Emergency care of metabolic bariatric surgery patients | British Journal of Surgery

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</li> <li class="section-jump-link head-1" link-destination="483199169"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#483199169">Management of acute major complications</a> </div> </li> <li class="section-jump-link head-1" link-destination="483199171"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#483199171">Funding</a> </div> </li> <li class="section-jump-link head-1" link-destination="483199173"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#483199173">Acknowledgements</a> </div> </li> <li class="section-jump-link head-1" link-destination="483199175"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#483199175">Author contributions</a> </div> </li> <li class="section-jump-link head-1" link-destination="483199177"> <div class="section-jump-link__link-wrap"> <a class="js-jumplink scrollTo" href="#483199177">Disclosure</a> </div> </li> <li 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Federation for the Surgery of Obesity and Metabolic Disorders European Chapter</div>, <div class="addr-line">Naples</div>, <div class="country">Italy</div></div> </div> <div class="info-card-location"> <a id="contrib-orcid-0000-0001-6533-8166" href="https://orcid.org/0000-0001-6533-8166"> <img class="orchid-icon" alt="ORCID logo" aria-hidden="true" src="//oup.silverchair-cdn.com/Themes/Silver/app/img/mini-icon.png"/>  https://orcid.org/0000-0001-6533-8166 </a> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/bjs/search-results?f_Authors=Ellen+Andersson" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Andersson Ellen%22">Google Scholar</a> </div> </div> </span> </span> <span class="al-author-name-more js-flyout-wrap"> <button type="button" class="linked-name js-linked-name-trigger btn-as-link">Cynthia M Borg</button><span class='delimiter'>, </span> <span class="al-author-info-wrap arrow-up"> <div class="info-card-author authorInfo_OUP_ArticleTop_Info_Widget"> <div class="name-role-wrap"> <div class="info-card-name"> Cynthia M Borg </div> </div> <div class="info-card-affilitation"> <div class="aff"><div class="institution">Multinational Advisory Group for International Federation for the Surgery of Obesity and Metabolic Disorders European Chapter</div>, <div class="addr-line">Naples</div>, <div class="country">Italy</div></div><div class="aff"><div class="institution">Department of General Surgery, University Hospital Lewisham</div>, <div class="addr-line">London</div>, <div class="country">UK</div></div> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/bjs/search-results?f_Authors=Cynthia+M+Borg" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Borg Cynthia M%22">Google Scholar</a> </div> </div> </span> </span> <span class="al-author-name-more js-flyout-wrap"> <button type="button" class="linked-name js-linked-name-trigger btn-as-link">Ronald S L Liem</button><span class='delimiter'></span> <span class="al-author-info-wrap arrow-up"> <div class="info-card-author authorInfo_OUP_ArticleTop_Info_Widget"> <div class="name-role-wrap"> <div class="info-card-name"> Ronald S L Liem <span class="info-card-footnote"><span class="xrefLink" id="jumplink-znae233-cor1"></span><a href="javascript:;" reveal-id="znae233-cor1" data-open="znae233-cor1" class="link link-ref link-reveal xref-default"></a></span> </div> </div> <div class="info-card-affilitation"> <div class="aff"><div class="institution">Multinational Advisory Group for International Federation for the Surgery of Obesity and Metabolic Disorders European Chapter</div>, <div class="addr-line">Naples</div>, <div class="country">Italy</div></div><div class="aff"><div class="institution">Nederlandse Obesitas Kliniek</div>, <div class="addr-line">The Hague and Gouda</div>, <div class="country">The Netherlands</div></div><div class="aff"><div