Complications of Bariatric Surgery: What You Can Expect to ... · Roux-en-Y gastric bypass (RYGB)...

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The American Journal of GASTROENTEROLOGY VOLUME 112 | NOVEMBER 2017 www.nature.com/ajg

CLINICAL AND SYSTEMATIC REVIEWS

INTRODUCTION

Th e increasing prevalence of obesity and its associated co-mor-

bidities has resulted in a substantial increase in the number of

bariatric procedures performed worldwide ( 1–5 ). In fact, bariatric

surgery has become one of the fastest growing operative proce-

dures and has gained acceptance as the leading option for sus-

tained weight-loss in the treatment of morbid obesity ( 3 ). As this

fi eld continues to expand, gastroenterologists will see an increas-

ing number of patients with surgically altered anatomy. Th ere

are a number of unique complications that arise in this patient

population that require specifi c knowledge for proper manage-

ment. Furthermore, conditions unrelated to the altered anatomy

typically necessitate a diff erent management strategy. As such, a

basic understanding of surgical anatomy, potential complications,

and endoscopic tools and techniques for optimal management is

essential for the practicing gastroenterologist. It is important to

co-manage these conditions with a surgical team, as endoscopic

approaches may not always be successful, and surgical reinterven-

tion may not always be suffi cient. For all of the endoscopic pro-

cedures discussed, it is critical to use carbon dioxide insuffl ation

to minimize complications and post-procedural pain. Further-

more, there should be a low threshold for anesthesia consultation,

as bariatric patients may have complicated airways, obstructive

sleep apnea, require more medication, or may be at other risk of

conscious sedation. Th is review will cover these topics and focus

on major complications that gastroenterologists will be most

likely to see in their practice.

ROUX-EN-Y GASTRIC BYPASS

Roux-en-Y gastric bypass (RYGB) has traditionally been the

most common bariatric procedure, accounting for almost half of

all bariatric surgeries performed worldwide ( 3 ). Th is procedure

involves stapling the stomach to create a small gastric pouch,

along with diversion of oral intake and biliopancreatic digestive

enzymes to the distal small bowel, via creation of a Roux limb

( Figure 1a ).

Various hormonal mechanisms are implicated depending on

surgical technique employed ( 6–8 ). Foregut theories suggest the

role of a hormone that is released from the duodenum and contrib-

utes to insulin resistance. Th is substance is no longer thought to be

secreted following gastric bypass surgery in the foregut hypothesis.

In addition, gastric inhibitory peptide (GIP), which is secreted

from the duodenum, is thought to have a role. In hindgut theory,

bile and undigested food are thought to stimulate L-cells to pro-

duce glucagon-like peptide-1 (GLP-1) and Peptide YY (PYY) as

well as other substances which cross the blood brain barrier and

enhance satiety signaling, slow gastric emptying, and increase

insulin production. It is likely that numerous mechanisms actually

contribute to the metabolic eff ect of this surgical procedure.

Th ere are several variants of the RYGB. In procedures performed

via a laparoscopic approach, the pouch is completely transected

and separated from the gastric remnant, whereas in the prior

open approach, a staple line merely separates the stomach. Gastro-

jejunal anastomosis (GJA) can be created with circular or linear

staplers, or using a hand-sewn. When sutures are used, these can

Complications of Bariatric Surgery: What You Can

Expect to See in Your GI Practice

Allison R. Schulman , MD 1 , 2 and Christopher C. Th ompson , MD, MSc, FASGE, FACG AGAF 1 , 2

Obesity is one of the most signifi cant health problems worldwide. Bariatric surgery has become one of the fastest

growing operative procedures and has gained acceptance as the leading option for weight-loss. Despite improvement

in the performance of bariatric surgical procedures, complications are not uncommon. There are a number of

unique complications that arise in this patient population and require specifi c knowledge for proper management.

Furthermore, conditions unrelated to the altered anatomy typically require a different management strategy. As

such, a basic understanding of surgical anatomy, potential complications, and endoscopic tools and techniques for

optimal management is essential for the practicing gastroenterologist. Gastroenterologists should be familiar with

these procedures and complication management strategies. This review will cover these topics and focus on major

complications that gastroenterologists will be most likely to see in their practice.

Am J Gastroenterol 2017; 112:1640–1655; doi: 10.1038/ajg.2017.241; published online 15 August 2017

1 Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital , Boston , Massachusetts , USA ; 2 Harvard Medical School , Boston ,

Massachusetts , USA . Correspondence: Christopher C. Thompson, MD, MSc, FACG, FASGE, AGAF, Division of Gastroenterology, Hepatology and Endoscopy,

Brigham and Women's Hospital , 75 Francis St, ASB II , Boston , Massachusetts 02115 , USA . E-mail: [email protected] Received 27 January 2017 ; accepted 27 June 2017

CME

Complications of Bariatric Surgery

© 2017 by the American College of Gastroenterology The American Journal of GASTROENTEROLOGY

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be absorbable or non-absorbable. In some procedures, a silastic

ring is placed at the level of the GJA in an eff ort to enhance dura-

bility. In addition, placement of the Roux limb can be performed

antegastric (“antecolic”) or retrogastric (“retrocolic”). Jejunojeju-

nal anastomosis can be constructed in an end-to-side or side-to-

side confi guration. Furthermore, limb lengths vary considerably

depending on the operator. All of these variants have specifi c

implications to the risk profi le of the RYGB ( Table 1 ).

Anastomotic ulceration

Ulceration at the GJA, also known as marginal ulceration, is

a common complication of RYGB, occurring in up to 16% of

patients. It can occur anytime postoperatively. It is diagnosed by

upper endoscopy and is typically located on the jejunal aspect of

the GJA ( Figure 2a ). Patients are oft en asymptomatic, suggesting

the incidence may be much higher. When symptoms do occur,

they can include epigastric pain, obstructive symptoms, or gastro-

intestinal bleeding. Further complications include stenosis and

rarely perforation.

