Transcript Slide 1

Complications of
Bariatric Procedures
William Bakhos,MD
Mortality (30 Days)
Overall: 0.1%-1%
- Restrictive: 0.1%
- GBP: 0.5%
- BPD+DS: 1.1%
- Higher: Male, Elderly, Surgeon experience
Buchwald, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA
2004.
Maggard, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005.
Complications
Focus:

RYGB, LAGB.
3 categories:
1. Early complications (1-6wks).
2. Late complications(7wks-12mo).
3. Very late complications.
Early Complications - RYGB

Pulmonary Embolus: 0-3.3%
Accounts
for 30% of mortality.
Prevent: pneumatic compression devices & subq
heparin.
Dx: difficult.
Tx when high level of clinical suspicion.

Bleeding: 0.6-4%
Early
Bleeding:
Staple lines / surgical anastamosis
Mainly intraluminal
PW:Melena, HR↑, HGB↓
Self limited
Tx: PC, reverse anticoagulation, EGD, Surgery.
Early Complications - RYGB

Leaks: 2-3% (VCU=No leak since july 2006)
Account
for 50% of mortality.
PW: fever, HR↑, resp. fail.
Dx: UGIS, CT.
Tx: A. Urgent Exploratory surgery:
1. Irrigation.
2. Repair of the defect.
3. Wide ext. drainage.
B. Abx.
Early Complications - RYGB

Gastric remnant distention: rare
Potentially
lethal (distention->rupture-
>peritonitis)
Etlg: ileus or mech. obstruction.
pain, hiccups, LUQ tympany, shoulder pain,
abdominal distension, tachycardia, or SOB.
X-Ray: large gastric air bubble.
Tx: decompression with gastrostomy
(OR/Percutaneous)
Early Complications - RYGB

Wound Infection:
Lap
3-4%
Open 10-15%
PW: fever, fluctuance, erythema, or drainage.
Tx: open and/or I&D, if cellulitis-> Abx.
Late Complications - RYGB

Bleeding: 0.6-4%
Late
Bleeding: rare
Etlg: PUD
Tx: conservative, partial gastrectomy.

Stomal Stenosis: 6-20%
Etlg:
tissue ischemia (poor perfusion, tension).
PW: 6-7wks post op, NV, dysphagia, GE reflux,
inability to tolerate oral intake.
Dx: UGIS, EGD.
Tx: Balloon dilation, surgical revision(<0.05%).
Late Complications - RYGB

Marginal Ulcers: 0.6-13%
Etlg:
poor tissue perfusion, anastomotic
tension, staple line disruption or gastrogastric
fistulas (-> chronic exposure of the gastrojej to
acid), or NSAID use.
Dx: EGD.
Tx: D/C NSAID, PPI, Stop Smoking,Sucralfate.
Surgery revision (+truncal vagotomy) – rare.
Late Complications - RYGB

Dumping Syndrome: 50%
PW:
nausea, shaking, diaphoresis, diarrhea shortly after
eating.
Tx: Dietary prohibitions.
Cholelithiasis:
proplxs – 38% (40% symp)
6mo post op w ursodeoxycholic acid – 2%
Risk factors: obesity, rapid weight loss.
 ? benefit for simultaneous cholecystectomy for incidental
gallstones at the time of RYGB (unless symptomatic).
w/o
Villegas et al. Obes Surg 2004.
Hamad, GG et al. Obes Surg 2003.
Late Complications - RYGB
Choledocholithiasis: uncommon
Dx: US, MRCP.

Tx: ERCP cannot be performed routinely.
PTC.
Surgery.
Incisional Hernia: Lap – 0-1.8% ; Open –
24%.

