How to manage intractable nausea and vomiting after gastric sleeve surgery?

Management of Intractable Nausea and Vomiting After Gastric Sleeve Surgery

A multimodal approach using antiemetics from at least three different drug classes combined with proper fluid management is essential for managing intractable nausea and vomiting after gastric sleeve surgery. 1

Causes and Risk Factors

• Patients undergoing bariatric surgery are at high risk for postoperative nausea and vomiting (PONV) due to multiple factors including female gender, non-smoking status, procedures lasting more than one hour, and perioperative opioid use 1
• Gastric surgery itself, history of acid reflux, and reduction in gastric size particularly after sleeve gastrectomy further contribute to PONV 1
• Functional stenosis (twist or kink) of the gastric sleeve can cause persistent nausea and vomiting 2
• Dehydration is a common complication that can both result from and exacerbate nausea and vomiting 1

Initial Assessment

• Evaluate for alarming signs including tachycardia ≥110 beats per minute, fever ≥38°C, hypotension, respiratory distress, or decreased urine output which may indicate serious complications 1
• Persistent vomiting and nausea are warning signs that may indicate complications such as internal hernia, volvulus, gastrointestinal stenosis, intestinal ischemia, or marginal ulcer 1
• Laboratory tests including complete blood count, electrolytes, C-reactive protein, and serum lactate should be performed to assess for complications 1
• Consider imaging studies if structural complications are suspected 1

Pharmacological Management

First-Line Antiemetic Therapy

• Implement a multimodal approach using one antiemetic agent from at least three of the following six classes 1:

  • 5-hydroxytryptamine (5HT3) receptor antagonists (e.g., ondansetron)
  • Long-acting corticosteroids (e.g., dexamethasone)
  • Butyrophenones (e.g., droperidol)
  • Neurokinin-1 receptor antagonists (e.g., aprepitant)
  • Antihistamines (e.g., promethazine)
  • Anticholinergics (e.g., scopolamine)

• For severe cases, consider aprepitant/dexamethasone combination which has shown superior efficacy in preventing PONV after laparoscopic sleeve gastrectomy 3

Prokinetic Agents

• Metoclopramide 10 mg IV or PO every 6-8 hours can be used to improve gastric emptying 4
• For diabetic patients with gastroparesis symptoms, metoclopramide may be particularly beneficial 4

Fluid Management

• Ensure adequate hydration with a mildly positive fluid balance to reduce PONV 1
• Intravenous fluid administration at a rate of approximately 2 ml/kg/h has been shown to reduce PONV 1
• Avoid fluid overload as this can worsen outcomes 1
• Target consumption of 1.5 L liquids/day to maintain adequate hydration once oral intake is possible 1

Surgical Considerations

• If medical management fails and functional stenosis is suspected, endoscopic evaluation should be performed 2
• Gastric sleeve fixation during the initial surgery has been shown to prevent functional stenosis and reduce postoperative nausea and vomiting 2
• For truly intractable cases not responding to medical therapy, revisional surgery such as conversion to Roux-en-Y gastric bypass may be considered 5

Non-Pharmacological Approaches

• Implement proper eating behaviors: slow pace of eating, prolonged chewing (≥15 "chews" per bite), and avoiding dry foods 1
• Separate liquids from solid foods to reduce symptoms 1
• Ensure adequate hydration by encouraging frequent small sips of fluid 1
• Consider gum chewing which may help stimulate gastric motility 1

Special Considerations

• If vomiting persists for >2-3 weeks, thiamin supplementation should be administered to prevent neurological complications 1
• Monitor for signs of dehydration which can lead to emergency room visits within the first 3 months after surgery 1
• For patients with diabetes, monitor glucose levels closely as gastroparesis may affect absorption 4

Prevention Strategies for Future Patients

• Consider total intravenous anesthesia with propofol (TIVA) instead of volatile anesthetics 1
• Minimize intra- and postoperative opioids through multimodal analgesia and regional anesthesia techniques 1
• Consider gastric sleeve fixation during initial surgery to prevent functional stenosis 2
• Implement a comprehensive preoperative PONV prevention protocol including multiple antiemetics 6

When to Consider Escalation of Care

• If nausea and vomiting persist despite maximal medical therapy for more than 48 hours 1
• If signs of dehydration, electrolyte abnormalities, or malnutrition develop 1
• If alarming signs such as tachycardia, fever, or severe abdominal pain are present 1
• If imaging or endoscopy reveals anatomical complications requiring intervention 2