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110 Lung Nodule/Lung Cancer
375
• Not mentioning pulmonary function tests pre-op
• Not performing mediastinoscopy pre-op when indicated
• Not knowing TNM classication or staging
• Incorrectly describing surgical techniques
• Operating on small-cell carcinoma
• Offering palliative resections
Summary
Lung cancer is one of the leading causes of death. A surgeon should be familiar with the workup of a pulmonary
nodule and be knowledgeable about the diagnosis and
staging of lung cancer. Knowing the preoperative barriers and various techniques of surgical resection will be
key for this section of the oral boards.
Bibliography
Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic
evaluation of the patient with lung cancer being considered for
resectional surgery: diagnosis and management of lung cancer, 3rd
ed: American College of Chest Physicians evidence-based clinical
practice guidelines. Chest. 2013;143(5 Suppl):e166S–90S. https://
doi.org/10.1378/chest.12- 2395.
MacMahon H, Naidich DP, Goo JM, Lee KS, Leung ANC, Mayo JR,
Mehta AC, Ohno Y, Powell CA, Prokop M, Rubin GD, SchaeferProkop CM, Travis WD, Van Schil PE, Bankier AA.Guidelines
for management of incidental pulmonary nodules detected
on CT images: from the Fleischner Society 2017. Radiology.
2017;284(1):228–43. https://doi.org/10.1148/radiol.2017161659.
National Comprehensive Cancer Network. Non-small cell lung cancer
(version 3.2024). 2024. https://www.nccn.org/professionals/physi-
cian_gls/pdf/nscl.pdf.
Part XIV
Bariatric Surgery
Bleeding After Gastric Bypass
SouravPodder
111
Way Question May BeAsked?
You are called to see a 36-year-old female on postoperative
day 2 after an uncomplicated Roux-en-Y gastric bypass
(RYGB) with weakness and tachycardia. On examination,
the patient is pale and diaphoretic. What do you want to do?
A 53-year-old male with a remote history of a RYGB presents to the emergency room with melanotic stools and tachycardia. He endorses recent use of nonsteroidal
anti-inammatory drugs (NSAIDs) for back pain. What are
your rst steps?
You may be presented with a similar scenario in a patient
that does not have any signs of bleeding, but presents with
tachycardia. For these patients, remember to keep anastomotic or staple line leak on your differential.
How toAnswer?
As with all general surgery patients, make sure to obtain a
thorough history and physical examination and determine if
the patient is stable or unstable as this will determine the
level of care and your treatment plan.
The key step will be to differentiate between intraluminal
and intra-abdominal bleeding as this will help determine
your decision-making.
History
• Common symptoms: hematemesis, melena, hematoche-
zia, abdominal discomfort or pain, weakness, dizziness.
• Ask about the following risk factors: end-stage renal dis-
ease, other abdominal surgeries, therapeutic anticoagula-
tion, recent use of NSAIDs, and history of smoking.
• Ask about proton pump inhibitor (PPI) use.
S. Podder (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Sourav.Podder@jefferson.edu
Physical Examination
• Tachycardia (most common clinical sign of early bleeding), hypotension, abdominal discomfort, hematemesis,
melena, and/or hematochezia—likely an intraluminal
bleed.
• Patients with a surgical drain with bright red blood likely
have an intra-abdominal bleed.
Diagnostic Tests
• Full laboratory panel including type and screen and coagulation tests. Obtain serial hemoglobin/hematocrit.
• An esophagogastroduodenoscopy (EGD) can be used as
both a diagnostic modality and a treatment option. It can
be used to treat bleeding in the gastric pouch.
– A negative EGD may mean that the bleeding is from
the jejunojejunostomy, the gastric remnant, the
excluded small bowel, or an intra-abdominal source.
– With the support of a laparoscopic gastrostomy, an
endoscopist can access the excluded small bowel and
stomach.
