32 year old women with a BMI of 60 presented with severe Gallstone disease.ERCP was performed to clear the Bile duct 2days prior to her admission.GallBladder was gangrenous and full of pus.Lap chole was difficult but no adverse events.Her temperature was swinging at 101 which is settling.She has no other comorbidities.
Any given day, this lady with a BMI of 60 is not going to be easy! You have done very well to get her out of her biliary problem just now. I would wait atleast a month before doing anything. Perhaps this waiting time could be well utilised by her for dietary adjustments to have her liver shrunk as much as possible. After a month, she could have her biliary stent removed (if it was placed) and then be listed for bariatric surgery.
As bariatric surgery is high risk surgery, I would put in a gastric balloon for 6 months to lower her initial weight, and perform surgery after 6 months Bariatric surgery is NEVER urgent and should ALWAYS be performed in the best circumstances even if a patient thinks it's urgent. Take your time for planning and do not let the patient rush you in to things.
The main issue about the timing of bariatric and biliary surgery is the possible need to endoscopically access the biliary tree after the bariatric procedure, in particular after a RY gastric bypass. When you feel confident that this risk is minimized (and your patient already had a laparoscopic cholecystectomy and a ERCP with a probable sphyncterotomy) you could plan her bariatric surgery. Of course, I agree with Guido Jutten that bariatric surgery is not urgent and a patient with a BMI of 60 should undergo a preoperative weight reduction plan, and a gastric balloon should be considered along with a period of ketogenic diet: another problem you are going to face is the technical difficulty of performing bariatric surgery due to the liver enlargement, visceral fat along with the adhesions of the previous inflammatory state. Of course, you want to operate after having maximized the preoperative weight loss and liver size reduction.
6 weeks is the golden interval before you can undertake any other elective procedure in Her provided all other conditions are controlled. I also agree with Mr Fabio about the accessibility of Biliary tree. Once all the other parameters are controlled Its entirely your decision to whether go for RYGB/ any other Bariatric procedure or Balloon followed by RYGB depending on the available expertise and experience.
I think the two issues are (1) is the patient fully recovered from recent surgery & the sepsis from Gangrenous cholecystitis?
If the answer is yes then the next issue (2) when is the ideal time to proceed with Bariatric surgery?
is this a bypass or sleeve? either way I would expect adhesions between liver & stomach.
So 6 weeks delay to allow full recovery & organization of adhesions seems logical.
Goodluck.