Postoperative Wound Dehiscence and Fistulas After Short-Interval Hysterectomy Following Bariatric Surgery

Postoperative Wound Dehiscence and Fistulas After Short-Interval Hysterectomy Following Bariatric Surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Postoperative Wound Dehiscence and Fistulas After Short-Interval Hysterectomy Following Bariatric Surgery Rachel Fleddermann, Tiffany Chang, Katherine Stansberry, Janifer Tropez, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9004071/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background: The effect of bariatric procedures on outcomes of gynecologic surgery is poorly defined. Case: A 47-year-old underwent a laparoscopic Roux-en-Y gastric bypass, followed seven weeks later by elective abdominal hysterectomy. An appendectomy was performed for appendiceal adhesions to the uterus and intraoperative cystoscopy was normal. The immediate postoperative course was unremarkable. Ten days later, she presented with a large pelvic abscess, dehiscence at the appendectomy site, vaginal cuff dehiscence, and bladder injury. Management included vaginal cuff repair, ileostomy, and cystorrhaphy. She then developed vesicovaginal fistula and superficial wound dehiscence, requiring prolonged hospitalization, total parenteral nutrition, and conservative management until resolution. Conclusion: Dehiscence and complex fistula formation are potential complications of gynecologic surgery performed during the rapid weight loss phase following bariatric surgery. Hysterectomy bariatric surgery wound dehiscence Background Obesity increases the risk of postoperative complications such as venous thromboembolism and wound infections after gynecologic surgery. 1 Surgical weight loss improves glycemic control and tissue healing, potentially enhancing subsequent surgical outcomes. 2 However, bariatric procedures induce macro- and micronutrient deficiencies, especially during the rapid weight loss phase; nutrients including protein, glucose, fatty acids, vitamins A and C, zinc, and selenium are essential for wound healing. 3 , 4 National organizations have not offered specific guidance on the optimal timing of gynecologic surgery following bariatric surgery. Both the American Society for Metabolic and Bariatric Surgery and the American College of Obstetrics and Gynecology recommend delaying pregnancy after bariatric surgery for 12 to 24 months to allow for weight stabilization and nutritional optimization. 5 , 6 In the obstetric population, prior bariatric surgery is associated with reduced rates of pregestational diabetes and hypertensive disorders. However, pregnancy within the first two years after bariatric surgery leads to an increased risk of preterm birth and small-for-gestational-age infants, highlighting the potential for poor health outcomes during the rapid weight loss phase. 6 , 7 Case A 47-year-old gravida 0 presented with abdominal pain, nausea, vomiting, and fever ten days after a total abdominal hysterectomy and bilateral salpingectomy for chronic pelvic pain at an outside hospital. Seven weeks earlier, she had undergone a laparoscopic Roux-en-Y gastric bypass, which was a revision of a prior sleeve gastrectomy. Her medical history included hypertension, treated with lisinopril-hydrochlorothiazide, and type 2 diabetes mellitus, which had resolved after initial bariatric surgery. Prior to the gastric bypass, her prealbumin and albumin levels were normal at 24.5 mg/dL and 3.9 g/dL, respectively. The hysterectomy was attempted laparoscopically but converted to laparotomy due to extensive adhesions. An appendectomy was performed by general surgery due to an adherent appendix at the uterine fundus. Cystoscopy performed at completion of hysterectomy was unremarkable. Her immediate postoperative course was uncomplicated, and she was discharged on postoperative day 2. On presentation to our emergency department on postoperative day 10, the patient was febrile to 101.2°F. Computed tomography (CT) imaging of the abdomen and pelvis revealed an 18-cm pelvic abscess. Laboratory evaluation showed a white blood cell count of 27,900/µL, hemoglobin of 6.6 g/dL, hematocrit of 20.9%, albumin of 3.1 g/dL (mildly low), and pre-albumin of 6.6 mg/dL (low). She was admitted to the gynecology service for intravenous antibiotics including pipercillin/tazobactam and vancomycin. She underwent CT-guided pelvic drain placement. The bariatric surgery team co-managed her care. She improved clinically with resolution of leukocytosis and fever. She received three units of packed red blood cells with an appropriate rise in her hemoglobin concentration. The abscess initially decreased in size on abscessogram. Diet was advanced and she received supplemental protein