PW:
enlarging bulge, pain, or obstructive symptoms.
Tx:
Postpone
repair until significant weight loss (>1 year).
Indications for early surgical repair include significant
pain, bowel obstruction, and rapid enlargement of the
hernia.
Late Complications - RYGB

Internal Hernias: 0-5%
Three potential areas
1-Mesenteric defect at the jejuno-jejunostomy
2-The space between the transverse mesocolon and
Roux-limb mesentery (Peterson's hernias).
3-The defect in transverse mesocolon if the Roux-limb
is passed retrocolic – most common.
If a patient is suspected of an internal hernia, urgent
surgical exploration is indicated !
Prevention: all previously mentioned defects are
usually closed.
Late Complications - RYGB

Failure to lose weight :
Maladaptive

eating patterns.
Weight regain: up to 20%
Noncompliant
Functional
Dx:
eating.
gastrogastric fistula:
UGIS.
Tx: surg rep. Endo stent/suture.
Dilation of gastric pouch or the gastrojej.
anastomosis:
Excessive food intake.
Endoscopic suture reduction.
Very Late Complications
Nutritional Defficiency after RYGB
Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini
S. Nutritional deficiencies following bariatric surgery: what
have we learned? Obes Surg. 2005. Review.
Poitou Bernert C. Nutritional deficiency after gastric
bypass: diagnosis, prevention and treatment. Diabetes
Metab. 2007. Review.
Shah M. Review: long-term impact of bariatric surgery on
body weight, comorbidities, and nutritional status. J Clin
Endocrinol Metab. 2006. Review.
Alvarez-Leite JI. Nutrient deficiencies secondary to
bariatric surgery. Curr Opin Clin Nutr Metab Care. 2004.
Review.
Fujioka K. Follow-up of nutritional and metabolic
problems after bariatric surgery. Diabetes Care. 2005.
Nutritional Defficiency
The mechanisms:
1.
2.
3.
4.
Insufficient intake d/t dietary restrictions and food
intolerance (meat, milk, fiber)
The exclusion of the stomach’s inferior part results in a
decreased secretion of gastric acid, sometimes required to
absorb vitamins and minerals (B12 and iron).
Duodeno-jejunal malabsorption related to the short-circuit.
The duodenum is the main absorption site for calcium, iron
and vitamin B1 (thiamin).
Asynergia occurs between the bolus and the bilio-pancreatic
secretions in the common portion of the intestine.
Proteins




Albumin <3.5 g/dL.
Mechanism:
 50% duodenal absorption
 Intake def (intolerance to meat)
 Decreased pancreatic enzyme secretion
 Contact time↓
Clinical: deterioration of general state of health, muscle
weakness with loss of muscle mass, anomalies of the skin,
mucosa and nails (alopecy, striated nails, dermatitis,
hypopigmentation), edema.
Prevalence:
 Distal RYGB – 6-13%
 Standard RYGB (Shorter R limb <150cm) – none.
 Peak incidence – 1-2yr post op.
Vitamin B12 (cobalamin)


<250 pg/ml.
Mechanism:
 ↓acid secretion (cleavage B12 – food proteins).
 Delayed/no link to IF (parietal c.).
 Schilling test after RYGB – abnrl in 50% of B12
def.

Prevalence: (no pre-op def. , despite advised MVI)



From 1yr post op. : 12-70%.
In the first 2 yr – 25%.
Post-op MVI use was shown to prevent folate and B12
deficiency when taken regularly.
Clinical: Macrocytosis – 0.8%. Megaloblastic anemia – rare. No
neurologic symp.
Vitamin B9 (folates)


<3 ng/ml
Mechanism:
↓dietary intake (fruits and vegetables).
 Because folates may be absorbed throughout the whole intestine.


Prevalence: (no pre-op deff. , despite advised MVI)

20% at 1 yr.
 Post-op MVI use was shown to prevent folate and B12 deficiency
when taken regularly.

Clinical: NTD, Anemia, apathy, fatigue, headaches, insomnia,,
weakness, Diarrhea, loss of appetite.
Vitamin B1 (thiamin)

Mechanism:




Prevalence:



Absorbed in the duodenum
↓intake (fruits, meat, cereals..)
Vomiting
1%
No def. when MVI
Clinical:


CVS: CHF
Neuro: Wernicke's encephalopathy, confusion, irritability, memory loss,
nervousness, numbness of hands and feet, pain sensitivity, poor
coordination, weakness.
 GI: Constipation, intestinal disturbances, loss of appetite

In all cases - administration of IV Vit B1 (50–100 mg) corrects the deficit.
Liposoluble vitamins (A, E, K)

Mechanism: ↓fat breakdown(limited/short time with biliary sec.)

