Complications in Metabolic and Bariatric Surgery, Part 1

Educational Objectives

The goal of this program is to improve the management of common complications of metabolic and bariatric surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize the complications of metabolic and bariatric surgeries.
2. Manage bleeding ulcers.
3. Compare the risk for complications associated with sleeve gastrectomy, gastric bypass, duodenal switch, single anastomosis duodenoileostomy with sleeve, and one anastomosis gastric bypass.

Summary

Sleeve gastrectomy (SG): 70% to 80% of the stomach is resected, increasing the rate of emptying into the small intestine; the part of the stomach that generates ghrelin (the appetite hormone) is removed; patients feel fullness with smaller amounts of food and have metabolic improvement with the change in emptying; 25% to 30% total weight loss is expected with SG

Complications of SG: dehydration — most common; perform imaging to rule out serious complications; vitamin and mineral deficiencies — any patient who has bariatric surgery should be given thiamine; appropriate supplementation is essential; staple-line bleeds — usually occur in the first 24 to 48 hr; may require transfusions but are often self-limited; drain hematomas that compress the stomach; consider antibiotics if there is concern for contamination; sleeve leak — can happen anywhere along the staple line; management depends on size and location of the leak and the patient’s condition; ideally, transfer the patient to the primary surgeon; if transfer is not feasible, consider washout and placing drains; for significant fluid collection, consult with interventional radiology for drainage; consider antibiotics; provide durable nutrition; consider a nasojejunal feeding tube, nasoduodenal feeding tube, or total parenteral nutrition; most leaks occur at the proximal third of the staple line; chronic leak management includes endoluminal vac therapy, double-pigtail stents placed into the cavity to drain fluids (preferred), endoscopic stents, and operative revision; using stents for leak management is off-label; sleeve stenosis — can occur if the staple line is too close to the lesser curve; consider balloon dilation or operative revision; sleeve spiraling — a form of helical stenosis; occurs when equal anterior and posterior parts of the stomach are not taken while stapling; can be viewed through endoscopy; treatment includes dilation or revision surgery

Gastric bypass (GB): procedure — commonly performed laparoscopically or robotically; the goal is to create a 30-mL pouch and bypass to the distal jejunum and proximal ileum; it increases emptying into the small intestine and achieves local hormonal release by the rapid transit of nutrients to affect insulin sensitivity and other metabolic parameters; create an anastomosis between the pouch and the small intestine (20-30 mm in size); the main perfusion of the pouch is from the left gastric artery; tension on the anastomosis and artery damage during dissection can cause ischemia of the connection, leading to ulcers that bleed or connections that leak

Ulcers: more common in patients who smoke or are on steroids and nonsteroidal anti-inflammatory drugs (NSAIDs); can occur from technical issues; for treatment, ensure that the inciting stimulus is eliminated and the patient has adequate nutrition, and reduce further acid exposure; presentation — pain often worsens with meals, and is constant, severe, and stabbing in the epigastrium; patients can have episodes of hematemesis or melena, and sentinel bleeding; perforations can cause tachycardia, fever, and peritonitis; diagnosed on esophagogastroduodenoscopy (EGD); treatment — includes removing the inciting source, twice-daily proton pump inhibitor (PPI) therapy, and sucralfate (Carafate) 4 times per day; misoprostol can be used to treat NSAID-induced ulcers; in addition to thiamine administration, obtain vitamin panel for additional supplementation

Treatment of bleeding ulcers: stable patients — hold anticoagulation, start PPI, and assess bleeding with EGD; endoscopic modalities include clipping the ulcer, applying heat, spraying chemical coagulation agents, and injecting epinephrine; obtain serial hemoglobin; unstable patients — resuscitate in the intensive care unit and perform emergent EGD or operative intervention; embolization of the left gastric artery is not recommended as it makes revisions significantly harder and can induce further ischemia

Perforated ulcers: typically diagnosed on dual-contrast computed tomography (CT); consider early diagnostic laparoscopy; washout can improve pain and speed up recovery; perforated ulcers can cause substantial pain and tachycardia; to locate perforation, check the omentum and check for fibrinous tissue that tends to form around areas of perforation, or use endoscopy; perforations can also be in the remnant or located posteriorly; a modified Graham patch can be used to close the hole and cover with omentum; use resorbable suture and perform endoscopy; irrigate generously; check for internal hernia defects; for a perforated remnant or duodenum, leave a gastrostomy tube (G-tube) to facilitate a contrast study to ensure there is no leak, reduce edema, and keep the pathway open to drain appropriately; a G-tube also provides access for therapy in patients with malignancy; remove the G-tube at 4 to 6 wk; perform endoscopy at 3 mo to ensure that the ulcer has healed and perform biopsy (if required)