Th e etiology of marginal ulceration is likely multifactorial

( 9–12 ). While the mechanisms underlying the development of this

complication have not been fully elucidated, there is substantial

evidence that acidity plays a signifi cant role in the disease patho-

physiology. Poor local tissue perfusion from ischemia or tension at

the site of the anastomosis, in addition to foreign materials (e.g.,

suture, staple), microvascular ischemia from smoking or poorly

controlled diabetes, and medications including but not limited to

non-steroidal anti-infl ammatories (NSAIDs) also play an impor-

tant role in ulcer development. Furthermore, surgical technique

may be relevant, with the majority of studies demonstrating higher

rates of marginal ulceration with the use of circular staplers and

non-absorbable sutures ( 13,14 ). However, the incidence varies

greatly between clinical series utilizing the same surgical tech-

nique, further supporting a multifactorial etiology to the devel-

opment of marginal ulceration. While the relationship between

Helicobacter pylori infection and the development of marginal

ulceration is controversial, a recent nationwide analysis suggests a

strong association ( 15–21 ). A complete list of predisposing factors

is shown in Table 2 .

Th e majority of patients with marginal ulceration respond to

medical therapy which includes high dose proton pump inhibi-

tors (PPIs) and oft entimes the addition of sucralfate solution (not

tablets), especially as adjunctive therapy or in patients already tak-

ing a PPI at the time the ulcer is discovered ( 22 ). Administration

of a soluble or open capsule form of PPI is essential as it allows

enhanced absorption in the Roux limb and common channel due

to increased gastrointestinal transit time post-RYGB, and this

method of administration has been shown to signifi cantly decrease

time to ulcer healing and overall healthcare utilization ( 23 ). Smok-

ing cessation and indefi nite discontinuation of NSAIDs are also

important to promote healing. Removal of foreign material such as

sutures and staples should also be performed if RYGB surgery was

Laparoscopicadjustablegastric banding(LAGB)

Roux-en-Ygastric bypass(RYGB)

a

b c

d e f

Retrocolicgastric bypass Antecolic

gastric bypass

Sleevegastrectomy

Verticalbandedgastroplasty

Figure 1 . Overview of bariatric surgeries. Bariatric surgeries including Roux-en-Y gastric bypass ( a ) with retrocolic ( b ) and antecolic ( c ) anatomy, gastric

banding ( d ), sleeve gastrectomy ( e ), and vertical banded gastroplasty ( f ) ( 136 )*. * with permission.

Schulman and Thompson


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Table 1 . Complications of common bariatric procedures

Type of

Surgery

Complication Symptom(s) *Time of

onset since

surgery

Diagnostic tips Management strategies

RYGB

Anastomotic ulceration Epigastric pain

N/V

Bleeding

Often

asymptomatic

Early or late Do not advance endoscope deeply

beyond area of ulceration

H. pylori stool antigen or serology

High-dose PPI (soluble form) +/−

sucralfate

Stop smoking

No NSAIDs

Consider suture removal

Anastomotic stenosis Dysphagia

N/V

Malnutrition

Late Upper endoscopy

Avoid UGI series given aspiration risk

Look for concomitant ulceration

Stepwise endoscopic balloon dilation

Do not over-dilate (≤15 mm)

Carefully direct wire into distal Roux

limb

Foreign body removal

LAMS for concomitant ulceration

Gastrogastric fi stula Weight regain

Epigastric pain

Refl ux

N/V

Anytime Upper GI series sensitive

EGD important to confi rm and rule

out ulceration

If asymptomatic: PPI+dietary

counseling

If symptomatic: closure (endoscopic

[<1 cm] vs. surgical)

Surgical leaks Tachycardia

C-reactive protein

Leukocytosis

Post-operative

or early

Cross-sectional imaging

High false negative rates for all

studies

Depends on location of leak and

timing since surgery; see text

Stents for acute pouch and GJ leaks

Clips for JJ leaks

Chronic walled-off leaks treat like

necrosectomy

Intestinal obstruction Abdominal pain (often

intermittent)

N/V

Anytime Cross-sectional imaging while the

patient is symptomatic

Surgery

Endoscopy is not indicated for extra-

luminal causes of obstruction

Choledocholithiasis Right upper quadrant

abdominal pain

Late RUQ u/s

Cross-sectional imaging

MRCP

Device-assisted enteroscopy, laparo-

scopic-assisted ERCP, possible EUS

directed ERCP

Dilated gastrojejunal

anastomosis

Weight regain Late Upper endoscopy

Dilation confi rmed with GJA>15 mm

Endoscopic revision (TORe)

APC for compliant yet not markedly

dilated GJA

LAGB

Refl ux esophagitis GERD Late Upper endoscopy High-dose PPI +/− sucralfate

Band defl ation

Esophageal dilitation Dysphagia

Refl ux

Epigastric discomfort

Late Upper endoscopy

Upper GI series

Band defl ation

Surgical replacement or conversion

Band erosion Pain

N/V

Weight loss

Sepsis

Late Upper endoscopy Endoscopic removal of band if

buckle is visible, with surgical

removal of port

Band slippage Vomiting

Epigastric pain

Late UGI Surgery

Sleeve gastrectomy

Sleeve stenosis Dysphagia,

N/V

Abdominal pain

Anytime Distinguish between stenosis and

twisting; consider imaging

Endoscopic pyloric dilation (hydro-

static to 20 mm) and pneumatic

balloon dilation of sleeve (starting at

30 mm)

Twisted sleeves less likely to respond

Sleeve leaks Tachycardia

C-reactive protein

Leukocytosis

Post-operative

or early

Cross-sectional imaging Depends on timing since surgical

procedure; see text

Acute: stent

Chronic: treat like necrosectomy

Esophageal pathology GERD Late Upper endoscopy High dose PPI +/− sucralfate

Surgical conversion to RYGB

Table 1 continued on following page



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performed at least six weeks prior, and this can be accomplished

by the use of biopsy or rat-tooth forceps, or endoscopic scissors

( 24 ). Testing for H. pylori is also recommended, and should be

accomplished by fecal antigen, or serology in immunocompetent

patients who are treatment naïve, as in our experience pouch biop-

sies and breath tests are less reliable in this patient population as

the majority of the stomach where H. pylori resides is inaccessible.

