Complications Post-Bariatric Surgery · Complications Post-Bariatric Surgery . ... Roux-en-Y gastric bypass 6 years ago ... Contained perforated marginal ulcer

Complications Post-Bariatric Surgery

Marc LaFonte PGY 4

SUNY Downstate April 16th, 2015

www.downstatesurgery.org

Case Presentation

55F epigastric abdominal pain x 12 hours, sudden onset, sharp, non-radiating. ROS otherwise negative. PMH: RA, GERD, obesity, depression PSH: c-section, Roux-en-Y gastric bypass 6 years ago (100lb net weight loss) UGIB 1 month prior, 2PRBC, adequate response. EGD: clot at GJ anastomosis, no vessel, no active bleed. Meds: adalimumab, methylprednisolone, pantoprazole, sulcralfate, fluoxetine NKA


Physical Exam

Vitals: T 99.6F, BP 133/91, HR 72, RR 16, 99% RA AAOx3, NAD Abd: soft, tympanic, non-distended, non-tender (no pain medication) Rectal: Guaiac negative, no masses


Laboratory and Radiological Studies

8.1 > 11.5/36.6 < 358 141 / 4.2 | 106 / 25 | 18 / 0.9 < 74 LFT WNL Lipase 81 UA negative CXR and AXR: no free air, no acute cardiopulmonary findings


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CT: Abdomen/pelvis Small amount of free air left hemidiaphragm and anterior to left lobe liver No portal venous gas, no thickened bowel no extravasation of PO contrast No free fluid


Assessment and Plan

Contained perforated marginal ulcer Admitted to SICU Serial abdominal exams, NPO Steroids held, started Zosyn If clinically changes, OR 6 hours later, abdominal pain returned


OR

Exploratory laparotomy Free air on entry to peritoneum, no free fluid or enteric content Jejunojejunostomy densely adherent to anterior abdominal wall. Stomach adherent to undersurface left lobe liver and omentum Appreciated gastrojejunostomy to proximal gastric pouch and confirmed Roux-en-Y


OR Continued

Confirmed perforation at gastrojejunal anastomosis, extremely fibrotic. Scant enteric content seen. Transected jejunum from stomach with perforation site and biopsied surrounding tissue, frozen negative Prior gastrojejunostomy site closed hand sewn Connell/Lembert New gastrojejunostomy created several cm from GE junction, NG passed 10cm distally into jejunum Lymphazurin blue with saline with Roux limb closed – no leak JP placed next to new GJ, fascia closed, retention sutures


Post-Operative Course POD#0-1 Extubated, re-intubated 2 hours later while agitated, lip smacking. Head CT and EEG negative, neurology “metabolic encephalopathy” POD#2-4 Patient removed her NGT Return of bowel function, foley d/c’ed POD#5 UGI series no leak, diet advanced POD#7 d/c home after 7 day course of fluconazole and zosyn (ID) Final pathology no malignancy (ulcer site, jejunum, omentum, tissue surrounding perforation)


Questions?


Obesity: Why it’s important

• Disease, now epidemic •Minorities, low socioeconomic, women

• 2nd cause of preventable death in US

•1980: 25% adults, 1990: 34% •12 fold ↑ mortality (age 25-34)


Pathophysiology

Factors

•Decreased energy expenditure •Reduced thermogenic response to meals •High set point for body weight •Decrease in heat energy loss •Intestinal flora composition

• Central/visceral fat distribution

•Excessive caloric intake while lacking satiety


Who’s fit for surgery?

•Diet, exercise, behavior changes

•75 lb weight loss •3% success rate, returns after 1 year •Best for BMI up to 35, or lower with risk factors

•Pharmacotherapy •Sibutramine: noradrenaline & 5-hydroxytryptamine reuptake inhibitor (appetite suppressant) •Orlistat: inhibits gastric/pancreatic enzymes (↓ lipid absorbtion)

•Failed management, BMI of 35 with significant co-morbidities, or BMI > 40 warrants surgical management

•Psychologically stable, ASA < IV, most drug addiction


•


History of Bariatric Surgery •1892: Dr. Cesar Roux developed Roux-en-Y for gastric obstruction

•1969: Dr. Edward Mason and Dr. Chikashi Ito applied to obesity •1977: Dr. Ward Griffin modified Roux-en-Y

•1950’s: jejunoileal bypass

•Liver failure and nutritional complications

•1979: Dr. Nicola Scopinaro developed biliopancreatic diversion •1980: Dr. Mason described vertical band gastroplasty •1980’s: Duodenal switch by Dr. Tom DeMeester

•Treat bile reflux gastritis

•1986: Dr. Douglas Hess combines BPD and DS

•1994: Dr. Belachew first lap gastric band, Dr. Wittgrove and Dr. Clark first lap Roux-en-Y



