of Complications of Bariatric Operations

Fig. 29.1

Fluoroscopic image of an anterior band prolapse. The arrow indicates the horizontal position of the band

Band Erosion

This complication is reported with an incidence of 0.3% to 14% [5]. Patients can present with nonspecific epigastric or abdominal pain, cessation of weight loss, gastrointestinal bleeding, abdominal abscess or infected/abscess at the port site, peritonitis, and pneumoperitoneum. The diagnosis is usually made by endoscopic evaluation. The management always entails band removal, which can be accomplished endoscopically when the buckle of the band is intragastric. More commonly the removal is done laparoscopically.

Esophageal Dilatation (Megaesophagus)

This is mostly seen in patients with slipped or overadjusted bands. The treatment of choice is to completely remove the fluid from the band and, after complete remission of the megaesophagus, slowly initiate readjustment. If tolerated, the band can be kept in place and monitored regularly with UGI series every 3 months. If no remission is encountered after a period of 12 weeks, the band has to be removed and the patient must continue close monitoring of symptoms. Alternative bariatric operations become controversial. Specifically, LSG might be contraindicated since these patients may require a gastric pull up if the megaesophagus does not go into remission.

Port and Catheter Complications

The port can dislocate or flip over. This can result in difficulty in adjusting the band and may require repositioning. Another complication that can occur is if the catheter connecting the port with the band breaks or gets disconnected. In this case, the patient will require a relaparoscopy to reconnect the port. Finally, as mentioned before, a port site infection can be the result of poor technique of adjustment or an early sign of erosion. In this case, the band and port have to be removed .

Sleeve Gastrectomy

Although regarded as one of the safest bariatric operations, it can potentially present with several complications.

Leaks

Leak is the most significant and feared complication of LSG. Reduction of gastric volume by 70–80% with competent pylorus and lower esophageal sphincter with resultant increased intragastric pressure along with a long staple line provides a fertile environment for leaks. Prevention of leaks can be accomplished with adequate mobilization of the greater curvature of the stomach and retrogastric attachment for proper visualization of the stomach to the lesser curvature, utilization of a 36 Fr or larger bougie to prevent strictures, avoiding rotation of the staple line with symmetrical lateral retraction, and consideration being given to the thickness of the stomach and appropriate selection of staple height cartridges. Although it is our routine practice, imbrication of the staple line has not definitively shown to decrease the leak rate [6]. The most common site of leak is the proximal staple line. Time of presentation is of importance, as acute leaks present within 7 days and are often related to technical problems with the staple line, ischemia, or energy source burns. Leaks developing between 1 and 6 weeks are termed as early and after 6 weeks as late—the latter posing a more challenging problem [6]. Diagnostic workup includes a CT abdomen and pelvis with PO and IV contrast. In unstable patients, emergent operative intervention is of paramount importance, with wide drainage and washout carried out in most cases, although direct repair of the leak can be attempted if location is obviously uncovered without risking further damage. Percutaneous image-guided drainage and endoscopic stent placement across the leak are a legitimate option in managing leaks in the acute and early settings in patients who are hemodynamically stable. Another option for mid to distal acute leaks is to convert them into controlled fistulas by placement of a T-tube and performing a feeding jejunostomy (Fig. 29.2) [7]. Chronic leaks are less amenable to the abovementioned techniques, and invasive surgical intervention remains the mainstay. Preoperative planning includes review of operative reports of the index operation and technique and extensive radiological review with upper gastrointestinal contrast studies inclusive of CT abdomen and pelvis. Reoperation is delayed until the patient is nutritionally replenished and the surgical field becomes less hostile (at 12 weeks). Surgical options can include suturing of an antecolic roux limb to the area of leak after adequate debridement of the inflamed gastric wall and an NG tube being advanced across the anastomosis or laparoscopic proximal gastrectomy with Roux-en-Y esophagojejunostomy [8]. The success rate of this approach is high, and the leak rate is documented to be 6.6%, requiring NPO for 4 weeks and TPN for its resolution. Endoscopic septotomy has been reported in the literature as a safe and effective technique for the management of LSG-associated leaks and collections, including those refractory to other endoscopic and percutaneous methods [9].

