Complications of bariatric surgery Calvin W. Leea, John J. Kellyb and Wahid Y. Wassefa Purpose of review Morbid obesity is an epidemic in the United States and parts of Europe, with severe health consequences. As the number of patients undergoing bariatric surgery has increased dramatically, it is crucial for the gastroenterologist caring for these patients to have a better understanding of the procedures, their unique complications and the proper management for these complications. Recent findings The incidence of the most significant complications is calculated from recent publications. Radiological and endoscopic workup is useful for diagnosis. Endoscopic dilation of strictures is possible. Endoscopic intervention for selected leaks and fistulas has been reported. Summary This review describes the most common types of bariatric surgery, discusses the complications that each can cause, and addresses the recommended approach for their work-up and management in order to better equip the gastroenterologist in dealing with this new field. Keywords bariatric surgery, surgical complications, therapeutic endoscopy Curr Opin Gastroenterol 23:636–643. ß 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins. a Department of Gastroenterology and bDepartment of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts, USA Correspondence to Dr Wassef, 55 Lake Avenue North Room S6-105, Worcester, MA 01655, USA Tel: +1 508 856 3068; e-mail: WassefW@ummhc.org Current Opinion in Gastroenterology 2007, 23:636–643 Introduction Morbid obesity is a common problem in developed countries with severe health consequences, including diabetes, cardiovascular disease, arthritis, obstructive sleep apnea, obesity hypoventilation syndrome, and increased risk of cancer [1]. Conservative therapy, including behavior modification and medications, is less effective than bariatric surgery in sustaining weight loss [2,3]. In addition, bariatric surgery produced a 50% mortality reduction in a nonrandomized, epidemiologic study of 1020 patients followed for 9 years (P ¼ 0.04) [4]. The goal of bariatric surgery is to reduce caloric intake by either restricting the amount of calories an individual can take in (restrictive procedure) or reducing the amount of calories absorbed from the gastrointestinal tract (malabsorptive procedure). This can be accomplished in a number of ways. The most commonly described techniques are the Roux-en-Y gastric bypass (RYGBP) (restrictive and some malabsorptive), laparoscopic adjustable banding (LAGB) (restrictive only), and the biliary-pancreatico diversion with duodenal switch (BPD/DS) (malabsorptive and some restrictive). Although the procedures can be successful, they are technically difficult and can be associated with a number of complications. Unfortunately, these complications can sometimes be subtle and difficult to diagnose early. For example, tachycardia greater than 120 bpm may be the most reliable sign of intra-abdominal sepsis from a surgical leak or abscess [5]. Since these patients have limited physiologic reserve, it is imperative that complications are identified early and appropriately managed [6]. Abbreviations BPD/DS CT LAGB RYGBP VBG biliary-pancreatico diversion with duodenal switch computed tomography laparoscopic adjustable banding Roux-en-Y gastric bypass vertical banded gastroplasty ß 2007 Wolters Kluwer Health | Lippincott Williams & Wilkins 0267-1379 The first part of the manuscript will be a brief description of the anatomical changes resulting from these procedures and the potential complications unique to each. The second part of the manuscript will discuss how these potential complications can present and how they should be evaluated. The third part of the manuscript will discuss management of surgical complications. We will close this manuscript by speculating on the potential future directions of this field. Bariatric surgery procedures The three most common types of bariatric surgery are RYGBP, LAGB and BPD/DS. 636 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Complications of bariatric surgery Lee et al. 637 Roux-en-Y gastric bypass The gastric bypass is formed by partitioning the stomach, with the aid of a stapling device, into a very small portion of the stomach arising just distal to the esophagus (termed the pouch) away from the main reservoir of the stomach (termed the remnant) (Fig. 1). An area of jejunum about 10–30 cm distal to the ligament of Treitz is then chosen for division. The distal jejunal limb is brought up to and anastamosed to the pouch with a limited sized stoma. The bypassed segment, which includes the remnant stomach, duodenum and proximal jejunum, is anastamosed at a variable location down the Roux limb (generally 40–150 cm length Roux limb). The result is a weight loss procedure which principally relies on pouch restriction for its weight loss and secondarily on the bypass segment for some malabsorption and dumping effects, as well as a way to prevent bile reflux. Complications