The primary role of endoscopic intervention in the care of bariatric surgery patients is in the management of late bariatric surgical complications and non-operative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will involve the gastroenterologist in primary weight loss interventions as cutting edge technology is currently undergoing rigorous scientific evaluation. Endoscopists caring for these patients should become familiar with post-bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal/extra-luminal findings, and endoscopic management of common bariatric complications; this review addresses these issues. This review will discuss common presenting symptoms, luminal as well as extra-luminal findings and endoscopic management of common bariatric complications.
Bariatric procedures for the surgical treatment of obesity are increasing in number annually. In 2008, it is estimated that 220,000 procedures were performed in the United States by the membership of the American Society for Metabolic and Bariatric Surgery. Although medical therapy is an effective intervention, weight loss surgery has been associated with the greatest reduction in obesity-related complications. With advances in technology and improved surgical techniques, the mortality following bariatric surgery is less than 1% at centers of excellence. Yet, approximately 5% to 10% of patients present for evaluation with acute postoperative complications and 9% to 25% have late complications following bariatric surgery. Early perioperative complications are defined as those that occur within the first 30 days of surgery, whereas late complications are those that occur after the first 30 days. The most common perioperative complications following bariatric surgery include anastomotic leaks, bowel obstruction, gastrointestinal or intra-abdominal hemorrhage, wound infection, deep vein thrombosis, and pulmonary embolus. Complications such as anastomotic stricture, marginal ulcers (jejunal surface of the gastrojejunal anastomosis), gastric ulcers, stomal ulcers (gastric surface of the gastrojejunal anastomosis), bowel obstruction, incisional hernia, internal hernias, ischemia, nutrient deficiencies, hepatobiliary complications, band erosion, staple-line dehiscence, bile reflux, acid reflux, dumping syndrome, functional abdominal pain, and inadequate weight loss occur months to years following surgical weight loss interventions. Whereas immediate symptoms in the first 30 days following surgery occasionally involve the gastroenterologist, the primary role of nonsurgical endoscopic intervention postoperatively is in the management of late bariatric surgical complications and nonoperative revision of the surgical anatomy. In the future, indications for therapeutic endoscopy will undoubtedly expand the role of the gastroenterologist to include primary weight loss interventions, as the cutting-edge technology is currently undergoing rigorous scientific evaluation. Therefore, endoscopists caring for these patients should become familiar with the post–bariatric surgical anatomy, potential complications, common presenting symptoms, anticipated luminal and extraluminal findings, and endoscopic management. This review discusses common presenting symptoms, luminal and extraluminal findings, and endoscopic management of common bariatric complications as outlined in Table 1 .
| Procedure Type | Restrictive | Restrictive | Restrictive | Malabsorptive | Combined | Combined |
|---|---|---|---|---|---|---|
| Procedure Name | GB | VBG | Sleeve | JIB | RYGB | DS |
| Complications: | ||||||
| Band erosion | x | x | ||||
| Bezoar | x | x | x | |||
| Disrupted staple/sutures | x | x | x | x | x | |
| Erosive esophagitis | x | x | x | x | x | x |
| Fistula | x | x | x | x | x | |
| Food impaction | x | x | x | |||
| Foreign material | x | x | x | x | x | |
| Gallstones | x | x | x | x | x | x |
| Gastritis | x | x | x | x | x | x |
| GERD due to procedure | x | x | x | x | ||
| Leak | x | x | x | x | x | |
| Stenosis/stricture | x | x | x | x | x | |
| Ulcer, duodenal | x | x | x | x | x | x |
| Ulcer, gastric (pouch) | x | x | x | x | x | x |
| Ulcer, marginal (jejunal) | x | x | ||||
| Ulcer, stomal (gastric) | x | x | ||||
Presenting symptoms and endoscopic findings
Several investigators report that 20% to 30% of bariatric surgical patients receiving care in academic medical centers and in community institutions present with symptoms that prompt endoscopic evaluation. Huang and colleagues found in 49 patients referred for evaluation following bariatric surgery that the major presenting symptoms were abdominal pain (53%), nausea with vomiting (35%), dysphagia (16%), gastrointestinal hemorrhage (12%), and weight regain (6%). Several patients had more than 1 symptom suggestive of a postsurgical complication, and the constellation of symptoms was predictive of endoscopic findings. When considering the predictive value of symptoms in 49 patients who underwent 69 procedures, the absence of nausea, vomiting, and dysphagia had a negative predictive value of 100% when assessing for the presence of stomal stenosis. Second, the time interval following surgery had a direct effect on the endoscopic findings. In the first 6 months following surgery, 85% of the endoscopies had at least 1 abnormal finding versus 47% after 6 months. Third, all symptomatic patients should be evaluated. Marano found that, of 23 of 200 symptomatic bariatric surgical patients in a single community hospital, all complained of some degree of epigastric pain, nausea, and vomiting regardless of endoscopic findings. The most common findings were ulcer disease (52%), anastomotic stricture (4.3%), obstructed biliopancreatic limb (4.3%), acute gastric pouch bleed (4.3%), and anastomotic rupture/dehiscence (4.3%). Although 30% had normal postoperative anatomy and Helicobacter pylori infection was not detected in any patient in the population, uncommon complications must also be considered. In another large series, outcomes following 1292 consecutive divided Roux-en-Y gastric bypass surgeries were examined with approximately 17.6 months of follow-up. Fifteen patients (1.2%) presented for endoscopic evaluation and were found to have gastrogastric fistulas. Of these, 12 (80%) complained of nausea, vomiting, and abdominal pain. Four patients (27%) presented because of failure to lose the expected amount of weight. On endoscopic examination, 8 patients (53%) were found to have a coexisting marginal ulcer, highlighting the need to consider the presence of a fistula or leak when an ulcer is found.