class="institution">Department of Surgery, Groene Hart Ziekenhuis</div>, <div class="addr-line">Gouda</div>, <div class="country">The Netherlands</div></div> </div> <div class="info-author-correspondence"> <div content-id="znae233-cor1"><em>Correspondence to:</em> Ronald S. L. Liem, Department of Surgery, Groene Hart Ziekenhuis, Bleulandweg 10, Gouda, 2803 HH, The Netherlands (e-mail: <a href="mailto:ronald.liem@ghz.nl" target="_blank">ronald.liem@ghz.nl</a>)</div> </div> <div class="info-card-location"> <a id="contrib-orcid-0000-0002-0165-5995" href="https://orcid.org/0000-0002-0165-5995"> <img class="orchid-icon" alt="ORCID logo" aria-hidden="true" src="//oup.silverchair-cdn.com/Themes/Silver/app/img/mini-icon.png"/>  https://orcid.org/0000-0002-0165-5995 </a> </div> <div class="info-card-search-label"> Search for other works by this author on: </div> <div class="info-card-search info-card-search-internal"> <a href="/bjs/search-results?f_Authors=Ronald+S+L+Liem" rel="nofollow">Oxford Academic</a> </div> <div class="info-card-search info-card-search-google"> <a href="http://scholar.google.com/scholar?q=author:%22Liem Ronald S L%22">Google Scholar</a> </div> </div> </span> </span> </div> </div> <div class="pub-history-wrap clearfix js-history-dropdown-wrap"> <div class="pub-history-row clearfix"> <div class="ww-citation-primary"><em>British Journal of Surgery</em>, Volume 111, Issue 9, September 2024, znae233, <a href='https://doi.org/10.1093/bjs/znae233'>https://doi.org/10.1093/bjs/znae233</a></div> </div> <div class="pub-history-row clearfix"> <div class="ww-citation-date-wrap"> <div class="citation-label">Published:</div> <div class="citation-date">11 September 2024</div> </div> <a href="javascript:;" class="history-label js-history-dropdown-trigger st-article-history at-ArticleHistory"> <span>Article history</span><i class="icon-general-arrow-filled-down arrow-icon"></i> </a> </div> <div class="ww-history js-history-entries-wrap at-history-entries-wrap"> <div class="history-entry at-history-entry"> <div class="wi-state">Received:</div> <div class="wi-date">20 July 2024</div> </div> <div class="history-entry at-history-entry"> <div class="wi-state">Accepted:</div> <div class="wi-date">21 August 2024</div> </div> <div class="history-entry at-history-entry"> <div class="wi-state">Published:</div> <div class="wi-date">11 September 2024</div> </div> </div> </div> </div> </div> <script> $(document).ready(function () { $('.article-top-widget').on('click', '.ati-toggle-trigger', function () { $(this).find('.icon-general-add, .icon-minus').toggleClass('icon-minus icon-general-add'); $(this).siblings('.ati-toggle-content').toggleClass('hide'); }); // In Chrome, an anchor tag with target="_blank" and a "mailto:" href opens a new tab/window as well as the email client // I suspect this behavior will be corrected in the future // Remove the target="_blank" $('ul.wi-affiliationList').find('a[href^="mailto:"]').each(function () { $(this).removeAttr('target'); }); }); </script> </div> <div class="widget widget-ArticleLinks widget-instance-OUP_Article_Links_Widget"> </div> <div class="article-body js-content-body"> <div class="toolbar-wrap js-toolbar-wrap"> <div class="toolbar-inner-wrap"> <ul id="Toolbar" 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</div> </div> <div class="navbar-search-advanced"><a href="/bjs/advanced-search" class="advanced-search js-advanced-search">Advanced Search</a></div> </div> <div class="navbar-search-collapsed"><a href="javascript:;" class="icon-menu_search js_expand-navsearch"><span class="screenreader-text">Search Menu</span></a></div> </div> </div> <input id="routename" name="RouteName" type="hidden" value="bjs" /> </div> </div> </div> </div> <div id="ContentTab" class="content active"> <div class="widget widget-ArticleFulltext widget-instance-OUP_Article_FullText_Widget"> <div class="module-widget"> <div class="widget-items" data-widgetname="ArticleFulltext"> <div