Bariatric surgery complications: Difference between revisions

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==Background==
==Background==
- Rou-en-Y - malabsorptive and restrictive physiology 
*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]]
[[File:Roux-en-y.png|thumb|Roux-en-y]]
[[File:Gastric sleeve.png|thumb|Gastric sleeve]]
[[File:Biliopancreatic diverstion.png|thumb|Biliopancreatic diversion]]
[[File:Lap band.png|thumb|Lap band]]


- Gastric Sleeve - restrictive
==Clinical Features==
*[[Abdominal pain]], food intolerance
*[[Sepsis]], abnormal vital signs


- Biliopancreatic diversion
==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


- Vertical banded gastroplaty - now historical as replaced by LAP band 
===Late===
 
*[[Upper GI bleed]]
==Diagnosis==
**Resuscitate in standard fashion
 
**Emergent endoscopy
- abdominal pain, food intolerance
**Often bleed from staple lines, ulcers
 
*Anastomotic Leak or Stricture
- sepsis, abnormal VS
**Progressive inability to tolerate PO
 
**[[Abdominal pain]]
==Workup==
**Solids first then liquids
**Needs UGI then likely endoscopy
*Marginal Ulcer
**[[Epigastric pain]] and dyspepsia
**Upper endoscopy
**Manage with acid suppression
*Internal [[hernia]]
**[[SBO|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


CT AP - use PO & IV contrast
==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


   - pts often cannot tolerated full 1L of PO contrast
==Specific Surgeries==
===Roux-en-Y gastric bypass===
*Creation of a small gastric pouch and an anastomosis to the jejunum
*'''Gastric remnant distention'''<ref>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. </ref>
**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
*'''[[Hernia]]s'''
**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]]


&nbsp; &nbsp;- sip as much contrast as possible in 3hrs then CT&nbsp; &nbsp;&nbsp;
===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


&nbsp; &nbsp;- weight limit of CT scanner often exceeded
===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


&nbsp; &nbsp;- can use Gastrograffin UGI series instead
==See Also==
*[[Lap Band Complications]]
*[[Acute gastric dilation]]


UGI series
==External Links==
*[https://www.acep.org/patient-care/beam/#sm.00012tey58gbae0mqhr158eoj1ppp 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/


- beware GI pouch limits on contrast volume
==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.


- usefull for perforation, internal hernia, stricture, leak
<references/>
 
==Complications==
===Early===
#VTE, PNA, UTI, SBO, etc
#Roux-Limb Obstruction
##NV, abd pain
##causes acute Gastric dilation
##surgical emergency
##IR&nbsp;decompression possible
#Anastamotic Leak
##abdominal exam often non-acute due to habitus
#Intra-abdominal bleeding
##may bleed into GI tract and only visualized on endoscopy
 
===Late===
#UGIB
##resuscitate in stanrd 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 intermitten abd pain radiating to back
##can have nl abd exam
##may strangulate herniated bowel
##w/u CT AP and UGI
##CT findings swirl sign, intussuscepted bowel
##needs surgery early
#Nurtitional Complications
##consider pts immunosuppressed due to malnourishment
##Anemia, neuropathy, fractures, hypercalcemia
##Wernickes encephalopathy
##Dumping syndrome


==Source==
[[Category:Surgery]]
Ann Emerg Med. 2006;47:160-166., Tintinalli

Latest revision as of 13:20, 8 February 2021

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

Differential Diagnosis

Early

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
  • 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

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
  • 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

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

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.
  1. ↑ 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.
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