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113 Bariatric Surgery Complications
389
DeMaria EJ, Pate V. Overview of bariatric surgery complications.
UpToDate [cited 2022 Jan]. https://www.uptodate.com/contents/
outcomes- of- bariatric- surgery.
Kuehn FG, Teixeira AF. Imaging after bariatric surgery: Roux-en-Y
gastric bypass, sleeve gastrectomy, and gastric banding. Abdom
Radiol. 2019;44(1):349–66.
Lim R, Beekley A, Johnson DC, Davis KA. Early and late compli-
cations of bariatric operation. Trauma Surg Acute Care Open.
2018;3(1):e000219. https://doi.org/10.1136/tsaco- 2018- 000219.
Mason EE.Tachycardia in post-bariatric surgery patients: a worrisome
sign. Obes Surg. 1979;1(3):319–20.
Reflux After Sleeve Gastrectomy
TinaBharani
114
Way Question May BeAsked?
A 44-year-old female with BMI 32, who is 2months post-SG,
presents with a burning sensation in her chest, usually after
eating. The sensation gets worse when she is lying down. She
reports that these symptoms have gotten more frequent since
after the surgery.
Some other symptoms that patients may present with
include chest pain, dysphagia, odynophagia, excessive salivation, chronic hoarseness, and choking feeling at night.
How toAnswer?
History
• History of gastroesophageal reux disease (GERD)
symptoms (differential should include Barrett’s esopha-
gus, stenosis, ulcer, esophageal cancer for chronic
history).
• Prior management of GERD symptoms—PPI/H2 blocker
therapy.
• Relationship of symptoms to solid and liquid intake,
maneuvers that help alleviate the symptoms—loose cloth-
ing, elimination of caffeine, dark chocolate.
• Degree of weight loss.
Physical Examination
• Rule out epigastric masses.
• Examine lymph node basins (e.g., supraclavicular
nodes—presence of lymphadenopathy would switch the
case to management of esophageal cancer).
Diagnostic Tests
• Full laboratory panel.
• Upper endoscopy (will help rule out stenosis, ulcers, ero-
sive esophagitis, Barrett’s, esophageal cancer).
T. Bharani (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Tina.Bharani@jefferson.edu
• Barium upper GI series (will help identify intrathoracic
slippage of SG and rule out esophageal motility disorder
like achalasia).
• If esophagitis is present, perform follow-up upper endoscopy with biopsy 4–8weeks after PPI treatment to conrm resolution of esophagitis and rule out Barrett’s
dysplasia.
• If there’s no improvement in GERD symptoms after
4–6weeks of PPI treatment, perform 24-h pH monitoring
to document relationship between patient’s symptoms
and reux and manometry to document lower esophageal
sphincter (LES) pressure and the location of LES.
Management
• In the absence of stenosis and dysphagia, rst-line treatment is 40–80mg PPI twice daily for 2 weeks followed
by dose reduction.
• If medical therapy fails to improve symptoms, then perform conversion of SG to RYGB.
• If the GERD is due to technical failure of SG such as
sleeve stenosis, rst-line treatment is balloon dilation.
The success rate of balloon dilation in sleeve stenosis is
up to 76%. If balloon dilation fails, then the next step is to
consider stent placement or conversion to RYGB.
Surgical Management
• Pneumoperitoneum, trocar placement, and abdominal
exploration.
• Identify ligament of Treitz.
• Divide the jejunum at an adequate distance (usually
50–100cm) distal to the ligament of Treitz to form the
biliopancreatic and Roux limbs.
• Split the mesentery and run a 75–150cm Roux limb.
• Construct jejunojejunostomy.
• Close potential internal hernia sites.
• Place a liver retractor and construct a 15–30mL gastric
pouch from the gastric sleeve.
• Perform gastrojejunostomy.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
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391
392
T. Bharani
Common Curveballs
• Bleeding at the staple line
• Bleeding from the liver while retracting
• Inability for Roux limb to reach the gastric pouch without
tension
• Malrotation of the ligament of Treitz (apply mirror image
approach to the technique)
Clean Kills
• One forgets to rule out esophageal cancer on a physical
exam or workup.
• One cannot describe conversion of SG to RYGB.
• One takes the patient to surgery right away without trying
medical therapy rst. Up to 30% of patients may experience GERD symptoms after SG; however, the majority
can be treated with medical therapy alone. About 6–8% of
patients require surgical conversion to RYGB.
• Discussing endoscopic measures to treat Barrett’s esophagus (cryotherapy, phototherapy).
Bonus Points
• A proposed theory for worsening or de novo GERD after
SG is the increased intraluminal gastric pressures due to
decrease in the diameter of the gastric lumen.
