Bariatric surgery remains the only effective method to initiate and sustain massive weight loss in morbidly obese patients. Along with the advent of minimal access surgery, its popularity has not only resulted in an exponential increase in number of cases but also a subsequent increase in number of complications. Although most postsurgical bariatric complications are managed surgically, it is imperative that all physicians be aware of the unique potential complications to effectively communicate and optimize the medical management in this emergent set of patients.
The prevalence of morbid obesity continues to increase at an alarming pace. Related comorbidities such as diabetes, hypertension, hyperlipidemia, and cardiovascular disease are responsible for 2.5 million deaths per year according to the World Health Organization. The approximate loss of life for each morbidly obese individual is 12 years compared with nonobese persons. Obesity is considered a disease of genetic predisposition and maladjusted behavior; however its cause is multifactorial and not yet completely understood. Perhaps because of ignorance and social stigmatization, morbid obesity is not yet fully accepted as a disease by the public or even among physicians. Complications resulting from obesity-related surgery may not be well received by the public and bariatric surgery is closely scrutinized in some environments.
A brief history
A thorough insight in clinical outcomes and managing complications first requires an understanding of procedures from a historical perspective. Through clinical observation, surgeons have learned that the shortened gut leads to massive weight loss. Early in the 1950s, it was observed that short gut syndrome could be manipulated to advantage by creating a malabsorptive procedure to provide massive weight loss and weight maintenance.
The first purposeful bariatric operation manifested as the jejunoileal bypass. By limiting intestinal length and surface area, malabsorption of ingested food leads to decreased body mass and also reduces the caloric need to accommodate the decreased body mass, achieving a metabolic equilibrium. The jejunoileal bypass was effective in malabsorption resulting in massive weight loss but carried many side effects, such as gas-bloating, steatorrhea, electrolyte disturbances, nephrolithiasis, and hepatic fibrosis, and was therefore later abandoned. In the 1960s and 1970s, malabsorptive procedures combined with restrictive procedures, such as the Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion, and duodenal switch, gained popularity. In the 1980s, gastroplasties in various forms, such as stapling and banding, came into favor. Now, favorable outcomes support laparoscopic sleeve gastrectomy as an attractive option.
Trial and error with malabsorptive, restrictive, and combined procedures, along with minimal access techniques, have progressed bariatric surgery into its contemporary form. In the laparoscopic era, the RYGB, adjustable gastric band, and sleeve gastrectomy are favored bariatric operations because of their efficacy and acceptable complication rates. There is no single bariatric operation suitable to all patients. Ultimately, multiple facets should be carefully examined to balance lifestyle and risk tolerance for complications.
Comparisons
Morbid obesity continues to occur at an epidemic rate. Fewer than 40,000 annual bariatric cases were reported before the advent of the laparoscopic era. That number is projected to increase to more than 200,000 annually. Although complication rates are among the lowest reported for major abdominal procedures, bariatric surgery remains in high profile and complications are not well received by the public, patients, or medical community.
In the largest review and meta-analysis of more than 85,000 patients, mortalities for bariatric procedures were among the lowest reported in the global surgical community ( Table 1 ). Reported outcomes revealed a total 30 day mortality of 0.28% and a 2-year mortality of 0.35% for all bariatric procedures. Mortality between open and laparoscopic operations for all procedures similarly remained low. Men had a disproportionately high 30-day mortality compared with women, 4.74:0.13, consistent with technical challenges as well as medical problems associated with android fat distribution. The superobese with body mass indices (BMIs) equal to or greater than 50 had a higher 30-day mortality (1.25%), and the elderly (>65 years) had a 30-day mortality of 0.34%.
| ≤30 d Mortality (%) | >30 d to 2 y Mortality (%) | |
|---|---|---|
| Total | 0.28 | 0.35 |
| Restrictive | 0.30 open 0.07 laparoscopic | 0.22 open 0.01 laparoscopic |
| Combined | 0.41 open 0.16 laparoscopic | 0.69 open 0.09 laparoscopic |
| Malabsorptive | 0.76 open 1.11 laparoscopic | 0.85 open N/A laparoscopic |
In comparison between open and laparoscopic operations, a randomized trial by Nguyen and colleagues of 155 patients discovered no difference in mortality between patients having laparoscopic versus open gastric bypass. However, patients having laparoscopic gastric bypass had a lower incidence of infectious complications, lower incidence of incisional hernias, less operative blood loss, shorter hospital stay, reduced frequency of late anastomotic stricture, and earlier return to work and activities of daily living.
