSurvey [3] reported that 634897 bariatric operations wereperformed worldwide in 2016The IFSO worldwide survey 2014 reported that the

current most commonly performed bariatric proceduresare the sleeve gastrectomy (SG) Roux en-Y gastric by-pass (RYGB) and laparoscopic adjustable gastric band(LAGB) These procedures represent respectively 459396 and 74 of all bariatric procedures performedworldwide RYGB is the most common bariatric surgeryin the UK followed by SG although the latter has beengaining in popularity and is now the most common bar-iatric surgery in countries where most bariatric surgeriesare performed such as other European and NorthAmerican countries A total of 6391 bariatric surgicalprocedures were performed in the UK in 2014 comparedwith 191920 in the USA and 46960 in France [3ndash4]The number of bariatric procedures performed is in-

creasing leading to more post-operative bariatric patientsthat will present with an acute abdomen in the emergencydepartmentPatients with early postoperative complications may be

managed in specialist centers by the bariatric surgeonduring the hospital stay but patients with acute abdom-inal pain that occurs after months or years post-operatively may present for assessment and managementin the local emergency unitsComplications following surgical treatment of severe

obesity vary based upon the procedure performed andcan be as high as 40 [4] Due to the wide variety of sur-gical bariatric techniques the functional outcomes andlate or long-term complications (those that occur after 1month after surgery) from bariatric surgery remain notcompletely known or well understoodNo consensus or guidelines about the emergency man-

agement of long-term complications following bariatricsurgery are currently availableThe aim of this study is to investigate by a web survey

how an emergency surgeon approaches this uniquegroup of patients in an emergency medical scenario andto report their experience

MethodThis study reports data collected by an internationalweb survey carried out with the aim to collect dataabout emergency surgeonsrsquo experience in the manage-ment of patients admitted in the emergency departmentfor acute abdominal pain (AA) after bariatric surgeryThe survey was conceived as a questionnaire com-

posed by 26 (multiple choice and open) questions and

was sent on January 28 2018 via Google Forms afterthe approval of the World Society of Emergency Surgery(WSES) project steering committee represented byFausto Catena (Parma Trauma Center Italy) Luca Ansa-loni (Cesena Trauma Center Italy) Yoram Kluger (Ram-bam Health Care Center Israel) and Walter L Biffl(Scripps Clinic San Diego USA) to the mailing list ofthe WSES membersThe deadline to participate was March 28 2018The projectrsquos main objectives were the following1) To extrapolate epidemiological characteristics and

clinical-pathological features about this population ofpatients admitted to the emergency department foracute abdominal pain2) To highlight life-threatening complications and out-

comes of bariatric surgery3) To analyze the decision-making algorithms of the

emergency surgeons in the management of AA in pa-tients previously treated with bariatric surgical proce-dures to determine best practices for early diagnosisand best operative and non-operative treatments to de-crease morbidity and in-hospital mortality rates

ResultsThe invitation to participate in the web survey was sentto 197 surgeonsOne hundred seventeen international emergency sur-

geons (ES) decided to join the project and answered tothe web survey with a response rate of 5939Sixty-four percent (6195) of ES worked in a university

hospital 2631 (2595) in a public hospital 168 (1695) in a private hospital and 136 (1395) in a traumacenter level I 74 (795) in a trauma center level II 21(295) in a trauma center level III as summarized in Fig 1Most participants (518 68117 ES) declared to have

over 10 years of surgical experience and 256 (30117)have surgical experience of 5 to 10 yearsThe majority of ES (556 65117) work in a hospital

with a bariatric unit and almost all (974 114117 ES)in a hospital with an intensive care unit (ICU) 595 ofresponders (69117) declared to have no experience inbariatric procedures but almost all surgeons (983115117) have been called to evaluate an AA after bariat-ric surgery in an emergency department (ED) The ma-jority of ES reported to have managed less than 10bariatric patients in their experience (52 61117) 24(29117) between 10 and 20 bariatric patients and 23(27117) more than 20 patientsAccording to the answers 368 (43117) of bariatric

patients examined presented with AA after less than 4weeks from the bariatric surgical procedure 222 (26117) between 4 weeks and 6 months 162 (19117) be-tween 6 months and 1 year and 25 (29117) after over1 year following bariatric surgery The majority of

De Simone et al World Journal of Emergency Surgery (2020) 152 of 9
























Unknown 9117 77





















33117 282















49117 419



Plain XR 1117 085

UGI CT 1117 085















lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085





Number ofanswers









Adhesions 49117 418



Volvulus 9117 76

Leak 5117 42




Peritonitis 3117 25









Sleevegastrectomy


stricture

hemorrhage




hemorrhage



Infection




























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References

























Unknown 9117 77





















33117 282















49117 419



Plain XR 1117 085

UGI CT 1117 085















lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085





Number ofanswers









Adhesions 49117 418



Volvulus 9117 76

Leak 5117 42




Peritonitis 3117 25









Sleevegastrectomy


stricture

hemorrhage




hemorrhage



Infection




























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References




















33117 282















49117 419



Plain XR 1117 085

UGI CT 1117 085















lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085





Number ofanswers









Adhesions 49117 418



Volvulus 9117 76

Leak 5117 42




Peritonitis 3117 25









Sleevegastrectomy


stricture

hemorrhage




hemorrhage



Infection




























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References















49117 419



Plain XR 1117 085

UGI CT 1117 085















lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085





Number ofanswers









Adhesions 49117 418



Volvulus 9117 76

Leak 5117 42




Peritonitis 3117 25









Sleevegastrectomy


stricture

hemorrhage




hemorrhage



Infection




























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References














lt 12 h 50117 4273

12ndash24 h 49117 419

gt 24 h 15117 128

lt 24 h 1117 085





Number ofanswers









Adhesions 49117 418



Volvulus 9117 76

Leak 5117 42




Peritonitis 3117 25









Sleevegastrectomy


stricture

hemorrhage




hemorrhage



Infection




























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References























































Abstract

Background

Method

Results

Conclusions

Background

Method

Results

Discussion

Conclusions

Abbreviations

Acknowledgements


Funding




Competing interests

Author details

References


The Operative management in Bariatric ... - BioMed Central

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