Bariatric surgery complications: Difference between revisions
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==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 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 | |||
*Anastamotic 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 | |||
**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 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 | |||
**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 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 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 | |||
*'''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 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 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 | |||
**Dx: 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 drainge/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)] | |||
- | ==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. | |||
<references/> | |||
[[Category:Surgery]] | |||
Revision as of 16:04, 8 November 2018
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 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
- Anastamotic 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
- 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 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
- 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 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 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
- 38% of RYGB patients
- 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 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 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
- Dx: 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 drainge/antibiotic/NPO
- Reflux
- Common post-op complication
- Treated medically initially with eventual RYGB for refractory cases
See Also
External Links
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.
- ↑ 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.