id="znae233-box1" class="boxed-text boxed-matter"><div class="caption caption-id-"><div class="title">Key points</div></div><div class="clearfix"></div><ul class="bullet"><li><p class="chapter-para">Although complication rates after metabolic bariatric surgery are low, increasing caseloads result in more patients presenting acutely to emergency departments</p></li><li><p class="chapter-para">Metabolic bariatric surgery patients with acute pathology may present with few symptoms and seemingly little pain, but still be critically unwell</p></li><li><p class="chapter-para">Tachycardia is the most common clinical sign of surgical complications after metabolic bariatric surgery, followed by tachypnoea and fever</p></li><li><p class="chapter-para">Patients presenting with complications after metabolic bariatric surgery should preferably be transferred to a specialist bariatric centre, but urgent surgery should never be postponed when patients are severely ill</p></li></ul></div> <h2 scrollto-destination=483199142 id="483199142" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s1>Introduction</h2> <p class="chapter-para">Metabolic bariatric surgery (MBS) is the most effective treatment for severe obesity, resulting in long-term weight loss and remission of obesity-related co-morbidity. MBS is safe, with perioperative mortality below 0.25%<sup><span class="xrefLink" id="jumplink-znae233-B1"></span><a href="javascript:;" reveal-id="znae233-B1" data-open="znae233-B1" class="link link-ref link-reveal xref-bibr">1</a></sup>. Postoperative complication rates are low, but increased caseload volume means a higher prevalence of MBS patients presenting with acute problems to emergency departments.</p><p class="chapter-para">To assist healthcare professionals in the assessment and management of post-MBS emergencies, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) European Chapter developed an emergency room poster (<em><span class="xrefLink" id="jumplink-znae233-F1"></span><a href="javascript:;" data-modal-source-id="znae233-F1" class="link xref-fig">Fig. 1</a></em>), adapted from an earlier version by the Dutch Society for Metabolic and Bariatric Surgery.</p> <a id="483199145" scrollto-destination="483199145"></a> <div data-id="znae233-f1" data-content-id="znae233-f1" class="fig fig-section js-fig-section" swap-content-for-modal="true"><div class="graphic-wrap"><img class="content-image" src="https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/bjs/111/9/10.1093_bjs_znae233/8/m_znae233f1.jpeg?Expires=1735954355&Signature=Pm8tEL0-Op4DkkjxGGKhtFUbrDFIDxDh38ahhowY3S7Gd3TTmA49oGJeropOGt9RZm1UH5TvXewcoXhlQNV3EvQ4hiVhfzcTF01XOduQThwYaXX3obYvkrf7yNNooJmEGXTfGt6rmZ8Cx7QCWdIcSYBQ1Lhn6gAnPJNgCd8luU93XZKhmSvXncG2BlMQ2DZwHZUiisnPEpOqutFgPSe8m5a8dp-PXXtfKr34eUDT4fyoCFWP44HjenX4o3YkYbJMbJxNYAZnvj3Ol7iDy9Al6krtj4ddJ3BZefgTsANFUP37JpfIxL7aIooYUquHR5gAndQlr7LkcBv14svV817Scg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA" alt="IFSO-EC emergency care poster" data-path-from-xml="znae233f1.jpg" /><div class="graphic-bottom"><div class="label fig-label" id="label-483199145">Fig. 1</div><div class="caption fig-caption"><p class="chapter-para">IFSO-EC emergency care poster</p><p class="chapter-para">IFSO, International Federation for the Surgery of Obesity and Metabolic Disorders; EC, European Chapter; RYGB, Roux-en-Y gastric pass; AGB, adjustable gastric band; VBG, vertical banded gastroplasty; RBC, red blood cells; IV, intravenous; IBS, irritable bowel syndrome; Hb, hemoglobin; PPI, proton pump inhibitor; ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangio-pancreatography; CBD, common bileduct; PTC, percutaneous transhepatic cholangiography.