Résumé
L’épidémie d’obésité a entraîné une augmentation du nombre de procédures bariatriques. Pourtant, les médecins sont moins à l’aise pour prendre en charge un patient obèse opéré d’une chirurgie bariatrique. Cet article a pour but de sensibiliser et de familiariser les médecins, à ces nouveaux patients. La particularité chez le patient obèse est que les signes classiques d’irritation péritonéale ne sont pas souvent présents car il n’existe pas de véritable musculature au niveau de la paroi abdominale chez ce type de patient. La défense et la contracture sont donc souvent absentes. Une simple tachycardie postopératoire chez un obèse doit être prise au sérieux. Le signe clinique d’alerte le plus spécifique est la tachycardie (>120/min). La complication la plus commune après la chirurgie est une péritonite liée à une fistule anastomotique. Il s’agit classiquement d’une complication précoce survenant dans les 10 jours postopératoires. L’incident de cette complication après bypass gastrique est de 1 à 3% (5,6) et de 3 à 7% après sleeve gastrectomy. Les dénutritions postopératoires sont exceptionnelles après chirurgie restrictive (anneau, sleeve gastrectomie). Par contre, elles sont possibles après chirurgie mal absorpative (bypass gastrique, dérivation biliopancréatique). Une cholécystectomie prophylactique n’est pas systématiquement effectuée dans le même temps opératoire que le bypass gastrique. La plupart du temps des conseils hygiéno-diétiques suffisent pour éviter le dumping syndrome. La thrombose de la veine mésentérique supérieure après chirurgie bariatrique est un diagnostic qu’il faut savoir évoquer devant toute douleur abdominale postopératoire. Dans un premier temps on réalise un bilan étiologique initial. Si l’anse en Y est longue il peut y avoir un déficit en vitamine D. Il a également été décrit des hyperparathyroïdies secondaires après bypass gastrique. Un déficit en vitamine B1 (Thiamine) est le plus souvent à l’origine des troubles neurologiques. Au moindre doute, il ne faut pas hésiter à demander une consultation médicale ou chirurgicale auprès d’un praticien spécialisé dans la prise en charge du patient obèse car le taux de décès augmente avec le retard diagnostic
Abstract
The epidemic in obesity has led to an increase in number of so called bariatric procedures. Doctors are less comfortable managing an obese patient after bariatric surgery. This article is designed to make doctors aware of and familiar with these patients. The specific feature in the obese patient is that the classical signs of peritoneal irritation are never present as there is no abdominal wall and therefore no guarding or rigidity. Simple post-operative tachycardia in obese patients should be taken seriously as it is a warning signal. The most common complication after surgery is peritonitis due to anastomotic fistula formation. This occurs typically as an early complication within the first 10 days postoperatively and has an incidence of 1 to 3% after gastric bypass and 3 to 7% after sleeve gastrectomy. Post-operative malnutrition is extremely rare after restrictive surgery (ring, sleeve gastrectomy) although may occur after mal absorbtive surgery (gastric bypass, biliary pancreatic shunt). Prophylactic cholecystectomy is not routinely carried out during the same procedure as the gastric bypass. It is usually sufficient to provide lifestyle and dietetic advice to avoid the Dumping syndrome. Superior mesenteric vein thrombosis after bariatric surgery is a diagnosis which should be considered in the presence ofany post-operative abdominal pain. Initially a first etiological assessment is performed. If the Alimentary loop is long, vitamin D deficiency may occur. Cases of secondary hyperparathyroidism after gastric bypass have also been described. Vitamin B1 (Thiamine) deficiency is usually the cause of the neurological problems. If the least doubt is present, a medical or surgical consultation should be requested with a specialist practitioner in the management of obese patients as death rates increase with delayed diagnosis.
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Kassir, R., Blanc, P., Lointier, P. et al. De la tension à l’attention : les nouvelles urgences liées à la chirurgie de l’obésité. Revue de la littérature. Obes 10, 135–142 (2015). https://doi.org/10.1007/s11690-015-0470-5
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DOI: https://doi.org/10.1007/s11690-015-0470-5