Bariatric surgery complications: Difference between revisions
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[[Category:Surg]]
[[Category:Surg]]
==Roux-en-Y gastric bypass==
*Creation of a small gastric pouch and an anastomosis to the jejunum
*'''Gastric remnant distension'''<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 a/w 40% mortality
**S/s: pain, hiccups, LUQ tympany, shoulder pain, abd distention
**Dx: XR shows large gastric air bubble vs CT
**Tx: emergent operative decompression with percutaneous drainage
*'''Stomal Stenosis'''
**Occurs in 6-20% of RYGB pts
**Possibly related to tissue ischemia or tension on GJ anastomosis
**Presentation several weeks after surgery
**S/s: N/V, dysphagia, GERD, inability to tolerate PO
**Dx with endoscopy vs UGI series vs CT
*'''Marginal Ulcers'''
**Occur in 0.6-16% of RYGB pts
**Acid injury to jejunum
**Causes: poor perfusion 2/2 tension/ischemia, increase gastric acid exposure, NSAID use, H pylori infection
**S/s: Nausea, pain, bleeding +/- perforation
**Dx with endoscopy
**Patients typically medically managed
*'''Cholelithiasis'''
**38% of RYGB pts
***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
**Dx: 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 pts when high levels of carbohydrates are ingested
**Early dumping syndrome
***Hyperosmolality of food → fluid shifts → colicky and pain, diarrhea, nausea, tachycardia
***Tx: Diet modification to avoid high simple sugars
**Late dumping syndrome
***Insulin response that leads to hypoglycemia 2-3 hours after meal
***S/s: 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 pts
**Typically 2/2 inclusion over excess perigastric fat vs tissue edema vs inappropriate sized band
**S/s: N/V, inability to tolerate PO
**Dx: 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
**a/w band erosion
**Tx: Replacement of port if isolated infection vs band if more extensive
*'''Band Erosion'''
**Up to 7% of GB pts
**Erodes through gastric wall 2/2 wall ischemia vs mechanical stress from band
**Occurs on average 22 months after surgery
**S/s: e/o infection, failure to lose weight, N/V; epigastric pain and hematemesis
**Dx: Endoscopy vs CT
**Tx: Band removal
*'''Band Slippage/gastric prolapse'''
**2-14% of pts
**Either anterior or posterior prolapse
**S/s: Food intolerance, epigastric pain, acid reflux
**Dx: Upper GI series vs CT
**Tx: Emergent surgery
*'''Esophageal dilatation'''
**Up to 10% of pts
**a/w over-inflated bands or excessive food intake
**S/s: Food/saliva intolerance, reflux, epigastric pain
**Dx: UGI series vs CT
**Tx: 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
**S/s: Dysphagia, vomiting, dehydration, inability to tolerate PO
**Dx: UGI series vs CT
**Tx: Endoscopic dilatation vs surgical intervention depending on involvement
*'''Gastric leaks'''
**Up to 5.3% of pts; most serious complication a/w sleeve gastrectomy
**2/2 poor healing in setting of inadequate blood supply vs weakness at staple line vs gastric-wall heat ischemia from cautery
**Tx: surgical repair vs percutaneous drainge/abx/NPO
*'''Reflux'''
**Common post-op complication
**Treated medically initially with eventual RYGB for refractory cases
==References==
<references/>

Revision as of 01:37, 11 September 2015

Background

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

Clinical Features

  • abdominal pain, food intolerance
  • sepsis, abnormal VS

Differential Diagnosis

Early

  • VTE, PNA, UTI, SBO, etc
  • Roux-Limb Obstruction
    • NV, abd pain
    • causes acute Gastric dilation
    • surgical emergency
    • IR 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

Diagnosis

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

See Also

Source

Ann Emerg Med. 2006;47:160-166., Tintinalli

Roux-en-Y gastric bypass

  • Creation of a small gastric pouch and an anastomosis to the jejunum
  • Gastric remnant distension[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 a/w 40% mortality
    • S/s: pain, hiccups, LUQ tympany, shoulder pain, abd distention
    • Dx: XR shows large gastric air bubble vs CT
    • Tx: emergent operative decompression with percutaneous drainage
  • Stomal Stenosis
    • Occurs in 6-20% of RYGB pts
    • Possibly related to tissue ischemia or tension on GJ anastomosis
    • Presentation several weeks after surgery
    • S/s: N/V, dysphagia, GERD, inability to tolerate PO
    • Dx with endoscopy vs UGI series vs CT
  • Marginal Ulcers
    • Occur in 0.6-16% of RYGB pts
    • Acid injury to jejunum
    • Causes: poor perfusion 2/2 tension/ischemia, increase gastric acid exposure, NSAID use, H pylori infection
    • S/s: Nausea, pain, bleeding +/- perforation
    • Dx with endoscopy
    • Patients typically medically managed
  • Cholelithiasis
    • 38% of RYGB pts
      • 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
    • Dx: 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 pts when high levels of carbohydrates are ingested
    • Early dumping syndrome
      • Hyperosmolality of food → fluid shifts → colicky and pain, diarrhea, nausea, tachycardia
      • Tx: Diet modification to avoid high simple sugars
    • Late dumping syndrome
      • Insulin response that leads to hypoglycemia 2-3 hours after meal
      • S/s: 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 pts
    • Typically 2/2 inclusion over excess perigastric fat vs tissue edema vs inappropriate sized band
    • S/s: N/V, inability to tolerate PO
    • Dx: 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
    • a/w band erosion
    • Tx: Replacement of port if isolated infection vs band if more extensive
  • Band Erosion
    • Up to 7% of GB pts
    • Erodes through gastric wall 2/2 wall ischemia vs mechanical stress from band
    • Occurs on average 22 months after surgery
    • S/s: e/o infection, failure to lose weight, N/V; epigastric pain and hematemesis
    • Dx: Endoscopy vs CT
    • Tx: Band removal
  • Band Slippage/gastric prolapse
    • 2-14% of pts
    • Either anterior or posterior prolapse
    • S/s: Food intolerance, epigastric pain, acid reflux
    • Dx: Upper GI series vs CT
    • Tx: Emergent surgery
  • Esophageal dilatation
    • Up to 10% of pts
    • a/w over-inflated bands or excessive food intake
    • S/s: Food/saliva intolerance, reflux, epigastric pain
    • Dx: UGI series vs CT
    • Tx: 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
    • S/s: Dysphagia, vomiting, dehydration, inability to tolerate PO
    • Dx: UGI series vs CT
    • Tx: Endoscopic dilatation vs surgical intervention depending on involvement
  • Gastric leaks
    • Up to 5.3% of pts; most serious complication a/w sleeve gastrectomy
    • 2/2 poor healing in setting of inadequate blood supply vs weakness at staple line vs gastric-wall heat ischemia from cautery
    • Tx: surgical repair vs percutaneous drainge/abx/NPO
  • Reflux
    • Common post-op complication
    • Treated medically initially with eventual RYGB for refractory cases

References

  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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