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Complications of Bariatric Surgery
Ahmad Assalia
Severe obesity restricts the movements and maneuvers of the body. It compresses
blood vessels causing their narrowness. Breathing passages are obstructed and the
flow of air is hindered leading to nasty temperament. … On the whole these people
are at risk of sudden death. … They are vulnerable to stroke, hemiplegia,
palpitation, diarrhea, fainting. … Any physical effort they make will weaken
them. (Avicenna, 980–1037)
Obesity is a modern epidemic. Bariatric surgery for morbid obesity is gain-
ing acceptance and recognition. It seems absurd that in certain countries people
now die of gluttony rather than hunger. Even more disturbing is that bariatric
surgery is performed in countries where hunger and malnutrition are common.
But, fortunately, philosophy is beyond our scope.
Luckily, most of the readers of this book do not engage in bariatric surgery.
But, because it is performed all around the world, we all must be familiar with the
diagnosis and treatment of the long list of complications that typically bedevil these
procedures. Most, but not all, bariatric surgery is performed laparoscopically.
Several basic points should be emphasized:
Obese patients have many related diseases, but even in the absence of such
diseases they are still considered to be sick! They impose special anesthetic and
medical challenges, and the surgical risk increases in tandem with their body
mass index (BMI). There is an increased incidence of respiratory, cardiac, infectious, thromboembolic, and wound complications. In particular, some may have
undiagnosed cardiac disease, which may lead to postoperative cardiac events
and even death.
Complications may be divided into those directly related to the surgical
procedure (leaks, obstruction, etc.) and those related to comorbidity (deep vein
thrombosis [DVT]), pulmonary embolism [PE], cardiac events, respiratory insufficiency, etc.). At times, diagnosis is difficult because both surgical and nonsurgi-
cal complications may produce similar clinical pictures (e.g., leak and PE). And, to
compound matters PE and gastrointestinal (GI) leaks are the two leading causes
of death after bariatric surgery. GI leaks in these patients may not present in the
way with which you are familiar. This may be partly due to the thick abdominal wall. In practice, in many of these patients GI leaks do not produce either
31
Ahmad Assalia
Rambam Health Care Campus, Haifa, Israel
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_31, © Springer-Verlag Berlin Heidelberg 2010
333
334 Ahmad Assalia
Gastric
pouch
Liver
Gallbladder
Food
channel
Bypassed
stomach
Digestive juice
channel
Point where digestive
juices mix with food
significant abdominal pain or abdominal findings. Instead, “soft” or nonspecific
signs such as tachycardia, dyspnea, or fever are much more common. Therefore,
do not think and work “by the book”! Think beyond the accepted frames.
Even in developed countries, the majority of hospitals lack appropriate radiological
facilities for “human hippopotami.” Therefore, it may be necessary to rely on other
modalities—your suspicion, clinical judgment, and laparoscopic re-exploration.
The focus of this chapter is directed to the common acute complications
requiring urgent attention and not to chronic complication of bariatric surgery
such as cholelithiasis, nutritional deficiencies, inadequate weight loss, esophageal dilatation, port problems after placement of gastric band, and others.
Laparoscopic Roux-en-Y Gastric Bypass
Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly practiced bariatric procedure and the one considered to be the gold standard for weight
loss surgery (> Fig. 31.1).
Early Postoperative Complications
Intestinal (anastomotic) leak. This is the most dreaded complication and
a major cause of death in this population; leak rates as high as 7% have been
reported. It can originate from either of the anastomoses (gastrojejunostomy or
jejunojejunostomy), the staple lines of the gastric pouch or the bypassed stomach,
or inadvertent intestinal perforation.
Fig. 31.1. Roux-en-Y gastric bypass (RYGB)
31 Complications of Bariatric Surgery 335
The clinical spectrum ranges from “minimal,” with subtle presentation, to
full-blown peritonitis and sepsis. Again: you should suspect a leak whenever you
are confronted with a patient with dyspnea, tachycardia or fever, abdominal tenderness, and signs of sepsis. Remember that abdominal pain and peritonitis are
not reliable in this group of patients; most of the findings are nonspecific and
can be confused with an acute cardiac event or PE. Electrocardiography, blood
tests for troponin levels, and even computed tomographic (CT) angiography of the
chest may occasionally be necessary to rule out cardiac or pulmonary events. It is
imperative that the appropriate tests be expeditiously performed to guide therapy.
