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Complications of bariatric surgery A.R. khalaj M.D. Minimal Invasive Surgery Research Center university of Iran

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MORTALITY Overall mortality was estimated to be less than 1 percent Meta-analysis: surgical treatment of obesity. AU - Maggard MA; Shugarman LR; Suttorp M; Maglione M; Sugarman HJ; Livingston EH; Nguyen NT; Li Z; Mojica WA; Hilton L; Rhodes S; Morton SC; Shekelle PG SO - Ann Intern Med 2005 Apr 5;142(7):547-59 increasing mortality was associated with advancing age, male sex, and lower surgeon volume of bariatric procedures Surgical volume impacts bariatric surgery mortality: a case for centers of excellence. AU - Hollenbeak CS; Rogers AM; Barrus B; Wadiwala I; Cooney RN SO - Surgery. 2008 Nov;144(5):736-43. Epub 2008 Jul 21

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MORTALITY The introduction of laparoscopic RYGB has been associated with a significant reduction in perioperative mortality. 0.17 percent as compared to 0.79 for open RYGB 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data. AU - Lancaster RT; Hutter MM SO - Surg Endosc. 2008 Dec;22(12):2554-63. Epub 2008 Sep 20.

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REHOSPITALIZATION RATES the rates of unexpected reoperations ranged from 6 to 9 percent AU - Santry HP; Gillen DL; Lauderdale DS SO - JAMA 2005 Oct 19;294(15):1909-17. 20, 18, and 15 percent of patients required readmission at one, two, and three years, respectively SO - JAMA 2005 Oct 19;294(15):1918-24. hospitalization in the year prior to surgery of approximately 8 percent.

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COMPLICATIONS OF MALABSORPTIVE PROCEDURES Jejunoileal bypass JIB resulted in high rates of diarrhea, arthritis, hepatic failure, cirrhosis, nephrolithiasis, protein malnutritio and vitamin deficiencies - Am J Med 1978 Mar;64(3):461- 75.n, Surg Clin North Am 1979; 59:1071.

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COMPLICATIONS OF MALABSORPTIVE PROCEDURES Biliopancreatic diversion and duodenal switch complications significant protein calorie malnutrition, anemia, metabolic bone disease, deficiencies of fat-soluble vitamins and vitamin B12- Gastroenterology 2001 Feb;120(3):669-81.

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Vertical banded gastroplasty staple line disruption 27-48%, stomal stenosis 20-33%, band erosion 1-7%, GERD, nausea/vomiting, marginal ulcers, and weight regain TI - Bariatric surgery. Surgery for weight control in patients with morbid obesity. AU - Balsiger BM; Murr MM; Poggio JL; Sarr MG SO - Med Clin North Am 2000 Mar;84(2):477-89.

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Laparoscopic adjustable gastric band Early complications include acute stomal obstruction 6%, band infection 0.3-9%, gastric perforation, hemorrhage, bronchopneumonia, and delayed gastric emptying. Gastrointest Surg 2003; 7:429.

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Laparoscopic adjustable gastric band Late complications include band erosion 7%, band slippage 2-14% or prolapse, port or tubing malfunction, leakage at the port site tubing or band, pouch or esophageal dilatation and esophagitis. SO - Obes Surg 2002 Apr;12(2):254-60

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Roux-en-Y gastric bypass Pulmonary embolus up to 3.3% Optimal strategies for preventing DVT/PE in the gastric bypass setting have not been established. However, most bariatric surgeons use both pneumatic compression devices in conjunction with subcutaneous heparin TI - Current practices in the prophylaxis of venous thromboembolism in bariatric surgery. AU - Wu EC; Barba CA SO - Obes Surg 2000 Feb;10(1):7-13; discussion 14

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Leaks 2 and 3 percent TI - Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients-- what have we learned? AU - Higa KD; Boone KB; Ho T SO - Obes Surg 2000 Dec;10(6):509-13. exploratory surgery should be performed without delay, even if test results are not confirmatory.

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Gastric remnant distension Clinical features include pain, hiccups, left upper quadrant tympany, shoulder pain, abdominal distension, tachycardia, or shortness of breath. Radiographic assessment may demonstrate a large gastric air bubble Treatment consists of emergent operative decompression with a gastrostomy tube or percutaneous gastrostomy TI - Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients. AU - Gagner M; Gentileschi P; de Csepel J; Kini S; Patterson E; Inabnet WB; Herron D; Pomp A SO - Obes Surg 2002 Apr;12(2):254-60.

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Marginal ulcers 0.6 to 16% Causes of marginal ulcers include : 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 Nonsteroidal antiinflammatory drug use Helicobacter pylori infection Smoking medical treatment

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Cholelithiasis Without prophylaxis, cholelithiasis develops in as many as 38 percent of patients within six months of surgery, and up to 41 percent of such patients become symptomatic. Am J Gastroenterol 1991 Aug;86(8):1000-5. The high frequency of cholelithiasis can be reduced to as low as 2 percent with a six month course of ursodeoxycholic acid (a synthetic bile salt) given prophylactically after surgery. Am J Surg 1995 Jan;169(1):91-6; discussion 96-7.

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Wound infection Rates of wound infection are significantly greater with open (10 to 15 percent) than laparoscopic (3 to 4 percent) gastric bypass procedures. SO - Ann Surg 2000 Oct;232(4):515-29 The incidence of wound infections can be decreased by perioperative administration of antibiotics (usually cefazolin).

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Stomal stenosis 6 to 20 percent Endoscopic balloon dilation is usually successful. Repeat dilation sessions may be required for some patients [ The complication rate for dilation is approximately 3 percent Surgical revision (required in less than 0.05 percent of patients) is reserved for those who have persistent stenosis despite repeated dilations.

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Bleeding Bleeding after gastric bypass has been described in 0.6 to 4.0 percent of patient Ann Surg 2001 Sep;234(3):279-89; discussion 289-91 A higher rate of postoperative gastrointestinal bleeding was observed following laparoscopic versus open GBP in a prospective randomized study Ann Surg 2001 Sep;234(3):279-89; discussion 289-91.

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Ventral incisional hernia Ventral incisional hernias occur with a frequency of 0 to 1.8 percent in laparoscopic series and as high as 24 percent in open series, underscoring a clear advantage of the laparoscopic approach in this regard SO - Ann Surg 2001 Sep;234(3):279-89; discussion 289-91.

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Failure to lose weight and weight regain Progressive noncompliant eating and other behavioral habits. Development of a functional gastrogastric fistula. Gradual enlargement of the gastric pouch. Dilation of the gastrojejunal anastomosis.

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Metabolic and nutritional derangements Iron, vitamin B12, and folate. Hyperoxaluria and nephrolithiasis have been reported following roux-en- Y gastric bypass surgery.

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Internal hernias Three potential areas of internal herniation are between: Mesenteric defect at the jejuno-jejunostomy The space between the transverse mesocolon and Roux-limb mesentery (Peterson's hernias) The defect in transverse mesocolon if the Roux-limb is passed retrocolic Internal hernias have been described in 0 [64] and 5 [73] percent of patients undergoing laparoscopic bariatric surgery. If a patient is suspected of an internal hernia, urgent surgical exploration is indicated

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Postoperative hypoglycemia and Dumping A small number of patients develop blackouts and seizures after weight loss surgery due to a severe form of recurrent hyperinsulinemic hypoglycemia. TI - Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. AU - Service GJ; Thompson GB; Service FJ; Andrews JC; Collazo-Clavell ML; Lloyd RV SO - N Engl J Med 2005 Jul 21;353(3):249-54

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