Q&A: Risk for small bowel obstruction is ‘not exclusively specific to bariatric surgery’
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On July 13, the LA County medical examiner’s office reported that Lisa Marie Presley, singer-songwriter and child of Elvis Presley, died of a small bowel obstruction caused by scar tissue that developed after a previous bariatric surgery.
Most small bowel obstructions are a result of prior surgeries, JAMA reported in 2018, noting “the more surgeries that involve the bowel, the more scars are likely to form.” This can lead to a bowel blockage that cuts off blood supply from the small intestine if left untreated.
“In terms of the risk for small bowel obstruction, like any other type of abdominal surgery, there is a risk for scar tissue formation after bariatric surgery,” Ali Aminian, MD, director of the Bariatric and Metabolic Institute at Cleveland Clinic, told Healio. “When there is scar tissue in the abdomen, that scar tissue makes thick bands that can kink or twist the bowel causing external compression and that can cause small bowel obstruction or blockage.”
Aminian also noted that the risk for small bowel obstruction is “not exclusively specific to bariatric surgery” and can occur after any other abdominal surgery, such as appendectomy or hysterectomy. In the International Journal of Surgery Case Reports, Vincenzo Pilone, MD, PhD, and colleagues reported that small bowel obstruction after laparoscopic Roux-en-Y gastric bypass occurs at a frequency of 0.2% to 4.5% years or months after surgery.
In a Healio interview exclusive, Aminian broke down the severity of small bowel obstruction, symptoms patients and providers should watch for, and risks vs. benefits of bariatric surgery.
What causes small bowel obstruction?
Aminian: There are different causes for bowel blockage, the most common cause is history of previous surgery which can cause scar tissue. Other common causes of mechanical bowel obstruction include tumors or hernias. When there are hernia defects in the abdominal wall, bowel can get into that defect and cause the bowel blockage.
What symptoms do patients usually experience?
Aminian: Patients develop some abdominal pain and discomfort that gradually gets worse, along with nausea and vomiting. Then, because of the blockage, they develop abdominal distention, they don’t have bowel movement and cannot pass gas. These symptoms get worse over time.
Often, small bowel blockage due to scar tissue resolves on its own with bowel rest and decompression of the stomach by placement of a nasal tube. However, sometimes it requires surgical intervention to clean the scar tissue and take care of kinks, twists or hernias.
In the case of partial small bowel obstruction, the progression of symptoms is slower compared with those who have high-grade or complete obstruction, in which pain increases in the first 6 to 12 hours. For partial obstruction, it may take 2 to 5 days for patients to seek medical care.
For bariatric surgery in particular, how common is small bowel obstruction and how soon after surgery can it develop?
Aminian: Like any other type of abdominal surgery, it can happen the next day or it can happen 50 years after surgery. It’s unpredictable and can happen at any time.
Of note, patients who have had multiple open surgeries in the past are at greater risk for developing scar tissue. These days we typically do bariatric surgery laparoscopically or with robotic assistance through five or six small holes; the risk for developing scar tissue is much less with the new advancements in technique.
Also, the risk for developing small bowel obstruction is not the same following different bariatric operations; the risk for bowel obstruction is extremely small following sleeve gastrectomy, which is the most common bariatric surgery in the current practice.
What are the consequences of untreated complete bowel blockage?
Aminian: Like any other severe medical problems, if a patient does not seek care, then the complication can increase in severity.
Imagine a pipe: If there is a blockage, pressure proximal to that blockage can increase and cause bowel perforation, where the contents of the bowel can then contaminate the whole abdominal cavity causing infection and a widespread inflammatory response.
The other problem is that a patient may develop bowel ischemia, in which pressure proximal to that obstruction point in the lumen of the bowel and in the wall of the small bowel can increase and impair the blood supply to the bowel. That segment of the bowel may die and release inflammatory markers that can cause multiple organ failure and, eventually, death.
For both partial and full bowel obstruction, there is a time window before those life-threatening outcomes can occur. Any patients who have symptoms, such as abdominal pain, nausea, vomiting, abdominal distention and inability to pass feces or gas, should seek medical care immediately and undergo an X-ray or abdominal CT scan to diagnose and determine the cause of obstruction. Nonsurgical and surgical treatments of small bowel obstructions are very effective.
What other side effects of bariatric surgery should patients and providers be aware of?
Aminian: Overall, bariatric surgery is extremely safe and the risk for complication is generally about 3% to 5%, which is like the risk of appendectomy or gallbladder removal surgery.
In the first 6 to 8 weeks after surgery, the main concerns include infection, complications from anesthesia, bleeding, blood clots and early postoperative small bowel obstruction. Beyond the early postoperative period, 2% to 3% of patients may develop complications in the medium- to long-term months or years after surgery.
Those complications include bowel obstruction, as we discussed, or nutritional problems such as iron deficiency or iron-deficiency anemia, low calcium levels and low vitamin D levels, which can manifest in bone fracture. This is why bariatric surgery is appropriate for patients who are compliant in taking lifelong supplements.
No therapy, including any medication or surgery, is without risk; It is important for medical providers to always weigh the risks vs. benefits when discussing surgery. Despite the small risk for short- and long-term outcomes, bariatric surgery has great potential to increase life expectancy and quality of life in selected patients with obesity.
References:
- Baiu I, et al. JAMA. 2018;doi:10.1001/jama.2018.5834.
- Cause and manner of death determined for Lisa Marie Beaulieu Presley. https://mec.lacounty.gov/2023/press-releases/cause-and-manner-of-death-determined-for-lisa-marie-beaulieu-presley/. Published July 13, 2023. Accessed July 25, 2023.
- Pilone V, et al. Int J Surg Case Rep. 2019;doi:10.1016/j.ijscr.2019.02.036.
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