Bariatric Surgery Complications by SUNNY

8/12/2019 Bariatric Surgery Complications by SUNNY

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Sunny Shah, MS IV



HPI

45 y/o Female with PMH of Anxiety, GERD, and Anemia presents to BMH

for elective laparoscopic gastric band and port removal. Patient has been

complaining of chronic GERD and associated Nausea over the last one

year. According to patient the problem occurs constantly and has been

unchanged. Patient denies abdominal pain, chest pain, congestion,

coughing, fatigue, fever, myalgias, or vomiting. Nothing aggravates thesymptoms and patient denies any management of her symptoms.

PMH Anxiety, GERD, and Anemia.



Past Surgical History-Laproscopic Gastric Banding –Before 2009? As per Radiology

Report from GI series in 2009 patient has “History of GastricBanding”

-Gastric Bypass- Before 2009? As per Radiology Report From GI

series in 2009 patient was reported as “S/P Gastric Bypass”

-C-Section Procedure-?-Tonsillectomy- 1976

-Appendectomy- 1971

Social History-No smoking History-Socially Drinks Alcohol- unknown amount

Family History-Unknown

Allergies-NKDA



Medication-clonazepam .5mg PO at bedtime

-Fluoxetine 40mg PO 1X/day

-Pantoprazole 40mg PO 1X/day

ROSConstitutional: Positive for weight loss. Negative for fever

and fatigue.HENT: Negative for congestion.

Respiratory: Negative for cough.

Cardiovascular: Negative for chest pain.

Gastrointestinal: Positive for nausea. Negative for

vomiting and abdominal pain.Musculoskeletal: Negative for myalgias.



Physical Exam Vitals : 119/72; 55 bpm; temp 36.1; RR 18; BMI: 21.4 (Weight 121pds; Ht: 5’3’’)

Constitutional: She is oriented to person, place, and time. She appears well-

developed and well-nourished.HENT:

Head: Normocephalic and atraumatic.

Right Ear: External ear normal.

Left Ear: External ear normal.

Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to

light.Neck: Normal range of motion.

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

Pulmonary/Chest: Effort normal and breath sounds normal.

Abdominal: Soft. Bowel sounds are normal.

Musculoskeletal: Normal range of motion.

Neurological: She is alert and oriented to person, place, and time. She hasnormal reflexes.

Skin: Skin is warm and dry.

Psychiatric: She has a normal mood and affect. Her behavior is normal.

Judgment and thought content normal.



LABS on 6/20 (4:00AM)

CBCWBC: 5.9RBC: 4.70

HBG: 8.9 L

Hematocrit: 29.6 L

MCV: 62.9 L

Platelets: 367BMPGlucose: 87

BUN: 14.0

Creat: 0.60

Calcium: 10.1Sodium: 142

Potassium: 4.1

Chloride: 104

CO2: 24

Anion Gap 14.0



On 05/23/2014

-Significant gastroesophageal reflux and esophagealdilatation. Significant narrowing of the stomach atthe level of the band. The appearance has notchanged significantly since the previous study.

On 3/29/2011:

- Significant narrowing at the level of the lap bandwith dilatation of the gastric pouch and esophagusand significant gastroesophageal reflux. Possibleulceration or diverticulum at the inferior aspect of thepouch.

On 3/06/2009:

- After oral administration of Gastrografin notedevidence of gastric banding. No leak. Flow of contrastis normal.



45 y/o F s/p Laparoscopic Gastric Bandingpresents with significant GERD and nauseaover the last year due to partial stomal

obstruction and esophageal dilation. Patient has opted for elective laparoscopic

gastric band and port removal



Hospital Course: Evolut ion/Compl icat ion: No complications noted

during procedure

Cond i tion Upon Discharge: -Vitals stable, tolerating clear liquid diet, pain well

controlled.

-Abd was soft, nondistended, dressing over incisionwas clean and dry.

-Discharged the following day, 06/21/2014, on

oxycodone-acetaminophen 5-325 mg PO Q6 as

needed with f/u in general surgery clinic in 1 week.-Told to avoid strenuous exercise and sports and stay

clear liquid diet.



Restrictive and Malabsorptive

*Roux-en-Y Bypass

*Adjustable LAP BAND

Restrictive

Sleeve Gastrectomy withDuodenal Switch

Restrictive and Malabsorptive





Roux-en-Y gastric bypass



AdvantagesRapid initial weight loss: >30-40% w/in 6 mo.Laparoscopic approach is possibleTakes 1-2 hours

DisadvantagesStomach cutting, stapling and intestinal re-routing requiredPortion of digestive tract is bypassed, resulting in

nutritional deficiencies“Dumping syndrome” can occur Non-adjustableExtremely difficult to reverse



Upto 16% of patients

Occur near the gastrojejunostomy acid injuring the jejunum

Due to:

1)poor tissue perfusion (ischemia @ the anastomosis)

2)Foreign material (staples or nonabsorbable suture)

3)Excess acid exposure (to gastric pouch )

4)NSAIDS5)H. Pylori

6) Smoking

Presentation

Nausea, pain, Bleeding and/or perforation



Up to 38% of patients within 6 months post-op

Bile stasis leads to increased sludge andgallstones

Prophylactic cholecystectomy prior to surgery(controversial) but some surgeons recommendif symptomatic gallstones preoperatively