may be divided into three groups: anastomotic related complications, bowel mobilization complications, and other (Table 1) [7,8–19,20,21–24]. Laparoscopic adjustable gastric band The LAGB procedure comprises three components: the band, the port, and the connector tubing (Fig. 2). Laparoscopically, the band is placed around the proximal stomach just distal to the gastroesophageal junction. Figure 1 Roux-en-Y gastric bypass Posteriorly its path is guided, and slippage prevented, by making a window from the inferior margin of the right crura toward the angle of His. Anteriorly the band lies on the cardia of the stomach and imbricating tacking sutures are used to prevent anterior slippage of the band. Tubing attached to the band is drawn across the abdominal wall where it is connected to an access port. The port is placed subcutaneously and is generally anchored to the anterior fascia to prevent movement or flipping of the port. The patient then returns to the office over the next year to obtain serial infusions of saline into the port. The infusions, over time, create adequate stomal restriction resulting in weight loss. Complications of LABG are primarily consequences of band malposition and system malfunction (Table 2) [21,24–26,27,28,29,30]. Biliary-pancreatico diversion with duodenal switch The BPD/DS procedure begins with the formation of a less restrictive pouch (Fig. 3). In contrast to the pouch created in the RYGBP procedure, this pouch is larger (approximately 200–300 cm3 versus approximately 30 cm3) and remains in continuity with the pylorus and duodenum. The pouch is created by removing a majority of the body and fundus associated with the greater curvature. The pouch must be larger to accommodate a patient’s need for more protein and calorie supplementation in order to prevent malabsorptive-induced malnutrition. The proximal duodenum is divided just distally to the pylorus (preserving the pylorus and few centimetres of duodenum mitigates dumping and marginal ulceration). The small intestine is then manipulated so as to bring up a certain short length of alimentary limb that will connect as a Roux limb just distally to the pylorus. The majority of the remaining small intestine will be associated with the defunctionalized biliary limb. The biliary limb will be re-anastamosed to the roux limb some 50–100 cm proximal to the ileocecal valve. Thus a common channel of 50– 100 cm will be created where mixing of food and digestive juice can occur. Complications include incisional hernia (18%) and infection (0.8–5%) as well as anastomotic ulceration (6.3–10.6%), fistula (0.1–1.7%), and leak (0.4–0.9%) [31]. Symptoms requiring gastroenterologist workup Reproduced with permission from Ethicon Endo-Surgery, a Johnson and Johnson Company. Despite the various procedures, complications of bariatric surgery generally present in one of five nonspecific ways: abdominal pain, suboptimal weight loss, diarrhea, gastrointestinal bleeding, or wound infections. When presented with these rather common complaints, it is crucial for the gastroenterologist caring for these patients to include postbariatric surgery complications in their differential diagnosis for early identification and successful management of these problems. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Reference Number Open RYGBP 25759 [7] [8] 22558 [9] 2271 [10] 1479 [11] 955 [12] 697 [13] 458 [14] 68 [15] 57 Totals Laparoscopic RYGBP [16] 11918 [7] [8] 4382 [17] 2190 [18] 2000 [10] 1539 [19] 1400  [20 ] 1345 [21] 844 [9] 554 [22] 1291 [11] 401 [23] 282 [24] 120 [15] 59 Totals Mortality Leaks Staple line disruption 0.25% (65) 0.80% (181) 1.5% (35) 0.34% (88) 0.9% (234) Marginal ulcer Stricture SBO Incisional hernia 0.36% (7/1913) 6.6% (1641) 9.7% (68) 2.6% (12) 77% (5) 2% (1) 2.9% 93/3193 16% (11) 39% (22) 6.5% 1674/25884 Internal hernia Wound infection 2.3% (53) 2.1% (31) 0.6% (6) 0% 0% 3% (2) 0.55% 287/51611 0.58% 172/29577 0.91% 236/25827 0% 2% (1) 0.80% 1/125 2.51% (300) 3.50% (193/5370) 2% (39/1843) 0.27% (12) 1.3% (29)a 3.1% (63) 2.1% (32) 0.2% (3) 0% 0% 0.5% (3) 3.7% (50) 1.4% (12) 1.9% (16) 4.2% (23) 15.2% (205) 6.3% (53) 1.4% (12) 3.7% (31) 4.2% (5) 3% (2) 3.3% 212/6393 1.6% (2) 7.3% (94) 0% 1.8% (5) 0.8% (1) 0.8% (1) 0.20% 16/7646 2.3% 110/4780 1.5% 6/402 9% (26) 3.3% (4) 0% 2.5% 121/4840 3.3% (4) 9.9% 356/3600 Values as percentage and n except where shown. RYGBP, Roux-en-Y gastric bypass; SBO, small bowel obstruction. a Absorbable suture group only. 2.4% 366/15318 3.4% 33/964 638 Stomach and duodenum Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Table 1 Roux-en-Y gastric bypass complications Complications of bariatric surgery Lee et al. 639 Figure 2 Laparoscopic adjustable banding Figure 3 Biliary-pancreatico diversion with duodenal switch Reproduced with permission from Ethicon Endo-Surgery, a Johnson and Johnson Company. Reproduced with permission from Ethicon Endo-Surgery, a Johnson and Johnson Company. Abdominal pain This is probably the most common