Other studies, including large case series, support similar complication rates. In a review by Parikh and colleagues of 780 laparoscopic bariatric operations, including LAP-BAND, laparoscopic RYGB (LRYGB), and biliopancreatic diversion bypass with or without duodenal switch (BPD ± DS), there was 1 reported late death. Major complications, including organ resection, irreversible deficits, and death, occurred in 0.2% for the LAP-BAND, 2% LRYGB, and 5% BPD ± DS.
Early initial results were not as uniform. Early data from Flum and colleagues revealed that mortality among Medicare patients 65 years and older was significantly higher than for patients younger than 65 years at 1 year, 11.1% compared with 3.9%. Men also had a higher 1-year mortality: 7.5% compared with 3.7% in women. In contrast, Hallowell and colleagues found no difference in mortality in their series of 928 Medicare patients, and argued that that there is inevitable selection bias. They attribute their results to careful patient selection, intensive preoperative education, and expert management.
Pregnancy and fertility following bariatric surgery has shown favorable outcome to those who undergo initial bariatric surgery then pursue pregnancy. Although, at first, the potential for neural tube defects from folate and nutrient deficiency following bariatric surgery must be considered, data support lower adverse maternal and neonatal outcomes in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese. Most advocate waiting at least 1 year after bariatric surgery, until a nutritional and metabolic steady state is reached, before pregnancy. Close coordination of care between gynecologists and surgeons is paramount to ensure that nutrition and potential complications are monitored in this population.
Bariatric surgery in the adolescent population remains controversial. Proponents favor early intervention to prevent chronic morbidities, whereas opponents argue that adolescents do not exhaust behavioral and medical options. Long-term data are still lacking, but bariatric surgery in adolescents seems to be as well tolerated as in adults when performed in high-volume centers of excellence.
Most series show that bariatric surgery can be performed with low rates of perioperative mortality. Overall, the mortality is extremely low compared with rates for other major operations such as aortic aneurysm repair (3.9%), coronary artery bypass graft (3.5%), esophagectomy (9.9%), pancreatectomy (8.3%), and pediatric cardiac surgery (5.4%). Societies such as the American Society for Metabolic and Bariatric Surgery (ASMBS), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Fellowship Council (FC), and the American College of Surgeons (ACS) have taken leadership roles to ensure safety and quality improvement. Like any surgical morbidity and mortality, complications depend on the surgeon’s skill, experience, and operative volume, appropriate patient selection, and choice of procedure.
Comparisons
Morbid obesity continues to occur at an epidemic rate. Fewer than 40,000 annual bariatric cases were reported before the advent of the laparoscopic era. That number is projected to increase to more than 200,000 annually. Although complication rates are among the lowest reported for major abdominal procedures, bariatric surgery remains in high profile and complications are not well received by the public, patients, or medical community.
In the largest review and meta-analysis of more than 85,000 patients, mortalities for bariatric procedures were among the lowest reported in the global surgical community ( Table 1 ). Reported outcomes revealed a total 30 day mortality of 0.28% and a 2-year mortality of 0.35% for all bariatric procedures. Mortality between open and laparoscopic operations for all procedures similarly remained low. Men had a disproportionately high 30-day mortality compared with women, 4.74:0.13, consistent with technical challenges as well as medical problems associated with android fat distribution. The superobese with body mass indices (BMIs) equal to or greater than 50 had a higher 30-day mortality (1.25%), and the elderly (>65 years) had a 30-day mortality of 0.34%.
| ≤30 d Mortality (%) | >30 d to 2 y Mortality (%) | |
|---|---|---|
| Total | 0.28 | 0.35 |
| Restrictive | 0.30 open 0.07 laparoscopic | 0.22 open 0.01 laparoscopic |
| Combined | 0.41 open 0.16 laparoscopic | 0.69 open 0.09 laparoscopic |
| Malabsorptive | 0.76 open 1.11 laparoscopic | 0.85 open N/A laparoscopic |
In comparison between open and laparoscopic operations, a randomized trial by Nguyen and colleagues of 155 patients discovered no difference in mortality between patients having laparoscopic versus open gastric bypass. However, patients having laparoscopic gastric bypass had a lower incidence of infectious complications, lower incidence of incisional hernias, less operative blood loss, shorter hospital stay, reduced frequency of late anastomotic stricture, and earlier return to work and activities of daily living.
Other studies, including large case series, support similar complication rates. In a review by Parikh and colleagues of 780 laparoscopic bariatric operations, including LAP-BAND, laparoscopic RYGB (LRYGB), and biliopancreatic diversion bypass with or without duodenal switch (BPD ± DS), there was 1 reported late death. Major complications, including organ resection, irreversible deficits, and death, occurred in 0.2% for the LAP-BAND, 2% LRYGB, and 5% BPD ± DS.