• Some of the strategies proposed to prevent GERD in
patients undergoing SG include:
– Using large bougie (e.g., 42 Fr) to reduce the risk of
narrowing.
– Preventing functional stenosis by shaping the sleeve
such that it is the widest at the antrum and narrowest at
cardia.
– Preserving the antrum by placing rst staple >5 cm
from the pylorus to preserve antral motility.
– Repairing large hiatal hernias (>4cm).
Words ofWisdom
GERD after sleeve gastrectomy is a very common problem
in bariatric surgery. Only a minority of patients require surgical revision. Compulsive evaluation for the presence of anatomic factors (hiatal hernia, anatomic problems with sleeve)
and functional issues (esophageal dysmotility disorders) can
guide appropriate therapies (both medical and surgical).
Often, the issue is associated with weight regain and can
improve with weight loss.
Bibliography
Chang SH, Popov VB, Thompson CC.Endoscopic balloon dilation for
treatment of sleeve gastrectomy stenosis: a systematic review and
meta-analysis. Gastrointest Endosc. 2020;91(5):989–1002.e4.
Ellison EC, Zollinger RM Jr, Pawlik TM, Vaccaro PS, Bitans M, Baker
AS.Roux-en-Y gastric bypass, laparoscopic. In: Zollinger’s atlas of
surgical operations. 11th ed. NewYork: McGraw-Hill Education;
2022. [cited 2023 Aug 16]. accesssurgery.mhmedical.com/content.
aspx?aid=1187821160.
Felinska E, Billeter A, Nickel F, Contin P, Berlth F, Chand B, etal. Do
we understand the pathophysiology of GERD after sleeve gastrectomy? Ann N Y Acad Sci. 2020;1482(1):26–35.
Peterli R, Wölnerhanssen BK, Peters T, Vetter D, Kröll D, Borbély
Y, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with
morbid obesity: the SM-BOSS randomized clinical trial. JAMA.
2018;319(3):255–65.
Salminen P, Helmiö M, Ovaska J, Juuti A, Leivonen M, Peromaa-
Haavisto P, etal. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among
patients with morbid obesity: the SLEEVEPASS randomized clinical trial. JAMA. 2018;319(3):241–54.
Part XV
Vascular
Abdominal Aortic Aneurysms
MadisonCrutcher
115
Way Question May BeAsked?
A 67-year-old man presents to the clinic after a 4-cm aortic
aneurysm was found incidentally on a CT scan after a fall.
How toAnswer?
Full History
• Any symptoms of pain (abdomen, back, ank, groin)
• History of smoking
• History of other vascular diseases (coronary artery disease, peripheral vascular disease, carotid artery stenosis)
or symptoms (e.g., angina, claudication, transient ischemic attack, amaurosis fugax)
• History of COPD
• History of hypertension
Full Physical Exam
• Pulsatile epigastric/periumbilical mass
• Tenderness over aneurysm
• Check for other aneurysms (e.g., popliteal fossa)
• Vascular/pulse exam
Diagnosis, Screening, and Surveillance of AAA
• Ultrasound: reliable to conrm presence of AAA and
measure diameter; tends to overestimate the diameter by
~20%; used for initial screening and surveillance.
• Men with any history of smoking and aged 65–75years
old should get ultrasound screening for AAA, even if
asymptomatic.
• Computed tomography (CT) scan: more accurate in
depicting aneurysm size; more accurate in conrming
juxta- or suprarenal extent of aneurysm.
• One-time screening with ultrasound for AAA in men
65–75years of age who have ever smoked.
M. Crutcher (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
• Ultrasound surveillance:
– Less than 3cm—no further testing
– 3–4cm—every 12months
– 4–4.5cm—every 6months
Indications for Repair
• Diameter of 5.5cm in men, 5cm in women
• Rapid rate of growth (>0.5cm in 6months)
• Symptomatic (abdominal or back pain)
• Signs of embolization
• Rupture
• Acute aneurysmal thrombus
Risk Factors for Rupture
• Chronic obstructive pulmonary disease (COPD)
• Hypertension
• Rapid increase in aneurysm size
• Absolute aneurysm size
Way Question May BeAsked?
This 62-year-old man re-presents to the emergency department. He is now hypotensive with increasing abdominal
pain. CT shows AAA measuring 6cm.
How toAnswer?
• Full history and physical exam as above.
• Bedside abdominal ultrasound.
• Permissive hypotension; tolerate systolic blood pressure
between 50 and 100; control double product (pulse and
blood pressure).
• Consider initiation of massive transfusion protocol so
blood product is immediately available.