• Double-balloon enteroscopy can be used to assess the
excluded small bowel and stomach, though it is a difcult
procedure to perform for gastroenterologists and is often
unsuccessful with the atypical anatomy.
• Computed tomography (CT) scan can be performed if the
patient is hemodynamically stable. CT scan is better at
diagnosing an intra-abdominal bleed by demonstrating a
hematoma or collection compared to an intraluminal
bleed.
Common Sites ofBleeding
• Intraluminal:
– Gastrojejunal (GJ) anastomosis, marginal ulcer, jeju-
nojejunal (JJ) anastomosis, gastric remnant, excluded
duodenal ulcer.
• Intra-abdominal:
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_111
379
380
S. Podder
– Mesenteric vessels, the various staple lines, iatrogenic
injury to the viscera or other structures including the
spleen, falciform ligament, and liver, or trocar sites.
– Remember that if there is a suspected bleed and the
patient is >30days since surgery, the bleed is unlikely
to be from an intra-abdominal source.
Treatment
• General supportive measures
– Changing diet to NPO
– Withholding prophylactic antithrombotic agents
– Resuscitating with uids
– Starting a proton pump inhibitor (PPI)
– Obtaining serial hemoglobin/hematocrits to determine
if blood transfusions are required
• If this is an early bleed and the patient is clinically stable,
further tests such as an EGD or a CT scan can be
performed.
• Majority of the time, the bleeding is self-limiting and can
be treated conservatively with volume resuscitation and
transfusions as needed.
• However, if the patient is unstable and not responding to
resuscitation, then immediate surgical intervention is
required. A diagnostic laparoscopy is appropriate for this.
• If this is a late bleed, it is most likely an intraluminal
bleed.
• An EGD should be performed rst. In many cases the
bleed is due to a marginal ulcer. If the bleed is due to ulcer
disease, medical treatment with a PPI is appropriate.
– If the bleeding persists with medical treatment, an
EGD is the treatment of choice.
– If a marginal ulcer or the cause of the bleeding is not
found, then a bleeding scan or CT angiography can be
performed.
– Other options include performing a double-balloon
enteroscopy or a laparoscopic-assisted transgastric
endoscopy to view the excluded small bowel and remnant stomach.
– Uncontrolled bleeding will require a surgical
intervention.
• Intra-abdominal bleeding rarely requires a reoperation.
However, if bleeding continues with conservative management, a diagnostic laparoscopy can be performed.
conrmation of hemostasis) and minimally invasive surgical approach can be utilized, particularly for early postoperative bleeding at the gastrojejunal anastomosis or
gastric pouch.
• Open surgical approach may be required for patients with
extensive prior abdominal operations, difcult to localize
hemorrhage sources, or hemodynamic instability.
Bonus Points
• Risk factors associated with marginal ulcer formation:
– Local ischemia due to poor blood supply
– Anastomotic tension
– The use of nonabsorbable sutures
– Increased gastric acidity
– Helicobacter pylori infection
– Tobacco use
– NSAID therapy
• Less common bleeding sources
– A patient with a history of a gastric bypass presents
with melena, normal EGD, and a CT scan showing a
dilated gastric remnant.
Bleeding could be from the jejunojejunal (JJ) anastomosis, gastric remnant, or excluded duodenum.
Intraluminal clot bezoar: Patients can develop an
obstruction due to accumulation of blood clots with
subsequent dilation of the biliopancreatic (BP) limb
and the gastric remnant with concerns for blowout.
• If there are concerns for intestinal obstruction, then urgent
reoperation is required
– Treatment involves creating an enterotomy distally to
the JJ to evacuate the blood clots, possible reopening
of the JJ to achieve hemostasis, and/or over-sewing the
remnant stomach suture line.
Clean Kills
• Any delay in resuscitative measures.
• Not ruling out or correcting coagulopathy.
• Sending a hemodynamically unstable patient for extensive imaging requests.
• Inadequate exploration of all the potential surgical sites
that may cause bleeding.
