Bariatric surgery complications

Background

• Roux-en-Y - malabsorptive and restrictive physiology;
• Gastric Sleeve - restrictive
• Biliopancreatic diversion
• Vertical banded gastroplasty - now historical as replaced by LAP band;
• Lap Band Complications

Roux-en-y

Gastric sleeve

Biliopancreatic diversion

Lap band

Clinical Features

• Abdominal pain, food intolerance
• Sepsis, abnormal vital signs

Differential Diagnosis

Early

• VTE, pneumonia, UTI, small bowel obstruction, etc
• Roux-Limb Obstruction
  • Nausea/vomiting, abdominal pain
  • Causes acute gastric dilation
  • Surgical emergency!
  • IR;decompression possible
• Anastomotic Leak
  • Abdominal exam often non-acute due to habitus
• Intra-abdominal bleeding
  • May bleed into GI tract and only visualized on endoscopy

Late

• Upper GI bleed
  • Resuscitate in standard fashion
  • Emergent endoscopy
  • Often bleed from staple lines, ulcers
• Anastomotic Leak or Stricture
  • Progressive inability to tolerate PO
  • Abdominal pain
  • Solids first then liquids
  • Needs UGI then likely endoscopy
• Marginal Ulcer
  • Epigastric pain and dyspepsia
  • Upper endoscopy
  • Manage with acid suppression
• Internal hernia
  • Obstructive or nonobstructive
  • Crampy, intermittent abdominal pain radiating to back
  • Can have normal abdominal exam
  • May strangulate herniated bowel
  • Work up with CT Abdomen/pelvis and UGI
  • CT findings: swirl sign, intussuscepted bowel
  • Needs surgery early
• Nutritional Complications
  • consider patients immunosuppressed due to malnourishment
  • Anemia, neuropathy, fractures, hypercalcemia
  • Wernicke's encephalopathy
  • Dumping syndrome

Evaluation

• CT AP - use PO & IV contrast
  • patients often cannot tolerate full 1L of PO contrast
  • sip as much contrast as possible in 3hrs then CT
  • weight limit of CT scanner often exceeded
  • can use Gastrografin UGI series instead
• UGI series
  • beware GI pouch limits on contrast volume
  • useful for perforation, internal hernia, stricture, leak

Specific Surgeries

Roux-en-Y gastric bypass

• Creation of a small gastric pouch and an anastomosis to the jejunum
• Gastric remnant distention
  • Remnant is a blind pouch that may become distended with paralytic ileus
  • Potential rupture → severe peritonitis
  • 3.9% leak rate for RYGB; overall mortality 0.6%
  • Jejunojejunostomy leak associated with 40% mortality
  • Signs/symptoms: pain, hiccups, LUQ tympany, shoulder pain, abdominal distention
  • Diagnosis: XR shows large gastric air bubble vs CT
  • Treatment: emergent operative decompression with percutaneous drainage
• Stomal Stenosis
  • Occurs in 6-20% of RYGB patients
  • Possibly related to tissue ischemia or tension on GJ anastomosis
  • Presentation several weeks after surgery
  • Signs/symptoms: nausea/vomiting, dysphagia, GERD, inability to tolerate PO
  • Diagnose with endoscopy vs UGI series vs CT
• Marginal Ulcers
  • Occur in 0.6-16% of RYGB patients
  • Acid injury to jejunum
  • Causes: poor perfusion 2/2 tension/ischemia, increase gastric acid exposure, NSAID use, H pylori infection
  • Signs/symptoms: Nausea, pain, bleeding +/- perforation
  • Diagnose with endoscopy
  • Patients typically medically managed
• Cholelithiasis
  • 38% of RYGB patients
    • Risk reduced to 2% if ursodiol given as post-op ppx
    • Some surgeons perform prophylactic cholecystectomy with RYB procedure
  • Rapid weight loss increases lithogenicity of bile
  • Diagnosis: U/S or MRCP
• Hernias
  • Ventral hernias (0-1.8% in lap RYGB)
  • Internal hernias (0-5%)
    • Intermittent and may be difficult to detect via CT
    • Suspected may require urgent surgical exploration lest patient has strangulated pathology
• Dumping Syndrome
  • Occur in up to 50% of patients when high levels of carbohydrates are ingested
  • Early dumping syndrome
    • Occurs when pylorus is either removed or bypassed, allowing hyperosmolar stomach chyme to "dump" into the small intestine.
    • Hyperosmolality of food → fluid shifts into GI lumen → colicky and abdominal pain, diarrhea, nausea, tachycardia, diaphoresis, dizziness, syncope.
    • Treatment: Diet modification to avoid high simple sugars
  • Late dumping syndrome
    • Insulin response that leads to hypoglycemia 2-3 hours after meal
    • Signs/symptoms: dizziness, fatigue, diaphoresis, weakness