</p></div><div class="ajax-articleAbstract-exclude-regex fig-orig original-slide figure-button-wrap"><a class="fig-view-orig js-view-large at-figureViewLarge openInAnotherWindow" role="button" aria-describedby="label-483199145" href="/view-large/figure/483199145/znae233f1.jpg" data-path-from-xml="znae233f1.jpg" target="_blank">Open in new tab</a><a class="download-slide" role="button" aria-describedby="label-483199145" data-section="483199145" href="/DownloadFile/DownloadImage.aspx?image=https://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/bjs/111/9/10.1093_bjs_znae233/8/znae233f1.jpeg?Expires=1735954355&Signature=JohqZp8hcJcl3I6W2LD1RKMOCoSZPGp8roUlahakFDs67g~8YlQACzFqncsB9oNNRqoBpE7bUYDYeBz5nnBGiCUDlKmhLUa3k-uLmIbxt78UkS6hY9VUQyUeEAt5EqBK--OJ207xZioRGlcniCUr-Ge5Y8nmf1Mj~Nb297pcMyiKZBaTitdTWgqnnYejpSQxIQGrhkJmzmYemhcx3aZCMO-a2AWUOgp~YY6dp0pUbx0rQztLM8TF4d19s0MtCPP9A-14o40-GIhha-VKZVTYQqB58PDXBzy-cznExbw4yLcbAzzJeekx0o5L9RaVYDjOIFz8y5ABffkHFvbvctsUmg__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA&sec=483199145&ar=7754937&xsltPath=~/UI/app/XSLT&imagename=&siteId=6337" data-path-from-xml="znae233f1.jpg">Download slide</a></div></div></div></div> <h2 scrollto-destination=483199146 id="483199146" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s2>General presentation</h2> <p class="chapter-para">MBS patients with acute pathology may present with few symptoms and seemingly little pain, but still be critically unwell. Tachycardia is the most widely reported clinical sign of surgical complications after MBS, followed by tachypnoea and fever<sup><span class="xrefLink" id="jumplink-znae233-B2"></span><a href="javascript:;" reveal-id="znae233-B2" data-open="znae233-B2" class="link link-ref link-reveal xref-bibr">2</a></sup>. Tachycardia alone may be an indication for a diagnostic laparoscopy. Though nausea is a common early side effect after MBS, vomiting is rare and should prompt investigation to exclude complications. The absence of clinical signs does not rule out pathology and is common, even in patients with peritonitis<sup><span class="xrefLink" id="jumplink-znae233-B2"></span><a href="javascript:;" reveal-id="znae233-B2" data-open="znae233-B2" class="link link-ref link-reveal xref-bibr">2</a></sup>. Localizing signs of peritoneal irritation are rarely provoked on palpation due to abdominal wall thickness. A high level of suspicion is warranted, as MBS patients typically have lower physiological reserves than the general population of abdominal surgery patients.</p> <h2 scrollto-destination=483199148 id="483199148" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s3>Side effects of the most common procedures</h2> <p class="chapter-para">Side effects of MBS differ between procedures. The most common are presented in <em><span class="xrefLink" id="jumplink-znae233-F1"></span><a href="javascript:;" data-modal-source-id="znae233-F1" class="link xref-fig">Fig. 1</a></em>.</p><p class="chapter-para">Whilst all MBS procedures may result in varying degrees of impaired micronutrient, protein, and fat absorption, highly hypoabsorptive procedures, such as biliopancreatic diversion/duodenal switch (BPD/DS) and single anastomosis duodenal-ileal bypass with sleeve (SADI-S), confer a higher risk. Gastro-oesophageal reflux is common after sleeve gastrectomy (SG) and bile reflux is common after one anastomosis gastric bypass or SADI-S<sup><span class="xrefLink" id="jumplink-znae233-B3"></span><a href="javascript:;" reveal-id="znae233-B3" data-open="znae233-B3" class="link link-ref link-reveal xref-bibr">3</a>,<span class="xrefLink" id="jumplink-znae233-B4"></span><a href="javascript:;" reveal-id="znae233-B4" data-open="znae233-B4" class="link link-ref link-reveal xref-bibr">4</a></sup>. In patients who have undergone endoscopic procedures, such as intragastric balloon insertion, nausea, vomiting, and reflux may occur.