Post Bariatric / Metabolic Surgery Emergencies

After Gastric Bypass Surgery

1. Leak at the Surgical Join (Anastomotic Leak)

During bypass surgery, your surgeon creates new connections between parts of your digestive system. Occasionally, one of these joins (most often the one between the stomach pouch and small intestine) doesn’t seal properly, allowing fluid to leak out.

Signs to watch for:

• Severe abdominal pain and a general feeling of being seriously unwell (this can signal fluid leaking freely inside the abdomen)
• Or, more subtly: ongoing pain, fever, a fast heart rate, nausea or vomiting (this usually means the leak is small and “walled off” by the body)

How it’s diagnosed:

• CT scan
• A swallow test using contrast dye (an X-ray that tracks dye as you swallow it)

How it’s treated:

• If the leak is causing widespread infection in the abdomen, emergency surgery is needed straight away.
• If the leak is small and contained, and you are otherwise stable, it can often be managed without major surgery — using a small drain placed through the skin, along with endoscopic treatments (such as stents, clips, stitches, or medical glue placed during a camera examination).

2. Narrowing at the Surgical Join (Stricture)

Scar tissue can sometimes cause the connection between your stomach and small intestine to narrow. This usually appears 4 to 6 weeks after surgery.

Signs to watch for:

• Increasing difficulty eating solid foods, while liquids still go down fine
• Pain when eating

How it’s diagnosed:

• An endoscopy (a thin camera passed down through the mouth to examine the digestive tract)

How it’s treated:

• Stretching the narrowed area using a small balloon or dilator during an endoscopy — this works for most people
• If the narrowing keeps coming back or doesn’t respond, surgery to revise the connection may be needed

3. Ulcer at the Surgical Join (Marginal Ulcer)

This is a sore that can develop where the stomach pouch joins the small intestine. It’s the most common complication seen after gastric bypass, affecting roughly 2 to 15 in every 100 patients.

What increases the risk:

• Smoking
• Regular or high-dose use of anti-inflammatory painkillers such as ibuprofen, naproxen, or diclofenac
• A larger stomach pouch that produces more acid

Signs to watch for:

• Pain in the upper abdomen, especially after eating
• Bleeding from the surgical join
• In rare cases, sudden severe pain from the ulcer perforating (breaking through the stomach wall)

How it’s treated:

• Most cases improve well with acid-reducing medication and by stopping smoking and NSAID painkillers
• If the ulcer has perforated and this isn’t settling, surgery is needed urgently
• If a perforation is small, contained, and you’re stable, it can sometimes be managed without immediate surgery — with a drain, IV fluids, tube feeding, and a follow-up endoscopy to check healing

4. Ongoing Bile Reflux

This is mainly seen after a one-anastomosis (mini) gastric bypass, where bile from the digestive system flows backward into the stomach pouch.

Signs to watch for:

• Burning pain in the upper abdomen
• Persistent nausea
• Vomiting bile (a yellow-green fluid)
• Pain after eating

How it’s diagnosed:

• Endoscopy

How it’s treated:

• Medications that reduce stomach acid (such as omeprazole or lansoprazole) and protect the stomach lining (such as sucralfate), sometimes combined with a medicine called cholestyramine to bind up the bile
• If symptoms don’t settle, converting the surgery to a standard Roux-en-Y gastric bypass may be recommended

5. Severe Malnutrition (Protein-Calorie Malnutrition)

This is more likely after a one-anastomosis (mini) gastric bypass, because of the longer segment of bowel that’s bypassed.

Signs to watch for:

• Muscle loss and weakness
• Persistent tiredness
• Swelling, particularly in the legs
• Low levels of key nutrients such as iron, vitamin B12, and vitamins A, D, E, and K

How it’s diagnosed:

• Blood tests to check your nutrition levels, including protein markers called albumin and pre-albumin

How it’s treated:

• High-protein supplements and intensive nutritional support
• In severe cases, surgery to shorten the bypassed segment of bowel, or convert to a Roux-en-Y gastric bypass

After Sleeve Gastrectomy

1. Leak Along the Staple Line

The sleeve is created using a line of staples along the stomach. A leak can occur anywhere along this line, though it happens most often near the top.

Signs to watch for:

• Severe abdominal pain and feeling seriously unwell (suggesting a leak that isn’t contained)
• Or, more subtly: ongoing pain, fever, a fast heart rate, nausea or vomiting (suggesting a smaller, contained leak)

How it’s diagnosed:

• CT scan
• Contrast swallow study

How it’s treated:

• An uncontained leak needs emergency surgery
• A contained leak in a stable patient can often be treated successfully with a drain placed through the skin, plus endoscopic treatments such as stents, clips, stitches, or medical glue

2. Narrowing of the Sleeve (Stricture)

This usually develops 4 to 6 weeks or later after surgery, as scar tissue forms and tightens.

What causes it:

• Reduced blood flow to the staple line, leading to scarring
• Twisting or kinking of the sleeve

The sleeve being made too narrow during the original operation

Signs to watch for:

• Increasing trouble eating solid food, more than liquids
• Nausea and vomiting, especially after meals
• Pain in the upper abdomen
• Sometimes reflux or a feeling of food “getting stuck”

How it’s diagnosed:

• Upper endoscopy — confirms the narrowing and may allow treatment at the same time
• Contrast swallow study — shows where food is being held up or narrowed

How it’s treated:

1. Balloon stretching during endoscopy (usually tried first) — often needs a few sessions, and most people improve without surgery
2. Temporary stent placement — used in certain cases to help reshape the sleeve
3. Surgery — considered if endoscopic treatment doesn’t work, or if there’s severe twisting that can’t be corrected any other way; options include a procedure to release the muscle layer (seromyotomy) or converting to a gastric bypass