Complications of Obesity Surgery

Section: UGI Sub-section: Bariatrics Curriculum: Curriculum, page 83

Slipped gastric band

• Present with obstructive symptoms
• 15% 1st 3 yrs, > 50% at 10 yrs
  • Typically at 2-3 yrs
• Usually anterior slippage
  • Posterior slippage rare
• Investigations
  • AXR to look at PHI angle
    • Posterior slippage
      • O-sign - gastric band being visible end on
    • Anterior slippage – band rotates clockwise
      • Recognised by loss of normal phi angle (10 - 60 degrees)
  • Contrast swallow
• Creates acute angle between oesophagus and stomach
  • Can lead to ischaemia of Fundus
• Management
  • Deflate band completely, may resolve symptoms
    • If works, then adequate acute rx, and send back to surgeon for further review
• May need removal of band
  • Or repositioning (by bariatric surgeon)

Eroded gastric band

• 1-7%
• Aetiology
  • Gastric wall ischaemia from tight band placement
  • Trauma/injury during band placement
• Presents with
  • Pain, nausea, vomiting +/- haematemesis
  • Failure of weight loss/Loss of restriction
  • Red port sign (infected port)
  • Usually seals itself so unusual to see free peritonitis
• Investigations
  • Diagnosed endoscopically
  • CT scan to look for leak/collection (rare)
• Management
  • Removal of band - Generally lap
    • Cut down over the capsule surrounding the band
    • There may be gastro-gastric stitches that need to be removed
    • Cut down onto buckle of band with diathermy
    • Divide band and then remove it
  • May need distal gastrotomy to access if phlegmon
  • Leave a drain
  • ALWAYS – Keep all pieces of the band on a mayo table and reassemble to be sure entire band is removed

Gastric band obstruction

• Dysphagia
• Can be
  • Slippage
  • Over inflation
  • Fibrotic foreign body reaction/oedema from surgery
• First step is to remove all of fluid from band
  • Pillow behind lower back
  • Lift head like sit-up
  • Brace with fingers and insert Huber needle
  • Huber needle is non-coring
• If can’t find, then use 25g fine bore
• NB: Can get pseudo-achalasia with the bands and resultant dysmotility

Post-op Leak

Bypsss

• JJ, GJ, Remant pouch, blind limb

Contained vs uncontained Stable vs unstable

Princples Source control Exclude distal obstruction Abx Nutrition Pyschosoical Treatment injury Communication with family and patient

Porto-mesenteric vein thrombosis

• 1% sleeve
• up to 1m after

Sleeve

• One staple line
• Definition
  • Deep/organ space surgical site infection
    • Infrequent but can be severe
• Is it
  • Localised vs Lateralised?
  • Early vs Persistent?
  • Stenosis involved?
• Key points
  • Stents (Megastent) very handy way of managing
    • But don’t over-rely or keep them in too long
  • Early and repeated use of endoscopy invaluable
    • Assessment, drainage, dilatation, stenting, feeding
  • Prevent external fistula by conservative use of external drainage
    • And removing any external drains early
  • Focus on
    • Drainage of cavity, then ablation of the cavity
    • Treatment of stenosis
    • Rapid discharge
  • Conversion of sleeve to RYGB is valid option for leak

Aetiology

• Crossed staple lines
• Anastomotic tension/ Ischaemia
• Stenosis
• Sleeve leaks more common than RYGB
  • High pressure organ with sphincters at both ends
    • At angle of HIS as this is the thinnest and most avascular part
• Most in first week, often after discharge
  • Can be weeks, months, years later
• Presentation - Sepsis, pain
• Investigations
  • CRP (if high be concerned)
  • Contrast swallow CT – 80-90% sensitivity
    • Free gas, fluid, +/- contrast extravasation
    • Abscess at top of sleeve = Leak until proven otherwise
    • Left pleural effusion may be sign of evolving leak
  • Fluoroscopy = 70% sensitivity

Classification

• Type 1
  • Phlegmon only
  • Oedema around staple line, maybe small amount of gas
• Type 2
  • Abscess (with or without contrast extravasation)
  • 2a Close to staple line
  • 2b Extends away from staple line
• Type 3
  • Generalised Peritonitis
  • Gas and fluid throughout abdomen
• Type 4
  • Chronic Fistula
  • 4a Close to staple line
  • 4b Distant

Management of bariatric

Early Leak (Type 1)

• Size of cavity, stenosis, and ileus are the main drivers
  • Appropriate resuscitation, antibiotics and nutrition
• Aim for rapid discharge (within 1-2 weeks)
• Avoid surgery if possible
  • Avoid resection if surgery done
• If patient does not progress, they are getting worse!
• Try something different
• Phlegmon
  • IV Abx, observation
  • Fasting until subjectively improved or CRP falling
    • Then high protein fluids
  • Low threshold for OGD within first 24hrs

