GI Complications of Gastric Bypass Caroline R. Tadros, MD May 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/Choledocholi thiasis • 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 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 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 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 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 References 1. 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