Early initial results were not as uniform. Early data from Flum and colleagues revealed that mortality among Medicare patients 65 years and older was significantly higher than for patients younger than 65 years at 1 year, 11.1% compared with 3.9%. Men also had a higher 1-year mortality: 7.5% compared with 3.7% in women. In contrast, Hallowell and colleagues found no difference in mortality in their series of 928 Medicare patients, and argued that that there is inevitable selection bias. They attribute their results to careful patient selection, intensive preoperative education, and expert management.
Pregnancy and fertility following bariatric surgery has shown favorable outcome to those who undergo initial bariatric surgery then pursue pregnancy. Although, at first, the potential for neural tube defects from folate and nutrient deficiency following bariatric surgery must be considered, data support lower adverse maternal and neonatal outcomes in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese. Most advocate waiting at least 1 year after bariatric surgery, until a nutritional and metabolic steady state is reached, before pregnancy. Close coordination of care between gynecologists and surgeons is paramount to ensure that nutrition and potential complications are monitored in this population.
Bariatric surgery in the adolescent population remains controversial. Proponents favor early intervention to prevent chronic morbidities, whereas opponents argue that adolescents do not exhaust behavioral and medical options. Long-term data are still lacking, but bariatric surgery in adolescents seems to be as well tolerated as in adults when performed in high-volume centers of excellence.
Most series show that bariatric surgery can be performed with low rates of perioperative mortality. Overall, the mortality is extremely low compared with rates for other major operations such as aortic aneurysm repair (3.9%), coronary artery bypass graft (3.5%), esophagectomy (9.9%), pancreatectomy (8.3%), and pediatric cardiac surgery (5.4%). Societies such as the American Society for Metabolic and Bariatric Surgery (ASMBS), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Fellowship Council (FC), and the American College of Surgeons (ACS) have taken leadership roles to ensure safety and quality improvement. Like any surgical morbidity and mortality, complications depend on the surgeon’s skill, experience, and operative volume, appropriate patient selection, and choice of procedure.
LAP-BAND complications
The LAP-BAND procedure was approved in 2001 by the US Food and Drug Administration for surgical weight loss ( Table 2 ). Considered the least technically difficult among bariatric operations, it is a restrictive procedure with low foreseeable complication rates and potential for reversibility. Early experience with the pars flaccida technique, routine use of postoperative contrast studies, and delayed first band adjustments contributed to low complication rates. Most series report less than 0.3% mortality. Conversion from laparoscopic to open surgery occurs in 1%, most commonly because of extreme hepatomegaly and intraoperative technical difficulty. The mean operative time is 40 minutes, mean hospital stay 1 day, and first band adjustments are made at least 3 months after gastric edema subsides. Total LAP-BAND complications may occur up to 35% and 11% may require reoperation. Most complications are minor and manageable in the clinic, and those requiring operations can usually undergo laparoscopic surgery.
| Complication | Among All Patients (%) |
|---|---|
| Access port dysfunction | 7.3 |
| Gastric pouch dilation ± esophageal dilation | 6.6 |
| Band slippage | 1.8 |
| Stoma obstruction | 1.8 |
| Pneumonia | 0.7 |
| Pulmonary embolism | 0.4 |
| Trocar site bleeding | 0.4 |
Access port (reservoir for adjustments) complications consist of half of all LAP-BAND complications and account for most reoperations. Of all access port complications, port infection is the most frequent. Staphylococcus aureus is usually cultured in the wound or from the port itself. Patients may complain of tenderness and have signs of erythema and rubor around the port site. Treatment consists of antibiotics until resolution of infection. Removal of the reservoir, closure of connector tubing, and introduction of the tube into the peritoneal cavity may be necessary. Leaving the port reservoir or connecting tubing within subcutaneous tissue usually fails to adequately treat infection or heal. Esophagoduodenoscopy may also be useful to evaluate the band for erosion, which may also present as an infected port site.
Mechanical or technical problems are the second most common access port complication. Disconnection between the junction of silicone tube and access port occur in 17.7%. Inability to puncture the reservoir and failure to adjust the band occur in 15.6%. Leaking from the tubing outside of the peritoneal cavity occur in 11.1%. Protrusion of the port reservoir through the dermis occurs in 4.45%. Treatment is usually successful in an outpatient setting under local anesthesia by shortening the tube and reconnecting it to the reservoir under fluoroscopy.