</p> <h2 scrollto-destination=483199151 id="483199151" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s4>Short-term complications</h2> <p class="chapter-para">Severe complications within 30 days of MBS may occur in 2.8% of patients<sup><span class="xrefLink" id="jumplink-znae233-B5"></span><a href="javascript:;" reveal-id="znae233-B5" data-open="znae233-B5" class="link link-ref link-reveal xref-bibr">5</a></sup>. Risk factors include male sex, older age, revisional procedures, open surgery, preoperative co-morbidity, and higher BMI.</p><p class="chapter-para">Bleeding occurs in 1.4% of cases<sup><span class="xrefLink" id="jumplink-znae233-B5"></span><a href="javascript:;" reveal-id="znae233-B5" data-open="znae233-B5" class="link link-ref link-reveal xref-bibr">5</a></sup>. It may be endoluminal, usually originating from staple lines and anastomoses, or intra-abdominal, secondary to injury or incomplete haemostasis. When patients are stable enough, contrast-enhanced Computer Tomografie (CT) of the abdomen can be helpful; however, a negative CT cannot exclude pathology and a CT should not delay urgent endoscopic or surgical intervention. After gastric bypass procedures, bleeding may occur within the gastric remnant, typically inaccessible by transoral endoscopy.</p><p class="chapter-para">Leakage usually occurs at anastomoses or staple lines, but may result from iatrogenic perforations. A meta-analysis of 56 146 patients revealed a 30-day leak incidence of 1.15%<sup><span class="xrefLink" id="jumplink-znae233-B6"></span><a href="javascript:;" reveal-id="znae233-B6" data-open="znae233-B6" class="link link-ref link-reveal xref-bibr">6</a></sup>. Associated sepsis should be treated promptly with broad-spectrum antibiotics and drainage and/or surgical washout. Nutrition needs to be optimized, with nasojejunal or parenteral feeding, and oral intake restricted. Abdominal CT with oral and intravenous contrast is useful to identify the location of a leak.</p><p class="chapter-para">Pulmonary embolism (PE) should be considered in the differential diagnosis of acutely unwell patients after MBS, as it increases 30-day mortality by more than 50-fold<sup><span class="xrefLink" id="jumplink-znae233-B7"></span><a href="javascript:;" reveal-id="znae233-B7" data-open="znae233-B7" class="link link-ref link-reveal xref-bibr">7</a></sup>. Though most cases of PE develop a few days post-surgery, the risk persists for several months<sup><span class="xrefLink" id="jumplink-znae233-B6"></span><a href="javascript:;" reveal-id="znae233-B6" data-open="znae233-B6" class="link link-ref link-reveal xref-bibr">6</a></sup>.</p><p class="chapter-para">Gastrointestinal obstruction may lead to perforation, leakage, or strangulation. Mechanical causes, such as internal herniation, anastomotic stricture, or technical errors, need to be excluded. Jejunojejunal obstruction may present with deranged liver enzymes and dilated gastric remnant and biliary tree on imaging.</p> <h2 scrollto-destination=483199157 id="483199157" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s5>Late complications</h2> <p class="chapter-para">Awareness and proper management of late complications are important to minimize late morbidity and mortality related to MBS.</p><p class="chapter-para">Gallstone formation increases with rapid weight loss. In the presence of common bile duct stones, the approach to duct clearance depends on the MBS procedure, as regular endoscopic retrograde cholangiopancreatography (ERCP) may not be possible after procedures with gastrointestinal diversion.</p><p class="chapter-para">Upper abdominal pain or gastrointestinal bleeding may be caused by gastric ulceration, typically located in staple lines or anastomoses. Gastroscopy is recommended and treatment with a open capsule proton pump inhibitor, <em>Helicobacter pylori</em> eradication, smoking and alcohol cessation, and sucralfate may be indicated. Ulcers are sometimes associated with stenoses/strictures, warranting endoscopic dilatation or a surgical revision. Severe dyspepsia unresponsive to pharmacotherapy may indicate bile reflux or internal herniation. After gastric bypass procedures, the remnant stomach and duodenum are inaccessible by regular gastroscopy. Whilst push endoscopy and laparoscopically assisted transgastric gastroduodenoscopies may be feasible, the procedures are technically challenging.