Laparoscopic Adjustable Gastric Banding: Key Steps

• Reverse trendelenburg • Divide peritoneum at angle of His • Divide gastrohepatic ligament at

pars flaccida • If hiatal hernia present, repair

• Pass grasper (right to left), pull band under posterior surface of GE junction, lock buckle at lesser curvature

• Imbricate fundus and proximal stomach over band

• Secure tubing/port to anterior abdominal wall fascia


LAGB Complications Relative risk low vs. other bariatric surgery

• High patient dissatisfaction (41% remove at 10 years)

Efficacy for BMI > 50 not impressive • Previous upper GI surgery (IE Nissen) poor candidates

Prolapse most common emergent complication requiring re-operation (3%)

• Excessive vomiting predisposes • Plain film – look for horizontal position of band

• Should be 1-2 o’clock / 7-8 o’clock

Initial treatment – remove fluid from system • If fails, upper GI series

• OR to reduce manually and re-suture band


LAGB Complications

Port/tubing leakage or kinking • Re-align or revise under local

Slippage -3% require operation • Greatly reduced with pars flaccida technique

Band erosion (1-2%) • High suspicion if port site infection or fever without

florid sepsis • Endoscopy diagnostic • Treat by removing band, repair perforation if not

already sealed by inflammatory process


Roux-en-Y Gastric Bypass: Key Steps

Port placement • Cleveland vs. Virginia Proximal jejunum divided 40-50cm distal to LoT, divide mesentery • Penrose/suture proximal Roux limb Measure Roux limb (100-150cm), create jejunojejunostomy

• Connect jejunum to biliopancreatic limb (side to side), close stapler defect, close mesentery


Roux-en-Y Gastric Bypass: Key Steps

Create gastric pouch Connect it to Roux limb


Roux-en-Y Gastric Bypass: Complications

Mortality 0.5% reported series BOLD reports 5.9% morbidity in 14,491 procedures

• 0.3% anastomotic leak • 0.33% venous thromboembolism • 3-5% wound infection • 3-15% marginal ulcer • 7% bowel obstruction • 1-19% anastomosis stenosis

Nutritional complications

• 5% Iron deficiency • 50% B12 deficiency • 15% vitamin D deficiency



Anastomotic leak – most feared complication • Immediate postoperative period • Tachycarida, tachypnea, fever, and oliguria

• CT and gastrograffin swallow false negative • Consider re-laparoscopy

Hematemesis

• Bleeding from gastrojejunostomy until ruled out

Small bowel obstruction –think INTERNAL HERNIA • Peterson defect (posterior to Roux limb) • Require surgical therapy emergency



Marginal ulcers • Diagnose with endoscopy • PPI effective 90% • Surgical treatment reserved for:

• gastrogastric fistula • stenosis of gastrojejunostomy that fails

dilatation • acute perforation


Biliopancreatic Diversion: Key Steps

Distal subtotal gastrectomy 200cm of most distal ileum anastomosed to stomach Biliopancreatic limb anastomosed 75-100cm proximal to ileocecal valve


Duodenal Switch: Key Steps

Gastrectomy: Lesser curvature spared • 32-40 Fr diameter optimizes wt loss • Pylorus intact Distal 250cm ileum anastomosed to duodenum (high leak rate)


Biliopancreatic Diversion and Duodenal Switch: Complications

Similar to Roux-en-Y BPD higher incidence of marginal ulcers • Led to adaptation of combined duodenal switch

Most nutritional problems

• Diarrhea • Protein-calorie malabsorption • Fat soluble vitamins must be supplemented

daily


Sleeve Gastrectomy: Key Steps

Pass 32F bougie along lesser curvature Divide stomach 2-3cm from pylorus to angle of His along greater curvature

•4.5mm stapler


Sleeve Gastrectomy: Complications

Low morbidity compared to other bypass procedures Excess weight loss at 3 years


Summary Obesity is a growing problem, preventable Screening requires taking steps, mental screening important Each bypass has large risks peri-operatively and long term Complications come in 2 flavors: early and late. Recognize early signs and symptoms with high index of suspicion.


References Fischer et al. Mastery of Surgery ,6th edition Schwartz’s Principles of Surgery, 9th edition Mason et al. Surgical Treatment of Obesity vol. XXVI Monkhouse et al. Complications of Bariatric Surgery: Presentation and Emergency Management-A Review http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2749388/


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2749388/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2749388/

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Complications Post-Bariatric Surgery · Complications Post-Bariatric Surgery . ... Roux-en-Y gastric bypass 6 years ago ... Contained perforated marginal ulcer