shakes. She was transitioned to oral antibiotic therapy on hospital day 5. On hospital day 6, the abdominal drain was noted to be malpositioned and exchanged, however imaging demonstrated persistent large abscess with possible gastrointestinal fistula. General Surgery was consulted and recommended continued conservative management with a drain. On hospital day 9, the patient reported bladder spasms with feculant material noted in the urinary catheter. Urology was consulted and conservative management was continued. On hospital day 12, the patient developed vaginal discharge consistent with enteric contents. She developed a fever on hospital day 13. She remained hemodynamically stable throughout her course. CT revealed cecal dehiscence at the appendectomy site with intraperitoneal stool collection. CT cystogram confirmed a fistulous connection between the pelvic collection and the anterior bladder. Due to failure of conservative management with drains, the patient was taken to the operating room on the same day which was post operative day 23 from hysterectomy. She underwent exploratory laparotomy via midline vertical incision with ileocecectomy, ileostomy creation and cystorrhaphy. The vaginal cuff was found to be completely dehisced with frank stool leaking into the vagina. The vaginal cuff was repaired with 0-Vicryl suture in an interrupted fashion. The patient was initially nil per os (NPO) following ileostomy creation. On postoperative day 1, her prealbumin level remained low at 8.4 mg/dL. The Bariatric Surgery team recommended total parenteral nutrition (TPN) with a protein goal of 80–100 g/day, which was initiated. Her diet was cautiously advanced over the next several days. On hospital day 20, six days after ileostomy, cystorrhaphy, and vaginal cuff repair, she developed painful bladder spasms with gushes of fluid from the vagina. CT imaging revealed a pelvic fluid collection with communication to the bladder and vagina. Interventional radiology drained the collection. On inspection and palpation, the vaginal cuff was grossly intact. Surgical repair of the fistula was deferred due to poor tissue healing. She was managed conservatively with bladder decompression via indwelling catheter, medical therapy for bladder spasms, and intravenous parenteral nutrition. The vaginal discharge improved and resolution of the vesicovaginal fistula was confirmed on repeat CT cystogram on post operative day 20 (hospital day 34). The Pfannenstiel incision from her hysterectomy and her midline laparotomy sites each developed a superficial dehiscence measuring several centimeters. The fascia and ileostomy site remained intact. The incisions were dressed with a sodium carboxymethylcellulose dressing and wet-to-dry packing changes daily. She was continued on intravenous antibiotics. Repeat abscessogram and colonoscopy showed closure of fistulous tracts. The patient underwent ileostomy reversal on hospital day 55. A negative pressure wound therapy device was applied to the superficially dehisced incision sites. From hospital day 55–60, her diet was advanced and she was weaned off TPN. She was discharged on hospital day 61 tolerating a regular diet and exhibiting normal bowel and bladder function. She received home health services for wound care. Prealbumin was still low but improved to 10.8 mg/dL at the time of discharge and had returned to normal at 28.1 mg/dL eight months later. Discussion Bariatric surgery improves long-term health outcomes through sustained weight loss, resulting in better control and resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension. Patients experience a reduced risk of stroke and myocardial infarction. 8 , 9 However, the effect of bariatric surgery on outcomes of subsequent surgeries is less well understood. While weight loss could reduce anatomic distortions associated with obesity, improve access to relevant structures, and reduce operative times, nutritional deficiencies could impair wound healing. Bariatric surgery is followed by a period of nutrient malabsorption and in some cases, malnutrition. Weight loss usually plateaus two years after surgery, but the duration of nutrient malabsorption is poorly defined and can vary depending on procedure type. 1 , 3 Deficiencies in protein, iron, vitamin D, calcium, vitamin B12, folic acid, vitamin A, copper, zinc selenium, and thiamine have been observed. 3 , 10 , 11 Lipid metabolism is substantially altered. 12 Glucose is essential for angiogenesis and new tissue formation while fatty acids contribute to the structure of cells. Micronutrients such as zinc and iron are essential cofactors for enzymatic reactions in tissue healing. Protein and vitamin C are essential for collagen synthesis. 