Prophylactic use of ursodiol (ursodeoxycholicacid)frequency of cholelithiasis reduced to2%)



Up to 50% post-op

When high levels of simple carbohydrates areingested

Early type: Rapid onset (w/in 15 min)due torapid emptying of food into small bowel

Late Type: result of hyperglycemia and

subsequent insulin response causeshypoglycemia



LAP-BAND

AdvantagesLowest mortality and complicationrateLeast invasive surgical approachNo stapling, cutting, or intestinal

re-routingAdjustableReversibleLow malnutrition risk

DisadvantagesSlower initial weight loss thanGastric BypassRegular follow-up critical foroptimal results: Need adjustmentsRequires implanted medical device



Source: O’Brien et al. Obesity is a Surgical Disease: Overview of Obesity andBariatric Surgery, ANZ J Surg, 2004; 74: 200-204.



EARLY

Acute StomalObstruction

Band Infection

Gastric Perforation Hemmorrage

Broncopneumonia

Delayed GastricEmptying

PulmonaryEmbolism

LateoBand ErosionoBand Slippage/ProlapseoPort or tubing

MalfunctionoLeakage at port sitetubing or bandoPouch or esophagealdilationoEsophagitis



Sleeve Gastrectomy:

-Significant Restriction component

-Pyloric Valve preserved Decrease in dumping

syndrome

-Decrease in Ghrelin (hunger hormone) –

removed with greater curvature of stomach

Disadvantages:

-Demanding to perform

-Nutritional deficiencies afterwards



Symptoms of Dysphagia, vomiting, dehydraption,and inability to tolerate an oral diet.

Occurs common at gastroesophageal junction andthe incisura angularis

Most Common Reasons: over sewing the stapleline and using a bougie to the too small (debatablebut normally ranges from 30-60 French)



Up to 7-10 days after surgery ( up to 5% ofpatients)

Most common at gastrojejunostomy,

enteroenterostomy, Roux limb stump, staple line Can lead to peritonitis, sepsis, possible death

Presentation Tachycardia, tachypnea

Fever

Abdominal pain/back pain

Pelvic pressure or rebound tenderness



Order Gastrograffin upper GI series Subclinical cases

Bowel rest

Parenteral nutrition

IV antibiotic if H. pylori Clinically suspect leak

Laparoscopic evaluation and leak repair

Failure to evaluate is the most common cause ofpreventable injury, major long-term disabilit,yor death in bariatric surgical patients



Iron deficiency anemia

B12 deficiency

Folate deficiency

Calcium and Vitamin D deficiency

Not seen with purely restrictive surgeries



Common following RYGB

As high as 49% of patients (esp. menstruatingwomen)

Multifactorial cause Low gastric acid levels prohibit iron cleavage from food

Absorption inhibited because no nutrient exposure toduodenum or proximal jejunum

Decrease in iron-rich food consumption due to intolerance

Treat with oral supplementation of ferrous sulfateor ferrous gluconate



Up to 70% of patients Lack of hydrochloric acid and pepsin in

stomach Prevents B12 cleavage from food

Affects secretion of intrinsic factor, thus B12absorption

Intolerance to meat and milk

Oral supplementation usually adequate,

otherwise, IM injections used Folate Deficiency (complete absorption

requires B12)



Vitamin D deficiency is common among obesepeople

Calcium absorption decreased because duodenum

is bypassed Intolerance to dairy, foods high in calcium

Vitamin D is required for Ca++ absorption

Prolonged deficiencies lead to

Bone resorption, osteomalacia, osteoporosis Treat with calcium citrate supplementation and 2

weekly doses of Vitamin D



Vitamins and Medications after Surgery

(REQUIRED for LIFE)

Gastric Bypass 2 chewable

multivitamins daily (ex:Flinstones)

Calcium Citrate or Tums

1000 mg daily

Vitamin D 800 iu daily

Vitamin B 12 250 mcgdaily

Ferrous Sulfate elixir 325mg daily (menstruatingwomen only)

Band 2 chewable

multivitamins daily (ex:Flinstones)

Calcium Citrate or Tums

1000 mg daily

Vitamin D 800 iu daily



REFERENCES

1)Lim RB, Blackburn GL, Jones DB. Benchmarking best practices in

weight loss surgery. Curr Probl Surg 2010; 47:79.

2)Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011.Obes Surg 2013; 23:427.

3)Lomanto D, Lee WJ, Goel R, et al. Bariatric surgery in Asia in the last

5 years (2005-2009). Obes Surg 2012; 22:502.

4) Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric

bypass in patients with superobesity. J Gastrointest Surg 2002; 6:195.

5)Uptodate article: Bariatric surgical operations for the management ofsevere obesity: Descriptions. Author: Robert B Lim, MD, FACS, LTC, MC,

USA. Section Editor: Daniel Jones, MD. Deputy Editor: Rosemary B

Duda, MD, MPH, FACS

http://www.uptodate.com/contents/bariatric-surgical-operations-for-the-management-of-severe-obesity-descriptions/abstract/1








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