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
•
•
•
•
•
•
•
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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.
Oxalate nephropathy complicating Roux-en-Y Gastric Bypass: an underrecognized cause of irreversible renal failure. Nasr SH, D'Agati
VD, Said SM, Stokes MB, Largoza MV, Radhakrishnan J, Markowitz GS Clin J Am Soc Nephrol. 2008;3(6):1676.
2.
Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. Service GJ, Thompson GB, Service FJ, Andrews JC,
Collazo-Clavell ML, Lloyd RV N Engl J Med. 2005;353(3):249.
3.
Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and
pancreatic islet hyperplasia. Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Goldsmith J, Hanto DW, Callery M, Arky R, Nose V,
Bonner-Weir S, Goldfine AB Diabetologia. 2005;48(11):2236.
4.
Bowel habits after bariatric surgery. Potoczna N, Harfmann S, Steffen R, Briggs R, Bieri N, Horber FF Obes Surg. 2008;18(10):1287.
5.
Dumping syndrome: pathophysiology and treatment. Ukleja A Nutr Clin Pract. 2005;20(5):517.
6.
Change in effective circulating volume during experimental dumping syndrome. MATHEWS DH, LAWRENCE W Jr, POPPELL JW,
VANAMEE P, RANDALL HT Surgery. 1960;48:185.
7.
Jacobs, DO, Robinson, MK. Morbid obesity and operations for morbid obesity. In: Maingot's abdominal operations, 11th ed, Zinner,
MJ, Ashley, SW (Eds), McGraw Hill, New York 2007. p. 471.
8.
Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases.Lee S, Carmody B, Wolfe L,
Demaria E, Kellum JM, Sugerman H, Maher JW J Gastrointest Surg. 2007;11(6):708.
9.
Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan
RJ, Landreneau RJ, GagnéDJ Obes Surg. 2003;13(5):797.
10. Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan
RJ, Landreneau RJ, GagnéDJ Obes Surg. 2003;13(5):797.
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Adv Surg Tech A. 2003;13(4):247.
References
12. Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Barba CA, Butensky MS, Lorenzo M, Newman R
Surg Endosc. 2003;17(3):416.
13. Stomal complications of gastric bypass: incidence and outcome of therapy. Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe L
Am J Gastroenterol. 1992;87(9):1165.
14. Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass. Go MR, Muscarella P 2nd, Needleman BJ, Cook CH,
Melvin WS Surg Endosc. 2004;18(1):56.
15. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Higa KD, Boone KB, Ho T Obes
Surg. 2000;10(6):509.
16. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Gumbs AA, Duffy AJ, Bell RL Surg Obes
Relat Dis. 2006;2(4):460.
17. Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Sapala JA, Wood MH, Sapala MA, Flake TM Jr Obes
Surg. 1998;8(5):505.
18. Ulcer disease after gastric bypass surgery.Dallal RM, Bailey LA Surg Obes Relat Dis. 2006;2(4):455.
19. Strictures following gastric stapling for morbid obesity. Results of endoscopic dilatation. Sataloff DM, Lieber CP, Seinige Am Surg.
1990;56(3):167.
20. Changes in gallbladder bile composition following gallstone formation and weight reduction. Shiffman ML, Sugerman HJ, Kellum JM,
Moore EW Gastroenterology. 1992;103(1):214.
21. Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Fuller W, Ali
MR Surg Endosc. 2007;21(7):1090.
22. Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Schirmer B, Erenoglu C, Miller A Obes Surg.
2002;12(5):634.
23. Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Csendes A, Burgos AM, Smok G, Beltran M
Obes Surg. 2007;17(1):28.
24. Early effects of Helicobacter pylori infection in patients undergoing bariatric surgery. Ramaswamy A, Lin E, Ramshaw BJ, Smith CD
Arch Surg. 2004;139(10):1094.
25. Bleeding Duodenal Ulcer After Roux-en-Y Gastric Bypass Surgery Marc Zerev, , MD, FRCSC;Lee B. Sigmon, BS; Timothy S. Kuwada,
MD; B. Todd Heniford, MD; Ronald F. Sing, DOJ Am Osteopath Assoc January 1, 2008 vol. 108 no. 1 25-27
References
26. Is routine cholecystectomy required during laparoscopic gastric bypass? Villegas L, Schneider B, Provost D, Chang C, Scott D, Sims T,
Hill L, Hynan L, Jones D Obes Surg. 2004;14(2):206.
27. Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: is it worth the wait? Hamad GG, Ikramuddin S, Gourash WF,
Schauer PR Obes Surg. 2003;13(1):76.
28. Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Baron TH, Vickers SM Gastrointest Endosc.
1998;48(6):640.
29. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Wright BE, Cass OW, Freeman ML Gastrointest
Endosc. 2002;56(2):225.
30. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Champion JK, Williams M Obes Surg.
2003;13(4):596.
31. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Nguyen NT, Goldman C,
Rosenquist CJ, Arango A, Cole CJ, Lee SJ, Wolfe BM Ann Surg. 2001;234(3):279.
32. Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric
bypass surgery. Iannuccilli JD, Grand D, Murphy BL, Evangelista P, Roye GD, Mayo-Smith W Clin Radiol. 2009;64(4):373.
33. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls.Lockhart ME,
Tessler FN, Canon CL, Smith JK, Larrison MC, Fineberg NS, Roy BP, Clements RHAJR Am J Roentgenol. 2007;188(3):745.
34. Binge eating among gastric bypass patients at long-term follow-up. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE,
LaMarca LB Obes Surg. 2002;12(2):270.
35. Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Capella JF, Capella RF Obes Surg.
1999;9(1):22.
36. Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive
patients and review of literature. Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N,
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37. Stomal ulcer after gastric bypass.MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP J Am Coll Surg. 1997;185(1):1.
38. Treatment of dilated gastrojejunostomy with sclerotherapy. Spaulding L Obes Surg. 2003;13(2):254.
39. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients
with weight regain. Thompson CC, Slattery J, Bundga ME, Lautz DB Surg Endosc. 2006;20(11):1744.