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Chapter 8
Management of Complications Following
Bariatric Surgery
Asim Shabbir* and Chih-Kun Huang
†
Introduction
The rise in obesity and the efficacy of bariatric
surgery in producing effective, sustainable and reproducible weight loss have brought bariatric surgery to the
forefront of medicine. The increasing number of bariatric procedures mandates that surgeons are familiar with
the management of complications of such procedures.
A proactive, vigorous surveillance after surgery for
signs and symptoms of complications is the key to
early detection and management.
General Complications
Thromboembolism
Obesity is a well-known risk factor for deep vein
thrombosis and pulmonary embolism, though the
incidence in Asia is apparently low. Preventive measures
during and after surgery include adequate hydration,
low molecular weight heparin, pneumatic calf compression, anti-embolic stockings, early ambulation and in
very high risk cases, even using vena caval filters.
Atelectasis
Good pain control, incentive spirometry, nursing
patients in 30° reverse Trendelenburg position and
early ambulation enhance respiratory function and is
key to preventing atelectasis.
Nausea and Vomiting
These are largely related to anaesthesia and administration of opioid analgesics.
Following sleeve gastrectomy, vomiting may
occur from oedema at the gastroesophageal junction, stricture as a result of too close stapling near
the incisura and/or gastric tube torsion. In most
patients, resting the gastrointestinal tract, anti-emetics
and IV hydration will be rewarding. When symptoms
are intractable, upper gastrointestinal contrast study
will help define the problem. After gastric bypass,
a narrow gastrojejunostomy opening due to oedema
will spontaneously, resolve. In intractable cases,
endoscopic dilatation or surgical revision would be
required.
* Dr Asim Shabbir, MBBS (Pak.), MMed (Surg.), FCPS (pak. FRCS (Edln.), FAMS (Surg), Consultant, Department of Surgery,
National University Hospital.
†
Dr Chih-Kun Huang, Chairman, International Excellence Federation for Bariatric & Metabolic Surgery; President, Taiwan Obesity
Support Association; Director, Bariatric & Metabolic International Surgery Center, E-Da Hospital, Taiwan; Director, Minimally Invasive
Surgery Training Center, E-Da Hospital, Taiwan.
73
74 Atlas of Complicated Abdominal Emergencies
Wound Complications
The laparoscopic approach has significantly diminished the rates of major wound complications which
have been frequent after open bariatric surgery.
To further reduce the risk of incisional hernia, it is
our practice to suture all port sites that are greater than
5 mm, especially those that employ tissue cutting
rather than splitting blades.
Acute Abdominal Complications
1. Bleeding
The incidence of gastrointestinal haemorrhage
ranges between 0.5 and 5 percent. The use of buttress
material has been shown to decrease the incidence of
post operative bleeding in bariatric surgery. However,
it cannot be stressed enough that meticulous haemostasis needs to be achieved prior to closing the abdomen. Perioperative management of bleeding disorders
and hypertension is important in preventing bleeding
tragedies.
In 50–70%, bleeding is self-limiting following
blood transfusion or fluid resuscitation. When reexploration is necessary after sleeve or gastric bypass,
a thorough survey of the entire operative field including the staple line, omentum and sutured areas is
necessary. Bleeding points can be secured by using
clips, suturing, or an energy device. The peritoneal
cavity is cleared of blood and a drain left near the
bleeding site. Early intra-luminal GI haemorrhage has
not been reported after sleeve resection but is well
documented after gastric bypass. It commonly occurs
either at the gastrojejunostomy or jejunojejunostomy
site and the presence of luminal clots may make
localisation difficult. Surgery is required when endoscopic localisation or therapeutic attempt fails.
Oversewing the entire anastomosis is preferred over
opening the anastomosis to look for the bleeder.
An option to detect acute GI haemorrhage is to do
a CT angiography followed by angioembolisation of
the bleeding site. Chronic GI bleeding could occur
after bariatric surgery. Endoscopy, capsule endoscopy
and radioactive labelled isotope scan may be diagnostic. For patients suspected to have gastric cancer after
gastric bypass, access to the remnant stomach would
require a gastrostomy under general anaesthesia.
2. Leaks
The aetiology of a leak is multifactorial, most commonly involving local factors like tension on the anastomosis and poor blood supply. Systemic patient
factors include diabetes and the use of steroids, etc.
