View source for Bariatric surgery complications

==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]]
[[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]]

==Clinical Features==
*[[Abdominal pain]], food intolerance
*[[Sepsis]], abnormal vital signs

==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

===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
**[[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

==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<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]]

===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==
*[[Lap Band Complications]]
*[[Acute gastric dilation]]

==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/

==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.

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[[Category:Surgery]]