To evaluate the predictors of endoscopic findings, a retrospective review of 1001 bypass surgeries performed in an academic medical center was completed. A total of 226 patients (166 open surgeries and 60 laparoscopic procedures), or 23% of the cohort, underwent endoscopic evaluation of gastrointestinal symptoms following surgery. Patients presented with nausea and vomiting (62%), abdominal pain (30%), dyspepsia (30%), early satiety (5%), dysphagia (4%), and heartburn (2%). Consistent with other series, the investigators found that 35% of the patients had more than 1 symptom. Other risk factors that were associated with a symptomatic presentation include nonsteroidal antiinflammatory drug (NSAID) use (27%), smoking (12%), and alcohol use (7%). About 14% were given proton pump inhibitor (PPI) therapy, and all had received 1 month of therapy with an H2 receptor antagonist for 1 month before surgery. On endoscopy, 127 patients had abnormal findings: marginal ulcer (36%), stomal stenosis (13%), and staple-line dehiscence (4%). Other less common findings (<3%) were esophagitis, nonmarginal ulcer, Schatzki ring, benign gastric polyps, and a solid food bezoar, with approximately 3% of the patients having more than 1 endoscopic finding. No gastrogastric fistulas were reported. Smoking, NSAID use, and abdominal pain predicted the presence of marginal ulcers at endoscopy; the use of PPI therapy was protective but only for the NSAID subgroup. Further, smoking and NSAID use predicted staple-line dehiscence. Age, gender, surgical technique, and surgeon experience did not predict abnormal findings at endoscopy. Time from surgery to presentation predicted findings for the presence of stomal ulcers and stomal stenosis. As in the series by Huang and colleagues, presenting more than 6 months after surgery was associated with a lower likelihood of stomal ulceration or stenosis. In contrast, presenting after 6 months was associated with a greater likelihood of staple-line dehiscence.
In addition to indicating the possible presence of stomal ulceration or stenosis, abdominal pain following bariatric surgery may be reflective of symptomatic gallstones and hepatobiliary disease. Nearly 30% to 36% of patients undergoing any type of bariatric procedure develop gallstones generally within 6 months of surgery, with sludge developing in as many as 13% of patients. Li and colleagues found that weight loss of more than 25% of the original weight was an independent risk factor for the development of symptomatic gallstone formation. The management of asymptomatic gallstones and gallbladder disease before bariatric surgery remains debated. Endoscopic therapy for symptomatic gallstones that develop in 4.7% to 7% of bariatric patients has also been described and is reviewed in the following section.