Prevalence:
 very low after RYGB.
 BPD(4yr):



Clinical (BPD):




A-69%, K-68%, E-4%.
Despite MVI.
Vit A - night blindness or ocular xerosis.
Vit E – non.
Vit K – non.
Prudence recommends that patients taking anticoagulants
(antivitamin K) must be closely monitored !
Calcium and vitamin D

Mechanism:
 Ca: ↓ intake, ↓absorption (duodenum & prox jej).
 Vit D: ↓absorption (lipid malabsorption).
 HyperPTH: Ca ↓ ->PTH↑ ->hyperPTH-> bone loss .

Prevalence:
 Distal RYGB:
 Ca: 10% at 2yr
 Vit D: 51% at 2yr
 BPD:
 Ca: 25-50%
 Vit D: 17-50%
 HyperPTH:
 RYGB: ↑risk in post menopausal.
 BPD: 69% at 4 yr , 3% ↑ bone resorption.

Clinical: osteoporosis, osteomalacia.
Iron & Anemia

Iron deficiencies are the most frequent deficiencies after RYGB.

Mechanism:




Prevalence: (despite MVI)



↓intake (red meat).
↓ HCL -> ↓ transformation ferric form (Fe3+) to ferrous form (Fe2+),
which is the absorbable form.
↓ absorbed in the duodenum.
at 2 yr 33%
↑ 50% among women of childbearing age.
Anemia:

Def. anemias (vitamin B12, iron, folates) ~ 30%.
 Microcytic anemia in 63% of patients with an iron deficit
 Other Clinical: tinnitus, hair loss.
Potassium and magnesium

Halverson JD. Am Surg 1986:

56% hypokalemia with diuretic.
 34% hypomagnesemia.

Amaral JF. Ann Surg 1985:

6.3% severe hypokalemia (<3).
 No hypomagnesemia.
Zinc

The absorption of zinc is dependent on the absorption of lipids
which is reduced after RYGB.

Prevalence:

BPD: 10-50%.
 RYGB: rare.

Clinical:

Hair loss is frequently observed among women 3 - 6 mo after the
RYGB.:


Mechanisms: iron, protein and zinc deficiencies, post surgical stress
and significant weight loss.
Only one study described an improvement of alopecia after treatment
with high zinc sulfate supplements.
Selenium

Only in BPD:

3-14.5 %
 No clinical repercussion.

Potential Symptoms:





Increased incidence of cancer.
Pancreatic insufficiency.
Immune impairment.
Liver impairment
Male sterility.
Prevention and treatment
of the nutritional deficiencies
after RYGB

No controlled trial exists to determine the type of
supplements and the dosages to be prescribed after
RYGB.

The majority of the reviews published on post-RYGB
deficiencies recommend a multivitamin supplement
providing 100% of the RDA.
Pregnancy





Iron def. anemia ~ prematurity, LBW.
Vit D def. ~ Rickets, Neonatal hypoCa.
Iodine def. ~ Goiter, intellectual impairment.
FA def. ~ NTD, Cleft palate.
An increase in cases of malformations of the
neural tube was reported:
Haddow JE. Neural tube defects after gastric bypass. Lancet 1986.
Knudsen LB. Gastric bypass, pregnancy, and neural tube defects. Lancet 1986.
Martin L. Gastric bypass surgery as maternal risk factor for neural tube defects. Lancet 1988.
Ladipo OA. Nutrition in pregnancy: mineral and vitamin supplements. Am J Clin Nutr 2000.
Laparoscopic
Adjustable Gastric
Band complications
Normal Position



Normal position of gastric
band.
Phi angle, corresponding
to angle between vertical
axis and gastric band, is
estimated at 55°.
Note large width (2 cm) of
Swedish Adjustable
Gastric Band
Normal Position/adjustment
Adjustment
Restriction/losing restriction
Over-Restriction