../images/473262_1_En_29_Chapter/473262_1_En_29_Fig2_HTML.jpg — Fig. 29.2

T-tube in gastric sleeve to control leak

Postoperative Bleeding

The overall incidence of postoperative bleeding is low and rarely requires operative intervention. There are three potential sites of bleeding: intraabdominal, intraluminal, or port site. Postoperative nausea or emesis, melena, and port site hematomas should prompt further radiological investigative workup. Management requires serial vital signs monitoring, urine output monitoring, hemoglobin/hematocrit, and PRBC transfusion for hemodynamic instability or Hb <7.0 and possible operative exploration and hemostasis for intra-abdominal bleeding. Endoscopic evaluation and hemostasis are required and effective in cases where intraluminal bleeding is persistent and causes instability.

Kinking/Stenosis/Obstruction

There are several points where partial obstruction or kink can be created. Most commonly this occurs while firing the stapling device at the incisura angularis, creating an almost 90° angle. If this sort of narrowing occurs and the patient develops persistent nausea and emesis, a conversion to RYGB may be necessary. Other alternatives include seromyotomy, which has a high leak rate, and central gastric resection with anastomosis (Fig. 29.3) [10].

../images/473262_1_En_29_Chapter/473262_1_En_29_Fig3_HTML.png — Fig. 29.3

Seromyotomy after stenosis of sleeve gastrectomy

GERD as a Late Complication After LSG

There are no major long-term complications after LSG, but there is development or worsening of GERD with or without esophagitis. To the authors’ knowledge, the literature does not have level 1 evidence studies that demonstrate that LSG is contraindicated in patients with GERD. However, it is the authors’ and the literature preference to recommend a gastric bypass in these patients instead. The latter should be supported by pH and manometry studies that demonstrate severe GERD with chronic esophagitis. When patients develop severe GERD after LSG, the initial treatment is proton pump inhibitors and close monitoring of esophagitis with EGD. In the case that GERD becomes intractable or complicated by aspiration pneumonia, gastric bypass is the preferred surgical approach.

Roux-en-Y Gastric Bypass

It induces weight loss by utilizing restrictive and malabsorptive strategies. The alimentary limb can be progressed to the gastric pouch in an antecolic or retrocolic fashion; there are mesenteric defects created during the course of the procedure that are potential sites for internal herniation and postoperative bowel obstruction. The complications of gastric bypass surgery can be divided into acute (7 days), early (7 days to 6 weeks), late (6 to 12 weeks), and chronic (>12 weeks).

Acute and Early Complications

Leaks

Undetected leaks remain the second leading cause of death after RYGB surgery. Potential sites of leaks include the gastrojejunal anastomosis, gastric pouch, gastric remnant, the jejunal blind end, and the jejunojejunal anastomosis. Approximately 70–80% of leaks occur at the gastrojejunal anastomosis, 10–15% at the gastric pouch, 5% at the jejunojejunal anastomosis, and 3–5% at the excluded stomach. Factors involved in the development of these leaks include tension, ischemia, and stapler misfiring. Some of the risk factors associated with higher incidence of leaks include male gender, super morbid obesity, age >55 years, and revisional procedures [11]. Signs and symptoms of leak include sustained tachycardia, abdominal pain, fever, nausea and vomiting, oliguria, and hemodynamic instability. The diagnosis can be confirmed by contrast upper gastrointestinal (UGI) fluoroscopic evaluation or CT scan. CT scan adds sensitivity to the diagnosis of GJ leaks because of the ability to show not only contrast extravasation and extraluminal collections but also indirect signs of leak, such as surrounding inflammatory changes, intraabdominal free air, and left pleural effusion (Fig. 29.4). Also, the CT scan is able to show additional sites of potential leaks, such as gastric remnant, J-J anastomosis, gastric remnant distention, etc. Management includes intravenous antibiotics, bowel rest, control of secretions, wide drainage, and early nutrition. The approach to drainage of the intra-abdominal collection is dictated by the clinical scenario. In the presence of hemodynamic instability, surgical intervention is warranted . During the operation, key steps include extensive irrigation; repair of the leak, if feasible and safe, although often unsuccessful; placement of feeding gastrostomy or enteral access distal to the leak site; and extensive closed-suction drain placement. Based on surgeons’ individual skills and experience, these steps can be either accomplished laparoscopically or via an open approach. It is the authors’ experience and recommendation to keep the surgical approach as simple as possible in this kind of clinical setting. In an emergency we should always choose the faster and simpler approach and refrain from redo anastomosis. Whenever the patient’s hemodynamic status allows, endoscopic stent placement can be considered, and local sepsis control can be accomplished via percutaneous drainage or with the drains previously placed at the time of surgery. Failure of nonoperative management has been reported in 12% of the cases [12]. Regardless of the approach utilized, the mortality of a leak remains high at about 10% [13].