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10-2012 Aspiration in a patient with bowel obstruction status postgastric bypass surgery Stanlies D'Souza MD Baystate Health, [email protected]

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Recommended Citation Riehl J, D'Souza S. Aspiration in a patient with bowel obstruction status postgastric bypass surgery. American Society of Anesthesiologists Annual Meeting, Oct 13-17, 2012, Washington, DC.

This Presentations, Research is brought to you for free and open access by Scholarly Commons @ Baystate Health. It has been accepted for inclusion in All Scholarly Works by an authorized administrator of Scholarly Commons @ Baystate Health. Aspiration in a Patient with Bowel Obstruction s/p Gastric Bypass Surgery

Jared Riehl DO, Stanlies D’Souza MD, Karthik Raghunathan MD MPH

Department of Anesthesiology, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA

INTRODUCTION

Patient with a history of gastric bypass surgery with acute small bowel obstruction presented for exploratory laparotomy. The attending surgeon requested that a Nasogastric (NG) tube not be placed prior to the induction of anesthesia, secondary to the prior Roux-en-Y procedure. Pulmonary aspiration occurred during rapid sequence induction with cricoid pressure.

CASE DESCRIPTION

Preoperative abdominal CT showing small 50 year old female with history of bowel obstruction with air-fluid Levels Chest X-ray Postoperative day 1 Roux-en-Y gastric bypass surgery ten years ago, presented with acute small bowel obstruction. Contrast-enhanced DISCUSSION CT scan showed extensive bowel distension with air fluid levels (yellow Aspiration of gastric contents is a risk during the induction of general anesthesia particularly in arrow). The patient was not vomiting. Roux-en –Y Gastric Bypass patients with a history of gastric bypass surgery. There is also an increase in the incidence of bowel

She was taken to the OR for emergent Source: http://www.citelighter.com/card/Gastric-Bypass/1352 obstruction and internal hernias in these patients.1,2 Our patient was at risk both because of prior exploratory laparotomy. The NG tube Roux-en-Y Gastric Bypass surgery and current bowel obstruction. Methods of decreasing the was not placed prior to induction due incidence of aspiration include appropriate preoperative fasting, decompression with a nasogastric to concerns of injury to the tube and cricoid pressure. At this time there is insufficient evidence to determine the effectiveness of 3 anastomosis and the inability to REFERENCES cricoid pressure in the prevention of passive regurgitation. In patients s/p gastric bypass surgery effectively decompress the bowel. The surgical concerns include potential disruption of anastamosis as well as failure to effectively patient aspirated during rapid 1. Jean J, Compere V, Fourdriner V, Marguerite C, Auquit-Auckbur I, Milliez PY, Dureuil B. decompress the bowel. However, no case reports of NG tube disruption of anastamosis in a gastric sequence induction with cricoid The risk of pulmonary aspiration in patients bypass patient were identified in our literature search. In fresh postoperative gastric bypass patients pressure. The airway was secured with after weight loss due to bariatric surgery. an NG tube may be placed safely with direct vision using an endoscope or via-fluoroscopic Anesth Analg 2008;107:1257-9 4 an endotracheal tube. Cricoid 2. Koppman JS, Li C, Gandsas A. Small bowel guidance. pressure was maintained. Aspirate obstruction after laproscopic Roux-en-Y was suctioned from the oropharynx gastric bypass: A review of 9,527 patients. J Am Coll Surg 2008;206:571-84 CONCLUSION and endotracheal tube prior to 3. Lerman J. On cricoid pressure: “May the ventilation, using a fiberoptic force be with you”. Anesth Analg Prevention of aspiration is important during the induction of anesthesia especially in the patient bronchoscope. The patient 2009;109:1363-66 population presented here. The conflicting concerns of injury to anastomosis and failure to 4. Carrasquilla C, Weiss M, Gianos J. Safe 4 subsequently developed aspiration intestinal decompression in fresh decompress the bowel should be contrasted with the benefit of risk reduction. We advocate for pneumonitis and acute respiratory postoperative gastric bypass. Obesity further study of this issue and the identification of a strategy to reduce aspiration in this patient Surgery 2006;6:1256-60 distress syndrome. population.