Caroline Tadros, MD - Ogden Surgical

GI Complications of
Gastric Bypass
Caroline R. Tadros, MD
May 15th 2013
• 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
• Sleeve Gastrectomy
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
• 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
Shoulder pain
Abdominal distension
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
– 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
– Presence of foreign material, such as staples or nonabsorbable suture
– Excess acid exposure in the gastric pouch due to gastrogastric 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
Discontinuation of NSAIDS
Smoking cessation
H. pylori therapy
Calcium channel blockers
Endoscopy/ IR embolization
Surgery (gastro-jejunostomy revision with truncal
Ulcers Within the Excluded Stomach
• Endoscopy is limited due to the post surgical
• Pancreatitis
• If suspected operative management/intraoperative
• 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
• ERCP is of limited benefit
• Typically requires PTC or
• Placement of a
gastrostomy tube into
bypassed stomach at the
time of surgery or as
necessary for
pancreatobiliary/ duodenal
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 Rouxlimb 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
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
– Repeated overdistention of the pouch from excessive food
– No benefit of revisional surgery.
Excessive Weight Loss
• Bacterial Overgrowth
• Gastro-intestinal fistula
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