Reflux/Regurgitation
Dilated esophagus.
Tertiary non peristaltic
waves.
Big concentric pouch.
Over-Restriction/Esophageal Dilatation
. Milone et al from Columbia University,NY in their series Of
440 patients,reported 121 patients who had follow-up
with a clinic visit and Barium Swallow performed at 1
year.
Seventeen patients (10 women and 7 men) (14%) were
found to have esophageal dilation with an average
diameter of 40.9 +/- 4.6 mm
Esophageal dilation after laparoscopic adjustable gastric banding.
Milone L et al. Surg Endosc. 2008 Jun;22(6):1482-6.
Over-Restriction/Esophageal Dilatation
Esophageal dilation after laparoscopic adjustable gastric banding.
Milone L et al. Surg Endosc. 2008 Jun;22(6):1482-6.
Over-Restriction/Pouch Dilatation

Brown et al from Melbourne Australia reported
17 cases of symmetrical pouch dilatation (SPD)
within their series of 425 LAGB procedure all
performed by pars flaccida technique (4.4 %).
Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence
and management.
Brown WA et al. Obes Surg. 2008 Sep;18(9).
Misplacement


Band was placed in
perigastric fat.
Failure to loose
weight.
Band Slippage
Acute pain and Vomiting unrelated to band fill
Band Slippage



Manganiello et al from Loyola university reported their
series of 660 LAGB patients, 34 (5%) experienced band
slippage and required 40 subsequent operative
procedures.
Of the 34 patients, 6 underwent multiple procedures for
their slipped band.
Overall, 10 removals, 13 gastric reductions, and 17
replacements were performed
Management of slipped adjustable gastric bands.
Manganiello M et al. Surg Obes Relat Dis. 2008 Jul-Aug;4(4):534-8; discussion 538.
Acute Erosion/Infection after placement

Fever and chills.

2 weeks s/p Band
Erosion
Port Infection
Erosion
Acute abdominal pain upon filling the band
Erosion
Tube infection
Port and Tube complications
Flipped reservoir/Disconnection
Port and Tube complications


In a series of 2191 morbidly obese patients treated by
LAGB, Boris Kirshtein et al reported 29 patients (1.3%)
with port disconnection.
Presentattion was sudden loss of restriction, failure to
adjust the band and regaining weight.
Presentation and management of port disconnection after laparoscopic adjustable gastric
banding.
Boris Kirshtein et al. Surg Endosc. 2008 Mar 25.
Port and Tube complications
Disconnection
Boris Kirshtein et al. Surg Endosc. 2008 Mar 25
Port and Tube complications
Disconnection
Parameter
Value
Mean age, years (range)
38.5 (18–63)
Sex, % female
79
BMI at primary bariatric surgery, mean ± SD (kg/m2)
43.7 ± 6.6
Mean time after primary surgery, months (range)
12.1 (3–41)
Type of band (SAGB/LapBand®)
23/5
Excess BMI loss at disconnection, mean ± SD (%)
42 ± 24.4
Excess weight loss at disconnection, mean ± SD (%) 52 ± 33.9
Boris Kirshtein et al. Surg Endosc. 2008 Mar 25
Port and Tube complications
Chronic leak
Port and Tube complications
Table 2 Incidence of tube breakage or disconnection in relation to different bands and need of laparoscopic operations to
retrieve the tube
Patients
Tube breakage Tube disconnection Lap operations
Heliogast® 269
28 (10.4%)
3 (1.1%)
1 (0.3%)
Lap-band® 220
19 (8.6%)
4 (1.8%)
3 (1.3%)
p = 0.50
p = 0.51
(χ 2 analysis)
Injection Port and Connecting Tube Complications after Laparoscopic Adjustable Gastric Banding.
Lattuada E et al Obes Surg. 2008 Jun 10.
Port and Tube complications
Debris with one way valve effect
Thrombosis of the Lap-Band system.
Sherwinter DA et al. Surg Endosc. 2008 Feb 23.
Port and Tube complications
Table 1 Complications of port and connecting tube in 489 patients
Complication
Tube breakage
Patients
Operations
47
54
Tube disconnection
7
7
Port-site infection
3
7
Port rotation
7
7
Port prominence with skin erosion
4
4
Tube kinking
1
1
Port-site hernia + tube breakage
1
1
Small bowel obstruction by the tube
1
1
71
82
Total
Lattuada E et al Obes Surg. 2008 Jun 10.
Mixed complications
Volvulus around the tube
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