Port site flip can be avoided by using at least 3 nonabsorbable sutures to the fascia to secure a plane and taking care not to injure the tube during subsequent punctures. Using a smaller, flatter port deep under fascia for those who lose a lot of weight and have reservoir protruding in the dermis may become necessary. Also, the surgeon can place the port in the subxiphoid location or left upper quadrant, whichever accommodates less mechanical friction from abdominal wall movement. Alternatively, ports may be fixed using synthetic mesh. In most cases of technical or mechanical port problems outside the peritoneum, minor procedures can be done under local anesthesia without removal of the gastric band itself.
Intra-abdominal complications involving the band present greater challenges in diagnosis and treatment. Upper gastrointestinal (GI) complaints are usually nonspecific and characterized by food intolerance, pain, and feelings of reflux. Dysphagia and vomiting are more ominous signs and warrant careful concern for obstruction. An upper GI contrast study may be valuable in determining band position and gastric configuration. Obtaining additional views in oblique positions may also aid in diagnosis. In addition to the diagnostic difficulty, the discordance of definitions among surgeons adds to the complexity. The terms prolapse, dilation, pouch enlargement, and slippage are variably defined in the literature and warrant clarification. Although most may be treated nonoperatively, several situations are surgical emergencies and require timely and accurate diagnosis.
Pouch enlargement, or concentric dilation refers to the expanded proximal esophageal or gastric lumen resulting from mechanical luminal stretch and compliance ( Fig. 1 ). This condition most likely results from patient noncompliance with oral intake instructions, usually from ingesting more than 110-g meals and/or overinflation of the band. Patients usually present with nonspecific upper GI complaints without vomiting or dysphagia. If left untreated, dilation may result in a permanent atonic gastric pouch and atonic esophagus in 50%. Unlike band slippage or eccentric prolapse, dilation of the proximal segment is concentric and the band remains in its original 45 degree orientation.
For prevention, most experts make 3 recommendations: (1) reduce gastric pouch to less than 15 cm 3 ; (2) place gastric-to-gastric sutures to secure the band; (3) position the posterior aspect of the band high and close to the gastroesophageal junction. Early treatment with band deflation, intravenous fluids (IVF) resuscitation, and dietary intake education may reduce symptoms and reverse the effects. If early treatment fails to resolve symptoms, a cause for obstruction should be suspected.
Eccentric prolapse, true prolapse, eccentric dilation, and slippage refer to the condition in which the gastric wall is displaced cranially and the band is displaced caudally. Patients with pouch enlargement or dilation are believed to be predisposed to prolapse. In addition to the upper GI complaints, patients complain of dysphasia and vomiting. A dilated eccentric gastric pouch with displacement of the original configuration of the band are seen on upper GI radiography (UGI) ( Fig. 2 ). Various configurations have been described, including anterior versus posterior slippages with differences in band angles; however, this entity in general is considered obstructive and the management is surgical. Because of the larger cross-sectional area at the level of the body compared with the area at the level of the angle of His, complete obstruction is inevitable and this situation is always a surgical emergency.
The pars flaccida technique has a lower association with band slippage compared with the earlier perigastric technique. Immediate management is similar to that for dilation as described previously. In addition, a nasogastric tube should be inserted to decompress the pouch, enable resolution of edema, and to prevent aspiration. Surgical options include band removal or gastric reduction with band repositioning.
Stoma obstruction refers to the obstruction of food from the gastric pouch to the rest of the stomach. Early postoperative causes are likely from bands applied over a thick gastroesophageal junction (GEJ), incorporating too much tissue inside the band, positioning the band too distally from GEJ, or edema. Late postoperative causes may be related to gastric pouch dilation, prolapse, erosion, pouchitis, or esophagitis. Patients may present with dysphagia, chest pain, reflux, and vomiting. Patients with early partial obstructions may be managed conservatively with nutritional support, systemic steroids, and diuresis. Most will respond within a few days as the edema subsides; however, patients with complete obstruction, either early or late, may need to undergo exploratory laparoscopy and revisional surgery.
Erosion of the LAP-BAND is rare, occurring in less than 2%. Patients may present with acute peritoneal signs ( Fig. 3 ). Most patients present with more chronic or subclinical findings that indicate a port site infection. Chronic erosion may present with port infection. Proposed causes include undetected intraoperative iatrogenic injury and pressure necrosis of the band. Chronic usage of immunosuppressive medications is also believed to greatly increase the risk of erosions. Treatment is surgical for acute presentations. Successful endoscopic retrieval for chronic erosion has also been described.
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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