symptom following bariatric surgery. Although it is commonly caused by rapid food consumption causing lower esophageal sphincter dilation and spasm, it may signify a postoperative complication especially if the pain starts early in the postoperative course before oral intake has been initiated or if it persists with appropriate modification of the diet [32]. In patients after RYGBP, this differential could include complications at the anastomosis (leaks, strictures, ulcers), complications due to bowel mobilization (strictures, adhesions, internal hernia), or miscellaneous ones such as gallstones or portal vein injury. In patients after LAGB, the complications will most commonly be due to band malfunction or malposition. Early suspicion of a leak after RYGBP or BPD/DS generally prompts urgent imaging such as barium swallow or abdominal computed tomography (CT) scan, although there is a very low threshold for urgent reexploration as Table 2 Laparoscopic adjustable banding complications Reference Number Mortality [25] [26] [27] [24] [28] [29] [30] [21] 727 554 516 470 317 304 256 152 Band Pouch Obstruction/ slippage enlargement stenosis 4.9% (36) 7% (51) 12% (61) 2% (12) 2% (12) 12% (56) 0.2% (1) 0% 1.3% (4) 0.4% (1) 1.9% (5) 0.4% (1) 0% 1.3% (2) 0.14% 5.5% 5.5% 2/1432 116/2121 124/2273 Band erosion Hardware Hardware infection leak 0.4% (2) 1.3% (7) 3.1% (15) 0.2% (1) 9.5% (30) 1.6% (5) 8.2% (26) 2.7% (13) 1.2% (4) 1.6% (4) 2.3% (6) 0.4% (1) 1.2% 14/1127 3.6% 41/1127 1.7% 18/1043 3.2% (5) 1.9% 22/1176 1.3% (2) 2.7% 40/1493 0.9% (5) Miscellaneous Severe Esophageal/ hardware esophageal gastric problem dilation perforation 1.6% (9) 0.2% (1) 3.2% (10) 2.6% (4) 3.0% 14/469 1.2% (2) 0.5% 3/622 LAGB, laparoscopic adjustable banding. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 640 Stomach and duodenum imaging may be delayed, insufficiently sensitive, or not feasible due to weight limitations. Gastric or esophageal perforation after LAGB is a rare complication; it is diagnosed by either CT scan or barium swallow, preferably done with water soluble contrast [33]. stomach, resulting in weight gain [39]. After LAGB, causes include pouch enlargement, band slippage, or insufficient restriction. If there is no structural reason for the weight gain, the most likely explanation for weight regain is dietary noncompliance. For late onset or chronic pain, selection of studies would depend on the differential diagnosis. Pain attributed to stricture or ulcer would be best evaluated with barium swallow or upper endoscopy. Abdominal ultrasound would be appropriate in the setting of pain more consistent with gallbladder disease, provided the patient has lost an appropriate amount of weight. CT scan may be necessary due to body habitus. Concerns about intestinal obstruction, internal hernia or chronic pain issues should be approached by abdominal CT. Pain or reflux/regurgitation after LABG usually prompts contrast esophagram studies to assess position and check for leaks or dilation. If the work-up is unremarkable, one would need to consider the unmasking of gastrointestinal problems unrelated to bariatric surgery, such as irritable bowel syndrome, esophageal dysmotility and gastroparesis. Post-bariatric surgery diarrhea Gallstone disease is common after bariatric surgery (3–30%) [34]. Preoperative imaging for cholelithiasis did not change the cholecystectomy rate for asymptomatic patients [35]. Many surgeons do not perform concomitant cholecystectomy for asymptomatic cholelithiasis. If no gallstones are present, most leave the gallbladder in place, although some authors recommend prophylactic cholecystectomy [36]. Many insurance carriers no longer cover the concomitant removal of an asymptomatic gallbladder. Ursodiol prophylaxis reduces the risk of stone formation, but patient compliance is unreliable [37]. Bariatric surgery may unmask or exacerbate esophageal dysmotility and gastroparesis. These are relative contraindications to the restrictive procedures [LAGB and vertical banded gastroplasty (VBG)]. If abdominal pain, gastroesophageal reflux disease (GERD), nausea/vomiting, or food intolerance occurs after LAGB, an excessively tight band may be the cause. As there is an increased chance of perforation, an upper gastrointestinal (UGI) series is the initial test of choice to assess constriction and band position. If GERD symptoms are refractory to band deflation, and band slippage is not evident from the imaging study, an EGD is reasonable [38], followed by a motility study. Suboptimal weight loss Following RYGBP bariatric surgery, rapid weight loss occurs during the first three months, slows during the remainder of the first year, and then plateaus for most by 18 months [6]. Weight gain is not unusual starting two to three years after surgery. Early or unusual weight gain, however, generally should prompt a workup for leaks and fistulas by UGI series. Staple line dehiscence or gastrogastric fistula may result in food passage into excluded This symptom