</p><p class="chapter-para">Patients presenting with sudden onset of severe abdominal pain often warrant CT to exclude gastrointestinal perforation. Perforations are rare, but typically occur at anastomoses or as a blowout of the remnant stomach after gastric bypass procedures. Patients with perforation should be treated surgically without delay.</p><p class="chapter-para">Gastrointestinal obstruction may be caused by stenoses/strictures in anastomoses after gastric bypass and by narrowing, most often located at the incisura angularis, after SG<sup><span class="xrefLink" id="jumplink-znae233-B8"></span><a href="javascript:;" reveal-id="znae233-B8" data-open="znae233-B8" class="link link-ref link-reveal xref-bibr">8</a></sup>. Vomiting of food should be considered pathological after gastric bypass, as the fast passage of food into the jejunum does not usually allow food to be kept in the proximal part of the gastrointestinal tract. Management varies, depending on the cause of obstruction, and can range from endoscopic dilatation to revision surgery.</p><p class="chapter-para">Patients with adjustable gastric bands and signs of obstruction should have band deflation. Gastroscopy, an upper gastrointestinal series, or abdominal CT should be performed promptly to locate the band and detect potential band-related complications, such as band erosion, slippage, or migration. When symptoms do not settle with deflation, surgical band removal may be required.</p><p class="chapter-para">After any MBS procedure involving small intestine diversion, internal herniation can occur. CT with oral and intravenous contrast, to detect indirect signs, such as a mesenteric vessel swirl, signs of ileus, or a dilated remnant stomach, may confirm the diagnosis. Negative CT should not exclude surgery when there is clinical suspicion of internal herniation.</p><p class="chapter-para">Kinking of the enteral anastomosis can cause abdominal pain, typically located in the left hypochondrium<sup><span class="xrefLink" id="jumplink-znae233-B9"></span><a href="javascript:;" reveal-id="znae233-B9" data-open="znae233-B9" class="link link-ref link-reveal xref-bibr">9</a></sup>. Since the introduction of mesenteric defect closure in gastric bypass, the long-term rate of internal herniation has decreased, but seemingly at the cost of a higher rate of early reoperations caused by kinking of the jejunojejunal anastomosis<sup><span class="xrefLink" id="jumplink-znae233-B10"></span><a href="javascript:;" reveal-id="znae233-B10" data-open="znae233-B10" class="link link-ref link-reveal xref-bibr">10</a></sup>. Surgical interventions should preferably be performed by a bariatric surgeon.</p><p class="chapter-para">Overeating and food bolus impaction can cause transient abdominal pain. Abdominal discomfort caused by irritable bowel syndrome may also be present after MBS. CT is usually performed, but good clinical judgement is advocated in patients with multiple visits to the emergency room because of abdominal pain for whom previous CT images or previous diagnostic laparoscopies have not yielded a diagnosis.</p><p class="chapter-para">Dumping can occur after gastric bypass and to a lesser extent after SG. Early dumping presents with palpitations, sweating, and flushing within 1 h of food ingestion. Late dumping, or late postprandial hypoglycaemia, commences 1–3 h after a meal and may, in severe cases, result in unconsciousness caused by neuroglycopenia. Patients may be suspected of having epileptic seizures or cardiac arrhythmias when presenting to the emergency room, as blood sugar levels have often returned to normal on arrival. Consultation with a bariatric dietitian is recommended, followed by referral to a bariatric physician.