Surgical Management
• Minimally invasive exploration is the initial approach of
choice if prior operation was done with minimally invasive techniques.
• For intraluminal hemorrhage not controllable by endoscopic means, combined endoscopic (for localization and
Words ofWisdom
Bleeding after a Roux-en-Y gastric bypass (RYGB) is a
complication of bariatric surgery that requires understanding
of the anatomy. Knowing the possible locations of bleeding
and timing of the operation will help you treat the patient.
Make sure to utilize your available diagnostic test appropri-
111 Bleeding After Gastric Bypass
381
ately, and make sure to know the indications that will require
you to take the patient to the operating room.
Bibliography
Agrawal S, Rose SM, Ahmed AR. Laparoscopic Roux-en-Y gastric
bypass: complications—diagnosis and management. In: Obesity,
bariatric and metabolic surgery: a comprehensive guide. 2nd ed.
Cham: Springer; 2023. p.349–53.
Heneghan HM, Meron-Eldar S, Yenumula P, Rogula T, Brethauer SA,
Schauer PR.Incidence and management of bleeding complications
after gastric bypass surgery in the morbidly obese. Surg Obes Relat
Dis. 2011;8:729–35.
Nguyen NT, Fridman A, Szomstein S, Rosenthal RJ. Postoperative
bleeding in the bariatric surgery patient. In: ASMBS textbook of
bariatric surgery. 2nd ed. NewYork: Springer; 2020. p.241–8.
Odovic M, Clerc D, Demartines N, Suter M.Early bleeding after lapa-
roscopic Roux-en-Y gastric bypass: incidence, risk factors, and
management—a 21-year experience. Obes Surg. 2022;32:3232–8.
Complications ofLaparoscopic
Adjustable Gastric Banding
WalkerLyons
112
What Questions May BeAsked?
Erosion
The cause of erosion in laparoscopic adjustable gastric banding (LAGB) is unknown. Common symptoms include loss of
satiety and weight regain despite increased band ll volumes
and vague abdominal pain. Spontaneous infection of the
access port years after surgery should prompt concern for
erosion.
A 53-year-old female with a history of a LAGB placed
4 years ago presents to the clinic with 8months of vague
abdominal pain. Additionally, she has had recurrence of all
the weight she lost after the LAGB was placed despite
steadily increasing the band ll volume. How do you manage
this?
• In all instances, start with a thorough history and
physical.
– Loss of restriction can be seen in band failure or
erosion.
• Radiographic imaging has poor sensitivity in diagnosing
band erosion. The diagnostic study of choice is
endoscopy.
An endoscopy is performed that shows erosion of 90% of
the band into the stomach lumen. What is your next step?
Alternative Scenario
A 53-year-old female with a history of a LAGB placed
4years ago presents to the clinic with erythema and tenderness of the skin over her access port. Additionally, she has
had recurrence of all of the weight she lost after the LAGB
despite steadily increasing the band ll volume. An endoscopy is performed that shows erosion of 30% of the band into
the stomach lumen. How do you manage this?
• This situation calls for surgical removal of the eroded
LAGB. This can be performed open, laparoscopic, or
robotic. After removal of the band, a gastric leak test
should be performed, and any gastric defects should be
closed with sutures. In the case of a small leak, an omental patch can be applied and a closed suction drain may be
left.
• Consider keeping patients NPO in the early postoperative
period. In some cases, upper gastrointestinal series can be
obtained to ensure no leak prior to initiating oral feeding.
What if the patient requires another bariatric procedure
for ongoing obesity and comorbidities?
• In the setting of erosion, conversion to another bariatric
procedure should be delayed at least 3months to allow for
resolution of perigastric inammation and healing of any
gastric defect.
• In this situation, the band can be removed endoscopically,
though the access port must still be removed surgically. At
least 50% of the band must be in the stomach lumen to be
removed endoscopically.