During surgery, special attention should be paid to
ensure a good blood supply and judicious use of
energy devices. For gastric bypass, proper orientation
of intestinal loops, tension-free anastomosis and
checking the anastomosis for integrity at the end of
surgery using an underwater air leak test would reduce
unpleasant outcomes. For patients undergoing sleeve
gastrectomy, ensure the use of an appropriate staple
height, prevent an hour glass gastric tube and remember not to staple the oesophagus.
Prompt identification and early detection of leakage are pivotal in preventing long-term morbidity.
Patients with leaks may present with decrease level in
haemoglobin resulting from intra-luminal or intraperitoneal bleeding, abdominal pain or subtle signs of
sepsis like tachycardia, pyrexia, hypotension and
tachypnoeia.
If a drain is in situ, then a simple methylene blue
test may confirm a leak. If clinical findings are suggestive of a leak, then a computerised tomography
scan with contrast can supplement clinical suspicion.
But if the scan is negative, it should not be used to
make a decision to abandon re-exploration as clinical
findings take precedence.
The principles of treatment of a leak include
early re-operation, decompression, peritoneal lavage,
drainage, fluid replacement, broad spectrum antibiotics and enteral feeding through a gastrostomy or
jejunostomy tube, depending on site of leak. Dealing
with a GJ leak after gastric bypass is not easy but as
this is a low pressure system with no bile, it heals
better in comparison with leaks from sleeve
gastrectomies.
Chapter 8 Management of Complications Following Bariatric Surgery 75
Figure 1.
Loose suture at site of gastrojejunostomy leak on laparoscopic exploration.
Treatment options for GJ leak
a) Sometimes the leak is very small and the site can-
not be identified even with an intraoperative
endoscopy, in this case, drainage and feeding
mechanism would suffice and healing would occur.
b) If the site of leak can be identified (Fig. 1), most
surgeons would attempt to repair it primarily but
the majority of these primary repairs would fail
and result in formation of a fistula that would
eventually close with conservative management.
c) The use of omental or falciform patch similar to
Ghram’s omental patch for perforated ulcer yields
better results.
For perforated chronic marginal ulcer, redoing the
enteric anastomosis may be warranted.
In more complex cases the use of retrievable stents
or tissue glues or redoing the whole anastomosis has
been reported.
Managing sleeve leak
1. The principles of management remain the same.
In addition, rule out the presence of stenosis that
is creating a high pressure zone. This can be done
by an upper GI contrast study.
2. Minor leaks with localised sepsis: conservative
management with drainage, feeding mechanism
and control of infection with antibiotics would
suffice.
3. For major leaks, in addition to the above, a
retrievable covered stent that spans from gastroesophageal junction to across the pylorus may be
necessary. This stent bridges the leak area, thus
limiting leak associated sepsis and promotes
healing. It also harmonises pressure across the
gastric tube that increases the chances of early
healing. If a long stent is not available, a stent
over a stent may be necessary.
4. Conversion of a leak into a controlled fistula
by placing a T-tube through the leak site and
exteriorising it is another option.
5. In certain cases the leak becomes chronic with
fistula formation-consider the following options
of treatments:
a) for distal staple line leaks, conversion to gas-
tric bypass and resection of distal stomach
b) jejunal Roux loop diversion, i.e. creating an
anastomosis between the leak and a jejunal loop
c) for proximal staple line leaks, total gastrec-
tomy and esophagojeujunostomy
3. Stenosis and Stricture
Patients can present with this immediately follow-
ing surgery, after a few weeks or years later.
Following gastric banding, dysphagia in the immediate postoperative period is the result of stomal
obstruction from postopertaive oedema or improper
placement of band. Dysphagia at a later stage is due to
either to an over-tightened band or band slippage.
In the operative procedure for sleeve gastrectomy,
the use of too small a calibration tube, creation of a
narrow acute angle at the incisura and ischaemia of
the gastric tube can result in structuring (Fig. 2).
Should watchful treatment with proton pump inhibitors, intravenous fluids and antiemetic fail, an endoscopic balloon dilatation with or without the placement
of a retrievable stent can be helpful. The exact number
of dilatation episodes and duration of stent placement
have to be tailored. There are reports of segmental
resection, stricturoplasty and of long seromyotomies
76 Atlas of Complicated Abdominal Emergencies
Figure 2.
Gastrografin meal with arrow head showing areas of
structuring after sleeve gastrectomy.
with good results. If all the above mentioned
options fail, then conversion to gastric bypass is an
alternative.