4 While research on surgical outcomes after bariatric surgery remains limited, existing data have shown mixed surgical outcomes. A study of 669 patients found that patients with a history bariatric surgery undergoing hysterectomy had a reduced risk of any intraoperative complications during hysterectomy compared to patients with body mass index (BMI) > 40 kg/m2 and no bariatric surgery (odds ratio 0.32; 95% CI 0.13–0.77). However, women with a history of bariatric surgery had an increased frequency of postoperative cuff dehiscence (p = 0.04). Most patients in that investigation (75.6%) had bariatric procedure more than two years prior to their hysterectomy; there was no difference in perioperative complications in patients who had bariatric surgery within two years before hysterectomy. 2 A separate cohort study using a national insurance database demonstrated that patients with a history of bariatric surgery who underwent hysterectomy had a lower risk of intraoperative and immediate postoperative complications compared those who had never had bariatric surgery, even when matched by BMI at time of hysterectomy admission. Relative risk of any complication was 1.048 (95% CI 1.06–1.09) for the non-bariatric surgery group. Bariatric procedure type and the interval between bariatric surgery and hysterectomy were not reported. 13 The non-gynecologic literature offers additional insights. Surgical weight loss preceding total knee arthroplasty was associated with decreased incidence of postoperative wound complications, prosthetic infections, and unplanned hospital re-admission. 14 Patients undergoing abdominoplasty with prior history of bariatric surgery had a higher rate of wound complications than abdominoplasty patients without a history of bariatric surgery. 15 Our patient underwent elective surgery when her body was depleted of the nutrients required to heal postoperatively, as evidenced by a low prealbumin level at hospital readmission. The patient experienced poor wound healing and spontaneous breakdown of the incisions of multiple tissues, including bowel, bladder, vaginal cuff, and abdominal wall. Even after attempted surgical repair, the tissue failed to heal and she continued to experience complex fistulas. With time and continued intravenous nutritional supplementation, the tissues gradually healed and the fistulas resolved without further surgical intervention. Bariatric surgery should be considered a relative contraindication to elective gynecologic surgery in the acute weight loss phase. As some data have demonstrated a benefit of bariatric surgery on hysterectomy outcomes, further research is needed into the optimal interprocedural interval between the two operations. Declarations Ethics approval and consent to participate: Ethics approval was not applicable. The patient described in this case report gave written informed consent for their personal or clinical details along with any identifying images to be published in this study. Consent for publication: Signed consent has been obtained from the patient described in this case report. Availability of data and materials: Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study Competing Interests: The authors declare that they have no competing interests Funding: Not applicable Authors’ contributions: RF analyzed the medical record of the patient about whom the case report is written, contributed to the background research, and was the primary author on the manuscript. TF, KS, JT, and AN contributed to the background research, chart review, and writing the manuscript. All authors read and approved the final manuscript. Acknowledgements: Not applicable References Committee opinion no. 619: Gynecologic surgery in the obese woman. Obstet Gynecol . Jan 2015;125(1):274-278. doi:10.1097/01.aog.0000459870.06491.71 Whitley J, Moore KJ, Carey ET, Louie M. The Effect of Bariatric Surgery on Perioperative Complications after Hysterectomy. J Minim Invasive Gynecol . Sep-Oct 2020;27(6):1363-1369. doi:10.1016/j.jmig.2019.12.011 Agha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. Plast Reconstr Surg . Aug 2008;122(2):604-613. doi:10.1097/PRS.0b013e31817d6023 Russell L. The importance of patients' nutritional status in wound healing. Br J Nurs . Mar 2001;10(6 Suppl):S42, s44-9. doi:10.12968/bjon.2001.10.Sup1.5336 American Society for Metabolic and Bariatric Surgery Public Education Committee. Life after bariatric surgery. https://asmbs.org/patients/life-after-bariatric-surgery/ ACOG practice bulletin no. 105: bariatric surgery and pregnancy. Obstet Gynecol . Jun 2009;113(6):1405-1413. doi:10.1097/AOG.0b013e3181ac0544 Parent B, Martopullo I, Weiss NS, Khandelwal S, Fay EE, Rowhani-Rahbar A. Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications. JAMA Surg . Feb 1 2017;152(2):128-135. doi:10.1001/jamasurg.2016.3621 Brown AM, Yang J, Zhang X, Docimo S, Pryo AD, Spaniolas K. Bariatric Surgery Lowers the Risk of Major Cardiovascular Events. Ann Surg . Nov 1 2022;276(5):e417-e424. doi:10.1097/sla.0000000000004640 Hua Y, Lou YX, Li C, Sun JY, Sun W, Kong XQ. Clinical outcomes of bariatric surgery - Updated evidence. Obes Res Clin Pract . Jan-Feb 2022;16(1):1-9. doi:10.1016/j.orcp.2021.11.004 Mechanick JI, Apovian C, Brethauer S, et al. CLINICAL PRACTICE GUIDELINES FOR THE PERIOPERATIVE NUTRITION, METABOLIC, AND NONSURGICAL SUPPORT OF PATIENTS UNDERGOING BARIATRIC PROCEDURES - 2019 UPDATE: COSPONSORED BY AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY, THE OBESITY SOCIETY, AMERICAN SOCIETY FOR METABOLIC & BARIATRIC SURGERY, OBESITY MEDICINE ASSOCIATION, AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS - EXECUTIVE SUMMARY. Endocr Pract . Dec 2019;25(12):1346-1359. doi:10.4158/gl-2019-0406 Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care . Sep 2004;7(5):569-75. doi:10.1097/00075197-200409000-00010 Hindsø M, Lundsgaard A, Marinkovic B, et al. Fat absorption and metabolism after Roux-en-Y gastric bypass surgery. Metabolism . Jun 2025;167:156189. doi:10.1016/j.metabol.2025.156189 Young MC, Bhandarkar AR, Portela RC, et al. Bariatric surgery reduces odds of perioperative complications after inpatient hysterectomy: Analysis from a national database, 2016 to 2018. Surgery . Oct 2023;174(4):766-773. doi:10.1016/j.surg.2023.06.018 Dowsey MM, Brown WA, Cochrane A, Burton PR, Liew D, Choong PF. Effect of Bariatric Surgery on Risk of Complications After Total Knee Arthroplasty: A Randomized Clinical Trial. JAMA Netw Open . Apr 1 2022;5(4):e226722. doi:10.1001/jamanetworkopen.2022.6722 Breiting LB, Lock-Andersen J, Matzen SH. Increased morbidity in patients undergoing abdominoplasty after laparoscopic gastric bypass. Dan Med Bull . Apr 2011;58(4):A4251. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 17 Apr, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers agreed at journal 12 Apr, 2026 Reviewers agreed at journal 05 Apr, 2026 Reviewers invited by journal 03 Apr, 2026 Editor assigned by journal 31 Mar, 2026 Editor invited by journal 12 Mar, 2026 Submission checks completed at journal 11 Mar, 2026 First submitted to journal 11 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9004071","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":617859466,"identity":"fa40b6a0-2f45-45b3-a0dc-b71ca684b709","order_by":0,"name":"Rachel Fleddermann","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYDAC5sMNDDxsUM4HBgYZCIsNpwagXCJCC+OMBAYe0rQw8xCjxbyNsfHBmzKbfN32s8ce2/44zMM/u/kAw4eywzi1yBxjbDaccy7NctuZvHTjnITDPBJ3jiUwzjiHW4uEfGObNG/bYQOzAzlm0iAtDDdyDJiBIri1sDG2/+Zt+29gdv6NmbQFUIv8jfwPzH/xa2kDmnnAwOwG0BYGoBaDGzkMzIz4tTRLzjmXDNTyxkyyJy2dx/BGmsHBnnPpeLQwH/zwpswO6LAcM4kfNtZycjeSHz74UWaNUwt2cIBE9aNgFIyCUTAK0AAAdZhS5Zxc6EEAAAAASUVORK5CYII=","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Fleddermann","suffix":""},{"id":617859467,"identity":"b96b3fc5-9ea9-4ff5-9b26-8a5240665130","order_by":1,"name":"Tiffany Chang","email":"","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tiffany","middleName":"","lastName":"Chang","suffix":""},{"id":617859468,"identity":"529b65e8-8818-4461-afc5-d56211699fa3","order_by":2,"name":"Katherine Stansberry","email":"","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Stansberry","suffix":""},{"id":617859469,"identity":"7c48aea4-4b18-4136-bfa4-df8ca12100d3","order_by":3,"name":"Janifer Tropez","email":"","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Janifer","middleName":"","lastName":"Tropez","suffix":""},{"id":617859470,"identity":"f2962d56-37c4-4264-82f9-83667c0d8e4f","order_by":4,"name":"Amber Naresh","email":"","orcid":"","institution":"Tulane University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Amber","middleName":"","lastName":"Naresh","suffix":""}],"badges":[],"createdAt":"2026-03-01 22:38:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9004071/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9004071/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106993969,"identity":"ecc284ff-4fec-4e0c-9114-134281624c07","added_by":"auto","created_at":"2026-04-15 15:01:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":344225,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9004071/v1/89069a26-cedb-4631-93e7-6e9bf8762b26.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Postoperative Wound Dehiscence and Fistulas After Short-Interval Hysterectomy Following Bariatric Surgery","fulltext":[{"header":"Background","content":"\u003cp\u003eObesity increases the risk of postoperative complications such as venous thromboembolism and wound infections after gynecologic surgery.