W. Lyons (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Walker.Lyons@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_112
Slippage/Prolapse
Gastric band slippage or prolapse is when any portion of the
stomach herniates under the band, resulting in an incorrectly
positioned band. This often leads to pouch dilation which
can cause decreased weight loss or weight recurrence, severe
GERD, and even obstruction or ischemia.
A 46-year-old male presents to the clinic with several
months of food intolerance, nausea, dysphagia, and GERD
symptoms. He has a history of a LAGB placed 2years ago
383
384
W. Lyons
and has achieved and maintained successful 30% excess
weight loss (%EWL). How would you manage this patient?
• Imaging modalities are necessary in the evaluation of this
patient, with computed tomography and esophagogastroduodenoscopy (EGD) being options, but a uoroscopic
upper gastrointestinal series conrms the diagnosis of a
prolapsed or slipped band.
• Any patient with symptomatic prolapse should have their
band deated to relieve their symptoms. In symptomatic
patients presenting to the ofce or emergency department,
this can be an initial step even before obtaining imaging
studies.
• Conservative management involves placing the patient on
a strict liquid diet and following them with reimaging and
slow band ination if the prolapse resolves.
• Surgical options include band replacement and band
removal with or without conversion to a different bariatric
procedure.
• Consider EGD right before the operation on the day of
surgery to ensure the patient has not developed interval
erosion.
– Band replacement should only be considered in
patients who have successful weight loss.
– Band removal without an additional procedure is an
acceptable answer.
– Band removal with conversion to a different bariatric
procedure can be completed in a single-stage procedure, but if there is signicant perigastric inammation, it can be done in a two-stage procedure.
Weight Regain/Ineective Weight Loss
One of the main reasons for the decrease in LAGB performed
over the last decade is poor long-term weight loss outcomes.
LAGB has both lower %EWL and higher rates of weight
recurrence than sleeve gastrectomy and Roux-en-Y gastric
bypass (RYGB).
A 47-year-old female presents to a clinic for evaluation of
weight recurrence. The patient has a history of a LAGB
placed 7 years ago. She denies any abdominal complaints
but notes a continued weight increase and currently weighs
20 pounds more than her pre-LAGB weight. How would you
manage this patient?
• A thorough history and physical examination should be
performed; make sure to get a detailed history of her
weight loss after LAGB placement and current dietary
habits.
• It is important to assess if the LAGB is functioning properly. Fluid should be aspirated from the band and the system interrogated to ensure no leak is present.
• If the LAGB is functioning properly, lifestyle and diet
modications should be reviewed to see if changes can
achieve better results.
• If signicant obesity still remains after performing the
above, conversion to a sleeve gastrectomy or RYGB
should be discussed.
Alternative Scenario
A similar patient presents to the clinic but with the additional
complaint of persistent GERD.How does this change your
management?
• If the patient is not already on an acid-suppressing medication, they should be started on one. If a conversion procedure is being considered, a RYGB is the surgery of
choice as sleeve gastrectomy has been found to exacerbate GERD.
Common Curveballs
• Erosion not noted on preoperative studies, but present on
the day of operation. Be prepared to alter operative treatment and postoperative recovery plans based on the intraoperative identication of a band erosion.
• Patient presenting to the ER with obstruction related to
band does not get relief of obstruction and pain with band
emptying. Be prepared to take the patient immediately to
the OR for treatment.
• Examiner describes fundoplication around the band and
notes that one has difculty identifying tissue plane
between the fundus and the superior stomach. In this
instance, the approximate location of the fundoplication
suture line can usually be identied and divided with a
stapler to ensure no untreated gastrostomy is created.
Clean Kills
• Failure to remove the access port when removing a
LAGB.
• Converting a patient with GERD to a sleeve gastrectomy.
• Immediately converting a patient with band erosion to an
alternate, stapled procedure.
• Failure to take a slipped band patient with severe abdominal pain, tachycardia, or sepsis for emergent operation.