may be a physiologic response to the procedure itself as a result of malabsorption/maldigestion, bile salt diarrhea, or dumping syndrome [32]. Of these, the most common possibility to consider is dumping syndrome. While most gastric bypass patients will experience this side effect within the first 18 months, the incidence of chronic dumping syndrome is 5–10%. Facial flushing, lightheadedness, fatigue, and postprandial diarrhea occur following consumption of sugars and processed starches [40]. The presence of a pylorus with the duodenal switch generally prevents dumping syndrome. Other possibilities include irritable bowel syndrome exacerbated by surgery or preexisting or de-novo food intolerances that developed following surgery. The diagnostic workup should be tailored to the severity of symptoms [32]. In nonsevere cases, empiric therapy with antibiotics/probiotics for bacterial overgrowth or dietary modification to prevent dumping syndrome (changing the composition of meals, consuming carbohydrates mid-meal, and eating slowly) usually mitigates the symptoms. Avoidance of food intolerances and empiric anticholinergic therapy are reasonable options. No matter the cause of the diarrhea, one has to make sure that patients are not developing nutritional and metabolic complications of bariatric surgery, as discussed in several reviews [41–43]. Gastrointestinal bleeding In the early postoperative period (72 h), significant bleeding is usually due to an intraoperative complication or anastomotic ischemia [32]. Peroral endoscopy should be avoided during this period, with a low threshold for early reoperation with intraoperative or laparoscopy-assisted endoscopy [38]. Transient obstruction from clot at the jejuno-jejunal anastomosis may increase risk of perforation at the gastro-jejunal anastomosis or gastric remnant [32]. From 72 h to 1 week, erosions and ulcerations occur at band sites or anastomosis (marginal ulcer). Endoscopy, including push enteroscopy to examine the Roux limb, is reasonable at this point although it may be technically challenging. Discussion with the surgeon and review of the operative report, including an understanding of length of the fashioned Roux limb, may help identify modifications in standard techniques [38]. This information, along with imaging studies, will aid the endoscopist in the selection of the proper endoscope and accessories. For a RYGBP, a standard upper endoscope allows examination to the gastrojejunal anastomosis and the proximal Roux limb. A pediatric colonoscope, push enteroscope, or double Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Complications of bariatric surgery Lee et al. 641 balloon enteroscope [44] is needed to look at the jejunojejunal anastomosis, the retrograde biliary-pancreatico limb, and bypassed stomach. Intraoperative endoscopy, endoscopy through previously placed percutaneous endoscopic gastrostomy, or double balloon enteroscopy is necessary for long-limb RYGBP or traversing a sharp angulation at the jejuno-jejunal anastomosis. The ampulla may be reached by an enteroscope or pediatric colonoscope, but limited accessory length is problematic. Techniques which have been moderately successful include advancement of a duodenoscope over a stiff guide wire previously placed into the bypassed stomach with an enteroscope, pulling up a duodenoscope by a wire-guided biliary balloon anchored at the pylorus, and access via a surgical gastrostomy [45]. Wound infection and dehiscence Fascial dehiscence occurs in up to 1%, and is diagnosed and managed surgically. Mesh repairs are common, as reapproximation usually fails and may be complicated by abdominal compartment syndrome [6]. Sealants and sclerosants Merrifield and colleagues [48] have utilized a combination of therapeutic endoscopic techniques, including fibrin glue, argon plasma coagulation, and hemoclips to seal leaks in three patients. Endoscopically injected morrhuate has been attempted for staple line dehiscence after RYGBP/VBG and for weight gain due to a large gastric stoma [49]. Anecdotally, endoscopically injected fibrin glue in combination with argon plasma coagulation and hemoclips is not effective at sealing gastro-gastric fistulas following staple line dehiscence after VBG or biliary-pancreatico diversion [38]. Stitching For dilated gastrojejunal anastomosis without leak, success has been reported using endoscopic suturing in 11 patients [50]. Targeted management of postbariatric surgery complications Clearly, these endoscopic approaches are new with little long-term data. In proper hands, they provide an excellent approach to the patients. Their use cannot be recommended, however, until more data are gathered and the specialized tools needed are more available. Gastroenterologists have an increasing role in treatment of postbariatric surgery complications. Stenosis Anastomotic leaks If the leak develops early, within 10 postoperative days, signs of toxicity such as tachycardia, fever, and leukocytosis may be