The diagnosis is made either clinically or by upper gastrointestinal (UGI) study.
Be aware, however, that a high percentage of leaks could be missed by the UGI
series. CT scan of the abdomen is more sensitive in this regard (if your scanner
can accommodate the patient). Notably, empiric abdominal exploration (usually
through the laparoscope) may be the only appropriate diagnostic test. Failure to
act quickly can result in the patient’s demise.
Treatment depends on the clinical situation. If the leak is contained and con-
trolled and the patient is not septic, it can be treated conservatively with nothing
by mouth (nil per os, NPO), broad-spectrum antibiotics, and intravenous nutrition. If the leak has resulted in a drainable abdominal collection, placement of a
percutaneous drain is the desired treatment. If the leak is not contained or the
patient is septic, laparoscopic or open exploration is mandatory. The exploration
involves three basic principles: (1) adequate drainage, (2) repair of the leak if possible (of course, such repairs tend to break down, but what do you have to lose?),
and (3) gastrostomy tube in the bypassed stomach. A jejunostomy tube (distal to
the jejunojejunostomy) should be considered if the leak originates from the bypassed stomach or the jejunojejunal anastomosis (see also > Chap. 50).
Pulmonary embolus. Obesity is a known risk factor for DVT and PE. Its
incidence in RYGB is estimated around 1%. We do not need to repeat here our
advice about DVT prophylaxis or discuss the investigation and management of
pulmonary thrombo-embolism. Just remember that differentiation of PE from
other bariatric surgery disasters can be difficult.
Acute gastric dilatation. Alb eit ra re, this c omplic atio n can b e dra mat ic. Dilat a-
tion of the bypassed stomach may occur spontaneously, as a result of obstruction at
the “downstream” jejunojejunostomy or secondary to the interruption of the nerves
of Latarjet during the creation of the gastric pouch. In the early post-op period, it is
most commonly due to bleeding from the gastric staple line. You should suspect this
in patients who develop hiccups and abdominal bloating accompanied by tachycardia; hemodynamic compromise may follow in extreme cases (remember: massive
acute gastric dilatation produces abdominal compartment syndrome). A plain abdominal radiograph may reveal a large gastric bubble with an air-fluid level. If the
stomach is filled with fluid, the radiograph may not be helpful; CT will be diagnostic.
336 Ahmad Assalia
Treatment is by urgent needle decompression of the excluded stomach (under fluoroscopy if time allows) or surgical gastrotomy for clotted blood. If there i s no obvious
improvement or in cases of hemodynamic instability, suspect gastric blowout. An
urgent laparotomy is then mandatory. The patency of the jejunojejunostomy (an obstructed anastomosis could be the cause for the dilatation of the excluded stomach)
should be verified in every case by a UGI study or during surgical exploration.
UGI hemorrhage. Usually, the source is at the gastrojejunostomy. This
should be treated by nonoperative methods and resolves in most cases. In rare
instances when the bleeding continues or causes a hemodynamic compromise,
open surgical re-exploration with direct control of the bleeding site is imperative. Access to the anastomosis may be gained either through an enterotomy in
the jejunal Roux limb or by dismantling of the anastomosis. UGI endoscopy has
limitations in this immediate postoperative period.
Late Postoperative Complications
Intestinal obstruction. This usually occurs after weight loss secondary to
internal herniation through one of the mesenteric defects created by the surgery.
With the antecolic technique, two potential defects are created: between the cut
edge of the Roux limb mesentery and the mesocolon (Petersen’s defect) and at
the jejunojenostomy. With the retrocolic technique, there is a mesocolic opening
through which the Roux limb is brought up to the gastric pouch. These defects (>
Fi g. 31.2) should be closed during the primary procedure to prevent internal herni-
ation. Following weight loss and disappearance of visceral fat, these defects become
large enough to easily allow internal hernias. In addition, adhesions that could prevent these internal herniations are minimal after laparoscopic procedures.
Fig. 31.2. Mesenteric defects after RYGB prone to internal herniation
31 Complications of Bariatric Surgery 337
The diagnosis of intestinal obstruction after RYGB can be frustrating. The pre-
sentation is usually vague, with crampy midabdominal pain with or without abdominal
distension. Because of the configuration of the GI reconstruction, nausea and vomit-
ing are usually absent. If vomiting does occur, however, its quality gives some clue to
the site of obstruction. Bilious vomiting implies holdup distal to the jejunojejunostomy
anastomosis. Multiple episodes may occur with only transient symptoms (spontaneous “in-and-out” herniation). The diagnosis of internal hernia should therefore be sus-
pected in every patient after RYGB presenting with unexplained abdominal pain.