The early strictures of GJ after gastric bypass are
generally amiable to balloon dilatation. The aim of
dilation is to have a GJ opening of around 1.5 cm. One
should avoid the use of rigid dilator and too aggressive
dilatation as this increases the risk of perforation.
4. Gastric Band Slippage and Intestinal Obstruction
The aetiology of intestinal obstruction include
internal hernias, adhesions, jejunojejunostomy angulations, stenosis at anastomosis, incarcerated ventral
or trocar hernia, intussusceptions, bezoars and the
procedure-specific problems.
In gastric banding, band slippage and adhesions
with a twist around the tubing can result in obstruction.
Band slippage was a major concern with the bursa
omentalis approach (Fig. 3). Now with the perigastric
(pars flaccida) approach, the incidence has dropped to
below 5%. The consequence of a slippage, be it anterior,
posterior or complete, is a stricture or complete closure
of the stoma through the band. The diagnosis is
Figure 3.
Abdominal X-ray of normal orientation of gastric band.
Figure 4.
Plain abdominal X-ray of slipped band.
established by a plain abdominal X-ray that would show
an abnormal band position and further confirmation can
be done with a UGI series or a CT scan (Figs. 4 and 5).
Band slippage with obstruction is an acute emergency
and would require deflating the band, nasogastric
decompression followed by surgery to remove or reposition the band.
Figure 5.
Chapter 8 Management of Complications Following Bariatric Surgery 77
Figure 6.
Mesenteric defects through which internal hernia can
potentially occur after gastric bypass.
Gastrografin meal showing gastric outlet obstruction due to
band slippage.
In patients who undergo an antecolic gastric bypass,
the space between the mesentery of the Roux limb and
transverse mesocolon called the Petersen’s defect and
jejunojenunostomy defect are common sites of herniation (Fig. 6). An added defect through the transverse
mesocolon is a potential site for internal hernias with
the retrocolic technique. Antecolic Roux limb, routine
closure of mesenteric defects, anti-obstruction suturing
at JJ site, and use of dilating trocars can reduce the
incidence of small bowel obstruction in patients undergoing gastric bypass. Patients can present with vague
abdominal pain an hour or so after meals or with overt
signs of intestinal obstruction, including vomiting,
abdominal distention and failure to open bowels and
pass flatus. A plain abdominal X-ray will show signs
of intestinal obstruction. CT scan aids in confirming
the diagnosis: it would show dilated loops of small
bowel, mesenteric congestion or twisting call “swirl
sign” or free gas if there is a perforation (Fig. 7).
Figure 7.
Swirl sign on CT scan.
78 Atlas of Complicated Abdominal Emergencies
The principles of management of internal hernia
obstruction include nasogastric decompression, fluid
resuscitation, early confirmation of diagnosis to prevent gangrene, and surgical exploration. At surgery, a
careful adhesiolysis is done followed by identifying
the gastrojejunostomy, the duodenojejunal flexure and
running the bowel to ileocaecal junction. Any mesenteric defect that is detected is closed with a nonabsorbable suture.
5. Other Complications
Gastric banding
Band erosion
A better understanding of band erosion has led to
the development of low pressure bands and improved
surgical technique of placing band. Failure on the
part of patients to comply with dietary advice to
loose weight and over-enthusiastic filling of band to
achieve weight loss goals in a patient who eats
against the advice of the bariatric team are key to
erosion. At erosion, patients note that they eat easily
and are regaining their weight. Others may present
with infected port site from a eroded band. Diagnoses
can be established by a gastroscopy and further
confirmed by a CT scan if necessary (Figs. 8 and 9).
If the patient is asymptomatic, then allowing the
band to completely erode through and then retrieving
Retroflexed view on gastroscopy of a normally placed band.
Figure 9.
Retroflexed view on gastroscopy of an eroded band.
it endoscopically is an option. If the patient has sepsis, then surgery is imminent during which removal
of the band, drainage and a feeding mechanism is
established.
Gastric bypass
Marginal ulcers
These occur in patients with a gastric bypass in
whom the pouch size is larger and there is higher parietal cell load. Factors that promote or prevent healing
of ulcers by either increasing acidity or mucosal damage, e.g. smoking, NSAID use, poor pouch blood supply of anastomosis and gastro-gastric fistula contribute
to such ulcers. Patients generally complain of abdominal pain mainly in the epigastrium related to meals.