Chronic ulcers (CU): can progress to nutritional deficiencies and other complications, eg, strictures; typically occur from smoking; provide nicotine replacement therapy to help patients quit smoking; avoid NSAIDs and steroids; put patients on PPI if NSAIDs or steroids are required; consider patient compliance with recommendations and medications; check whether the patient is receiving appropriate nutrition to support healing; ulcers can persist if there are foreign bodies causing chronic inflammation and irritation; treatment options include surgical revision, denervating procedures (vagotomy), and reversing the bypass; revisions are complicated and have higher rates of leaks and infections because of disrupted blood supply; consider endoscopic options; in a study by Bonanno et al (2019), there were substantial rates of complications and ulcer recurrence after vagotomy; a study by Hunter et al (2012) reported lower ulcer recurrence but significant symptoms in patients after truncal vagotomy; stricture — can occur after a CU heals; can cause nausea, vomiting, food intolerance, and pain; treatment includes endoscopic balloon dilatation (EBD); after 3 EBD, consider assessment for revision

Duodenal switch (DS): recommended for patients with weight regain after SG; the goal for the common channel should be 150 to 300 cm; as body mass index (BMI) increases, the common channel should get shorter for more malabsorption and weight loss; complications — DS can cause leaks, bleeds, ulcers (less common), strictures, and malabsorption; patients require protein replacement and vitamin supplementation postoperatively; small intestine bacterial overgrowth (SIBO) can occur and requires testing and antibiotic therapy; internal hernia can occur

Single anastomosis duodenoileostomy with sleeve gastrectomy (SADIS): advantages — involves SG with single anastomosis of the duodenum to the distal ileum; it has greater reported weight loss than SG and is technically easier; there is less perceived risk for vitamin and mineral deficiencies and protein malabsorption than a full switch; complications — include leaks, bleeding from the staple lines or areas of dissection, strictures or stenosis, internal hernia (less common), malabsorption, SIBO, and bile reflux (the main concern of the operation)

One anastomosis gastric bypass (OAGB): also known as omega loop gastric bypass; it is a sleeve with loop anastomosis and a long pouch (16-18 cm long); provides comparable weight loss to Roux-en-Y gastric bypass; there is a higher risk for iron and fat-soluble vitamin deficiencies compared with SG; technically easier to perform; an option for patients with significant gastroesophageal reflux disease; complications — include ulcers (because of the long pouch), bleeds, perforations, leaks, strictures, bile reflux (may need conversion to standard GB), internal hernia, and vitamin and mineral deficiencies

Readings

Bonanno A, Tieu B, Dewey E, et al. Thoracoscopic truncal vagotomy versus surgical revision of the gastrojejunal anastomosis for recalcitrant marginal ulcers. Surg Endosc. 2019;33(2):607-611. doi:10.1007/s00464-018-6386-7; De Luca M, Piatto G, Merola G, et al. IFSO update position statement on One Anastomosis Gastric Bypass (OAGB). Obes Surg. 2021;31(7):3251-3278. doi:10.1007/s11695-021-05413-x; Giannopoulos S, Pokala B, Stefanidis D. Management of gastrointestinal bleeding following bariatric surgery. Mini-invasive Surgery. 2022; 6:22. http://dx.doi.org/10.20517/2574-1225.2021.135; Hunter J, Stahl RD, Kakade M, et al. Effectiveness of thoracoscopic truncal vagotomy in the treatment of marginal ulcers after laparoscopic Roux-en-Y gastric bypass. Am Surg. 2012;78(6):663-668. doi:10.1177/000313481207800619; Kessler Y, Adelson D, Mardy-Tilbor L, et al. Nutritional status following One Anastomosis Gastric Bypass. Clinical Nutrition. 2020;39(2):599-605. doi:https://doi.org/10.1016/j.clnu.2019.03.008; Moon RC, Alkhairi L, Wier AJ, et al. Conversions of Roux-en-Y gastric bypass to duodenal switch (SADI-S and BPD-DS) for weight regain. Surgical Endoscopy. 2019;34(10):4422-4428. doi:https://doi.org/10.1007/s00464-019-07219-6; Seeras K, Sankararaman S, Lopez PP. Sleeve gastrectomy. StatPearls Publishing. 2022 May 1. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519035/; Shoar S, Poliakin L, Rubenstein R, et al. Single Anastomosis Duodeno-Ileal Switch (SADIS): A systematic review of efficacy and safety. Obes Surg. 2018 Jan;28(1):104-113. Doi: 10.1007/s11695-017-2838-8.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Landin’s lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Landin was recorded at the 51st Annual Phoenix Surgical Symposium, held on February 2-4, 2023, in Scottsdale, AZ, and presented by the Phoenix Surgical Society. For information on upcoming CME activities from this presenter, please visit http://www.phoenixsurgicalsociety.com. Audio Digest thanks Dr. Landin and the Phoenix Surgical Society for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

GS700801

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.