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
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[1]
- 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
- 38% of RYGB patients
- 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
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
- 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.
- ↑ Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, Sugerman H, Maher JW. Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases. J Gastrointest Surg. 2007;11(6):708.