Rhabdomyolysis after Bariatric Surgery

Background: Rhabdomyolysis is a potential threat after bariatric surgey. The severity ranges from asymptomatic elevations of serum muscle enzyme levels to life-threatening cases associated with muscle necrosis, compartment syndrome, acute renal failure and cardiac arrest. Methods: We studied 98 consecutive obese patients who underwent primary uncomplicated bariatric surgery during a 1-year period. A database was created for all patients (sex, age, BMI, duration of the operation); serum creatinine phosphokinase (CPK) was systematically measured before surgery and on the first and second postoperative day. Results: The study sample consisted of 35 males (35.7%) and 63 females (64.3%) with preoperative CPK level 156.6 ± 41.1 U/L (40 to 220), 24 hours postoperatively 1,075.2 ± 596.5 U/L, (85 to 2,790 U/L) and 48 hours postoperatively 967.3 ± 545.3 U/L (79 to 2,630). There was no difference in mean BMI (P=0.1) and mean duration of operation (P=0.5) between males and females. However, a statistically significant difference in mean elevation of CPK between males and females (P=0.003) was found. The variables sex, age, weight and duration of surgery were analyzed by multivariate logistic regression, but did not show a statistically significant difference. Conclusion: Rhabdomyolysis is a potentially fatal complication of surgical procedures in obese patients, and can be minimized with simple measures such as additional padding, aggressive hydration and urine alkalinization. Diagnosis requires a high level of physician awareness.     

Rhabdomyolysis after intraoperative myelography

This case report suggests that the nonionic contrast agents may cause myoclonic spasms and seizures like the ionic ones. A 14-year-old female with congenital scoliosis was scheduled for T2-L3 scoliosis surgery. She had no medical history of a seizure disorder. After a negative wake-up test, myelography was performed with iohexol. Myoclonic spasms, disseminated intravascular coagulopathy (DIC) and rhabdomyolysis were diagnosed postoperatively. Anaesthesiologists should be aware of the complications which may occur after the use of nonionic and water-soluble contrast agents.     

Rhabdomyolysis after penetrating trauma

Rhabdomyolysis (RHAB) is a known complication following blunt trauma. RHAB after penetrating trauma has not been studied. The objective of this study was to evaluate the incidence, risk factors, and complications of RHAB following penetrating trauma. Over a 5-year period, penetrating trauma patients admitted to our intensive care unit (ICU) were studied. Significant RHAB was defined as a CK level of 5000 U/L or higher. There were 873 patients (29 +/- 12 years old, 92% male), of whom 767 (88%) had abnormal CK levels (range 520-165,943 U/L), and 111 patients (13%) developed significant RHAB. Victims of penetrating trauma who sustain vascular and severe extremity injury are at a sixfold increased risk to develop significant RHAB. Patients with significant RHAB had a higher rate of renal failure (23% vs 7%, P < 0.0001) and longer ICU stay (15 +/- 26 days vs 8 +/- 12 days, P < 0.0001). CK elevations and significant RHAB are common after penetrating trauma. Patients who sustain vascular and severe extremity injury as a result of their penetrating wounds are at high risk to develop significant RHAB, resulting in renal failure and prolonged ICU stay. Therefore, critically injured penetrating trauma patients should be routinely screened with CK levels.     

Rhabdomyolysis following renal autotransplantation

A 26-year-old male body builder diagnosed with renal artery stenosis and middle aortic syndrome underwent an autotransplantation with bench reconstruction and end-to-end anastomosis using the hypogastric artery. Shortly after the procedure, the patient developed rhabdomyolysis and renal insufficiency, possibly related to his increased muscle mass, potentially greater susceptibility to hypertrophic skeletal muscle cells or his unique vascular condition. We review the risk factors, diagnosis, management and outcome of a case of rhabdomyolysis in a male patient who underwent autotransplantation for renal vascular hypertension.     

Rhabdomyolysis and operating position

Rhabdomyolysis during routine surgery was studied in three groups of patients who had surgery, with limited trauma to muscle, in the lateral and supine positions, and prone on the spinal frame. A range of blood tests was performed (before surgery, and on the first, third and seventh day after operation). These showed that a creatine kinase increase in the 24 hours and the early appearance of myoglobin in the serum were the best indicators. Rhabdomyolysis was associated with the lateral position and long lasting surgery. No blood test before surgery was of any predictive value.     

Rhabdomyolysis after laparoscopic nephrectomy.

BACKGROUND AND OBJECTIVES: Laparoscopic renal surgery has become a widely applied technique in recent years. The development of postoperative rhabdomyolysis is a known but rare complication of laparoscopic renal surgery. Herein, 4 cases of rhabdomyolysis and a review of the literature are presented with respect to pathogenesis, treatment, and prevention of this dire complication. METHODS: A retrospective review of over 600 laparoscopic renal operations over the past 8 years was performed. All cases of postoperative rhabdomyolysis were identified. A Medline search was performed to find articles related to the development of postoperative rhabdomyolysis. Cases of rhabdomyolysis developing after laparoscopic renal surgery and common risk factors between cases were identified. RESULTS: The incidence of postoperative rhabdomyolysis in our series is 0.67%. It is similar to the rate reported in other series. Male sex, high body mass index, prolonged operative times, and the lateral decubitus position are all risk factors in its development. CONCLUSION: The prevention and optimal management of postoperative rhabdomyolysis following laparoscopic renal surgery has yet to be defined. The risk factors we identified should be carefully addressed and minimized. A better understanding of the pathogenesis of rhabdomyolysis will also be a key component in its prevention.     

Rhabdomyolysis after laparoscopic donor nephrectomy

Rhabdomyolysis is a postoperative complication that may result in acute renal failure owing to excessive myoglobinuria. After uncomplicated laparoscopic left transperitoneal donor nephrectomy, a 32-year-old man developed anuric acute renal failure secondary to postoperative rhabdomyolysis that required intermittent hemodialysis for 2 weeks. The presumed risk factors in this case were the patient's high body mass index, intraoperative flank position with flexion, a solitary kidney, and the duration of surgery. Our current surgical technique has been modified to drop the kidney bridge early, immediately after visualization of the hilum.     

Postoperative Rhabdomyolysis with Bariatric Surgery

Rhabdomyolysis has been reported in all postoperative patients including those in prone, supine, lithotomy and lateral decubitus positions. Only a few reports suggest that bariatric surgical patients are at risk for rhabdomyolysis. We describe a male (BMI 69 kg/m²) who underwent an uneventful open Roux-en-Y gastric bypass for weight reduction lasting 5 hours. Postoperatively the patient suffered oliguria. Evaluation included subjective pain in both hips, a normal temperature and physical examination, creatinine increase to 3.5 mg/dl, CPK levels as high as 41,000 IU/L, and urinalysis showing a large amount of occult blood with 5-7 RBCs/HPF. Intravenous hydration with 0.9% normal saline, bicarbonate, and mannitol demonstrated initial success, but the patient eventually developed renal failure, respiratory distress, and tachycardia leading to cardiac arrest. Prior to his death, intraoperative evaluation demonstrated intact anastomoses. Obese patients undergoing bariatric surgery should be considered at risk for rhabdomyolysis, especially in view of prolonged surgeries, difficult physical examination, low volume status, and larger or immobile patients.