• Obtain rapid CT angiography.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
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396
M. Crutcher
Open Repair
• Indications for open repair
– Short, extremely angled, heavily calcied, thrombus-
lled infrarenal aortic neck
– Severe iliac disease
– Patient preference (can defer surveillance after EVAR)
• Steps
• Induction of anesthesia after patient is prepped and draped
– Prepped and draped from xiphoid to knees
– Midline incision from xiphoid to pubis
– Pack small bowel and transverse colon out of the way
with moist laps
– Ligament of Treitz divided and duodenum mobilized
to the right
– Dissection over the aorta with identication of the
inferior mesenteric artery
– Tricks for better suprarenal exposure:
Division of the lesser omentum and gastrohepatic
ligament
Medial visceral rotation
– Proximal control
Aortic neck encircled with tape as close to renal
artery origin as possible
If ruptured:
• Open gastrohepatic omentum and enter thru the
lesser sac
• Retract the stomach and esophagus to the left
• Clamp aorta as it exits the crura of the diaphragm
(may need to divide left crura)
• Allow anesthesia to catch up and begin blood
transfusions
• Replace the vascular clamp at the infrarenal
neck, if possible, once the patient stabilizes
– Distal control
Encircle common iliacs with vascular tape as distally as possible
If one iliac artery is or both arteries are too calcied
for clamping, attain individual control of the external and internal iliac arteries
Place distal clamps prior to proximal clamps to pre-
vent embolization
– Heparinize (100mg/kg) 3min before cross clamping
– Aneurysm sac is opened and back-bleeding lumbar
vessels are oversewn
– Aneurysm replaced with a Dacron graft in an end-to-
end fashion
– Aneurysm sac closed over graft
– Peripheral pulses checked, protamine given, abdomen
closed
Inferior Mesenteric Artery (IMA)
• If it is chronically occluded, it may be ligated (already fed
by collaterals).
• If it has signicant back-bleeding, it may be ligated (adequate collateral circulation).
• If it has sluggish ow, reimplantation should be considered (inadequate collateral circulation).
• If the patient had a prior colectomy, IMA may need reimplantation (loss of collateral ow).
Endovascular Repair
• CTA to evaluate preoperative anatomy.
• Bilateral open or femoral percutaneous access with
micropuncture set.
• Perform an aortogram.
• Position the endograft below the lowest renal artery.
• Deploy main body.
• Cannulate the contralateral gate.
• Deploy contralateral iliac limb.
• Deploy remainder of the main body.
• Balloon junctions of the graft.
• Perform completion angiogram to assess for endoleaks.
• Femoral access closure.
Ruptured Patients
• Permissive hypotension with systolic blood pressure
between 50 and 100
• Induction of anesthesia after patient is prepped and draped
• Aortic occlusion balloon if rapid deterioration
Way Question May BeAsked?
Your patient presents to the emergency department several
years after AAA repair with hematemesis.
Aortoenteric Fistula
• Rare complication
• Presents with herald upper or lower gastrointestinal
bleed—typically a bleed from smaller vessels in the intestine wall, not from the aorta itself
• Should be considered in patients with past surgical history of EVAR or open aortic graft
• Imaging
– Evidence of inammation or bleeding into the bowel
on CT scan
– Direct visualization of graft material on upper
endoscopy
• Procedure
– Proximal and distal control (similar to open aorta)
– Removal of entire affected graft
– Wide debridement of affected tissues
– Irrigation with antibiotic solution
– Reestablishment of arterial ow (in situ or
extra-anatomic)
Dacron soaked in rifampin
Silver impregnated
Cryopreserved allograft
– Coverage with omentum or surrounding tissue
– Long-term intravenous antibiotics
115 Abdominal Aortic Aneurysms
397
Common Curveballs
• Incidental intra-abdominal pathology: Do not perform
concurrent colectomy or cholecystectomy.
• Bowel injury: Repair enterotomy, irrigate, and consider
antibiotics.
• Ureteral injury: Methylene blue administration can help
identify injury; intraoperative urology consultation.
• Postoperative colonic ischemia: Flexible sigmoidoscopy
to evaluate; if transmural ischemia or sepsis is present, the
involved colon should be resected (Hartmann’s
procedure).
Clean Kills
• Missing the diagnosis
• Not taking patient to surgery for appropriate surgical
candidate
Summary
In asymptomatic patients, abdominal aortic aneurysms
(AAA) are typically found on astute physical exams, incidentally on abdominal imaging done for other reasons, or
through screening tests. Risk factors for AAA include a
history of smoking and some connective tissues diseases.
