Diving After Bariatric Surgery

I’m an instructor, and I have a student who completed his pool sessions, but he had gastric bypass surgery before he could do his open-water dives. Before I allow him to continue with his training, I’m asking him to get an updated medical form signed by his doctor and to contact DAN® for advice. What does DAN think about diving after this kind of surgery?

Please note that DAN is not in a position to either approve or disapprove of an individual diving. We share medical information and resources to allow you and your physician to make an informed decision regarding diving.

There are a few factors to consider with regard to bariatric surgery. The first is the recovery time from the surgery. It is important that surgical wounds have closed and healed before the patient dives to ensure there’s not an elevated risk of infection. Depending on the type of surgery that was performed, air is sometimes introduced into the abdominal cavity. The body requires time to reabsorb this air. Air pockets are of concern given their ability to compress and expand as ambient pressure changes. Similarly, there is air within the gastrointestinal tract that may contract and expand as the depth changes. Therefore it is important to allow the surgical sites inside the abdomen to heal to avoid creating a leak.

Another consideration is the delayed complications and/or known side effects of the surgery. These factors depend on the particular surgery that was performed. Some bariatric surgeries put an individual at increased risk for intestinal blockage, gastroesophageal reflux disease (GERD) or malabsorption.

Next, consider the physical demands of scuba diving. Weight-loss surgery and the resulting drastic change in body mass that may occur afterward can involve loss of muscle mass and general deconditioning. As scuba diving is physically demanding, it is important that an individual can perform vigorous physical activity.

Finally, many patients who undergo bariatric surgery have other medical problems that are associated with obesity (such as diabetes, heart disease and high blood pressure). These issues should be addressed and stabilized prior to returning to diving. A common expected recovery time is 6-12 months.

As you suggested, it would be worthwhile for a physician trained in dive medicine to evaluate your student and clear him for diving. He will require clearance for full, unrestricted activity — including lifting heavy weights such as dive gear, unrestricted mobility and tolerance for vigorous exercise such as extended swimming. We can search the DAN referral database for a doctor trained in dive medicine close to the student’s location.

— Mala Trivedi, M.D.

I did some wreck diving this summer and got a minor abrasion on my knuckles while digging for artifacts. It was so superficial that I continued diving and didn’t give it much thought. Several weeks later, however, it doesn’t seem to be getting any better. It is red and bumpy and occasionally has some crust on it, although it doesn’t hurt. Antibiotic ointment has not helped, so I plan to see a doctor about it. Are there any marine-specific pathogens I should ask the doctor about?

While some infections might be more frequently associated with aquatic environments, there are no marine-specific pathogens, at least not to humans.
 
Based on your brief description, this may be an infection by an opportunistic pathogen known as Mycobacterium marinum. This organism is responsible for a condition known as aquarium granuloma. These wounds typically look like what you described: red and bumpy nodules no larger than a centimeter, usually isolated but sometimes in small clusters and not necessarily painful. There may or may not be discharge associated with the wound, and little or no improvement may follow what seems to be adequate care for the wound. This is due in part to several unique characteristics of this bacterium:

• M. marinum is an opportunistic pathogen: It causes an infection only when the right conditions (environmental and patient-related) are met. This explains why it is often not even considered as a potential culprit. It could be considered rare.
• M. marinum likes cooler temperatures, which explains why these wounds tend to flourish in areas with lower body temperatures such as hands, knuckles, elbows and knees.
• M. marinum is sensitive only to specific antibiotics, which explains why the typical antibiotic treatments are usually unsuccessful.
• M. marinum has a slow life cycle, which means treatments last a long time. Sometimes patients will abandon what could have been a successful treatment, and/or doctors may look for other potential explanations for the symptoms.
• M. marinum requires specific culture media that a doctor would not ask for unless he or she suspects this pathogen. This explains why sometimes standard culture results are negative and diagnoses are delayed.

Allow your doctor to examine the wound and follow his or her normal procedures. The doctor will probably ask you how it happened or when it started. This is where you should let him or her know about the superficial abrasion in a marine environment. You may also want to tell your doctor you read about Mycobacterium marinum (because you are a prepared and well-informed diver) and are wondering if this could be the cause. Good medical practice benefits tremendously from mutual trust and good communication. Let the doctor examine you and ask questions, and trust him or her — no dive-specific medical knowledge is needed for this type of issue.

Finally, remember to always take care of wounds and clean them thoroughly, even when they seem benign. The skin is our most effective and efficient means of immunological defense.

— Matías Nochetto, M.D.

I occasionally have vasovagal/neurocardiogenic syncope and am trying to decide if I should dive. The fainting happens once every year or two. It has happened on roller coasters at points with a lot of downward force (likely from decreased cerebral perfusion) and sometimes when I have hurt myself (such as when I smashed my hand in a boat lift). It has happened once from an unknown trigger when I was just standing around talking. I know the recommendation is to get checked out by a doctor, but I am a doctor, and I have spoken with other doctor friends, some of whom dive, and no one really knows the answer.

Recurrent vasovagal/neurocardiogenic syncope is a significant risk factor when diving. One of the main problems is that your vasovagal syncope has been induced by basic Valsava maneuvers, which are common in diving as they are used to equalize pressure in the middle ear during descent to depths as shallow at 5-10 feet. In addition, people often perform a Valsalva or “bear down” unintentionally when lifting heavy objects, which will be necessary when handling gear or when getting into and out of a dive boat, for example.

Vasovagal syncope may also occur in times of pain or stress (as in the situation of smashing your hand). While under most circumstances scuba diving is a relaxing recreational sport, the underwater environment can be unpredictable.

Were you to have a syncopal episode and pass out underwater, this would put you at a risk of drowning and death. In addition, there would be a risk of decompression illness should you have an episode necessitating a rapid ascent, which would put both you and your diving partner at risk.

Should you experience complications from diving (such as an arterial gas embolism resulting in loss of consciousness), it may be difficult to differentiate the dive-related illness from your known baseline medical condition. This might lead to unnecessary treatment or, more problematically, delayed treatment of a potentially dangerous condition such as gas embolism.

Scuba diving is probably not advisable given your history. Additional evaluation, however, may be helpful prior to eliminating the possibility. Useful tests would include an echocardiogram, stress test and Holter monitor.

— Mala Trivedi, M.D.

I would like to report an incident for your statistical database and other uses. Do you have a standard mechanism for that?

Thank you for your interest in sharing that information. There are two separate mechanisms you can use to report an incident to DAN, and we would appreciate you submitting the report via both mechanisms if you are willing.

The DAN incident reporting system can easily accessed online. This area of our website allows submission of new incidents as well as review of other divers’ (anonymised) reports. Information shared via this system is submitted to DAN Research.

DAN Medical Services would also like details of the incident. While reports submitted via the incident reporting system can be anonymous, DAN Medical Services would like contact information if it’s available (and you and other involved parties are willing to share it). We use this information to follow-up with injured divers, not for marketing purposes. We can direct them to continuing medical care as needed, refer them to our claims department (if they’re

DAN members), assist with locating a dive-medicine expert and answer questions as needed. Please send an email to danmedic@dansa.org or request on the incident report form to have your information shared with DAN Medical Services.

— Frances Smith, EMT-P, DMT