Type 2a - Medial Abscess

• Endoscopy and internal drainage (better if available)
  • Suitable for sleeve, total gastrectomy, staple-line leak in RYGB
  • Avoids fistula formation
  • Allows endoscopic reassessment of defect
  • Can place NJ feeding tube past it
  • Aim for PO fluids day 1, and early discharge
• External Drainage if not available
  • Laparoscopy and drainage, or CT guided drainage
  • But will create external fistula unless drain removed early

Type 2b - Lateral Acute Abscess

• Usually more complex and unwell
• May have ileus +/- stenosis driving increased intraluminal pressure and increased leak volume
• Patients need rapid sepsis control and drainage
  • Laparoscopy, external drainage, and stent (esp. RYGB)
    • NB: Laparoscopy will convert small abscess to large abscess
    • Stents very good at preventing fistulas but not as good at treating them
      • So place stent early!
  • Consider endosponge
• Remove stents or endosponges after 2/52 and convert to internal drains
• Usually need TPN

Type 3 - Generalised Peritonitis

• Laparoscopy, lavage, and drain
• On table endoscopy and stent
  • Place stent from 4cm above GOJ
    • If sleeve, go to pre-or post-pyloric distally
    • If RYGB, go across anastomosis
  • Lap suture stent to stomach/small bowel to prevent migration
• TPN for Sleeve, Free fluids for bypass
• Remove stent in 1-3 weeks once clinically well and ileus settled
  • Remove external drain BEFORE stent if possible to avoid external fistula
• If not improving at the end of the first week with stent in-situ
  • Consider converting Sleeve to RYGB
  • Leak in a RYGB will heal with a drain better than sleeve
  • Can just anastomose below the leak level
    • Ensure anastomosis wide to prevent pressure on upstream leak

Stent Problems

• Poorly tolerated
• If occludes due to impaction
  • Will then fill with fluid
  • Which will then leak around stent and into abscess cavity
• Stent straightening can lead to impaction/erosion
  • Occurs in most stents over time
  • Erosion can occur
    • Remove by 6 weeks
• Consider segmental stent

Type 4 – Chronic Fistulas

• Usually associated with
  • Lateralisation of sepsis
  • Prolonged unsuccessful therapy
    • Where there is a failure to consider alternative management
  • Stenosis
    • Causes preferential drainage into the cavity
• Bacteria change from expressing virulence, to persistence factors
  • Biofilm, antibiotic resistance etc.
• Needs referral to specialist centres
  • Internal drainage and pneumatic dilatation (30-40mm)
  • Usually on fluid diets
• Outpatient management commonly

Post-Operative Bleed

• 0.4-4%
• Sites
  • Staple line (Sleeve Gastrectomy, DS)
  • Anastomosis (RYGB, DS)
  • Intra-luminal or extra-luminal
  • Vascular
    • Gastric or Short Gastric vessels
  • Mesentry
  • Omentum
• Management
  • 2 x IVL, resus/transfuse, Correct coags
  • Conservative (PPI) vs. Operative
• Late bleeds
  • Cause: Usually ulcers

Stenosis

• Main cause of on-going leak problems
  • Causes increased pressure
  • Assume all persisting fistulae/abscesses have at least a functional stenosis
  • Endoscopy specific but very insensitive
  • Even if scope through, doesn’t mean no stenosis
  • Can dilate balloon to 20mm and pass through stomach
• 30mm dilatation safe after 2 weeks in sleeve
  • After 6 weeks in bypass
  • Therapeutic and diagnostic procedure
• 3D CT can help (FIZZ scan)

Stricture

• 6-20%
• Aetiology
  • Tissue ischaemia
  • Marginal ulceration
  • GJ anastomosis tension
• Symptoms usually if < 10mm
  • Several weeks post-op
  • Nausea, vomiting, dysphagia, GORD
  • Inability of oral intake (even liquids)
  • Can potentiate leaks
• Most commonly at GOJ and angularis
• Endoscopic diagnosis and initial management
  • Dilatation 3-4mm at a time, aim 15mm
  • Anything > 20mm will decrease restrictive effect of operation
• If refractory – surgical revision of GJ, or convert a Sleeve to RYGB

Roux-En-O Configuration

• BP limb accidentally anastomosed onto the gastric pouch
• Requires re-do surgery

Candy Cane Roux Syndrome

• Excessively long blind afferent Roux limb at the gastrojejunostomy
  • Causes post-prandial pain
  • Often relieved by vomiting
• Blind afferent limb acts as an obstructed loop when filled with food (often preferentially)
  • Distention of the loop causes pain until the food either spills into the Roux limb or is vomited back out
• Diagnosis is confirmed by:
  • Contrast studies
    • Afferent limb fills before contrast spills into the Roux limb
  • Endoscopy
    • Afferent limb is usually the most direct outlet of the gastrojejunostomy
• Management is revision bariatric surgery
  • Laparoscopic resection of the afferent limb
• Symptoms resolve after revision surgery in most