Some patients present with obvious intestinal obstruction with increasing
abdominal pain, tenderness, and some degree of distention. Plain radiograph
may be nondiagnostic, UGI series or CT scan are more helpful, but even these
will likely be normal if symptoms subside spontaneously.
The preferred treatment, even in equivocal cases, is laparoscopic explo-
ration, reduction, and closure of the defects. Open exploration would be
needed if the patient is hemodynamically unstable or there is necrotic bowel,
confused anatomy, or poor visualization due to dilated small bowel loops.
Stomal stenosis. Stricture of the gastrojejunostomy is not rare and presents
with severe dysphagia, nausea, vomiting, and at times, odynophagia. Patients
should undergo endoscopy for both diagnosis and treatment with balloon dilatation. Occasionally, there is an associated marginal ulcer that should be treated
with acid suppression. Persistent ulceration, especially if combined with some
weight gain, should raise the possibility of gastrogastric fistula. The diagnosis is
achieved by UGI series, and it should be treated surgically.
Laparoscopic Adjustable Gastric Banding (LAGB)
Once the most popular bariatric procedure in Europe and Australia, laparoscopic adjustable gastric banding (LAGB) has lost some appeal due to a high reoperation rate and disappointing long-term effectiveness.
Early Postoperative Complications
Gastric perforation. This has been described in less than 1% of patients
undergoing LABG. It is caused by inadvertent gastric wall damage during dissection or the creation of the retrogastric tunnel (> Fig. 31.3). The diagnosis and
management should follow the general lines outlined for RYGB. Again, confirm-
ing the diagnosis could be very difficult even with UGI studies and CT scanning—so keep it in mind and suspect, suspect, and suspect. There should be
a low threshold for laparoscopic re-exploration in any case with unexplained
338 Ahmad Assalia
Esophagus
Pouch
Adjustable band
Duodenum
Stomach
Access port
Fig. 31.3. Gastric banding
dyspnea, tachycardia, abdominal pain, or fever. Treatment includes removal of
the band, repair of the perforation site, drainage, intravenous antibiotics, and
nutrition, preferably through a jejunostomy feeding tube.
Gastric bleeding is very rare. Unlike after RYGB, endoscopy may be utilized
for the diagnosis and treatment.
Gastric pouch necrosis. This rare complication is due to severe dilatation of
the pouch proximal to a tight band and edema, possibly combined with operative
damage to the gastric wall and its blood supply. The clinical presentation is vague,
so you should keep this diagnosis in mind. UGI endoscopy may be helpful, and
re-exploration is mandatory for the confirmation of diagnosis and treatment.
Obviously, you will have to resect either the proximal stomach (proximal gastrectomy) or do a total gastrectomy.
Infection of the port site usually presents as superficial cellulitis, which
should respond to antibiotics. With deeper infections (manifesting with recurrence of the infection, persistent drainage, or periband fluid on imaging), removal
of the port is necessary. In some cases, even removal of the entire LAGB system
might be required to eradicate extensive infections. These principles apply also to
late infections of the port site.
Late Postoperative Complications
Band slippage. This late complication has been associated with a particular
technique of band insertion. There is prolapse of the anterior or posterior wall
of the stomach. Anterior band slippage with consequent gastric herniation can
occur if anterior fixation of the band was inadequate or as a result of early severe
vomiting. The clinical presentation can be subacute or chronic, but occasionally
31 Complications of Bariatric Surgery 339
it is acute and dramatic. Symptoms and signs include epigastric pain, pouch
dilatation, reflux, vomiting, dysphagia, or even acute obstruction. An upper
GI study usually makes the diagnosis. Immediate band deflation followed by
laparoscopic exploration should be performed with reduction of the herniated
stomach, band repositioning, and anterior fixation of the band. If the slippage
is posterior, the band should be removed and the pars flaccida technique used
to reposition the band. This is obviously in the realm of the bariatric surgeon.
Rarely, gastric wall necrosis may result from late diagnosis and treatment.
Band erosion. In most cases, the presentation is subacute or chronic, but it
may present as an acute infection of the port site or as intra-abdominal infection.
