›Renal dosing adjustment when eGFR reduced
›First-line for confirmed or suspected intra-abdominal leak with peritonitis
›Ceftriaxone IV 2 g daily plus metronidazole IV 500 mg every 8 hours
›Acceptable alternative
›Meropenem IV 1 g every 8 hours
›Reserve for severe sepsis or resistant organism risk
›Renal dosing adjustment when eGFR reduced
›Source control principles
›Operative exploration and repair or resection for uncontained leak with peritonitis
›Percutaneous drainage for a stable, well-contained collection in selected patients
›Endoscopic stenting or clipping in selected chronic or contained leaks under bariatric surgical guidance
›Treatment failure and troubleshooting
›Persistent tachycardia, fever, or rising inflammatory markers despite antibiotics and drainage
›Reimage to reassess collection size and adequacy of source control
›Escalate to operative exploration if percutaneous or endoscopic management fails to improve trajectory within 24 to 48 hours
Internal hernia and obstruction management
›Operative exploration
›Indicated on clinical suspicion of internal hernia regardless of imaging result
›Diagnostic laparoscopy preferred when the patient is stable
›Reduction of herniated bowel and closure of the mesenteric defect
›Immediate operative pathway
›Peritonitis
›Bowel ischemia signs on imaging
›Closed loop obstruction
›Nonoperative trial limitations
›Not appropriate for internal hernia with classic intermittent postprandial pain and a suggestive history
›Unlike adhesive small bowel obstruction, watchful waiting risks bowel strangulation
›Therapy is not working troubleshooting
›Recurrent or worsening pain after conservative management
›Escalate to operative exploration rather than repeating imaging alone
Band slippage, erosion, and port infection management
›Acute band slippage with obstruction
›Emergency band deflation
›Access the subcutaneous port with a noncoring Huber-point needle
›Aspirate all fluid from the band, typically 4 to 10 mL of saline
›Relieves acute obstruction and reduces strangulation and erosion risk while awaiting definitive surgical management
›Surgical consultation for definitive band repositioning or removal
›Band erosion
›Band removal, typically via laparoscopy or endoscopic-assisted retrieval
›Antibiotics for associated infection
›Port infection
›Antibiotics targeting skin flora
›Cefazolin IV 1 to 2 g every 8 hours or equivalent
›Port site drainage or removal if abscess or persistent infection
›Evaluate for underlying erosion as a cause of infection
Marginal ulcer and perforation management
›Marginal ulcer without perforation
›Proton pump inhibitor therapy
›Pantoprazole IV 80 mg bolus then 8 mg/hour continuous infusion for active bleeding
›Transition to oral pantoprazole 40 mg twice daily once tolerating intake
›Discontinue NSAIDs permanently
›Smoking cessation counseling
›Endoscopic evaluation and biopsy to exclude a gastrogastric fistula as the underlying cause
›Marginal ulcer perforation
›Immediate general or bariatric surgery consultation
›Operative repair, typically laparoscopic
›Broad-spectrum antibiotics as above for leak or peritonitis
VTE prophylaxis and anticoagulation cautions
›Venous thromboembolism prophylaxis
›Enoxaparin subcutaneous 40 mg daily
›Weight-based dose adjustment considered in severe obesity per institutional protocol
›Renal dosing adjustment when eGFR less than 30 mL/min
›Mechanical prophylaxis with intermittent pneumatic compression
›Extended outpatient chemoprophylaxis for 2 to 4 weeks after discharge in high-risk patients
›Anticoagulation caution
›Hold therapeutic anticoagulation if occult leak, bleeding, or planned reoperation suspected
›Confirm hemodynamic stability and absence of active bleeding before initiating full-dose anticoagulation for confirmed pulmonary embolism
›Fibrinolysis caution
›Relatively contraindicated within weeks of abdominal surgery
›Bleeding risk at fresh staple lines and anastomoses
›Catheter-directed or surgical embolectomy preferred for massive pulmonary embolism in this population
Wernicke encephalopathy and micronutrient repletion
›Thiamine administration
›Thiamine IV 500 mg every 8 hours for 2 to 3 days
›Verify against current guideline before use
›Followed by thiamine IV or IM 250 mg daily for 5 days
›Verify against current guideline before use
›Then oral thiamine 100 mg daily maintenance
›Administer thiamine before any dextrose-containing fluid
›Carbohydrate load without thiamine can precipitate or worsen Wernicke encephalopathy
›Do not delay treatment awaiting a confirmatory thiamine level
›Empiric treatment for any patient with persistent vomiting and altered mental status, ataxia, or ophthalmoplegia
›Refeeding syndrome monitoring
›Check phosphate, potassium, and magnesium mmol/L before and during nutritional repletion
›Replace potassium chloride IV 10 to 20 mmol over 1 hour, via central line if greater than 10 mmol in 1 hour
›Replace magnesium sulfate IV 8 mmol (2 g) over 1 hour
›Replace potassium phosphate IV 15 to 30 mmol over 2 to 6 hours
›ECG monitoring during electrolyte repletion
›QT prolongation and U waves from hypokalemia and hypomagnesemia
›Advance nutrition slowly and monitor electrolytes closely for the first 3 to 5 days of repletion
›Other micronutrient repletion
›Vitamin B12 IM 1000 micrograms monthly or high-dose oral maintenance
›Iron replacement for deficiency anemia
›Copper replacement when deficiency confirmed, particularly with unexplained neurologic deficits
›Fat-soluble vitamin A, D, E, K repletion in malabsorptive procedures
›Correct coagulopathy from vitamin K deficiency before invasive procedures