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Surgical weight loss improves glycemic control and tissue healing, potentially enhancing subsequent surgical outcomes.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, bariatric procedures induce macro- and micronutrient deficiencies, especially during the rapid weight loss phase; nutrients including protein, glucose, fatty acids, vitamins A and C, zinc, and selenium are essential for wound healing.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eNational organizations have not offered specific guidance on the optimal timing of gynecologic surgery following bariatric surgery. Both the American Society for Metabolic and Bariatric Surgery and the American College of Obstetrics and Gynecology recommend delaying pregnancy after bariatric surgery for 12 to 24 months to allow for weight stabilization and nutritional optimization.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In the obstetric population, prior bariatric surgery is associated with reduced rates of pregestational diabetes and hypertensive disorders. However, pregnancy within the first two years after bariatric surgery leads to an increased risk of preterm birth and small-for-gestational-age infants, highlighting the potential for poor health outcomes during the rapid weight loss phase.\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e "},{"header":"Case","content":"\u003cp\u003eA 47-year-old gravida 0 presented with abdominal pain, nausea, vomiting, and fever ten days after a total abdominal hysterectomy and bilateral salpingectomy for chronic pelvic pain at an outside hospital. Seven weeks earlier, she had undergone a laparoscopic Roux-en-Y gastric bypass, which was a revision of a prior sleeve gastrectomy. Her medical history included hypertension, treated with lisinopril-hydrochlorothiazide, and type 2 diabetes mellitus, which had resolved after initial bariatric surgery. Prior to the gastric bypass, her prealbumin and albumin levels were normal at 24.5 mg/dL and 3.9 g/dL, respectively. The hysterectomy was attempted laparoscopically but converted to laparotomy due to extensive adhesions. An appendectomy was performed by general surgery due to an adherent appendix at the uterine fundus. Cystoscopy performed at completion of hysterectomy was unremarkable. Her immediate postoperative course was uncomplicated, and she was discharged on postoperative day 2. On presentation to our emergency department on postoperative day 10, the patient was febrile to 101.2°F. Computed tomography (CT) imaging of the abdomen and pelvis revealed an 18-cm pelvic abscess. Laboratory evaluation showed a white blood cell count of 27,900/µL, hemoglobin of 6.6 g/dL, hematocrit of 20.9%, albumin of 3.1 g/dL (mildly low), and pre-albumin of 6.6 mg/dL (low). She was admitted to the gynecology service for intravenous antibiotics including pipercillin/tazobactam and vancomycin. She underwent CT-guided pelvic drain placement. The bariatric surgery team co-managed her care.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eShe improved clinically with resolution of leukocytosis and fever. She received three units of packed red blood cells with an appropriate rise in her hemoglobin concentration. The abscess initially decreased in size on abscessogram. Diet was advanced and she received supplemental protein shakes. She was transitioned to oral antibiotic therapy on hospital day 5. On hospital day 6, the abdominal drain was noted to be malpositioned and exchanged, however imaging demonstrated persistent large abscess with possible gastrointestinal fistula. General Surgery was consulted and recommended continued conservative management with a drain. On hospital day 9, the patient reported bladder spasms with feculant material noted in the urinary catheter. Urology was consulted and conservative management was continued. On hospital day 12, the patient developed vaginal discharge consistent with enteric contents. She developed a fever on hospital day 13. She remained hemodynamically stable throughout her course. CT revealed cecal dehiscence at the appendectomy site with intraperitoneal stool collection. CT cystogram confirmed a fistulous connection between the pelvic collection and the anterior bladder. Due to failure of conservative management with drains, the patient was taken to the operating room on the same day which was post operative day 23 from hysterectomy. She underwent exploratory laparotomy via midline vertical incision with ileocecectomy, ileostomy creation and cystorrhaphy. The vaginal cuff was found to be completely dehisced with frank stool leaking into the vagina. The vaginal cuff was repaired with 0-Vicryl suture in an interrupted fashion.