Band erosion into the stomach has been reported in up to 7.5% of cases. Patients
are usually asymptomatic, but they may rarely present with an acute abdomen. Diagnosis is made by UGI study or endoscopy. Late port site infection combined with
weight gain (as a result of alleviation of the restriction of food after erosion) and
occasional epigastric pain should raise suspicion of band erosion. As mentioned,
this may cause an intra-abdominal abscess. Management of this complication is
usually not an emergency and referral to a bariatric surgeon should be possible.
The best treatment is not yet established, and details of this debate are outside
the scope of this book, but essentially it entails removal of the entire band system and repair of the gastric wall. In case of an acute perforation with associated
abscess, laparotomy and closure of the perforation and wide drainage should be
performed. Note that band erosion can lead to port infection but not always. And,
vice versa, port infection could occur primarily without band erosion.
Laparoscopic Sleeve Gastrectomy
Laparoscopic sleeve gastrectomy (LSG) is a relatively novel, and increasingly
popular, procedure that was introduced as a stand-alone procedure for morbid
obesity. It involves vertical resection of around 80% of the gastric volume along
the greater curvature (> Fig. 31.4).
Fig. 31.4. Sleeve gastrectomy
340 Ahmad Assalia
Early Postoperative Complications
Intra-abdominal bleeding. This usually originates from the long gastric staple
line. In most cases, it stops spontaneously and thus can be treated conservatively.
It may be associated with UGI bleeding. Surgical re-exploration is rarely required
and involves oversewing of the staple line. Occasionally, the hematoma could get
infected and present as an intra-abdominal abscess that requires drainage.
Leakage. This occurs more frequently at the upper part of the staple line,
at or just below the gastroesophageal junction. The exact reason for this is not
known. Diagnosis and management follow the same principles described for leakages after RYGB. Mild, contained or controlled leaks should be treated with percu-
taneous drainage, fasting, and intravenous nutrition. Uncontrolled leaks causing
peritonitis and sepsis should be treated surgically by peritoneal toilet, attempt
at reclosure of the leaking point (this will usually fail), and adequate drainage to
achieve a controlled fistula (> Chap. 50). In these cases, placement of a feeding
jejunostomy is strongly suggested. Most resulting controlled gastric fistulas will
close spontaneously.
Stenosis of the gastric tube (sleeve). This is rare and may be seen either early
or late. The early form is due to the creation of a too-tight gastric tube (when the
staple line is being reinforced with sutures). Patients complain of severe dysphagia,
odynophagia, and vomiting. UGI study confirms the diagnosis. Treatment is conservative, and this might require later endoscopic dilatations.
Necrosis of the gastric tube. This is an extremely rare complication that oc-
curs as a result of interruption of the blood supply to the lesser curvature. Early
re-exploration with completion (total) gastrectomy is usually required.
Late Postoperative Complications
Except for gastric tube stenosis with the “hourglass figure,” all other complications do not require urgent attention. Late stenosis is the result of ischemia, and
the diagnosis and management follow the same principles described. In the late
form, patients may present with vomiting, regurgitation, and reflux symptoms.
Biliopancreatic Diversion and Duodenal Switch
Biliopancreatic diversion and duodenal switch (BPD-DS) is a modification
of the Scopinaro procedure. It entails the creation of sleeve gastrectomy, duodenal
switch, and intestinal bypass (> Fi g. 31.5). In the acute setting, one can see the
same complications described for other bariatric procedures. The same principles
for the management apply here as well.
31 Complications of Bariatric Surgery 341
Fig. 31.5. Biliopancreatic diversion and duodenal switch (BPD-DS)
Editorial Comment
While bariatric procedures performed in “good hands” should be safe, when
complications develop the morbidity and mortality reach serious proportions.
Surgical complications of bariatric procedures are far from being as funny as
>
Fig. 31.6 would suggest.
Fig. 31.6. “It seems that your band is a little too tight!”
342 Ahmad Assalia
Obviously bariatric surgeons are (it is hoped) those with the optimal expertise to treat all these complications. Thus, if your practice does not routinely include bariatric surgery, try to refer at least those patients who do not require an
immediate lifesaving operation back to their original surgeons. Increasingly,
however, patients shop online for these procedures and travel by air to boutique
clinics elsewhere. After undergoing the operation, they fly back home and present with the complication on your doorstep; by that time, their original surgeon
is scuba diving in the Bahamas or skiing in St. Moritz.
“Bariatric surgeons should inhabit a special place in Hell, where they are
condemned to deal with the complications they have created.” (Angus Mciver)
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