Independent of etiology, we recommend repeat endoscopy in two

to three months to confi rm ulcer healing. Of note, marginal ulcer-

ation complicated by stenosis is particularly diffi cult to manage,

and more likely to require surgical intervention.

Endoscopic suturing techniques in the treatment of recalcitrant

marginal ulceration have demonstrated technical feasibility, safety,

and effi cacy in small series, although additional studies regard-

ing durability are needed ( 25 ). Surgical revision is performed in a

small percentage of patients who do not improve with maximum

medical management, in whom endoscopic techniques are not

successful, or in whom perforation has occurred ( 26 ). Unfortu-

nately, reoperation carries signifi cant morbidity and a 7.7% recur-

rence rate ( 27 ).

Anastomotic stenosis

Stenosis of the GJA is perhaps the most common complications

in RYGB and has been reported in as many as 20% of patients,

however, the majority of studies report incidence in the single dig-

its ( 28–39 ) ( Figure 2b ). Patients can present from weeks to years

post-operatively with progressive dysphagia, nausea, vomiting,

and malnutrition. Some patients may paradoxically have weight

gain as they convert to higher calorie full liquid diets. While the

exact mechanism of stenosis is unknown, ulceration and ischemia

at the GJA, in addition to subclinical anastomotic leak, and

smaller diameter circular staplers used during the initial surgery

are likely contributory factors ( 37–39 ).

Although there is no precise defi nition for stomal stenosis, the

diagnosis is typically made when a patient is symptomatic and

a standard upper endoscope is unable to pass through the GJA.

Endoscopic balloon dilation is fi rst-line for management of this

condition ( Figure 3 ). As the GJA is an end-to-side anastomosis

with a thin jejunal wall directly behind the gastric aspect, care

must be taken to advance the balloon into the Roux limb proper

without traumatizing the adjacent jejunum or blind portion of

the Roux limb. If resistance is met despite careful repositioning,

a fl exible wire may be used as a guide, and rarely an ultrathin

upper endoscope may be required to assist in wire advancement.

Some patients will require multiple procedures to achieve dura-

ble results, and the procedure is safe with a complication rate of

<3% ( 31–33,35,40 ). Dilation should be performed with the goal

of achieving symptom resolution and a durable stomal diameter

of roughly 8–12 mm. Dilation above 15 mm should be performed

in rare circumstances where the patient remains symptomatic

despite having achieved a stable anastomotic diameter that

allows endoscope passage without resistance. Dilation to larger

diameters is associated with increased complications including

perforation and weight regain. It is important to exercise cau-

tion in the setting of coexistent marginal ulceration because this

may increase the risk of perforation and are more likely to require

surgical revision.

Other therapeutic techniques to treat stomal stenosis have also

been described including needle-knife electroincision, intral-

esional steroid injection, and placement of lumen apposing metal

stent ( 41–43 ), the latter of which is particularly helpful in concom-

itant ulceration ( Figure 3 ). Surgical revision for refractory stenosis

is required in approximately two percent of cases ( 44 ).

Gastrogastric fi stula

An abnormal connection between the gastric pouch and the

excluded stomach is known as a gastrogastric fi stula (GGF)

( Figure 2c ). Th ere are several postulated etiologies for the

development of this complication, including surgical technique

without complete division or transection of the gastric pouch,

marginal ulceration, anastomotic leak, and foreign body ero-

sion ( 45–47 ).

Table 1 . Continued

Type of

Surgery

Complication Symptom(s) *Time of

onset since

surgery

Diagnostic tips Management strategies

VBG

Anastomotic stenosis Dysphagia

N/V

Malnutrition

Late Upper endoscopy Endoscopic balloon dilation

Staple line dehiscence Weight regain Anytime Upper endoscopy Surgery

Band erosion Pain

N/V

Weight loss

Sepsis

Late Upper endoscopy Endoscopic removal if band is

silastic

APC, argon plasma coagulation; GERD, gastroesophageal refl ux disease; GJA, gastrojejunal anastomosis; LAGB, laparoscopic adjustable gastric banding; MRCP, mag-

netic resonance cholangiopancreatography; RUQ, right upper quadrant; RYGB, Roux-en-Y gastric bypass; UGI, upper gastrointestinal series.

*Post-operative: immediate post-operative period; early: <30 days; late: ≥30 days.



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persistent symptoms clearly attributable to the fi stula. Tradition-

ally, this has been accomplished with surgical revision. However,

newer per-oral approaches using endoscopic suturing systems

carry decreased morbidity, and sustain successful closure in ~20%

of patients at 12 months ( 49,50 ). Endoscopic repair is especially

eff ective when the fi stula is less than one centimeter ( 50,51 ). Sur-

gical revision following unsuccessful suturing appears to be safe.

Use of over-the-scope clips has also been reported, but should be

used with caution, as unlike with endoscopic suturing techniques,

these may interfere with subsequent revision surgery should it be

required ( 52–54 ).

Surgical leaks

Leaks are among the most serious complications and typically

occur within days of the procedure, but can also present in a

more delayed fashion. Th e incidence ranges from 0.1 to 5.6 per-

cent, and is much higher following revision surgery ( 55–58 ).

Th e typical presenting symptom is weight regain or inability to

lose weight as food does not bypass the remnant stomach. Pain,

refl ux, nausea, emesis, and marginal ulceration are also oft en

reported ( 43,48 ). Th e diagnosis is most reliably made by upper gas-

trointestinal series or upper endoscopy, although cross-sectional

imaging can also demonstrate this fi nding ( Figure 4a,b ). Never-

theless, there is a high false positive rate with this approach, as con-

trast can refl ux into the remnant stomach from the duodenum. A

defi nitive diagnosis should be reserved for when an actual fi stula

is seen, and not just contrast in the remnant stomach. Once con-

fi rmed, high dose PPI should be administered to prevent gastric

acid production in the remnant stomach from entering the gastric

pouch and jejunum through the GGF, as this can lead to abdomi-

nal pain and development of marginal ulceration, and potential

stenosis ( Figure 2d ).