Bonus Points
• The phi angle is measured between the longitudinal axis
of the band and the spinal column. With normal gastric
band positioning, the phi angle is typically between 4°
112 Complications ofLaparoscopic Adjustable Gastric Banding
385
and 58°. An abnormal phi angle greater than 58° will be
seen with malposition or slippage of the band (typically
greater than 90°).
Words ofWisdom
• Any bariatric conversion surgery should be performed by
experts and patients need to be aware that these procedures come with higher rates of complications.
• When considering a conversion procedure, think about
factors that would inuence your surgical procedure. For
instance, patients with hiatal hernias should have them
repaired or patients with GERD, pre-existing or de novo
after LAGB, should not have sleeve gastrectomies
performed.
• When in doubt, consider simply performing band removal
and give the patient a period of several months to recover.
This may inform choice of stapled weight loss operation
depending on resolution of symptoms such as dysphagia
or reux.
Bibliography
Herron DM, editor. Bariatric surgery complica-
tions and emergencies. Springer; 2016. https://doi.
org/10.1007/978- 3- 319- 27114- 9.
Lyons W, Omar M, Tholey R, Tatarian T.Revisional bariatric surgery:
a review of workup and management of common complications
after bariatric surgery. Mini-invasive Surg. 2022;6:11. https://doi.
org/10.20517/2574- 1225.2021.140.
Bariatric Surgery Complications
MarcNe andTsimafeiMarchuk
113
Concept
Given the escalating prevalence of bariatric surgery to nearly
250,000 patients a year, encountering bariatric surgery complications is inevitable in the practice of general surgery.
While revisiting the primary surgical site with the original
surgeon is optimal, it’s often impractical. Notably, leak and
obstruction pose signicant concerns, albeit a spectrum of
other complications is conceivable.
Potential Scenario
A 66-year-old female with a BMI of 49 presented to the
emergency department post-bariatric surgery 7 days ago,
complaining of abdominal pain, nausea, and vomiting. Now
you are called to evaluate them in the emergency department
for abdominal pain, nausea, and vomiting.
How toAnswer?
History
• What surgery did they have performed? Where? By who?
• How did the pain start? (Sudden and severe pain radiating
to the back is often suggestive of internal hernia.)
• Any concerns during the surgery?
• When did they start feeling ill? (Patients will report that
they were doing well and then felt something went
wrong— they developed constant, worsening pain, not
responding to pain meds, and with associated shortness of
breath, chest pain, fever and vomiting. Such a presentation should alert the surgeon to a real problem.)
• Medications (a beta-blocker may blunt the reex tachycardia seen in the septic patient).
Physical Examination
• Vital signs are vital! Unexplained tachycardia (be sure
patient is on a beta-blocker) is ominous.
• Evaluate the incision sites. Wound infections can be quite
deep in bariatric patients.
• Remember that physical exams are often limited to
patients with a 2- or 3-in.-thick abdominal wall. Peritonitis
is often a late nding.
• Pain out of proportion to physical examination could be a
sign of bowel ischemia.
Workup
• Abdominal X-rays are often not very helpful in morbidly
obese patients, unless you see free air.
• CT scan with 4 oz (about 120 mL) PO contrast to
identify:
– Twist in the mesentery for internal hernia
– Air or contrast extravasation near staple line for leak
– Thickened bowel wall for ischemia
– Dilated remnant stomach for obstruction at
jejunojejunostomy
• Upper GI with water-soluble contrast may be a great diagnostic tool, but its utility may be restricted, particularly
during nocturnal hours, and can be limited by a radiologist who is not clinically familiar with post-bariatric surgery anatomy.
Treatment
M. Neff (*)
Department of Surgery, Jefferson Health of New Jersey,
Cherry Hill, NJ, USA
e-mail: Marc.neff@jefferson.edu
T. Marchuk
Department of Surgery, Jefferson Einstein Hospital,
Philadelphia, PA, USA
e-mail: Tsimafei.marchuk@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_113
Bypass Leak
• Stents aren’t as useful as in sleeves.
