Singer-songwriter Lisa Marie Presley died from a “strangulated,” or twisted, small bowel on Jan.12, surprising many fans who had seen her attend the Golden Globe awards ceremony just days before. The daughter of the late Elvis Presley was 54 years old.

The Los Angeles medical examiner ruled Presley died of natural causes and, in a report issued last week, linked her small bowel obstruction to bariatric surgery she had years earlier. CNN, which first obtained the autopsy, said it included the official opinion of deputy medical examiner Juan M. Carrillo, MD, who said the obstruction was caused by “adhesions (or, scar tissue) that developed after bariatric surgery years ago. This is a known long-term complication of this type of surgery.” 

Surgery experts don’t dispute that a cutoff of blood supply to her small bowel, also known as the small intestine, led to her death. But they’re less certain that internal scarring from previous weight loss surgery is to blame.

“It just doesn’t make exact sense to all of us [surgeons],” said Marina Kurian, MD, president of the American Society for Metabolic and Bariatric Surgery. “It sounds like she had a bowel obstruction for sure. But it’s not clear to me … that it is related to the bariatric surgery, because those scars would be right up by the liver and the stomach, and the small intestine is not usually up there.”

Presley reported belly pain earlier that day, according to the medical examiner. It’s unclear if her pain had persisted for days or come and gone in severe bouts, which are common signs of bowel obstruction. Vomiting and abdominal distention – when air or fluid gathers in the belly and causes it to expand – are also common.

In many cases, bowel obstructions can be treated if medical care is sought early enough. “The message is obviously if you have abdominal pain, and it’s persistent abdominal pain, go see a physician,” Kurian said.

Not All Bariatric Procedures are the Same

Bariatric surgery includes many different procedures, and Kurian thinks from the medical examiner’s report that Presley most likely had a single anastomosis duodenal ileostomy (SADI). This kind of procedure lowers food intake by reducing the stomach size and limiting the absorption of food by bypassing part of the small intestine.

A bowel obstruction can occur after many types of surgery, not just bariatric procedures. Gynecologic surgery, urinary system surgery, and general abdominal surgeries can leave internal scarring that causes this complication, said Kurian. “So it could very well have been from some other surgery.”

Dr. Stacy Brethauer, bariatric surgeon, warns untreated bowel obstructions may cause blood supply cut off, as in Ms. Presley’s case.

Brethauer stated that the majority of bariatric surgeries past two decades were minimally invasive, reducing scarring compared to open surgery.

“Fortunately, bowel obstructions are quite rare now after laparoscopic bariatric surgery and occur in only 1-2% of patients long-term,” he said.  

Short- and Long-Term Risks

Overall, the risks of bad outcomes after weight loss surgery are “very, very low,” Kurian said. Short-term risks include leaks, bleeding, infection, and blood clots. Long-term adverse effects can include bowel obstruction and malnutrition. The risk of malnutrition from lower absorption of nutrients can be lessened by patients taking multivitamins, for example. 

For the vast majority of patients seeking bariatric surgery, the benefits far outweigh the risks, both in the short term and long term, Brethauer said.  Benefits include a significant reduction in long-term deaths, cancer risk, cardiovascular disease, and diabetes.

“Physicians should counsel patients that bariatric surgery, like any surgical procedure, has some inherent risks,” he added. Mortality rates are currently less than 0.1% and major short- and long-term complication rates range from 1% to 4%.

Risks differ based on patients and bariatric procedures (sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric band).

Whether the association with bariatric surgery was behind Presley’s death, “It’s so important to outline how safe bariatric surgery actually is. We get most people through surgery ‘healthy, hale and hearty,’” Kurian said. 

Anti-Obesity Medications vs. Surgery?

Kurian expressed doubt about decreasing weight loss surgery due to the popularity of anti-obesity medications like Wegovy and Ozempic.

“Bariatric surgery, actually, I think will not drop off,” she said. “These drugs are helpful, but the ones that we currently have have not taken off as much weight as surgery.”

Kurian believes surgery offers a more durable approach to treating severe obesity. 

Customize obesity treatment, meds, or surgery based on discussions between patients and doctors, considering individual needs. It also depends, in part, on how much weight a person would need to lose to be healthier, Kurian said. 

“These medications are a fantastic addition to our armamentarium for the treatment of obesity,” Brethauer said. “Injectables mimic gut hormone changes post-bariatric surgeries, e.g., gastric bypass, sleeve gastrectomy, and duodenal switch.”

“Both bariatric surgery and pharmacological agents like 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,” Brethauer added. The biggest difference between the two approaches is changes from surgery are more permanent compare to the medications that require taking on an ongoing basis. 

On the plus side, more people are talking about obesity with the popularity of Wegovy, Ozempic, and other anti-obesity medications. Kurian’s insight removes obesity stigma, highlighting that it’s beyond diet and exercise, fostering understanding and empathy.

“People gaining insight into weight struggles as they learn about physiological and hormonal factors affecting weight loss—empowering and reassuring.”

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