GGF may be managed conservatively with PPI therapy and

dietary counseling. Closure is indicated when the patient has

a b

c d

>30 mm

e f

Figure 2 . Endoscopic examples of gastric bypass complications. Endoscopic examples of complications of gastric bypass including marginal ulceration

( a ), stenosis of the gastrojejunal anastomosis ( b ), gastrogastric fi stula (single arrow) with gastrojejunal anastomosis (double arrow) ( c ), gastrogastric fi stula

(triple arrows) complicated by marginal ulceration leading to stenosis of gastrojejunal anastomosis (single arrow) ( d ), staple line leak in gastric pouch ( e ),

and dilated gastrojejunal anastomosis ( f ).



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Tachycardia, leukocytosis, and elevated C-reactive protein are

the most common presenting fi ndings, and any one of these

should trigger appropriate supportive care and an expedited

evaluation ( 59 ).

Th ese leaks can occur at multiple points along any staple line

including the gastric pouch ( Figure 2e ), the GJA, the blind por-

tion of the Roux limb, the jejunojejunal anastomosis, and the rem-

nant stomach ( Figure 5 ). Before any therapy is undertaken, it is

important to identify the location of the leak using cross sectional

imaging or combined endoscopic and fl uoroscopic interrogation

of possible sites, as that will dictate the appropriate management.

In addition, it is important to treat downstream obstruction and

remove foreign material from the leak site. Th is includes staples,

sutures, and drains that may be in close proximity.

Endoscopic placement of self-expandable metal stents is eff ec-

tive in the treatment of proximal leaks of the pouch or GJA that

occur in the acute setting ( 60–70 ). Stent migration occurs in

16.9% of patients with rare serious complication ( 58 ). Optimal

time for stent removal is between 6 and 8 weeks, with leak reso-

lution rate of 87.8% ( ref. 58 ). Stents are the preferred treatment

method for leaks in these locations, as it is eff ective and there

is less evidence for the use of other modalities. In chronic leaks

with a walled-off cavity, these modalities are less eff ective, and

treating the collection as walled-off necrosis and ultimately plac-

ing plastic double pigtail stents between the cavity and the gastric

lumen (as detailed below in the sleeve gastrectomy section) is

oft en required ( 71,72 ).

Leaks at other locations are typically not amenable to stent-

ing. Other therapeutic options include clips, over-the-scope clips,

endoscopic suturing, tissue sealants and biochemical matrices.

Th ese modalities have variable results, and the evidence for their

use is limited to case series ( 68,73–75 ).

Table 2 . Etiology of Marginal Ulceration

Predisposing factors

Surgical Technique

Smoking

NSAID use

Alcohol

Lack of PPI use

Factors implicated in the physiopathology

H. pylori

Infl ammation

Foreign body reaction

Acid secretion

Bile refl ux

Fistula

Ischemia

NSAID, non-steroidal anti-infl ammatory.

*Reproduced from Fernandez-Esparrach G, Guarner-Argente C, and Bordas

JM. Ulceration in the Bariatric Patient. Bariatric Endoscopy . Springer

Science+Business Media; 2013, with permission.

a b

c d e

Figure 3 . Management of stenosis of the gastrojejunal anastomosis in gastric bypass. Endoscopic management of stenosis of the gastrojejunal anastomosis

without ulceration ( a ) with balloon dilation ( b ); endoscopic management of stenosis of the gastrojejunal anastomosis with ulceration ( c ) placement of a

lumen apposing metal stent ( d ), and resolution of stenosis and subsequent ulcer healing ( e ).



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Intestinal obstruction

Early post-operative bowel obstruction following gastric bypass

occurs at similar rates to other abdominal surgeries. Late bowel

obstruction will be more commonly seen in a gastroenterology

practice, and includes ventral incisional and internal hernias,

adhesions, and intussusceptions ( 76,77 ).

Adhesions and ventral incisional hernias occur more commonly

following open gastric bypass surgery. Both of these entities pre-

sent with pain or obstructive symptoms, with the latter classically

also causing a visible bulge. Internal hernias, on the other hand,

are more common following a laparoscopic surgical approach, and

have a reported incidence of 3–16% ( ref. 78–81 ). Th ere are three

mesenteric defects created during RYGB through which hernias

occur including the jejuno-jejunostomy, the space between the

transverse mesocolon and Roux-limb mesentary (i.e., Peterson’s

defect), and in the transverse mesocolon in patients with a retro-

colic Roux-limb. Computed tomography (CT) may demonstrate

swirled vessels or fat at the root of the mesentary ( Figure 4c ), a

fi nding which is known to have the highest sensitivity and speci-

fi city for making the diagnosis. However, these oft en occur inter-

mittently making radiographic detection diffi cult, and therefore

imaging should be performed while the patient is symptomatic

and there should be a low threshold for re-exploration is indicated

in bariatric patients with unexplained pain or symptoms of bowel

obstruction ( 82 ). If left undetected, bowel necrosis can occur

requiring large segment bowel resection.

a

b

c d

Figure 4 . Radiographic examples of gastric bypass complications. Computed tomography ( a ) and upper gastrointestinal series ( b ) demonstrating evidence

of gastrogastric fi stula; computed tomography demonstrating internal hernia ( c ) with arrows showing swirled vessels and fat at the root of the mesentary

and ( d ) intussusception with arrows showing telescoping of bowel.

Gastric pouch

1

5

4

2

3Remnantstomach

Roux limb

Biliopancreaticlimb (75–150 cm)

Commonlimb

Cecum

Duodenum

Commonbile duct

Gastrojejunostomy

Blind limb

Jejuno-jejunal anastomosis

Ligamentof Treitz

Figure 5 . Multiple points of gastric leak following RYGB.



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Intussusception is most commonly seen at the jejunojejunal

anastomosis, where the common limb telescopes through in a

retrograde fashion (distal to proximal) ( Figure 4d ). Th e reported

incidence rates range from 0.1 to 1%, and it oft en presents with sig-

nifi cant weight loss ( 80,83,84 ). Th e etiology is not well understood

but appears to be multifactorial, possibly involving a lead point

(suture lines, food boluses or adhesions), motility disturbances,

or thinning of intestinal mesentery that occurs with weight loss

and allows increased mobility of the bowel and an unstable region

around the site of the Roux limb ( 80,83,84 ). Endoscopy is not typi-

cally useful in these patients.