• Free intraperitoneal leaks need wide drainage with diagnostic lap and would consider placing feeding tube in
defunctionalized stomach.
• Contained leaks can be managed non-operatively with
percutaneous drains, NPO, IV Abx, TPN, and time.
387
388
M. Ne and T. Marchuk
Internal Hernia
• Minimize time in the ED, “golden 6 hours,” to get them to
the operating room before signicant bowel ischemia.
• Start at the TI and work backwards.
• Low threshold to convert to open if can’t untwist.
• Petersen’s space in antecolic Roux-en-Y and base of the
JJ most common sites.
Sleeve Leak
• Free leaks need return to OR and wide drainage.
• Contained leaks can be managed non-operatively.
• Esophageal stents are helpful but often migrate.
• Over the scope clips helpful, with intra-procedure UGI to
document no leak.
• Recent popularity of endoVACs.
• May need to consider converting to Roux-en-Y depending on location of the leak.
• Can control with drain and turn into a controlled stula.
Mesenteric Thrombosis (Sleeve)
• Etiology controversial but felt to be related to
hypercoagulability.
• Anticoagulation.
• Catheter-directed thrombolysis.
• May require bowel resection.
Clean Kills
• You don’t recognize tachycardia in the bariatric patient is
a surgical emergency until proven otherwise (rule out PE
and intra-abdominal catastrophe before blaming anxiety
or pain control).
• Don’t understand the difference between contained and
free leaks.
• Don’t know where to look for internal hernias or how to
describe repair.
• Unnecessary delays before taking the bariatric patient to
the operating room when intra-abdominal process is
suspected.
• You identify the internal hernia and reduce but can’t
describe how to close the defect or only describe closing
one when told both are present.
• You are given normal labs and decide to monitor the
tachycardic patient overnight.
Bonus Points
• You put a feeding tube into the difunctional stomach in a
bypass patient.
• You don’t trust nondiagnostic imaging in tachycardic bariatric patient.
Common Curveballs
• The presentation may be years after a RYGB with perforation of a marginal ulcer (treat as a Graham patch and ck
H. pylori).
• There will be dilation of the remnant stomach (from
obstruction at the JJ from clot or technical error—this too
is a surgical emergency with decompression of the stomach by percutaneous or surgical means) seen on abdominal X-ray.
• The patient will not know what surgery they had
performed.
• The patient may have a complication from a lap band
(hundreds of thousands of bands were inserted; check the
“phi angle”; if band looks horizontal, promptly deate or
it can result in gastric ischemia).
• The patient may have an intussusception at the JJ.
• Labs will be normal.
• The patient won’t be tachycardic but is still writhing in
pain (no one will fault you for a diagnostic laparoscopy in
a bariatric surgery patient, only for a delay in surgical
intervention).
• Drain with new purulent output.
• Patient with a history of a duodenal switch or SADI.
• Hematemesis on presentation.
• Patient with bloody bowel movements.
Words ofWisdom
In 1979, Mason astutely identied tachycardia as a signicant red ag in post-bariatric surgery patients, signaling
potential complications. Today, amidst advancements in surgical techniques and patient care, bariatric procedures stand
out as safer options compared to cardiac or orthopedic surgeries. Statistics afrm the safety of these procedures, highlighting their efcacy in addressing morbid obesity.
Whether encountering a patient fresh from surgery or
years post-operation, maintaining a heightened level of suspicion is paramount. Until ruled out by prompt radiologic
evaluation, such as a CT scan, every presentation warrants
scrutiny. Bariatric patients, by their very nature, defy textbook descriptions, presenting unique challenges for physicians. Vigilance, therefore, is the cornerstone of effective
management, ensuring that potential complications are identied and addressed expediently.
Bibliography
American Society for Metabolic and Bariatric Surgery. ASMBS
updated position statement on gastric bypass leaks. Surg Obes Relat
Dis. 2019;15(7):1136–7.