They can also present to the emergency with signs of
peritonitis if there is a perforation.
Upon recognition of an ulcer, a thorough investigation into what the inciting cause is needs to be made.
This is accompanied by the use proton pump inhibitors along with avoidance of the inciting agent. In
severe cases where surgical intervention is required
for a non-healing symptomatic ulcer, or one that has
Chapter 8 Management of Complications Following Bariatric Surgery 79
perforated or is bleeding, surgical revision of the anastomosis would need to be done, along with correction
of problems like large pouch or fistula.
Pouch dilatation
The aetiology of dilatation of gastric pouch after
RYGB still remains controversial. Is it a natural phenomenon or the patients overeat causing dilatation?
Whatever the case may be, it is definitely one of the
many causes of weight regain. Diagnosis can be established by endoscopy and upper GI contrast study. The
classical treatment is revising the pouch to 15–30 mL
size, or using other procedures like biliopancreatic
diversion. Newer endoscopic treatment options that
have been published include circumferential injection
of sodium morrhuate to induce scarring resulting in
stenosis, and the use of endoscopic suturing or plication devices, but their long-term safety and efficacy
remain to be determined.
Nutritional problems
After bariatric surgery till weight loss is stable,
increased lipolysis and decreased intake contribute to
macro- and micro nutritional deficiencies. For the
restrictive procedures, namely gastric banding and
sleeve gastrectomy, these changes are seen largely during the weight loss phase and patients need to be supported with multivitamins, minerals and trace elements.
However, patients who undergo malabasorptive procedures like gastric bypass and biliopancreatic diversion,
in order to absorb suffice macro- and micro nutrients,
need to have a diet rich in proteins, supplements of iron,
calcium, other trace elements and various vitamins for
life. Failure to comply with the dietary supplement
intake can result in deficiencies and their syndromes.
At follow-up, patients are clinically screened for protein, vitamin and trace element deficiencies and their
blood levels checked in order to adjust intake in an
effort to prevent deficiency and toxicity.
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Chapter 9
Surgery for Appendicitis
Tan Tse Kuang Charles*
1. Indications
Acute appendicitis may be the most common surgically correctable cause of abdominal pain. The diagnosis remains difficult in many instances. The classic
presentation is an initial vague periumbilical pain,
followed by migration of the pain to the right lower
quadrant. It is often associated with nausea and vomiting, and a fever. These patients often have anorexia.
On examination, the patients may look ill, with maximal tenderness of the abdomen at McBurney’s point.
Patients often do not have this classic presentation,
commonly having none or one of the few symptoms
described. It is often understood that the natural history of appendicitis is a progressive inflammation of
the appendix till perforation, thus presentation of the
patient varies with the time at which the encounter
with the patient and doctor occurs. Another reason for
the variation of presentation is the position of the
inflamed appendix.
What initially was a solely a clinical diagnosis has
progressed to have radiological confirmation with an
ultrasound or a computed tomographic scan.
Operative Strategy of Acute Appendicitis
The primary aim of surgery is to identify the
inflamed appendix and resect it without any stump
leak. This can be performed via the open or laparoscopic method.
2. Preoperative Preparation
1. Ensure adequate fluid resuscitation. May need a
urinary catheter to monitor adequate volume status.
2. Intravenous antibiotics.
3. Surgery
Open Appendectomy
Exposure. The surgeon must decide on the location
and type of incision. The patient should be re- examined
after the induction of general anaesthesia, which
allows deep palpation of the abdomen to determine
where the mass of inflamed appendix is. The incision
should be centred at that location. A skin crease
incision is performed, followed by a muscle-splitting
dissection down to the peritoneum. Too medial an
incision is avoided as it would lead to injury to the
anterior rectus sheath.
Locating the appendix. If it is an early appendicitis,
the appendix is enlarged and free floating and thus palpable. Its location can vary from different individuals
(Fig. 9.1). If it has been more than 24 hours, the appendix is frequently adhered to the adjacent structures. The
adhesions can often be dissected by finger. Firmer adhesions necessitate formal dissection under direct vision.
If the appendix is not found, locate the caecum. The
appendix is invariably at the base of the caecum.
* Charles T. K. Tan, MBChB (UK), FRCSEd (Gen), FAMS, Consultant, Department of surgery, National University Hospital, Singapore.
81