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