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.

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 anastamosisMainly intraluminalPW:Melena, HR↑, HGB↓Self limitedTx: 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: rarePotentially 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.

Early Complications - RYGB

Bleeding: 0.6-4%Late Bleeding: rare

Etlg: PUDTx: 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: w/o 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).

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-jejunostomy2-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 eating.Functional gastrogastric fistula:

Dx: UGIS. Tx: surg rep. Endo stent/suture.

Dilation of gastric pouch or the gastrojej. anastomosis:

Excessive food intake.Endoscopic suture reduction.

Late Complications - RYGB

Nutritional Defficiency after RYGBBloomberg 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. Review.

Very Late Complications

Nutritional Defficiency

The mechanisms:

1. Insufficient intake d/t dietary restrictions and food intolerance (meat, milk, fiber)

2. 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).

3. Duodeno-jejunal malabsorption related to the short-circuit. The duodenum is the main absorption site for calcium, iron and vitamin B1 (thiamin).

4. 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:

Absorbed in the duodenum ↓intake (fruits, meat, cereals..) Vomiting

Prevalence: 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):

A-69%, K-68%, E-4%. Despite MVI.

Clinical (BPD): 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: ↓intake (red meat). ↓ HCL -> ↓ transformation ferric form (Fe3+) to ferrous form (Fe2+),

which is the absorbable form. ↓ absorbed in the duodenum.

Prevalence: (despite MVI) 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 SlippageAcute 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

ErosionPort Infection

ErosionAcute abdominal pain upon filling the band

ErosionTube 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 complicationsDisconnection

Boris Kirshtein et al. Surg Endosc. 2008 Mar 25

Port and Tube complicationsDisconnection

ParameterValue

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

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%)

  (χ 2 analysis) p = 0.50 p = 0.51  

Port and Tube complications

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.

Table 1 Complications of port and connecting tube in 489 patients

ComplicationPatients Operations

Tube breakage 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

Total 71 82

Port and Tube complications

Lattuada E et al Obes Surg. 2008 Jun 10.

Mixed complications

Volvulus around the tube

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