GI Complications ofGastric Bypass

Caroline R. Tadros, MDMay 15th 2013

Disclaimer• This presentation has no commercial content,

promotes no commercial vendor and has not been supported financially by any commercial vendor. I have not received financial remuneration from any commercial vendor related to this presentation.

Bariatric Procedures• Lap band

http://www.nationalbariatric link.org

• Sleeve Gastrectomy

http://www.stfranciscare.org

Roux-en-Y Anatomy

Medical Complications of Roux-en-Y• Metabolic and nutritional derangements – Iron, calcium, vitamin B12, thiamine, and folate

• Nephrolithiasis/Renal Failure1

– Hyperolaxuria

• Post-operative hypoglycemia2,3

– Pancreatic nesidioblastosis (beta islet cell hypertrophy)

Medical Complications of Roux-en-Y• Change in bowel habits4

• Steatorrhea– Excessive fat intake– Lactose intolerance

• Dumping Syndrome5

– Early6

• Onset within 15 minutes• Colicky abdominal pain, nausea, tachycardia, diarrhea • Usually self limited and resolves 7-12 weeks post operatively

– Late• Onset 2-3 hours• Dizziness, fatigue, diaphoresis, and weakness

Mechanical Complications• Gastric Remnant Distention• Stomal Stenosis• Marginal Ulcers• Ulcers in excluded stomach• Cholelithiasis/

Choledocholithiasis• Fistulas– Gastro-gastric– Gastro-intestinal

Gastric Remnant Distention• Etiology7,8

– paralytic ileus – distal mechanical obstruction– Iatrogenic injury to vagal fibers along the lesser curvature – Progressive distension can ultimately lead to rupture

• Presentation9

– Abdominal pain– Hiccups– Shoulder pain– Abdominal distension– Tachycardia – Shortness of breath

Gastric Remnant Distention• Diagnosis– Left upper quadrant tympany– Gastric air bubble on imaging

• Treatment10

– emergent decompression with a gastrostomy tube or percutaneous gastrostomy

– Immediate operative exploration and decompression are required if percutaneous drainage is not feasible, or if perforation is suspected.

Stomal Stenosis• Etiology11

– Tissue ischemia– Increased tension on the gastro-jejunal anastamosis

• Presentation– Several weeks postop– Nausea, vomiting, dysphagia, decreased oral intake,

weight loss

Stomal Stenosis ( cont’d )• Diagnosis– EGD – Upper GI series

• Treatment12,13,14

– Endoscopic balloon dilation (perforation rate 3%)– Surgical revision (<0.05%)

Marginal Ulcers• Etiology 15,16

– Poor tissue perfusion due to tension or ischemia at the anastomosis

– Presence of foreign material, such as staples or non-absorbable suture

– Excess acid exposure in the gastric pouch due to gastro-gastric fistulas

– Non-steroidal anti-inflammatory drug use

Marginal Ulcers• Etiology ( cont’d )– Helicobacter pylori infection21-24

• High prevalence of H. pylori in bariatric patients• Preoperative treatment of HP decreased marginal ulcer rate form

6.8 to 2.4%– Smoking

• Presentation– nausea, abdominal pain, bleeding and/or perforation

Treatment of Marginal Ulcers13

• Gastric acid suppression• Sucralfate • Discontinuation of NSAIDS• Smoking cessation • H. pylori therapy • Calcium channel blockers• Endoscopy/ IR embolization• Surgery (gastro-jejunostomy revision with truncal

vagotomy)

Ulcers Within the Excluded Stomach• Endoscopy is limited due to the post surgical

anatomy• Pancreatitis• If suspected operative management/intraoperative

endoscopy25

Cholelithiasis• Rapid weight loss increases lithogenicity of bile20

• Frequency can be reduced with a six month course of ursodiol given post-operatively

• Cholecystectomy at the time of bypass in those with symptomatic cholelithiasis26,27

• Cholecystectomy in asymptomatic patients is controversial

Choledocholithiasis• ERCP is of limited benefit• Typically requires PTC or

surgery• Placement of a

gastrostomy tube into bypassed stomach at the time of surgery or as necessary for pancreatobiliary/ duodenal access28,29

Internal Hernias• Occur in up to 5 % of patients undergoing

laparoscopic bariatric surgery

• Hernias through the transverse mesocolon are the most common and require operative repair30

Internal Hernias• Three potential areas of internal herniation31,15

– Mesenteric defect at the jejuno-jejunostomy

– The space between the transverse mesocolon and Roux-limb mesentery (Peterson's hernias)

– The defect in the transverse mesocolon if the Roux-limb is passed retrocolic

Internal Hernias ( cont’d )• Intermittent, difficult to detect radiographically32,33

• If suspected, urgent surgical exploration is indicated• strangulated hernia may result in short bowel

syndrome.

Mesenteric Swirl Sign

Rev. Col. Bras. Cir. vol.39 no.3 Rio de Janeiro May/June 2012

Persistent Obesity• Failure to lose weight34

– rare and is often due to maladaptive eating patterns during the early postoperative period

• Weight Regain34

– Occurs in up to 20% of patients, especially those with super-obesity (BMI>50 ) at the time of surgery

Differential Diagnosis of Weight Regain• Progressive noncompliant eating

• development of a gastro-gastric fistula35,36,37

• gradual enlargement of the gastric pouch38,39

• dilatation of the gastro-jejunal anastomosis

Weight Regain Management• Fistula35, 36,37

– UGIS if persistent or new onset GERD symptoms– surgical repair may be indicated

• Dilatation of gastric pouch or the gastro-jejunal anastomosis – Repeated overdistention of the pouch from excessive food

intake– No benefit of revisional surgery.

Excessive Weight Loss• Bacterial Overgrowth

• Gastro-intestinal fistula

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