GS27 - Roles of Osteopathic Manipulative Treatment in Reducing Post-Bariatric Surgery Complications: Systematic Review

Introduction/Purpose: Bariatric surgery has become increasingly common to treat chronic obesity with the long-term goal of reducing mortality. In the United States, bariatric procedures such as laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) have become the most effective weight loss method, resulting in partial or complete resolution of obesity-related comorbidities. However, as with all surgical procedures, bariatric surgery has the potential for intraoperative and postoperative complications, which may vary in timing and severity. Understanding and treating such postoperative complications have been incorporated into osteopathic training since the earliest history of osteopathic medicine. This study aims to identify long-term complications likely to arise in a post-bariatric surgery patient. Additionally, this study discusses the role of osteopathic manipulative treatment (OMT) principles in early diagnosis. It highlights potential benefits OMT may have as an alternative or augmented treatment method in reducing risks associated with managing postoperative complications.

Methods or Case Description: This study is a systematic review of 248 articles published between 2017 to 2022 identified through PubMed. The search keywords are “bariatric surgery” and “postoperative complications.” Exclusion criteria include articles not written in English and studies performed on non-human subjects. Three investigators reviewed the articles and extracted different types of post-surgery complications and number of patients diagnosed with each complication as reported in the articles. One investigator reviewed the Guidelines for Perioperative Care in Bariatric Surgery: Enhanced Recovery After Surgery (ERAS) Society

Recommendations: 2021 Update to identify the current standard of non-OMT associated treatment. While referencing Michael Seffinger’s Foundations of Osteopathic Medicine (4th ed.) and Nicholas and Nicholas’s Atlas of Osteopathic Techniques (4th ed.), investigators proposed specific OMT techniques that could potentially reduce the risk of the identified complications when applicable.

Figure 1. PRISMA flow chart displaying article retrieval and exclusion process

Outcomes: A total of 248 articles were identified via PubMed, of which ninety-nine were included. Detailed information is provided in Figure 1.

Upon literature review, complications most likely treatable with OMT were identified (Table 1) based on prior knowledge that these complications have responded to OMT in non-surgical scenarios. Complications, such as postoperative nausea/vomiting (PONV), constipation, and small bowel obstruction (SBO) or ileus, occur earlier in the postoperative period, while acid reflux and malabsorption are long-term. This systematic review determined malabsorption-derived deficiencies of vitamins (25.2%), iron (35.5%), and calcium (37.87%) as the most common GI-related complications, followed by PONV (20.96%). Gallbladder disorders (3.43%) were noted to be the most common non-GI complication, followed by liver (0.9%), lungs (0.2%) and heart (0.01%).

Table 1 summarized GI and non-GI complications, number of patients reported in each article, recommended guidelines, and the proposed OMTs categorized into diagnostic and therapeutic management. Diagnostic methods include viscerosomatic reflexes (SD at specific spinal cord levels corresponding with innervated viscera) and Chapman points (region-specific congestion and tissue reactions due to viscero-autonomic reflexes). Either strategy may be applied to the post-bariatric complications discussed.

The treatments discussed in Atlas of Osteopathic Techniques aim to alleviate SD with passive techniques, including reflex-oriented therapy, myofascial release, balanced ligamentous tension, and vibratory/stimulatory techniques. Passive methods require minimal patient exertion while treating the facilitated segment, a spinal level maintained in a state of partial excitation. Some treatments may benefit multiple complications, such as rib raising [pulmonary complications (0.2%) and ileus (1.4%)] and myofascial treatments [acid reflux (6.95%), gallbladder complications (3.4%), and liver complications (0.9%)].

Table 1. Proposed OMT techniques for gastrointestinal and non-gastrointestinal post-bariatric surgical complications

Conclusion: Osteopathic literature highlights a relationship between somatic dysfunction and alimentary tract function. This implies a role for OMT in treating complications of the gastrointestinal system, including those that occur after bariatric surgery. Though OMT is unlikely to effectively treat short-term postoperative complications such as staple line leaks and strictures, it has a potential benefit when used as an adjunct to standard guidelines. This study focuses on complications in a postoperative situation, and the complications identified, such as acid reflux, have successfully been treated with OMT in non-perioperative conditions. This study also indicates that OMT can treat other physiologic systems. Enhancing pre-treatment relaxation with suboccipital release before performing a non-exertional passive technique allows OMT to be more versatile in managing post-surgical complications.

Incorporating OMT in long-term management provides the benefit of administering uncomplicated techniques, such as the passive treatments discussed in the outcomes section of this study. Another advantage of therapeutic OMT is its multipurpose nature; as when treatment with rib raising prevents both pulmonary complications and long-term ileus. Achieving multiple results with OMT sessions could limit unnecessary clinic visits or hospital readmissions, prevent potential medication overdose, and avoid reliance on pain medications. OMT can either be performed by an osteopathic surgeon during inpatient admission or clinic follow-up or by an outpatient osteopathic specialist. Lastly, OMT occasionally provides an alternate option when standard treatment poses greater risk than benefit. For example, PPIs have multiple adverse effects associated with prolonged use. The risk of unnecessary harm can be eliminated by substituting a higher PPI dosage with OMT. This study, therefore, encourages incorporating OMT as part of long-term management for post-bariatric surgery patients to minimize post-surgery complications.