Cholelithiasis

Gallstone disease is common following RYGB. It is estimated

to occur in 28 to 71 percent of patients within six months fol-

lowing surgery, and as many as 40 percent of these patients are

symptomatic ( 85 ). Rapid weight loss may increase the choles-

terol saturation in the bile and the gallbladder mucin concentra-

tion, increasing the risk of gallstone development. Postoperative

anatomical changes and compromised gallbladder emptying

may also play a role ( 85–90 ). In addition, cholecystectomy is less

commonly performed in the era of laparoscopic RYGB. As such,

gastroenterologists are seeing these patients more frequently.

Endoscopic retrograde cholangiopancreatography (ERCP) is

particularly arduous in RYGB anatomy due to the relative inac-

cessibility of the duodenum and ampulla, making treatment

of choledocholithiasis challenging. Surgical technique plays in

important role in likelihood of success, as long a Roux limbs and

side-to-side jejunojejunal anastomosis poses even more diffi -

culty to the endoscopist. Oft entimes the procedure is attempted

using a pediatric colonoscope, spiral overtube, balloon-assisted

enteroscope, or a duodenoscope back-loaded onto a guidewire.

Balloon-assisted enteroscopy is the most well described pro-

cedure, with pooled procedural success rates of 62% ( ref. 91 ).

Alternative approaches include passage through a gastrogastric

fi stula if present with dilation if necessary, placement of a pro-

phylactic gastrostomy tube into the bypassed stomach, or EUS-

directed gastrostomy ( 92 ). A controversial emerging procedure is

the endoscopic ultrasound-directed transgastric ERCP (EDGE)

procedure, where a lumen-apposing metal stent is placed through

the gastric pouch and into the remnant stomach to allow access.

Th is stent is later removed and carries a risk of a persistent gastro-

gastric fi stula ( 93,94 ).

Failure to lose weight or weight regain

RYGB is associated with 15–35% failure, defi ned as inability to

achieve signifi cant weight loss (>50% loss of excess weight) or

excessive weight regain aft er initial adequate weight loss ( 8,95–98 ).

A signifi cant minority of these patients experience substantial

weight regain even two years post-surgical aft er RYGB ( 8,96–99 ).

In addition, studies have demonstrated that, on average, patients

have regained one third of the maximum weight lost 10 years fol-

lowing RYGB ( 100 ). Dietary non-compliance is contribute known

risk factor for weight regain. It has also been demonstrated that

anatomical changes such as dilation of the GJA ( Figure 2f ), and

development of gastrogastric fi stula ( Figure 2c,d ) play a signifi -

cant role in promoting weight regain ( 101 ).

Endoscopic suturing, plication devices, argon plasma coagula-

tion and other forms of thermal therapy ( 102–106 ) used to tighten

the stoma and reduce pouch volume have proven to be technically

feasible and safe, with recent studies showing sustained weight loss

at three years, and suturing demonstrating level I evidence in a

randomized sham-controlled trial ( 107 ). Th ese endoscopic thera-

pies off er a less invasive treatment option for post-bypass weight

regain, with minimal morbidity.

Nutritional abnormalities

Metabolic and nutritional defi ciencies are not uncommon fol-

lowing RYGB, as reconfi guration of gastrointestinal anatomy,

alteration in motility, pH and enzymatic profi les can lead to

derangements. Th ere should be a low threshold to evaluate and

treat nutritional defi ciencies aggressively. Common nutritional

defi ciencies and clinical symptoms are shown in Table 3 .

Dumping syndrome

Dumping syndrome following RYGB occurs when large quanti-

ties of simple carbohydrates are ingested. Early dumping occurs

within 15 min of ingestion and has been attributed to rapid fl uid

shift s from the plasma into the bowel due to hyperosmolality of

the food. Symptoms include both gastrointestinal complaints

(abdominal pain, diarrhea, bloating, and nausea) and vasomotor

changes (fl ushing, palpitations, perspiration, tachycardia, hypo-

tension, and syncope). Treatment includes avoidance of foods that

are high in simple sugar content, in addition to small frequent

meals in which liquids and solids are separated. Late dumping

results from hyperglycemia and the subsequent insulin response

leading to hypoglycemia, and occurs several hours aft er eating

with resultant symptoms due to low serum glucose (perspiration,

palpitations, weakness, confusion, tremor, and syncope). Treat-

ment includes similar dietary modifi cation, with medications

such as acarbose, an alpha-glucosidase inhibitor, reserved for

non-responders. Each of these conditions may present as a spec-

trum of symptoms captured by the Sigstad scoring system ( 108 ).

Abdominal pain

Abdominal pain is one of the most common reasons for gastro-

enterology consultation in the post-surgical population and is

not unique to gastric bypass. A standard abdominal pain work-

up evaluating potential etiologies unrelated to bariatric surgery

should be pursued as appropriate. Th ere are also several etiolo-

gies specifi c to post-surgical anatomy that must be considered.

Patient history and physical examination are oft en essential in

making the diagnosis. Careful evaluation for a Carnett’s sign is

important, as abdominal wall pain is common. Carnett’s sign is

elicited by having the patient lie fl at on an examination table, and

identify the point of maximal abdominal tenderness ( 109 ). Th e

physician then focally compresses this area with continuous pres-

sure and instructs the patient to lift their legs off the table, tens-

ing abdominal musculature. If the focal pain intensifi es, this is a

positive sign suggesting an abdominal wall syndrome. Th e most



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line diagnostic study. Endoscopy may also be therapeutic if pain

is due to retained foreign body such as suture material ( 24 ). If the

pain is intermittent, positional, or severe, cross-sectional imaging

should be initially performed to evaluate for potential intestinal

obstruction such as volvulus, intussusception, or internal hernia.

common treatment for abdominal wall pain is trigger point injec-

tion, whereby a local anesthetic is injected directly into the site of

pain. Prioritization of diagnostic studies depends on presenting

symptoms. If consistent mid-epigastric pain is present suggesting

marginal ulceration, upper endoscopy is recommended as a fi rst

Table 3 . Common nutritional defi ciencies and symptoms in Roux-en-Y gastric bypass

Defi ciency Common symptoms

Fat-soluble vitamins

Vitamin A Conjunctival dryness

Retinopathy

Night blindness

Dermatologic changes

Immune system impairment

Vitamin D Often asymptomatic (if mild-moderate)

Demineralization of bones, osteomalacia (if severe)

Weakness

Fracture

Vitamin E Neuromuscular disorders

Hemolytic anemia

Vitamin K Impaired coagulation leading to bruisability, mucosal bleeding.

