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gi complications of gastric bypass

GI Complications ofGastric Bypass

Caroline R. Tadros, MD

May 15th 2013

  • 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
Bariatric Procedures
  • Lap band


  • Sleeve Gastrectomy

medical complications of roux en y
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 y1
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
Mechanical Complications
  • Gastric Remnant Distention
  • Stomal Stenosis
  • Marginal Ulcers
  • Ulcers in excluded stomach
  • Cholelithiasis/Choledocholithiasis
  • Fistulas
    • Gastro-gastric
    • Gastro-intestinal
gastric remnant distention
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 distention1
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
Stomal Stenosis
  • Etiology11
    • Tissue ischemia
    • Increased tension on the gastro-jejunalanastamosis
  • Presentation
    • Several weeks postop
    • Nausea, vomiting, dysphagia, decreased oral intake, weight loss
stomal stenosis cont d
Stomal Stenosis ( cont’d )
  • Diagnosis
    • EGD
    • Upper GI series
  • Treatment12,13,14
    • Endoscopic balloon dilation (perforation rate 3%)
    • Surgical revision (<0.05%)
marginal ulcers
Marginal Ulcers
  • Etiology 15,16
    • Poor tissue perfusion due to tension or ischemia at the anastomosis
    • Presence of foreign material, such as staples or non-absorbable suture
    • Excess acid exposure in the gastric pouch due to gastro-gastric fistulas
    • Non-steroidal anti-inflammatory drug use
marginal ulcers1
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 ulcers 13
Treatment of Marginal Ulcers13
  • Gastric acid suppression
  • Sucralfate
  • Discontinuation of NSAIDS
  • Smoking cessation
  • H. pylori therapy
  • Calcium channel blockers
  • Endoscopy/ IR embolization
  • Surgery (gastro-jejunostomy revision with truncalvagotomy)
ulcers within the excluded stomach
Ulcers Within the Excluded Stomach
  • Endoscopy is limited due to the post surgical anatomy
  • Pancreatitis
  • If suspected operative management/intraoperative endoscopy25
  • 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
  • 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
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 hernias1
Internal Hernias
  • Three potential areas of internal herniation31,15
    • Mesenteric defect at the jejuno-jejunostomy
    • The space between the transverse mesocolon and Roux-limb mesentery (Peterson's hernias)
    • The defect in the transverse mesocolon if the Roux-limb is passed retrocolic
internal hernias cont d
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
Mesenteric Swirl Sign

Rev. Col. Bras. Cir. vol.39 no.3 Rio de Janeiro May/June 2012

persistent obesity
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
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
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
Excessive Weight Loss
  • Bacterial Overgrowth
  • Gastro-intestinal fistula
  • 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 SocNephrol. 2008;3(6):1676.
  • Hyperinsulinemichypoglycemia 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.
  • 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.
  • Bowel habits after bariatric surgery. Potoczna N, Harfmann S, Steffen R, Briggs R, Bieri N, Horber FF Obes Surg. 2008;18(10):1287.
  • Dumping syndrome: pathophysiology and treatment. Ukleja A NutrClinPract. 2005;20(5):517.
  • Change in effective circulating volume during experimental dumping syndrome. MATHEWS DH, LAWRENCE W Jr, POPPELL JW, VANAMEE P, RANDALL HT Surgery. 1960;48:185.
  • 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.
  • 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.
  • Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan RJ, Landreneau RJ, GagnéDJObes Surg. 2003;13(5):797.
  • Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan RJ, Landreneau RJ, GagnéDJObes Surg. 2003;13(5):797.
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  • Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Gumbs AA, Duffy AJ, Bell RL SurgObesRelat Dis. 2006;2(4):460.
  • Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Sapala JA, Wood MH, Sapala MA, Flake TM JrObes Surg. 1998;8(5):505.
  • Ulcer disease after gastric bypass surgery.Dallal RM, Bailey LA SurgObesRelat Dis. 2006;2(4):455.
  • Strictures following gastric stapling for morbid obesity. Results of endoscopic dilatation. Sataloff DM, Lieber CP, Seinige Am Surg. 1990;56(3):167.
  • Changes in gallbladder bile composition following gallstone formation and weight reduction. Shiffman ML, Sugerman HJ, Kellum JM, Moore EW Gastroenterology. 1992;103(1):214.
  • Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Fuller W, Ali MR SurgEndosc. 2007;21(7):1090.
  • 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.
  • 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.
  • 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.
  • Bleeding Duodenal Ulcer After Roux-en-Y Gastric Bypass SurgeryMarc 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
  • 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.
  • 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.
  • Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Baron TH, Vickers SM GastrointestEndosc. 1998;48(6):640.
  • ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Wright BE, Cass OW, Freeman ML GastrointestEndosc. 2002;56(2):225.
  • Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Champion JK, Williams M Obes Surg. 2003;13(4):596.
  • 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.
  • 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 ClinRadiol. 2009;64(4):373.
  • 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.
  • 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.
  • Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Capella JF, Capella RF Obes Surg. 1999;9(1):22.
  • 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, Rosenthal R SurgObesRelat Dis. 2005;1(5):467.
  • Stomalulcer after gastric bypass.MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP J Am Coll Surg. 1997;185(1):1.
  • Treatment of dilated gastrojejunostomy with sclerotherapy. Spaulding L Obes Surg. 2003;13(2):254.
  • Peroralendoscopic 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 SurgEndosc. 2006;20(11):1744.