\u003c/p\u003e\u003cp\u003eThe patient was initially nil per os (NPO) following ileostomy creation. On postoperative day 1, her prealbumin level remained low at 8.4 mg/dL. The Bariatric Surgery team recommended total parenteral nutrition (TPN) with a protein goal of 80–100 g/day, which was initiated. Her diet was cautiously advanced over the next several days.\u003c/p\u003e\u003cp\u003eOn hospital day 20, six days after ileostomy, cystorrhaphy, and vaginal cuff repair, she developed painful bladder spasms with gushes of fluid from the vagina. CT imaging revealed a pelvic fluid collection with communication to the bladder and vagina. Interventional radiology drained the collection. On inspection and palpation, the vaginal cuff was grossly intact. Surgical repair of the fistula was deferred due to poor tissue healing. She was managed conservatively with bladder decompression via indwelling catheter, medical therapy for bladder spasms, and intravenous parenteral nutrition. The vaginal discharge improved and resolution of the vesicovaginal fistula was confirmed on repeat CT cystogram on post operative day 20 (hospital day 34).\u003c/p\u003e\u003cp\u003eThe Pfannenstiel incision from her hysterectomy and her midline laparotomy sites each developed a superficial dehiscence measuring several centimeters. The fascia and ileostomy site remained intact. The incisions were dressed with a sodium carboxymethylcellulose dressing and wet-to-dry packing changes daily. She was continued on intravenous antibiotics. Repeat abscessogram and colonoscopy showed closure of fistulous tracts. The patient underwent ileostomy reversal on hospital day 55. A negative pressure wound therapy device was applied to the superficially dehisced incision sites. From hospital day 55–60, her diet was advanced and she was weaned off TPN. She was discharged on hospital day 61 tolerating a regular diet and exhibiting normal bowel and bladder function. She received home health services for wound care. Prealbumin was still low but improved to 10.8 mg/dL at the time of discharge and had returned to normal at 28.1 mg/dL eight months later.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eBariatric surgery improves long-term health outcomes through sustained weight loss, resulting in better control and resolution of type 2 diabetes mellitus, dyslipidemia, and hypertension. Patients experience a reduced risk of stroke and myocardial infarction.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e However, the effect of bariatric surgery on outcomes of subsequent surgeries is less well understood. While weight loss could reduce anatomic distortions associated with obesity, improve access to relevant structures, and reduce operative times, nutritional deficiencies could impair wound healing.\u003c/p\u003e \u003cp\u003eBariatric surgery is followed by a period of nutrient malabsorption and in some cases, malnutrition. Weight loss usually plateaus two years after surgery, but the duration of nutrient malabsorption is poorly defined and can vary depending on procedure type.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Deficiencies in protein, iron, vitamin D, calcium, vitamin B12, folic acid, vitamin A, copper, zinc selenium, and thiamine have been observed.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Lipid metabolism is substantially altered.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Glucose is essential for angiogenesis and new tissue formation while fatty acids contribute to the structure of cells. Micronutrients such as zinc and iron are essential cofactors for enzymatic reactions in tissue healing. Protein and vitamin C are essential for collagen synthesis.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhile research on surgical outcomes after bariatric surgery remains limited, existing data have shown mixed surgical outcomes. A study of 669 patients found that patients with a history bariatric surgery undergoing hysterectomy had a reduced risk of any intraoperative complications during hysterectomy compared to patients with body mass index (BMI)\u0026thinsp;\u0026gt;\u0026thinsp;40 kg/m2 and no bariatric surgery (odds ratio 0.32; 95% CI 0.13\u0026ndash;0.77). However, women with a history of bariatric surgery had an increased frequency of postoperative cuff dehiscence (p\u0026thinsp;=\u0026thinsp;0.04). Most patients in that investigation (75.6%) had bariatric procedure more than two years prior to their hysterectomy; there was no difference in perioperative complications in patients who had bariatric surgery within two years before hysterectomy.