The consultant you will need more than any other is probably a gastroenterologist. RNY or other gastric bypass weight loss surgery patients may need dilation of their stomas, anastomosis, or stomachs. In additions many bariatric patients develop problems with diarrhea or constipation. These patients can be a challenge. They often have common GI problems that need to be worked up and addressed. RNY-gastric bypass patients cannot have parts of their GI tract evaluated. The gastroenterologist cannot maneuver the endoscope into the lower stomach or the duodenum (unless it is a very short proximal limb and you have a very talented gastroenterologist). This means that ERCP will be impossible to get into bariatric patients who have had RNY procedure. You can scope the entire stomach, as well as the post pyloric duodenum, of patients with a Duodenal Switch—but a gastroenterologist can not get to that part of the duodenum necessary to perform an ERCP. Patients who have the lap-band or the VBG have their entire GI tract available for endoscopy.
If the weight loss surgeon did not remove the gallbladder at the time of the operation, then it is important to watch for signs and symptoms of cholecystitis. Large changes in weight, as happens with any patient who diets, can precipitate gallstones. So many bariatric patients are at risk for cholecystitis. Remember, unless your patient had the lap-band or the VBG, the gastroenterologist cannot do an ERCP, which means if they develop gallstones with symptoms, make certain the gallbladder is removed before the stones migrate down the duct. Any weight loss surgeon can do gallbladder removal laparoscopically, even if your patient had an “open” gastric bypass procedure.
Many obese people have sleep apnea, and as they lose pounds, their sleep apnea needs to be reevaluated. No bariatric operation patient is happier than one who gets rid of a CPAP machine. A pulmonologist must be involved with the patient to facilitate this.
Nausea and vomiting after weight loss surgery
Early nausea and vomiting are common with postoperative bariatric patients. Often it is because they overeat (really, their eyes are bigger than their stomachs—in fact, their mouths hold more than their stomachs—talk about inverse biology). Visualizing a shot glass, or three shot glasses (depending on the size of the pouch or stomach), sometimes helps bariatric operation patients learn to measure food twice, eat once, and vomit never.
Some foods are tolerated one day and not tolerated the next. One day tuna can be the greatest thing, the next day it comes back up. This is a period of adjustment for the stomach and the patient. If vomiting continues, they need to stop eating entirely and take a teaspoon of liquid (water is preferred) every five minutes while awake. That will keep them hydrated without stretching their stomach and inducing vomiting. They can slowly progress from here. Vomiting is the enemy in early bariatric operations. It can cause a slip of the lap-band, can disrupt staples, and can even cause a rupture of the esophagus (Boerhaave’s syndrome). Fortunately, those complications are rare, but avoiding vomiting is important.
Bariatric patients who have diabetes often have a gastroparesis, and will need to be on Reglan before meals and at bedtime.
Stomal stenosis cannot be diagnosed with an upper GI, but can be diagnosed with endoscopy and treated at the same time. Often if they have this stenosis, they will need several dilations. A stenosis can also occur in the mid-body of the stomach in those who have had the duodenal switch. So, keep your gastroenterologist’s number handy.
If a bariatric patient continues vomiting, he needs to be hospitalized and made n.p.o., given some round the clock medication (Zofran), and placed on intravenous fluids. Remember to give your patients Thiamin, as well as multi-vitamins, in the intravenous fluids to avoid Vitamin B deficiency. While the patient is hospitalized, you can strictly regulate his intake (giving 60 cc per hour per OS maximum) and if the nausea disappears with such regulation, then reinforce the rule about not out-eating the pouch.
Bowel obstruction is always a concern in any postoperative weight loss surgery patient
Pain, nausea and vomiting may mean an emergency operation. These patients should be admitted and have appropriate x-rays taken (CT of the abdomen and pelvis, as well as 3-views of the abdomen). Remember, if the patient had some bowel bypassed, there will be unopacified bowel on the CT scan, and that might be mistaken for an abscess—so communicate that with the radiologist.