</p><p class="chapter-para">Malnutrition and nutritional deficiencies can occur after all MBS procedures and may present with a wide range of symptoms. Vitamin B1 deficiency should be suspected and treated empirically in patients who have frequent vomiting after MBS due to the risk of Wernicke–Korsakoff encephalopathy. Testing blood samples to diagnose deficiencies of vitamin B1, vitamin B12, vitamin D, iron, calcium, and protein is recommended during follow-up after MBS. Iron-deficiency anaemia is common. In hypoabsorptive procedures, vitamin A, E, and K deficiencies and severe protein malnutrition may occur. When planning nutrition for severely malnourished patients, the risk of refeeding syndrome must be considered.</p> <h2 scrollto-destination=483199169 id="483199169" class="section-title js-splitscreen-section-title" data-legacy-id=znae233-s6>Management of acute major complications</h2> <p class="chapter-para">Patients presenting with complications after MBS should preferably be transferred to a specialist bariatric centre. The index centre where the primary procedure was performed should be consulted early to confirm the diagnosis and decide on the suitability for transfer. Urgent surgery should never be postponed when patients are severely ill. When an MBS surgeon is not available, damage control surgery may be a good option, with transfer to an MBS centre for definitive management once stable. It is also important to consider that patients may suffer from diseases unrelated to their MBS procedure.</p> <h2 scrollto-destination=483199171 id="483199171" class="backsection-title js-splitscreen-backsection-title" data-legacy-id=znae233-s7>Funding</h2> <p class="chapter-para">The authors have no funding to declare.</p> <h2 scrollto-destination=483199173 id="483199173" class="backacknowledgements-title js-splitscreen-backacknowledgements-title" data-legacy-id=ack1>Acknowledgements</h2> <p class="chapter-para">The authors would like to thank the members of the IFSO European Chapter Multinational Advisory Group for their contribution to the development of the IFSO European Chapter emergency poster: Tadeja Pintar, Ronald Liem, Ramon Villalonga, Marc Schiesser, Jerome Dargent, Harry Pappis, Felix Langer, Nasser Sakran, Paulina Salminen, and Gerhard Prager. R.Z. and E.A. share first authorship.</p> <h2 scrollto-destination=483199175 id="483199175" class="backsection-title js-splitscreen-backsection-title" data-legacy-id=znae233-s8>Author contributions</h2> <p class="chapter-para">Roxanna Zakeri (Writing—original draft, Writing—review & editing), Ellen Andersson (Writing—original draft, Writing—review & editing), Cynthia M. Borg (Supervision, Writing—review & editing), and Ronald S. L. Liem (Conceptualization, Project administration, Resources, Supervision, Visualization, Writing—review & editing)</p> <h2 scrollto-destination=483199177 id="483199177" class="backsection-title js-splitscreen-backsection-title" data-legacy-id=znae233-s9>Disclosure</h2> <p class="chapter-para">The authors declare no conflict of interest.</p> <h2 scrollto-destination=483199179 id="483199179" class="backreferences-title js-splitscreen-backreferences-title" data-legacy-id=ref1>References</h2> <div class="ref-list js-splitview-ref-list"><div content-id="znae233-B1" class="js-splitview-ref-item" data-legacy-id="znae233-B1"><div class="refLink-parent"><span class="refLink"><a name="jumplink-znae233-B1" href="javascript:;" aria-label="jumplink-znae233-B1" data-id=""></a></span></div><div class="ref false"><div id="ref-auto-znae233-B1" class="ref-content " data-id="znae233-B1"><span class="label title-label">1</span><div class="mixed-citation citation"><p 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Emergency care of metabolic bariatric surgery patients | British Journal of Surgery | Oxford Academic