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA separate cohort study using a national insurance database demonstrated that patients with a history of bariatric surgery who underwent hysterectomy had a lower risk of intraoperative and immediate postoperative complications compared those who had never had bariatric surgery, even when matched by BMI at time of hysterectomy admission. Relative risk of any complication was 1.048 (95% CI 1.06\u0026ndash;1.09) for the non-bariatric surgery group. Bariatric procedure type and the interval between bariatric surgery and hysterectomy were not reported.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe non-gynecologic literature offers additional insights. Surgical weight loss preceding total knee arthroplasty was associated with decreased incidence of postoperative wound complications, prosthetic infections, and unplanned hospital re-admission.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Patients undergoing abdominoplasty with prior history of bariatric surgery had a higher rate of wound complications than abdominoplasty patients without a history of bariatric surgery.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eOur patient underwent elective surgery when her body was depleted of the nutrients required to heal postoperatively, as evidenced by a low prealbumin level at hospital readmission. The patient experienced poor wound healing and spontaneous breakdown of the incisions of multiple tissues, including bowel, bladder, vaginal cuff, and abdominal wall. Even after attempted surgical repair, the tissue failed to heal and she continued to experience complex fistulas. With time and continued intravenous nutritional supplementation, the tissues gradually healed and the fistulas resolved without further surgical intervention.\u003c/p\u003e \u003cp\u003eBariatric surgery should be considered a relative contraindication to elective gynecologic surgery in the acute weight loss phase. As some data have demonstrated a benefit of bariatric surgery on hysterectomy outcomes, further research is needed into the optimal interprocedural interval between the two operations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthics approval was not applicable. The patient described in this case report gave written informed consent for their personal or clinical details along with any identifying images to be published in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSigned consent has been obtained from the patient described in this case report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRF analyzed the medical record of the patient about whom the case report is written, contributed to the background research, and was the primary author on the manuscript. TF, KS, JT, and AN contributed to the background research, chart review, and writing the manuscript. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCommittee opinion no. 619: Gynecologic surgery in the obese woman. \u003cem\u003eObstet Gynecol\u003c/em\u003e. Jan 2015;125(1):274-278. doi:10.1097/01.aog.0000459870.06491.71\u003c/li\u003e\n\u003cli\u003eWhitley J, Moore KJ, Carey ET, Louie M. The Effect of Bariatric Surgery on Perioperative Complications after Hysterectomy. \u003cem\u003eJ Minim Invasive Gynecol\u003c/em\u003e. Sep-Oct 2020;27(6):1363-1369. doi:10.1016/j.jmig.2019.12.011\u003c/li\u003e\n\u003cli\u003eAgha-Mohammadi S, Hurwitz DJ. Nutritional deficiency of post-bariatric surgery body contouring patients: what every plastic surgeon should know. \u003cem\u003ePlast Reconstr Surg\u003c/em\u003e. Aug 2008;122(2):604-613. doi:10.1097/PRS.0b013e31817d6023\u003c/li\u003e\n\u003cli\u003eRussell L. The importance of patients\u0026apos; nutritional status in wound healing. \u003cem\u003eBr J Nurs\u003c/em\u003e. Mar 2001;10(6 Suppl):S42, s44-9. doi:10.12968/bjon.2001.10.Sup1.5336\u003c/li\u003e\n\u003cli\u003eAmerican Society for Metabolic and Bariatric Surgery Public Education Committee. Life after bariatric surgery. https://asmbs.org/patients/life-after-bariatric-surgery/\u003c/li\u003e\n\u003cli\u003eACOG practice bulletin no. 105: bariatric surgery and pregnancy. \u003cem\u003eObstet Gynecol\u003c/em\u003e. Jun 2009;113(6):1405-1413. doi:10.1097/AOG.0b013e3181ac0544\u003c/li\u003e\n\u003cli\u003eParent B, Martopullo I, Weiss NS, Khandelwal S, Fay EE, Rowhani-Rahbar A. Bariatric Surgery in Women of Childbearing Age, Timing Between an Operation and Birth, and Associated Perinatal Complications. \u003cem\u003eJAMA Surg\u003c/em\u003e. Feb 1 2017;152(2):128-135. doi:10.1001/jamasurg.2016.3621\u003c/li\u003e\n\u003cli\u003eBrown AM, Yang J, Zhang X, Docimo S, Pryo AD, Spaniolas K. Bariatric Surgery Lowers the Risk of Major Cardiovascular Events. \u003cem\u003eAnn Surg\u003c/em\u003e. Nov 1 2022;276(5):e417-e424. doi:10.1097/sla.0000000000004640\u003c/li\u003e\n\u003cli\u003eHua Y, Lou YX, Li C, Sun JY, Sun W, Kong