July 17, 2023 – Singer-songwriter Lisa Marie Presley died on January 12 of a “strangulated” small intestine torsion, surprising many fans who had seen her just days earlier on the Golden Globe Awards. The daughter of the late Elvis Presley was 54 years old.
The Los Angeles County Medical Examiner ruled Presley died of natural causes and, in a report released last week, linked her small bowel obstruction to bariatric surgery she had years earlier. CNN, which first obtained the autopsy, said it contained the official opinion of deputy medical expert Juan M. Carrillo, MD, who said the obstruction was brought on by “adhesions (or scar tissue) that formed after bariatric surgery years ago. This is a known long-term complication of this type of surgery.”
Surgical experts don’t dispute that a disruption within the blood supply to her small intestine led to her death. But they’re less certain that internal scarring from a previous weight-loss surgery is the cause.
“It just doesn’t make sense to any of us [surgeons],” said Dr. Marina Kurian, president of the American Society for Metabolic and Bariatric Surgery. “It sounds like she definitely had an intestinal obstruction. But it's not clear to me … if that's related to the bariatric surgery, because those scars would be right on the liver and stomach, and the small intestine isn't normally up there.”
According to the medical expert, Presley had abdominal pain that very same day. It is unclear whether her pain lasted for several days or got here and went in violent bouts, that are common signs of intestinal obstruction. Vomiting and Flatulence – when air or fluid collects within the abdomen and causes it to expand – are also common.
In many cases, bowel obstructions will be treated if medical attention is sought early enough. “The message is, of course, if you have abdominal pain, and persistent abdominal pain, go see a doctor,” Kurian said.
Not all bariatric procedures are the identical
Bariatric surgery involves many alternative procedures, and Kurian believes based on the medical expert's report that Presley probably had a straightforward duodenal ileostomy (SADI). This variety of procedure reduces food intake by reducing the scale of the stomach and limits food intake by bypassing a part of the small intestine.
Bowel obstruction can occur after many sorts of surgery, not only bariatric surgery. Gynecological surgery, surgery on the urinary system and general abdominal surgery can leave internal scars that cause this complication, Kurian said. “So it could very well be from another surgery.”
If left untreated, intestinal obstructions can cut off blood supply, “which is unfortunately what happened in Ms. Presley's case,” says Dr. Stacy Brethauer, a bariatric surgeon and professor within the division of general and gastrointestinal surgery at Ohio State University's Wexner Medical Center.
Almost all bariatric surgery over the past twenty years has been performed using minimally invasive techniques reminiscent of laparoscopy, which cause less scarring than open surgery, Brethauer said.
“Fortunately, bowel obstructions after laparoscopic bariatric surgery are now quite rare and only occur in 1-2% of patients in the long term,” he said.
Short and long-term risks
Overall, the chance of poor outcomes after weight reduction surgery is “very, very low,” Kurian said. Short-term risks include incontinence, bleeding, infections and blood clots. Long-term negative effects can include intestinal obstruction and malnutrition. The risk of malnutrition because of lower nutrient absorption will be reduced by taking multivitamin supplements, for instance.
For the overwhelming majority of patients who undergo bariatric surgery, the advantages outweigh the risks in each the short and long run, Brethauer said. The advantages include significant reductions in long-term death, cancer risk, heart problems and diabetes.
“Doctors should advise their patients that bariatric surgery, like any surgical procedure, carries certain risks,” he added. The mortality rate is currently lower than 0.1% and the speed of great short- and long-term complications is between 1% and 4%.
Risks also vary depending on individual patient aspects and the variety of bariatric procedure, reminiscent of sleeve gastrectomy, Roux-en-Y gastric bypass, or adjustable gastric banding.
It is unclear whether the connection to bariatric surgery was the rationale for Presley's death. “It is so important to show how safe bariatric surgery really is. Most people come through the operation healthy and happy,” Kurian said.
Anti-obesity drugs or surgery?
When asked whether the growing popularity of anti-obesity drugs reminiscent of Wegovy or the off-label use of Ozempic would result in a decline within the variety of weight-loss surgeries, Kurian expressed doubts.
“I believe bariatric surgery is not going to make people lose weight,” she said. “These medications are helpful, but the ones we currently have haven't saved as much weight as surgery.”
Kurian believes that surgery is a more sustainable method for treating severe obesity.
Ultimately, the choice about obesity medications and/or bariatric surgery needs to be individualized and based on a discussion between patient and doctor. It also depends partly on how much weight an individual would want to lose to be healthier, Kurian said.
“These drugs are a fantastic addition to our arsenal for treating obesity,” Brethauer said. “These injectable drugs actually mimic the same gut hormone changes we see after metabolic surgeries like gastric bypass, sleeve gastrectomy and duodenal switch.”
“Both bariatric surgery and pharmacologic agents such as the GLP-1 receptor agonists are safe and effective, and we use these medications before and after surgery to promote additional weight loss and control hunger,” added Brethauer. The biggest difference between the 2 approaches is that the changes from surgery are more everlasting than with the medications, which have to be taken repeatedly.
On the positive side, with the recognition of Wegovy, Ozempic and other obesity drugs, more individuals are talking about obesity. This could help reduce the stigma around obesity, Kurian said, and “it makes everyone realize that it's not just about diet and exercise.”
“It's wonderful that people are being helped to understand that it's not their fault that they're failing, but that there are physiological and hormonal reasons why they can't lose weight easily.”