Prolonged prothrombin time (PT)

Water-soluble vitamins

Thiamine (vitamin B1) Wernicke encephalopathy (encephalopathy and confabulation, oculomotor

dysfunction, ataxia)

Vitamin B12 Pernicious (megaloblastic) anemia

Folate Megaloblastic anemia

Vitamin C Petechiae

Gingivitis

Arthralgias

Poor wound healing

Trace minerals

Iron Hypochromic, microcytic anemia

Zinc Impotence

Impaired immune function

Hair loss

Copper Microcytic anemia

Neutropenia

Ataxia

Selenium Skeletal muscle dysfunction

Cardiomyopathy

Other

Calcium Metabolic bone disease

Secondary hyperparathyroidism

Protein Protein energy malnutrition



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Th is imaging should ideally be performed when the patient is

symptomatic, which increases the sensitivity. Right upper quad-

rant pain may warrant ultrasound, cross-sectional imaging, or

magnetic resonance cholangiopancreatography (MRCP) to evalu-

ate for cholelithiasis or cholodocholithiasis as a fi rst line test.

For diff use or lower abdominal discomfort, abdominal bloating,

and change in bowel habits, hydrogen or methane breath tests to

evaluate for small intestinal bacterial overgrowth (SIBO) should

also be part of the work-up. Th ese studies may be fraught with false

positives, as there is also faster transit time in RYGB patients ( 110 ).

As such, transit time to the colon should be estimated by small

bowel follow-through, and the breath test evaluated in light of

patient specifi c results. If the pain is generalized or predominantly

in the left upper quadrant, enteroscopy to the remnant stomach

may also be considered to look for remnant gastropathy or other

gastric remnant pathology. Th is is critical in patients that also

have unexplained anemia. For patients without anemia and who

are high risk for procedural intervention, we recommend obtain-

ing cholescintigraphy (99mTc-heapto-iminodiacetic acid (HIDA)

scanning), which allows for a radiolabeled substance to be taken

up selectively by hepatocytes and excreted into bile, thereby pro-

viding information about bile fl ow. Pooling of bile in the remnant

stomach suggests a positive test. Recent studies suggest that this

may off er a non-invasive alternate diagnostic strategy for iden-

tifying increased risk for bile acid gastropathy ( 111 ). If refl ux to

the remnant stomach is noted, then use of ursodiol, in addition

to PPI therapy, has been shown to eff ectively treat this condition

in small studies, and we have found it to be a useful management

strategy ( 111 ).

Surgical management

For chronic marginal ulceration or gastro-gastric fi stula, revision

of RYGB reconstituting the normal RYGB anatomy is being per-

formed more commonly and safely. Reversal of RYGB is an option

for patients with excessive weight loss, dumping syndrome, per-

sistent nausea and emesis. Esophagojejunostomy is reserved for

persistent leaks in the proximal pouch as it is a relatively morbid

procedure. Surgical revisions for weight regain, including Roux

limb distalization, are also performed when less invasive options

are not successful.

LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING

Laparoscopic adjustable gastric banding involves the insertion of

an adjustable, prosthetic band over the cardia of the stomach to

form a gastric pouch with roughly 15 ml capacity ( Figure 1b ). Th e

mechanism of action for this procedure is primarily restrictive in

nature. Th e gastric band consists of a silicone ring connected to

an infusion port, the latter of which remains in the subcutaneous

tissue and can be easily accessed for fl uid injection to increase the

degree of restriction, thus rendering it fl exible to meet the chang-

ing needs of the patient. While this procedure has the lowest peri-

operative complication rate and mortality among all bariatric

procedures, there are several disadvantages including presence of

a foreign body.

Refl ux esophagitis

Acid refl ux and esophagitis are common following banding

procedures ( 112–115 ) ( Figure 6a ). A systematic review demon-

strated newly developed refl ux symptoms aft er gastric banding in

up to 50% of patients without prior symptoms, and new esophagi-

tis confi rmed in up to 38.4% ( ref. 113 ). Treatment involves acid-

suppression therapy with or without sucralfate, as well as referral

to a surgeon for potential defl ation of the band.

Esophageal dilation

An achalasia-like syndrome can occur in less than ten percent

of patients and results from esophageal dilation proximal to the

band ( 116–119 ) ( Figure 6b ). Excessive fi lling of the band can

precipitate this condition and cause symptoms of refl ux, epigas-

tric discomfort, and inability to tolerate oral intake. Treatment

involves fl uid removal via the subcutaneous port (“band holiday”)

with reevaluation in 6 weeks ( 120 ). If this is not eff ective, replace-

ment of the band in a new location, or conversion to an alternative

bariatric procedure, is the typical course of action.

Band erosion

Band erosion, or intragastric migration, occurs in less than

6.8 percent of patients ( 121 ). Mean time to occurrence of 22.5

months post operatively, with a range of weeks to years ( 121,122 ).

Early erosions are usually attributed to undetected perforations

during surgery or early infection, while late erosions may be the

a b c

Figure 6 . Endoscopic examples of laparoscopic adjustable gastric banding complications. Severe refl ux esophagitis ( a ), pseudoachalasia following lap-

band placement ( b ) and lap band erosion ( c ).



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( refs 129,130 ). Over-sewing the staple line or use of a bougie that

is too small both predispose to narrowing at these locations. Rota-

tion of the stomach during stapling can also lead to a twisted and

narrowed sleeve.

