Post Operative Anastomotic Leak

Reported rate

Mean time to presentation Within 1-2 days post-op

Symptoms Treatment Prognosis

Tachycardia, respiratory distress

NPO, drainage tube, watch carefully

Can progress to systemic sepsis and organ failure

During the immediate perioperative period, obesity-related medical comorbidi-ties change dramatically. Blood pressure often decreases to the normal range without medications, and blood-pressure monitoring is important to document during all postoperative visits. Hypotension is commonly seen, especially if there is poor fluid intake or persistent postoperative vomiting. The need for reinstituting antihypertensive medications needs to be monitored carefully. Routine antireflux medications should be discontinued, unless symptoms persist after surgery.

Every patient with a diagnosis of diabetes should have frequent monitoring of blood glucose, and a sliding scale for subcutaneous insulin injections should be provided. Many diabetic patients decrease the need for insulin after bariatric surgery. In diabetic patients previously managed with oral medications, such as sulfonylureas or thiazolidinediones, there is an increased risk of hypoglycemia after bariatric surgery. The biguanides (metformin) is the safest drug in the postoperative period since it is not associated with dramatic fluctuations in blood glucose. The decreased requirement for insulin and modification of oral medications after bariatric surgery is due to several reasons. The average caloric intake ranges between 400-800 Kcal/day for the first month and is associated with rapid weight loss, and decreased insulin needs. Weight loss can be significant in the first month postoperatively, ranging from 20-40 lbs, resulting in decreased need for insulin. It has also been suggested that the anatomical changes after RYGB results in changes in insulin signaling. Discontinuation of diabetic medications should be entertained when blood glucose normalizes and after the patient is eating.

Patients on antidepressants and other psychiatric medications should have these medications continued in the immediate postoperative period. Dramatic weight loss occurs in the first few months after bariatric surgery, and this can be associated with emotional liability. Emotional stability associated with continuation of antidepres-sants allows smooth transition after surgery, and patients should be urged to continue these medications

Patients in this phase are dealing with many different changes, both physiological and psychological. The small gastric pouch only allows very small portion sizes, and they feel full and satisfied. They are not hungry, and often forget to eat. Attempts at overeating result in vomiting, and they quickly learn to control portion sizes and food reactions. The patient in this phase is dealing with significant changes in comorbidities, physiological feedback, and psychological changes associated with surgery.

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