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Emergencies After Bariatric Surgery
AI Sarela MD FRCS
Consultant Surgeon
St James’s University Hospital
Agenda
• Laparoscopic Bariatric Procedures– Roux-en-Y gastric bypass– Adjustable gastric band– Sleeve gastrectomy
• Technical/mechanical complications– Early– Late
• Case-scenarios
Difficulties in the Bariatric Patient
• The classical symptoms and signs of peritonitis are usually absent in the bariatric patient
• Problematic venous access• Cuff measurement of BP is often
inaccurate• May not fit into CT scanner• Unfamiliarity with anatomy of the operation• Immobile – patient transfer is not easy!
Complications of Laparoscopic Roux-en-Y gastric bypass
• Early (< 30 days after operation)– Leakage – peritonitis– Acute distention of the gastric remnant– Bleeding
• Early or Late– Intestinal obstruction– Stomal stenosis– Stomal ulceration– Gallstones
Roux-en-Y Gastric BypassCase Scenarios
• POD#1 Laparoscopic Bypass: Fresh rectal bleeding, tachycardia, hypotension
• POD#4 Laparoscopic Bypass: A&E admission. Abdominal pain, tachycardia, not well.
• POD#7 Laparoscopic Bypass: A&E admission. Vomiting.
• POD#20 Laparoscopic Bypass. Abdominal pain, fever, tachycardia.
• 2 years after Laparoscopic Bypass. Abdominal pain.
GI Luminal Bleeding after Bypass
• Endoscopy – clipping of bleeder
• Laparoscopy– Bleeding from the J-J anastomosis?
• Open anastomosis to inspect staple-line• Evacuate blood clots – may obstruct bowel
– Bleeding from the gastric remanant?• Gastrotomy - Evacuate blood• Oversew staple-lines
Acute Abdomen in the Bypass Patient
• Leakage – Peritonitis
• Intra-peritoneal bleeding
• Intestinal obstruction
Sites of Leakage after Gastric Bypass
– Gastrojejunal anastomosis
– Jejuno-jejunal anastomosis
– Staple line on the residual stomach
– Gastrotomy for insertion of anvil
– Missed enterotomy
Laparoscopic Roux-en-Y Gastric BypassNormal Radiological Anatomy
Suspected Leak: Radiology or Re-Laparoscopy?
• Contrast swallow examination – beware the false-negative!
• CT scan – timing of oral contrast; limited enhancement with IV contrast
• Consider re-exploration for all patients with suspected GI leak – radiology may delay intervention
Causes of Obstruction after Gastric Bypass
• Internal hernia – Peterson’s space• Internal hernia – small bowel mesenteric defect• Incorrect identification of small intestine
– Closed loop– Twisted loop
• Narrow/occluded jejuno-jejunal anastomosis• Blood clot at jejuno-jejunal anastomosis• Port-site hernia• Abdominal wall hernia
Anatomy of Intestinal Obstruction in the Bypass Patient
• Isolated obstruction of the biliopancreatic limb– Upper abdominal pain– Deranged liver function tests– Distention of the gastric remanant
• Isolated obstruction of the alimentary limb– Inability to tolerate oral intake
• Obstruction of the common channel– Bilious vomiting
Massively Dilated Gastric Remnant
• Acute Dilatation– Obstruction at J-J, BP limb or CC– Clot due to staple-line bleeding. Technical
error in construction of the anastomosis.– CT guided or operative decompression of
remnant.
• Chronic Dilatation– Peptic ulcer, vagotomy, cancer,
gastroparesis- in all these cases duodenum will remain collapsed
Intestinal Obstruction with Distened Gastric Remnant
Dysphagia with Bypass
• Stomal stenosis
• Early post-operative presentation
• Dilatation
• Routine post-operative PPI therapy
• Smoking cessation
Marginal Ulcer
• Incidence up to 15%• Barium study – gastro-gastric fistula• Non-operative management
– Smoking cessation– NSAID cessation– Endoscopic removal of retained sutures– PPI
• Operation– Excision and revision of anastomosis
Gallstone & Biliary Sepsis
• Risk of gallstones may double during rapid weight loss (from 15 to 30%)
• Combined cholecystectomy is controversial
• Post-bypass – how to manage choledocholithiasis?– Laparoscopic bile duct exploration– Trans-gastric ERCP– Percutaneous trans-hepatic biliary drainage
Dysphagia with a Band
• Slippage
• Over-inflation
• Fluid Shifts
– “Auto-fill”
– Gastric wall oedema
Band Slippage
• Cephalad migration of the gastric wall such that band is displaced
• Symptoms– Pain– Dysphagia – Gastric outlet obstruction
• Danger: Gastric wall necrosis
Band SlippageRadiology – Contrast Swallow
• Enlarged pouch that is obstructed at the
level of the band
• Change in the orientation of the band on
contrast swallow or plain radiograph
Band in Good Position
Slipped Band
Slipped Band
Operations for Band Slippage
• Reduction of prolapsed stomach without opening the band
• Opening the band, reduction of prolapsed stomach, repositioning of the band.
• Removal of the band
• Avoid cutting – expensive!
• If opened, can leave it in the tunnel – do not have to remove.
Band Erosion
• Inadequate weight loss or weight regain
• Intra-abdominal abscess
• Port-site infection
Re-operation on the Bariatric Patient Positioning
• Abduction of both thighs on “split leg” table
• Foot supports
• No chest straps
• Arms “tucked in” at sides
• Extension arm-boards for retraction clamps
• Maximum head-up incline
Re-operation on the Bariatric PatientEquipment
• Extra-long laparoscopic ports and instruments
• Liver retractor with Fastclamp
• Methylene blue solution (two ampoules in 1 litre of sterile water/NS)
• NG tube – introduce under laparoscopic vision
Bariatric Surgery Emergencies
• Scary!!
• Try to contact the operating surgeon
• Determine the anatomy of the procedure
• Radiology is not usually helpful
• Very low threshold for RE-LAPAROSCOPY
• Ensure availability of correct equipment
• LAVAGE & DRAIN