Surgeons should have basic knowledge of screening regimens and indication for elective repair. Risks for AAA
rupture include hypertension and COPD.Ruptured AAA
patients often present dramatically with sudden onset of
abdominal, back, ank, or groin pain and hypotension. A
high index of suspicion, appropriate bedside or rapid
imaging modalities, and prompt surgical intervention are
necessary for successful rescue of such patients.
Bibliography
Ferranti K.Abdominal and aortoiliac aneurysm. 2023. https://www.sur-
gicalcore.org/modulecontent.aspx?id=1000548.
Perler BA.Open repair of abdominal aortic aneurysms. In: Cameron
JL, Cameron AM, editors. Current surgical therapy. 13th ed.
Philadelphia, PA: Elsevier; 2019. p.901–4.
Prushik SG, Cambria RP. Endovascular treatment of abdominal aortic
aneurysms. In: Cameron JL, Cameron AM, editors. Current surgical
therapy. 13th ed. Philadelphia, PA: Elsevier; 2019. p.905–10.
Schaub TA, Upchurch GR. Abdominal aortic aneurysm. American
Family Physicians; 2006. p.1198–204.
Smeds MR, Nukala M.Management of infected grafts. In: Cameron
JL, Cameron AM, editors. Current surgical therapy. 13th ed.
Philadelphia, PA: Elsevier; 2019. p.1022–8.
Vascular: Chronic Lower Extremity Ischemia
HaleyKittle
116
Way Question May BeAsked?
A 54-year-old man presents to the ofce for evaluation of
pain in his right calf after walking three blocks. He is a
smoker, overweight, and currently not on medication. How
would you manage this patient?
How toAnswer?
• Start with a complete history and physical exam.
• History:
– Pain with walking.
– Location of pain may indicate level of stenosis (i.e.,
bilateral buttocks, aortoiliac disease; calf pain, SFA or
popliteal disease).
– Risk factors:
Smoking
Diabetes
Hypertension
Obesity
Prior MI or CVA
Buerger’s disease
• Physical exam (bilateral assessment):
– Skin changes (dry, hairless)
– Neurologic exam
– Pulses/signals at all levels
– Presence of bruits
• Workup includes ankle-brachial index (ABI) with segmental pulse volume recording (PVR)—PVD at ABI
<0.9, symptomatic at <0.7.
H. Kittle (*)
Department of Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
e-mail: Haley.Kittle@jefferson.edu
Management
• Patients with claudication should initially be treated with
nonoperative therapy
– Risk reduction (smoking cessation, weight reduction,
glucose control, BP control)
– Graded exercise program
– Antiplatelet therapy (ASA, Plavix)
– Statin therapy
– Beta-blocker therapy if HTN
– Other medications (Trental, Pletal as second-line)
Alternate Scenario
A 50-year-old female presents to the ofce with a nonhealing
ulcer on her right malleolus for 6 weeks. She is obese with
hypertension and hyperlipidemia.
• Indications for operative management of PVD:
– Rest pain
– Nonhealing ulcer
– Gangrene
– Claudication that failed medical management or
impairs the patient’s lifestyle
• Noninvasive imaging:
– Duplex ultrasound bilaterally and including the iliacs
– ABI with segmental PVR
Critical limb ischemia is considered at ABI <0.4
– Magnetic resonance arteriography (MRA)
– Computed tomography arteriography (CTA) with
runoff
• Invasive imaging includes aortogram with lower extremity angiogram.
• Remember to perform a preoperative cardiac workup
(these patients have a high rate of concomitant coronary
artery disease).
• Interventions:
– Interventional therapy is recommended only after all
attempts at medical therapy have failed.
– Never take a smoker to the OR!
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_116
399
400
H. Kittle
– Endovascular treatment can be recommended for focal
lesions in large diameter vessels (aorta/iliacs).
– Open bypass surgery for distal disease, multiple seg-
ments, long lesions, and aortoiliac disease.
Surgical Management
• Open bypass:
– Use vein whenever possible (~70% 5-year patency).
– Preoperative duplex to evaluate suitability of the vein.
– In situ or reverse autologous greater saphenous vein
(GSV).
– If in situ, must use valvulotome and tie off all
branches.
– Heparin-bonded polytetrauoroethylene (PTFE) if
synthetic graft is used.
• Obtain proximal and distal control.
• Distal target depends on preoperative arteriography (must
have adequate outow).
• Vertical incision to expose femoral artery (allows exten-
sion if exposed area not suitable to clamping).
• Medial incision to expose the popliteal artery for above-
knee bypass.
• Exposure of peroneal and posterior tibial arteries below
the trifurcation often requires detachment of the soleus.