present. Endoscopy should be avoided in the immediate postoperative period (72 h) due to the risk of leak exacerbation or wound dehiscence. Treatment is primarily surgical, although small leaks may be followed expectantly. A large case series of 63 patients with leaks after RYGBP reports that most were not detected by CT imaging and that most required surgery (63%), with morbidity of 53% and mortality of 10% [10]. If the leak/fistula develops late, with no signs of toxicity, a number of approaches can be used. After VBG, this may be treated by Roux-Y jejunal limb to a newly created pouch [46]. After RYGBP, gastric division solves the problem. Adding a malabsorptive limb to the Roux or converting to biliary-pancreatico diversion is usually not helpful and can cause intolerable malabsorptive diarrhea [6]. Endoscopic approaches include the placement of covered stents, the injection of sealants, and stitching. Post-RYGBP stenosis may occur at anastomotic sites such as the gastro-jejunal or the jejuno-jejunal, or at sites where the Roux limb traverses the transverse colon or is retrogastric. These partial obstructions may be treated with endoscopic TTS balloon dilation, with a 2.1% perforation rate [22]. Huang and Farraye [38] report a technique to achieve a stomal size of 10–12 mm using a maximum dilator size of 15 mm. Kaplan uses a maximum dilator size of 20 mm for tight stenosis requiring dilation over several sessions [32]. Complications include perforation, dumping syndrome, and weight gain. To reduce the risk of perforation, the endoscopist must be aware of the short blind loop beyond the gastrojejunal junction and use a guidewire if advancement of the dilator is difficult. Balloon dilation to 12 mm is also effective for VBG stenosis but recurrence is common [20]. Stenoses that occur beyond 2 months are usually due to marginal ulceration. Minimizing risk factors (steroids, NSAIDs, and smoking), removing foreign material at the anastomosis (stitch material), and treatment with proton pump inhibitors may help relieve the cause of ulcer and prevent restenosis. Stenting Salinas [47] reported a small case series of self-expandable metal stent placement for RYGBP leaks 1–3 weeks after surgery, with removal several months later. Sixteen of 17 sealed successfully, but two esophageal mucosal tears and one stent migration to the colon requiring endoscopic removal resulted. For narrowings associated with LAGB, deflating the balloon may be helpful to ease stenosis without substantially increasing the lumen diameter [32]. Irreversible stenosis associated with LAGB is almost always a result of band slippage or erosion. Revisional or removal surgery is generally recommended. Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 642 Stomach and duodenum Anastomotic ulcers 9 Fernandez AZ Jr, DeMaria EJ, Tichansky DS, et al. Experience with over 3000 open and laparoscopic bariatric procedures: multivariate analysis of factors related to leak and resultant mortality. Surg Endosc 2004; 18:193–197. Treatment usually consists of antisecretory therapy [38,51,52]. Some recommend eradication of Helicobacter pylori, if it is present, although there are little or no data supporting this strategy. Others recommend sucralfate [32]. Complications from ulcers include gastro-gastric fistula (five of 282) [23] and perforation. If the ulcer is refractory to medical therapy, surgery should be considered. Surgical options include ulcer resection with revision of the pouch or staple line. 12 Capella RF, Iannace VA, Capella JF. Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg 2006; 203:328–335. Band malfunction 13 Nelson LG, Gonzalez R, Haines K, et al. Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006; 2:377–383. Usually band malfunction necessitates deflation of the band. LAGB complications often require reoperation [53] and revision to RYGBP [54,55], which may be done laparoscopically [56]. Conclusion Bariatric surgery is increasingly being utilized to accomplish weight loss. Although generally effective and safe, outcomes can be improved and complications can be decreased. In pigs, an endoscopic transgastric technique to reduce the size of the stomach is being developed [57]. Transgastric surgery could conceivably reduce procedure time, decrease complications, and improve outcomes [58–60]. This technique, however, is still in its infancy. In the meantime, it is imperative that the gastroenterologist and surgeon work closely together cooperatively in order to recognize and treat complications of bariatric surgery early in order to optimize outcomes and decrease morbidity and mortality in this challenging group of patients. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as:  of special interest  of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 695). 1 Li Z, Bowerman S, Heber D. Health ramifications of the obesity epidemic. Surg Clin North Am 2005; 85:681–701; v. 2 O’Brien PE, Dixon JB, Laurie C, et al. 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