Internal Hernia

• Occurs in 2% (usually months/years later)
  • Massive weight loss creates long floppy mesentery with loose ligaments
• Presentation non-specific
  • Suspect in any bypass with vomiting or abdominal pain
• Investigations
  • CT scan (70-80% sensitive), signs can be subtle and difficult to diagnose
    • Needs to go to OT if evidence of SBO on CT
    • Mesenteric swirl sign, retroperitoneal stranding
    • Increased volume of bowel in LUQ
    • Closed-loop internal hernia
  • Diagnostic laparoscopy
• Occurs in 3 locations:
  • Petersen’s Space (Transverse Colon and Roux limb mesentery)
  • Mesenteric defect behind the jej-jej anastomosis
  • Mesocolic space (if retrocolic)

Mesenteric defects: A) transverse mesocolic; B) Petersen’s space; and C) jejunojejunostomy mesentery

• Needs to go to OT as can decompress biliary limb AND increased risk of vascular compromise
• Risk lower in laparoscopic cases and if mesenteric defects closed
  • But can never prevent 100% risks

Gastric Remnant Distension (BP Limb Obstruction)

• Aetiology
  • Ileus
  • Mechanical obstruction
  • Iatrogenic vagal injury causing decreased gastric emptying
• Gastric remnant distends and becomes necrotic
• Pt becomes hypovolaemic
• Stomach ruptures
• Massive fluid loss as well as massive 3rd spacing will cause sudden cardiac arrest
• Management
  • Needs urgent decompression
  • Surgical or percutaneous gastrostomy

Alimentary Limb Obstruction

• Occurs in situations like over-closure of mesenteric defects
• Causes food build up at gastro-jej, in pouch, and oesophagus
• Manage by NG decompression
• Not as severe as BP limb obstruction

Gastro-Gastric Fistula

• Rare complication of RYGB
• Can lead to
  • Weight regain
  • Marginal ulceration
• Aetiology
  • Anastomotic leak
  • Incomplete gastric division
  • Marginal ulcers
  • Distal obstruction
  • Erosion of foreign body
• Endoscopy is diagnostic but therapeutic efficacy is very low
• Can also use PO contrast CT
• Surgery, incl. remnant gastrectomy, is the definitive treatment
  • Treatment results in resolution of symptoms and improved weight loss

Marginal Ulcer

• 2-10%
• Incidence can be reduced by pre-op treatment for H. pylori
• Aetiology
• H. pylori, Smoking, NSAIDs, EtOH
• Also consider
• Poor tissue perfusion/tension
• Foreign body
• Gastro-gastric fistula
• Presentation
• Usually constant boring epigastric pain
• Nausea, GI bleed, stricture, perforation
• Usually settle with medical treatment
• Manage with high dose PPI and re-endoscopy
• Eradicate H. pylori
• Persistent ulcers may require surgical revision
• Resect ulcer/fistula and revise gastro-jej anastomosis
• Consider other causes (Gastrin levels etc.) if recurs after this
• May need reversal or gastric remnant resection

Gallstones

• Expected complication of weight loss
• 10% have symptomatic stones at 1 yr
• Can mitigate with the use of ursodeoxycholic acid
• Ursodiol 300mg po BD
• Drops risk to 2%
• But expensive
• If choledocholithiasis:
• Lap/open CBDE
• Lap/open assisted ERCP
• Enteroscopy assisted ERCP

Dumping Syndrome

• Recommend small frequent meals
• Low CHO intake
• Octreotide can help if dietary modification fails

Early Dumping Syndrome

• Occurs within 20-30mins after meal
• More common than late dumping
• More GI and less cardiovascular effects

Late Dumping Syndrome

Reflux Post Sleeve

• 20% have GORD at 5 years
  • Barrett’s 10% at 10 yrs
• 2.5-5% require surgery for reflux at 5 years
• Options
  • First line is anti-reflux medical therapy
  • Hiatus hernia repair (with falciform sling) if hernia present and no weight regain
  • Rule out and treat strictures
  • RYGB if weight regain, no HH, or failure of above

Gastric volvulus

• Due to loss of fixation along greater curvature
• Symptoms
  • Borchardt’s triad
    • Epigastric pain
    • Retching
    • Inability to pass NGT
• Management
  • Reduce
  • Operative fixation to omentum

Portal Vein Thrombosis

• Rare
• Present with pain
• Often missed on CT, need to specifically look for this
• Easily treated, but major if missed