Symptoms of obstruction can occur depending on the sever-

ity of the narrowing. Th is diagnosis is typically made by endo-

scopy or upper gastrointestinal series, and endoscopic dilation

is the primary mode of management. We recommend starting

with a hydrostatic balloon, and dilating both the pylorus and the

incisura to 20 mm. If there is no symptomatic improvement, use

of a pneumatic dilation balloon is then recommended at the level

of the gastric stenosis. We recommend starting with a 30 mm bal-

loon. Depending on resistance, maximal PSI may not be reached

in the fi rst session. In two weeks the procedure is repeated with

the same size balloon if maximum PSI was not reached, or with

a balloon fi ve mm greater in size. Th is process is repeated every

two weeks as needed until symptoms resolve ( Figure 7 ). A recent

study has demonstrated 96% effi cacy when using this algorithm

( 131 ). It is important to ensure the pneumatic balloon is not span-

ning the gastroesophageal junction or the pylorus to minimize risk

of perforation. If the sleeve is twisted, this technique is oft en less

eff ective.

Sleeve leaks

One complication that is common and particularly bothersome

is leak following sleeve gastrectomy. Th is complication has been

reported in up to 5.3 percent of patients, and usually occur along

the superior aspect of the staple line just below the gastroesopha-

geal junction ( 132 ). Th ese patients present in a more delayed fash-

ion than aft er RYGB.

Endoscopic approaches have proven successful, and off er a

less invasive fi rst line therapy for many patients. Th e timing of

presentation for sleeve leaks aff ects management strategy and

the literature supports diff erent time cut-off s in this regard.

If the leak occurs early (i.e., within six weeks following sleeve

gastrectomy) we recommend stent placement with simultane-

ous dilation of the pylorus to treat downstream obstruction. If

the leak is delayed and the collection is walled-off ( Figure 8 ),

we instead recommend dilation of the pylorus and distal sleeve,

and approach the collection in a manner similar to endoscopic

necrosectomy technique ( 71,72 ). In this approach, an endo-

scope is advanced into the collection and is used to mechani-

cally debride non-viable tissue and perform antibiotic lavage

with subsequent placement of pigtail stents for ongoing drain-

age. Other centers report use of a needle-knife fenestration

technique ( 133,134 ). Both of these approaches allow healing by

secondary intention.

Gastroesophageal refl ux disease and Barrett’s esophagus

Sleeve gastrectomy may predispose to esophageal pathology

including gastroesophageal refl ux disease and Barrett’s esopha-

gus. While some studies have failed to consistently demonstrate

an association, new evidence suggests that patients who have

undergone sleeve gatrectomy may be at substantially higher risk

of developing these complications. A recent study found that the

consequence of gastric wall ischemia from an excessively tight

band. Clinical manifestations of this complication can include

refl ux, nausea and vomiting, epigastric pain, excessive weight loss,

and life-threatening sepsis. In addition, if the site of erosion occurs

into the posterior part of the stomach near the cardioesophageal

junction, massive hematemesis can occur from involvement of the

gastric artery ( 123 ). Th e fi nding of abdominal cellulitis (overlying

the port) also indicates likely band erosion and warrants further

investigation. Diagnosis can be made endoscopically ( Figure 6c ),

and if the band buckle is visible, removal may be accomplished at

the time of the procedure, using a stiff guidewire and mechanical

lithotripter ( 124,125 ). Th is requires the patient to be under gen-

eral anesthesia, and that a surgeon is available to remove the sub-

cutaneous port (which can be performed in endoscopy). Th e wire

is fed through the opening of the band and the ends are placed

into the mechanical lithotripter. Th e band is then severed and can

be pulled out through the mouth.

Band slippage

Band slippage leads to prolapse of a portion of the stomach

through the band, and is one of the most common and bother-

some late complications of gastric banding. Patients oft en present

with vomiting and epigastric pain, and should prompt surgical

consultation.

Port infection or malfunction

Th e mechanical port component of the adjustable band device

exposes the patients to infectious complications given the pres-

ence of a foreign body, in addition to the inevitable consequences

of device weathering, which can lead to its failure ( 126–128 ).

Endoscopy is of no therapeutic value in this setting.

Surgical management

Laparoscopic adjustable banding can be easily reversed with

endoscopic or surgical removal of the band. Th is is oft en done for

failure of effi cacy or the aforementioned complications. Conver-

sion to other bariatric procedures such as sleeve gastrectomy or

RYGB is commonly and safely performed.

SLEEVE GASTRECTOMY

Laparoscopic sleeve gastrectomy is a procedure in which a large

portion of the greater curvature of the stomach is removed, leav-

ing just a small conduit along the lesser curvature. In so doing,

this procedure eff ectively removes fundal ghrelin-producing cells

and increases gastric emptying, which is associated with a vari-

ety of metabolic consequences leading to weight loss ( Figure 1c ).

Mechanistically, ghrelin levels decrease following sleeve gastrec-

tomy, and this is believed to aff ect appetite regulation. In addi-

tion, hind gut mechanisms including post-prandial increase in

Peptide-YY and GLP-1 are thought to play a role ( 6–8 ).

Sleeve stenosis

Stenosis following sleeve gastrectomy classically occurs at the

incisura ( Figure 7 ). Th e incidence is reported to be 0.7–4%



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incidence of GERD symptoms signifi cantly increased compared

with preoperative values (68.1% vs. 33.6%). Furthermore, PPI intake

similarly increased following surgery (57.2% vs. 19.1%). Finally,

a signifi cant increase in the incidence and severity of erosive

esophagitis was evidenced, and a signifi cant number of patients

were diagnosed with non-dysplastic Barrett’s esophagus ( 135 ).

As the prevalence of sleeve gastrectomy increases, the develop-

ment of these conditions should be monitored closely.

Surgical management

For complications not amenable to endoscopic or medical therapy,

surgical options are available. For refractory severe erosive

a b

c

Figure 7 . Management of stenosis of the incisura in sleeve gastrectomy. Sleeve gastrectomy complicated by stenosis of the incisura with pooling of bile

acid ( a ) managed by pneumatic balloon dilation under endoscopic ( b ) and fl uroscopic ( c ) guidance.

a b

Figure 8 . Management of late leak in sleeve gastrectomy. Sleeve gastrectomy complicated by late leak presenting with contained walled-off necrosis ( a )

managed by debridement and subsequent stent placement through leak site (arrow) ( b ).



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Financial support: None.