• Anterior tibial artery exposed by a longitudinal incision
two nger breadths lateral to anterior tibial border.
• Saphenous vein graft harvesting starts proximally and
progresses distally.
• If vein is too short, one can use composite graft.
• Intraoperative systemic heparin administration before
clamping.
• Completion angiogram and documentation of pulses in
OR.
Common Curveballs
• Postoperative hemorrhage.
• Postoperative graft thrombosis or infection.
• Any stent placed will occlude.
• Angioplasty performed will suffer restenosis.
• Angioplasty performed will lead to vessel dissection.
• Postoperative compartment syndrome.
• The patient will develop heparin-induced
thrombocytopenia.
Clean Kills
• Not being clear in indications for surgery
• Not trying nonoperative therapy for intermittent
claudication
• Not knowing noninvasive vascular studies
• Not taking patient back for immediate post-op graft
thrombosis
• Trying to describe a technique you do not do
• Not being prepared for postoperative complications
• Not being able to read an angiogram if one is handed to
you
Bonus Points
• Patients may have falsely normal or elevated ABI due to
severe calcic disease—a normal ABI does not rule out
PVD.
• PVD in diabetics often affects the microvasculature and
may not be amenable to revascularization; these patients
often require amputation.
• Critical limb ischemia is a chronic disorder and should
not be confused with acute limb ischemia as they have
different management.
Words ofWisdom
Management of peripheral vascular disease is no longer commonly handled by general surgeons, but examinees should
still be aware of the basic workup and management principles. One should indicate that one would consult a vascular
surgeon or surgeon experienced in the management of PVD if
this is not part of one’s common practice. Such oral board
scenarios may also lead the examinee into discussing the
management of compartment syndrome or systemic postoperative problems (e.g., myocardial infarction, pulmonary
embolism), which a general surgeon should be familiar with.
Bibliography
Abbott JD, editor. Peripheral artery disease (PAD) of the lower
extremities. DynaMed. https://www.dynamed.com/condition/
peripheral- artery- disease- pad- of- lower- extremities#GUIDC989FC64- 753D- 4FC4- 9959- F2F53D670D75. Accessed 4 Sept
2023.
Acute Extremity Ischemia
PranjalThosani
117
Scenario
“A 63-year-old male was admitted to the hospital status post
an inferior wall MI.Five days later, he develops a sudden
onset of acute left leg pain. On exam his leg is cool to the
touch and pulses are absent below the inguinal ligament.”
• Extremity bypass surgery
• Hypercoagulable state (i.e., malignancy)
• Recent trauma or surgery (i.e., orthopedic)
• Arterial dissection
(c) Physical exam
• Examine bilateral lower extremities
• Remember that a history consistent with an embolus does
not necessarily rule out other causes!
– Palpate/Doppler pulses
Water hammer pulse just proximal to the
clot
Absent pulses distal to the clot
Management
– Acute, cool, white, pulseless leg requires emer-
gent intervention
1. Focused history and physical
(a) Duration of symptoms
• 6–8h before irreversible muscle necrosis
(b) Risk factors
• Other embolic events (CVA/TIA/endocarditis)
• Arrhythmia or valvular heart disease
• Recent MI with mural thrombus
• AAA
– Be mindful of aneurysms (abdominal/femoral/
popliteal)
Bruits/pulsatile masses
• Neuro-exam: Assess for sensory and motor
function
– Paralysis is a late nding and is a sign of nonvi-
able limb that will require amputation (Table 1)
• Rutherford classication for acute limb ischemia:
• PVD
Findings
Stage Prognosis
I Limb viable, not immediately threatened None None Audible Audible
IIa Limb marginally threatened, salvageable if promptly treated Minimal (toes) None Often
IIb Limb immediately threatened, salvageable with immediate
revascularization
III Limb irreversibly damaged, major tissue loss or permanent nerve
damage inevitable
Source: Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM, Ahn S, etal. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26(3):517–38. https://www.ncbi.nlm.nih.gov/pubmed/9308598.
Sensory loss
More than toes, pain at
rest
Profound, anesthetic Paralysis
Muscle
weakness Arterial Venous
Mild or
moderate
(rigor)
Doppler signal
Audible
inaudible
Inaudible Audible
Inaudible Inaudible
• ABIs (can be done, however in most cases will be
zero)
(d) Management
• Imaging—should not delay denitive treatment
– CT angiography (imaging of choice for acute
ischemia)
Be mindful of renal function
P. Thosani (*)
Department of Surgery, Main Line Health—Lankenau Medical
Center, Philadelphia, PA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_117
– Duplex ultrasonography (can be done at
bedside)
401