XQ. Clinical outcomes of bariatric surgery - Updated evidence. \u003cem\u003eObes Res Clin Pract\u003c/em\u003e. Jan-Feb 2022;16(1):1-9. doi:10.1016/j.orcp.2021.11.004\u003c/li\u003e\n\u003cli\u003eMechanick JI, Apovian C, Brethauer S, et al. CLINICAL PRACTICE GUIDELINES FOR THE PERIOPERATIVE NUTRITION, METABOLIC, AND NONSURGICAL SUPPORT OF PATIENTS UNDERGOING BARIATRIC PROCEDURES - 2019 UPDATE: COSPONSORED BY AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY, THE OBESITY SOCIETY, AMERICAN SOCIETY FOR METABOLIC \u0026amp; BARIATRIC SURGERY, OBESITY MEDICINE ASSOCIATION, AND AMERICAN SOCIETY OF ANESTHESIOLOGISTS - EXECUTIVE SUMMARY. \u003cem\u003eEndocr Pract\u003c/em\u003e. Dec 2019;25(12):1346-1359. doi:10.4158/gl-2019-0406\u003c/li\u003e\n\u003cli\u003eAlvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. \u003cem\u003eCurr Opin Clin Nutr Metab Care\u003c/em\u003e. Sep 2004;7(5):569-75. doi:10.1097/00075197-200409000-00010\u003c/li\u003e\n\u003cli\u003eHinds\u0026oslash; M, Lundsgaard A, Marinkovic B, et al. Fat absorption and metabolism after Roux-en-Y gastric bypass surgery. \u003cem\u003eMetabolism\u003c/em\u003e. Jun 2025;167:156189. doi:10.1016/j.metabol.2025.156189\u003c/li\u003e\n\u003cli\u003eYoung MC, Bhandarkar AR, Portela RC, et al. Bariatric surgery reduces odds of perioperative complications after inpatient hysterectomy: Analysis from a national database, 2016 to 2018. \u003cem\u003eSurgery\u003c/em\u003e. Oct 2023;174(4):766-773. doi:10.1016/j.surg.2023.06.018\u003c/li\u003e\n\u003cli\u003eDowsey MM, Brown WA, Cochrane A, Burton PR, Liew D, Choong PF. Effect of Bariatric Surgery on Risk of Complications After Total Knee Arthroplasty: A Randomized Clinical Trial. \u003cem\u003eJAMA Netw Open\u003c/em\u003e. Apr 1 2022;5(4):e226722. doi:10.1001/jamanetworkopen.2022.6722\u003c/li\u003e\n\u003cli\u003eBreiting LB, Lock-Andersen J, Matzen SH. Increased morbidity in patients undergoing abdominoplasty after laparoscopic gastric bypass. \u003cem\u003eDan Med Bull\u003c/em\u003e. Apr 2011;58(4):A4251. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hysterectomy, bariatric surgery, wound dehiscence","lastPublishedDoi":"10.21203/rs.3.rs-9004071/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9004071/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eThe effect of bariatric procedures on outcomes of gynecologic surgery is poorly defined.\u003c/p\u003e\u003ch2\u003eCase:\u003c/h2\u003e \u003cp\u003eA 47-year-old underwent a laparoscopic Roux-en-Y gastric bypass, followed seven weeks later by elective abdominal hysterectomy. An appendectomy was performed for appendiceal adhesions to the uterus and intraoperative cystoscopy was normal. The immediate postoperative course was unremarkable. Ten days later, she presented with a large pelvic abscess, dehiscence at the appendectomy site, vaginal cuff dehiscence, and bladder injury. Management included vaginal cuff repair, ileostomy, and cystorrhaphy. She then developed vesicovaginal fistula and superficial wound dehiscence, requiring prolonged hospitalization, total parenteral nutrition, and conservative management until resolution.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eDehiscence and complex fistula formation are potential complications of gynecologic surgery performed during the rapid weight loss phase following bariatric surgery.\u003c/p\u003e","manuscriptTitle":"Postoperative Wound Dehiscence and Fistulas After Short-Interval Hysterectomy Following Bariatric Surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 16:14:33","doi":"10.21203/rs.3.rs-9004071/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-17T19:22:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301924934618230204531326366137594002575","date":"2026-04-15T05:34:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126181444595997869785075077221410385854","date":"2026-04-12T18:27:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267437905523225323119044508680280844066","date":"2026-04-05T18:16:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-03T08:15:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-31T13:00:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-12T12:14:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-12T00:05:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2026-03-11T16:11:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"714b0064-3ad0-4e08-9985-e8d1995fef36","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-09T16:14:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 16:14:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9004071","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9004071","identity":"rs-9004071","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}