Gastric Banding

• Placement of restrictive ring over the gastric cardia near the GE junction
• Lowest mortality rate among all bariatric surgeries (0.05% mortality)
• Stomal Obstruction
  • Early complication; occurs in 14% go GB patients
  • Typically due to inclusion over excess perigastric fat vs tissue edema vs inappropriate sized band
  • Signs/symptoms: nausea/vomiting inability to tolerate PO
  • Diagnosis: UGI series vs CT
  • If due to edema, may be treated with NG tube decompression until swelling improves
    • May require surgical revision if above unsuccessful
• Port infection
  • 0.3-9% of GB patients
  • associated with band erosion
  • treatment: Replacement of port if isolated infection vs band if more extensive
• Band Erosion
  • Up to 7% of GB patients
  • Erodes through gastric wall secondary to wall ischemia vs mechanical stress from band
  • Occurs on average 22 months after surgery
  • signs/symptoms: evidence of infection, failure to lose weight, nausea/vomiting, epigastric pain and hematemesis
  • Diagnosis: Endoscopy vs CT
  • Treatment: Band removal
• Band Slippage/gastric prolapse
  • 2-14% of patients
  • Either anterior or posterior prolapse
  • Signs/Symptoms: Food intolerance, epigastric pain, acid reflux
  • Diagnosis: Upper GI series vs CT
  • Treatment: Emergent surgery
• Esophageal dilatation
  • Up to 10% of patients
  • associated with over-inflated bands or excessive food intake
  • Signs/symptoms: Food/saliva intolerance, reflux, epigastric pain
  • Diagnosis: UGI series vs CT
  • Treatment: Fluid removal from band initially and behavioral modifications
• Hiatus hernia
  • Results in refractory reflux

Sleeve gastrectomy

• Creates sleeve out of the stomach and removes portion of greater curvature of stomach
• Complication rate 3-24%; mortality 0.39%
• Bleeding
  • Typically occur from the staple line
• Stenosis
  • Can lead to gastric outlet obstruction
  • Signs/symptoms: Dysphagia, vomiting, dehydration, inability to tolerate PO
  • Dx: UGI series vs CT
  • treatment: Endoscopic dilatation vs surgical intervention depending on involvement
• Gastric leaks
  • Up to 5.3% of patients; most serious complication associated with sleeve gastrectomy
  • 2/2 poor healing in setting of inadequate blood supply vs weakness at staple line vs gastric-wall heat ischemia from cautery
  • Treatment: surgical repair vs percutaneous drainage/antibiotic/NPO
• Reflux
  • Common post-op complication
  • Treated medically initially with eventual RYGB for refractory cases

See Also

• Lap Band Complications
• Acute gastric dilation

External Links

• ACEP BEAM (BARIATRIC EXAMINATION, ASSESSMENT, and MANAGEMENT in the Emergency Department Tool)
• Complications of Bariatric Procedures: ED Evaluation and Management from emDocs: http://www.emdocs.net/complications-of-bariatric-procedures-ed-evaluation-and-management/

References

1. Tack, Jan, et al. “Complications of bariatric surgery: Dumping syndrome, reflux and vitamin deficiencies.” Best practice and research clinical gastroenterology; 28; 2014; pages 741-749.