Symptoms associated with the nutritional complications of bariatric surgery are less specific and, thus, require a higher index of suspicion, as they coexist with abnormal endoscopic findings. Patients with persistent vomiting, rapid weight loss, or inadequate nutrient intake following any bariatric procedure are at risk for deficiencies such as thiamine deficiency. Thiamine is a water-soluble vitamin that is not synthesized in vivo, requiring adequate dietary consumption. Dietary sources of thiamine include cereals, whole grains, lean pork, organ meat (liver), eggs, and legumes. Total depletion of the body’s thiamine stores can occur within 20 days of surgery or in the setting of inadequate intake. If left untreated, thiamine deficiency can be fatal. Undertreatment or misdiagnosis can lead to preventable but irreversible clinical sequellae, including encephalopathy, paralysis, and heart failure. Other nonspecific symptoms such as chronic diarrhea, muscle cramps, aplastic anemia, glossitis, unexplained weakness, or fatigue may be harbingers of underlying micronutrient deficiencies, indicating the need for small-bowel mucosal biopsies. Further, other small-bowel mucosal disorders, such as celiac disease, may also be found in patients who present with nutritional deficiencies, including refractory iron deficiency anemia, after bariatric surgery. Regardless of specialty, physicians caring for the post–bariatric surgical patients must be diligent to monitor for and treat nutritional deficiencies. Given the seriousness of this concern, the American Society for Metabolic and Bariatric Surgery, The Obesity Society, The Endocrine Society, the American Association of Clinical Endocrinologists, and the American Society for Parenteral and Enteral Nutrition have published guidelines for clinical practice that are worthy of review. The upcoming bariatric guidelines from the American Gastroenterological Association and other leading gastrointestinal organizations should also be reviewed. The next section provides an overview of the most common complications that typically require endoscopic diagnosis or therapy. More detail is provided about the management of specific conditions in other articles in this issue.
Endoscopic management of common bariatric complications
Stomal and Marginal Ulcers
Although bleeding duodenal ulcers have been rarely reported following Roux-en-Y gastric bypass, ulcerations on the gastric side of the anastomosis (stomal ulcers) or on the jejunal surface of the anastomosis (marginal ulcers) occur in approximately 20% of patients. The cause of true stomal ulcers is thought to be ischemic in nature, whereas the cause of marginal ulcers is poorly understood. Multiple mechanisms have been proposed to explain marginal ulcers. Local ischemia, larger pouch size leaving retained parietal cells that produce gastric acid, acidic gastric secretions poorly tolerated in the jejunum, NSAID use, alcohol use, smoking, a coexisting gastrogastric fistula, and the presence of a foreign body such as nonabsorbable suture material have been implicated. The role of H pylori is not clear but has also been implicated as a risk factor in a review of 260 patients. H pylori serology may be the most reliable method for detecting the presence of the bacteria in this population, as pouch biopsies and breath tests may have problems with false-negative results. In patients who have been treated for H pylori infection, fecal antigen is a reliable method of detection. In treating marginal ulcers, endoscopists are encouraged to remove nonabsorbable sutures when visible intraluminally to assist with healing, prevent gastrogastric fistulas, and relieve chronic abdominal pain in patients who underwent bariatric surgery. Long-term treatment with oral Carafate and PPI therapy, along with antibiotics if H pylori infection is present, have led to healing of the ulcers. Refractory ulcers should raise concern for the presence of a gastrogastric fistula. In one study, marginal ulcer and associated gastrogastric fistula responded to a combination of PPI therapy and fibrin glue injections. Healing times for ulcer resolution vary from 8 weeks to 6 months but were longer in the presence of an untreated or undiagnosed fistula.
Stomal Stenosis
Stomal stenosis occurs in as many as 4.73% to 27% of patients undergoing Roux-en-Y gastric bypass. These patients typically present with dysphagia, nausea with vomiting, or early satiety as previously noted. The primary endoscopic intervention is balloon dilation up to 15 to 18 mm, which has been associated with a greater than 93% success rate in symptom resolution and subsequent weight loss. Dilation with Savary-Gilliard bougie (Cook Endoscopy; Winston-Salem, NC, USA) may be considered and is an effective intervention. In one review, both methods required 2 to 3 sessions of therapy, with a complication rate of 3%. Gradual dilation over a few sessions is likely the best, as overdilation could potentially lead to loss of restriction and weight regain in some patients. For symptomatic patients presenting with refractory vomiting, thiamine repletion should be considered early and before exogenous glucose administration to prevent the precipitation of Wernicke encephalopathy.
Gastrogastric Fistulas
Most large series report that gastrogastric fistulas occur in 1.2% to 1.8% of patients undergoing gastric bypass. However, incidence rates from zero to as high as 46% have been reported, with substantial improvements in recent years because of modifications in the surgical technique. Because of the high rate of morbidity and mortality associated with surgical revision of gastrogastric fistulas, initial treatment has evolved from surgical interventions to endoscopic management, with variable success. Reported endoscopic techniques include the use of fibrin glue sealants, insertion of a Surgisis fistula plug (Cook Surgical, Inc, Bloomington, IN, USA) with or without a self-expanding stent, endoluminal stent placement, the use of mucosal suturing devices for tissue apposition, and local debridement following argon plasma coagulation. The optimal method of treatment is unknown, as comparison studies and randomized controlled trials are lacking.