Potential competing interests: C.C. Th ompson—Apollo Endo-

surgery (Consultant/Research Support); Olympus (Consultant/

Research Support); Boston Scientifi c (Consultant); Covidien (Con-

sultant, Royalty, Stock); Medtronic (Consultant, Royalty, Stock);

USGI Medical (Consultant/Research Support). Th e remaining

author declares no confl ict of interest.

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review and meta-analysis . JAMA 2004 ; 292 : 1724 – 37 . 2. Arterburn DE , Olsen MK , Smith VA et al. Association between bariatric

surgery and long-term survival . JAMA 2015 ; 313 : 62 . 3. Buchwald H , Oien DM . Metabolic/bariatric surgery worldwide 2011 .

Obes Surg 2013 ; 23 : 427 – 36 . 4. Perry CD , Hutter MM , Smith DB et al. Survival and changes in comor-

bidities aft er bariatric surgery . Ann Surg 2008 ; 247 : 21 – 7 . 5. Colquitt JL , Clegg AJ , Loveman E et al. Surgery for morbid obesity . In:

Colquitt JL editor(s). Cochrane Database of Systematic Reviews John Wiley & Sons, Ltd : Chichester, UK , 2005 , pp CD003641 .

6. Ramón JM , Salvans S , Crous X et al. Eff ect of Roux-en-Y gastric bypass vs sleeve gastrectomy on glucose and gut hormones: a prospective ran-domised trial . J Gastrointest Surg 2012 ; 16 : 1116 – 22 .

7. Peterli R , Steinert RE , Woelnerhanssen B et al. Metabolic and hormonal changes aft er laparoscopic Roux-en-Y gastric bypass and sleeve gastrec-tomy: a randomized, prospective trial . Obes Surg 2012 ; 22 : 740 – 8 .

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18. Lin Y-S , Chen M-J , Shih S-C et al. Management of Helicobacter pylori infection aft er gastric surgery . World J Gastroenterol 2014 ; 20 : 5274 .

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20. Rawlins L , Rawlins MP , Brown CC et al. Eff ect of Helicobacter pylori on marginal ulcer and stomal stenosis aft er Roux-en-Y gastric bypass . Surg Obes Relat Dis 2013 ; 9 : 760 – 4 .

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esophagitis or persistent dysphagia due to a stenosed or twisted

sleeve, conversion to RYGB is a successful option. For patients

who lose inadequate weight or develop weight regain following

sleeve gastrectomy, conversion to RYGB or duodenal switch (i.e.,

sleeve with distal small bowel anastomosis) is a viable option.

VERTICAL BANDED GASTROPLASTY

Vertical banded gastroplasty (VBG) is a purely restrictive proce-

dure that involves the creation of a small proximal gastric pouch

<50 ml lined by a vertical staple line and a tight prosthetic mesh

that is sutured to itself but not the stomach ( Figure 1d ). Th is sur-

gery has the benefi t of providing an outlet diameter that remains

constant.

Familiarity with the complications of this procedure is impor-

tant, despite the fact that VBG has largely been replaced by other

procedures. Staple line dehiscence can result in formation of a fi s-

tula to the fundus, oft en leading to weight gain. Th is type of fi stula

is found in as many as half of all patients on routine post-operative

endoscopy. Stomal stenosis can also occur and present as obstruc-

tive symptoms, and be managed by endoscopically by balloon

dilation, although results are oft en short-lived and revision may

be necessary. Band erosion is a late complication of VBG, and can

be removed via endoscopy if the band is silastic. Removal of mesh

bands is typically not feasible. All of these complications warrant

consideration for surgical revision.

Surgical management

Th is procedure is most commonly converted to a RYGB when

there is inadequate weight loss, as the proximal stomach has been

modifi ed into a pouch.

CONCLUSION

Obesity is one of the most signifi cant health problems worldwide.

Despite improvement in the performance of bariatric surgical

procedures, complications are not uncommon. It is our respon-

sibility as gastroenterologists to be familiar with these procedures

and complication management strategies. In addition, primary

endoscopic therapies for obesity are seeing broader use in the

United States. As obesity is one of the most challenging medical

and economic problems faced by our society, fellowship programs

should place a greater emphasis on the management of this con-

dition and procedure-related complications. Endoscopy is a less

invasive alternative to primary and revisional procedures, and

will have a signifi cant role in the care of these patients moving

forward.

CONFLICT OF INTEREST

Guarantor of the article: Christopher C. Th ompson, MD, MSc,

FACG, FASGE, AGAF.

Specifi c author contributions: Draft ing of the manuscript: Allison

R. Schulman; this author has approved the fi nal draft submitted.

editing of the manuscript: Christopher C. Th ompson; this author has

approved the fi nal draft submitted.



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GASTROENTEROLOGY ARTICLE OF THE WEEK December 14, 2017

Schulman AR, Thompson CC. Complications of bariatric surgery: What you can expect to see in your GI practice. Am J Gastroenterol 2017;112:1640‐1655. 1. True statements regarding sleeve gastrectomy include a. Remove most of the lesser curvature of the stomach b. Removal of ghrelin‐producing cells contribute to the weight loss c. Gastric emptying is delayed, contributing to early satiety and lower intake d. Sleeve gastrectomy has effects on the hind gut secretion of peptide YY and GLP‐1 True or False 2. Erosive esophagitis from acid reflux is a common complication after gastric banding procedure for weight loss 3. Dumping syndrome after bypass surgery usually occurs following ingestion of a high fat meal 4. Balloon dilation of a stenotic gastrojejunal anastomosis to a 18mm size is the mainstay of therapy for anastomotic stenosis 5. Abdominal wall cellulitis after gastric banding may be an indication of band erosion into the gastric lumen 6. A patient with severe dysphagia after lap band surgery should be managed by endoscopic balloon dilation to a diameter not larger than 12mm. 7. Swirled vessels at the root of the mesentery seen on CT are a highly specific sign for internal hernia after gastric bypass 8. Administering the PPI as an open capsule for patients with anastomotic ulceration significantly reduces the time to ulcer healing 9. Visible suture material should not be removed even if the surgery was done months prior to the EGD 10. Marginal ulceration associated with anastomotic stenosis will usually require surgical revision

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