Ask the Experts: Severe Abdominal Pain 24 Hours after Conversion of Sleeve Gastrectomy to Gastric Bypass

| December 23, 2010

Ask the Experts: Dilemmas in Bariatric Surgery

This ongoing column is dedicated to providing information to our readers on various dilemmas in bariatric surgery. We invite questions from our readers. The answers are provided by experts in the field.

This Month’s Dilemma: Severe Abdominal Pain 24 Hours after Conversion of Sleeve Gastrectomy to Gastric Bypass

This Month’s Featured Expert: Samuel Szomstein, MD, FACS
Dr. Szomstein is Clinical Associate Professor of Surgery, Florida International University; Associate Director, Bariatric and Metabolic Institute and Section of Minimally Invasive Surgery and Director, Bariatric Endoscopy, Cleveland Clinic Florida, Department of General and Vascular Surgery

Bariatric Times
. 2010;7(12)14

The Dilemma
A 46-year-old woman, 24 hours after conversion of a sleeve gastrectomy to a gastric bypass, complained of abdominal pain and stated that she was “dying.” An upper gastrointestinal (UGI) series showed no leak or obstruction. Vital signs were stable and in normal range besides a single episode of sinus tachycardia that resolved after pain medication. Laboratory analysis at 7am and 4pm were unchanged in normal range. A drain left in the subhepatic space drained serosanguineous material. Urine output was 50cc q/hour. At 6pm, the patient continued to complain about severe abdominal pain. What would you do?

Expert Commentary
by Samuel Szomstein, MD, FACS
Thank you for the invitation to serve as a guest expert and for the opportunity to answer this month’s dilemma. This case describes a 46-year-old woman who underwent a revision/conversion from sleeve gastrectomy to a gastric bypass 24 hours previously. The only significant symptoms the patient experienced were persistent abdominal pain and a “sense of impending doom.”
This case brings to mind my days of medical school, during which I first heard the phrase “sense of impending doom” to describe angina. At the beginning of the first century, Seneca, the stoic philosopher, described one of the earliest and most definite reports of an angina attack by saying, “This experience was dying, and yet, even in the act of suffocating, I did not cease to derive satisfaction from pleasing and courageous thoughts.” Dr. William Heberden, who was the first medical professional to describe angina, also used the phrase “a sense of doom” in his description. He said, “They who are afflicted with it are seized while they are walking, with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but the moment they stand still, all this uneasiness vanishes.”[1]

Many years later, I came across an article by Awais et al,[2] in the journal Surgery of Obesity and Related Diseases. The authors used the term “a sense of impending doom” as part of the symptomatology related to bariatric surgery, rather than angina. They recounted five cases in which patients developed proximal small bowel obstruction at the jejunojejunostomy, secondary to intraluminal clot; four of these five patients (80%) presented with tachycardia and “a sense of impending doom.”

“A sense of impending doom” does exist in the medical lexicon. This symptom, if you will, is distinguishable from a panic attack. As a surgeon, one sometimes gets the “vibe” or the feeling that the patient’s situation is very bad and possibly worsening, and often without absolute certainty as to the cause. In this case, one does everything possible to figure out the cause and how to handle the situation.

In the case presented, a high index of suspicion should be paramount. After more than 12 hours of observation in which severe and worsening abdominal pain is constantly present, combined with transient tachycardia and “a sense of dying,” the safest course of action is to take the patient back to the operating room for a diagnostic laparoscopy. A computed tomography scan (CT) scan can be a viable course of action; however, a negative report should not deter us from a diagnostic laparoscopy based on the symptoms and may lose us precious time.

Based on the details given in this month’s dilemma, my initial differential diagnosis would be a leak.  As I have already mentioned, radiological studies are in order. In this case, a UGI series was negative, and possibly one could perform a CT scan. However, in one of the largest multicenter studies that included patients who had a leak after a gastric bypass, Gonzalez et al[3] reported that a UGI series or a CT scan demonstrated leaks in only 30 and 56 percent of patients, respectively, and when done jointly, both studies were negative in 30 percent of patients. Given that this is a revision, the incidence of leaks and complications is expected to be even higher. Acute bowel obstruction from multiple causes, such as trocar-site hernia, bowel kinking, narrow jejunojejunostomy anastomosis, internal hernia, or a proximal small bowel obstruction from an intraluminal clot, are other possibilities as this patient resembles the patients described in the study by Awad et al. Another differential diagnosis may include pancreatitis, which could be caused by trauma during the initial surgery; elevated amylase/lipase should be diagnostic for this condition

The take-home point in this case is, I believe, something that a good friend and surgeon, Dr. Harvey Sugerman once told me, “I’ve always followed the premise that when a patient tells me he or she thought they were going to die, I listen and take them back to the operating room because invariably, they have been right! My motto—always listen to the patient.” Perhaps this should be OUR collective motto as bariatric surgeons.

Follow up from the treating surgeon on the case presented
The patient was taken to the operating room and approached via laparoscopy. An obstructing hemathoma at the level of the jejunojejunostomy was found. The surgeon performed an enterotomy and evacuation of the hemathoma. A decompressive remnant gastrostomy was placed.
The patient had an uneventful recovery.

References
1.    Heberden W. Some account of a disorder of the breast. Medical Transactions 1772 London: Royal College of Physicians; 2:59–67.
2.    Awais O, Raftopoulos I, Luketich J, et al. Acute, complete proximal small bowel obstruction after laparoscopic gastric bypass due to intraluminal blood clot formation. Surg Obes Relat Dis. 2005;1:418–423.
3.    Gonzalez R, Sarr MG, Smith CD, Baghai M, et al. Diagnosis and contemporary management of anastomotic leaks after gastric bypass for obesity. J Am Coll Surg. 2007;204:47–55.

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