Anastomotic Rupture/Dehiscence/Leaks
Published incidence rates for leaks following bariatric surgery range from 0.4% to 26%, and leaks are associated with a mortality rate of 1.5%. Next to pulmonary embolus, intra-abdominal sepsis secondary to leaks is the most serious life-threatening complication associated with bariatric surgery. The potential causes of leaks are multiple: tension on the anastomosis, staple or stapler malfunction, suture or staple-line seepage, poor surgical technique, obstruction, hypovascularization, and hematomas. Leaks require early recognition of symptoms, detection, and prompt treatment to prevent loss of life. Recent reports demonstrate that endoluminal interventions are effective in healing anastomotic breeches. Multiple investigators are reporting the successful placement of covered endoluminal stents and the initiation of oral nutrition leading to recovery from this postoperative complication. Nonsurgical interventions were found to result in the healing of anastomotic leaks in 17 of 21, or 81%, of affected patients.
Hepatobiliary Complications Including Cholelithiasis
The development of hepatobiliary disease is common following bariatric surgery. Shiffman and colleagues reported that gallstones developed in 36% and sludge developed in 13% of 81 patients with normal gallbladder ultrasonograms at the time of surgery. About 40% of these subjects developed symptoms, and 28% underwent elective cholecystectomy. Controversies exist as to the best evaluation and treatment of this high-risk population. At present, only 30% of surgeons actively perform elective preoperative cholecystectomy procedures to remove normal-appearing gallbladders. Although prophylactic administration of ursodiol has decreased the frequency of gallstone disease requiring intervention to 2%, it is not widely prescribed. In fact, some practitioners have questioned the validity of prophylactic management.
Because the incidence of hepatobiliary complications is high, evaluation should be performed in a systematic fashion to identify those who need endoscopic intervention. To evaluate a symptomatic patient for the presence of stones or other hepatobiliary disease, magnetic resonance imaging (MRI) or computed tomography (CT) is preferred, as ultrasound image resolution is adversely affected by body fat, contributing to missed diagnoses. When symptomatic disease occurs, endoscopic retrograde cholangiopancreatography is the gold standard procedure for nonsurgical therapeutic management of hepatobiliary disease. The endoscopic approach is complicated by the post–bariatric surgical anatomy, limiting transoral access. Laparoscopy-assisted transgastric approach is the most commonly reported intervention. Single-balloon and double-balloon enteroscopy and temporary restoration of digestive continuity have been advocated, allowing for stone extraction and sphincterotomy as indicated.
Weight Regain
Although highly debated, it has been reported that 18% to 30% of bariatric patients experience a near-total weight regain following bariatric surgery, constituting surgical failure. Although weight regain or failure to lose weight following a bariatric procedure is typically considered to be related to dietary indiscretions, failure to exercise, or failure of the body to maintain the surgically induced changes in regulatory gut hormones such as peptide YY, other causes that are amenable to endoscopic intervention have been identified. Loss of restriction because of a dilated gastrojejunostomy and/or a dilated gastric pouch after bariatric surgery results in weight gain as a consequence of loss of satiation and increased caloric intake. Some investigators point out that stomal size correlates with the risk of weight regain for bariatric patients. Therefore, when patients present with weight regain or failure to lose weight, endoscopic evaluation and radiologic studies should be considered. When an enlarged gastrojejunal stoma is found, potential endoscopic interventions that promote restriction and facilitate additional weight loss include (1) sclerotherapy of the site using 6 to 30 mL of sodium morrhuate injected circumferentially, which is associated with a 72% to 75% success rate ; (2) the use of a tissue plication system to reduce the size of the gastrojejunostomy and the gastric pouch, known as the revision obesity surgery endoscopic procedure ; (3) revisional surgery using a tissue plication device known as StomaPhyX (EndoGatric Solutions; Redwood City, CA, USA) to reduce the pouch size ; and (4) application of the endoclip to reduce the size of the gastrojejunal anastomosis. Weight regain may also indicate the presence of a gastrogastric fistula, which may be addressed endoscopically in a similar manner. Although endoscopic therapy facilitates weight loss, it must be accompanied by dietary, behavioral, and lifestyle changes to ensure long-term success.
Related posts:
Obesity Overview: Epidemiology, Health and Financial Impact, and Guidelines for Qualification for Surgical Therapy
Medical Therapy for Obesity
Presurgical Evaluation and Postoperative Care for the Bariatric Patient
Management of Acute Postoperative Hemorrhage in the Bariatric Patient
Accessing the Pancreatobiliary Limb and ERCP in the Bariatric Patient
Management of Postsurgical Leaks in the Bariatric Patient
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