Complications in Metabolic and Bariatric Surgery, Part 2

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. Detect internal hernias based on presenting symptoms and radiologic findings.
2. Identify specific complications that can occur after laparoscopic gastric banding.

Summary

Internal hernias (IH): diagnosis — IH is one of the main complications of gastric bypass (GB) and duodenal switch (DS); an IH is defined as the protrusion of the abdominal viscera, most commonly small bowel loops, through a peritoneal or mesenteric aperture into a compartment in the abdominal or pelvic cavity; IH can lead to acute intestinal obstruction and strangulation or ischemia of the bowel; symptoms include pain, nausea, and vomiting; radiographic signs include mesenteric swirl (most predictive sign), hurricane eyes, and the mushroom sign; other signs include clustered bowel loops, small bowel loops behind the superior mesenteric artery other than the duodenum, and presence of the jejunojejunostomy (JJ) on the right side of the abdomen; treatment — acute symptomatic IH are surgical emergencies; if the alimentary limb is significantly dilated on computed tomography (CT), place a nasogastric tube (NG-tube) before surgery as patients may regurgitate or vomit, which could cause aspiration and pulmonary injury; IH can be managed in a minimally invasive fashion or with open surgery; start at the terminal ileum and run the bowel retrograde to reduce the IH; check the JJ and every other limb to ensure there are no other areas of obstruction or stricture; identify the mesenteric spaces and close with permanent suture (monofilaments are preferred to avoid infectious nidus); indocyanine green (ICG) can be used as an adjunct for intraoperative management of mesenteric ischemia, IH, and adhesive bowel disease (Joosten et al [2022]); ICG helps avoid potential malabsorption by facilitating a lesser resection

JJ revision: identify and mark the Roux limb, common channel, and biliopancreatic limb; ensure that the Roux limb is not too short; if the Roux limb is short (50-75 cm) in a JJ revision, there is a possibility of bile reflux into the pouch, and the patient may develop new symptoms; keep the common channel as long as possible to prevent vitamin and mineral deficiencies and malabsorption; consider leaving a decompressive G-tube (can be helpful in patients who have an ileus or failure to thrive, and in performing contrast studies to check for leaks)

Intussusception: JJ can cause intussusception; typically presents with nausea, vomiting, and abdominal pain; symptoms are usually transient but chronic; target sign can be seen on CT; treatment involves reduction and plication of the JJ or resection; in the emergency department, perform an upper gastrointestinal (GI) series with small bowel follow-through; if contrast passes beyond the level of intussusception (no obstruction), no treatment is required in patients who can tolerate food and are otherwise fine

Chronic abdominal pain (CAP) after metabolic and bariatric surgery (MBS): maladaptive eating — the most common reason for CAP; can result in dumping syndrome; dumping occurs as hyperosmolar food arrives in the intestine; early dumping (≤30 min after a meal) occurs because of fluid shifting and causes abdominal pain, nausea, vomiting, and diarrhea; late dumping (1-3 hr after eating) is caused by postprandial hyperinsulinemic hypoglycemia from the carbohydrate load in the ingested meal; administering oral glucose for hypoglycemia postoperatively can cause a constellation of symptoms; use intravenous (IV) 50% dextrose instead; food and nutrition — patients should avoid simple carbohydrates and add proteins to their meals; hygroscopic food (eg, rice, bread, pasta) and fibrous foods can become impacted in the anastomosis; gluten allergies, lactose intolerances, iron and B₁₂ deficiencies, and small-intestine bacterial overgrowth (SIBO) can cause CAP; functional disorders — include constipation, dehydration, irritable bowel syndrome, gastroparesis, and esophageal dysmotility (ED); consider surgery for gastroparesis and ED; if per-oral pyloromyotomy, pyloroplasty, and gastric pacers fail, consider drainage procedures; sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB) can also be performed with consideration of resecting the remnant stomach; other causes — include biliary disease (associated with rapid weight loss), ulcer disease, gastroesophageal reflux disease (GERD), strictures, incisional hernias, chronic internal hernias, stenosis of the JJ, and cancer

Diagnostics: imaging is recommended for CAP diagnosis; negative imaging does not rule out the various causes; obtain a full vitamin panel; consider diagnostic laparoscopy (DL); if DL is negative, perform a push enteroscopy to assess remnant stomach

Vitamin and mineral deficiencies: anemia — GB exacerbates anemia; postoperative supplementation is important; decreased intrinsic factors and absorption of micro and macronutrients, iron deficiency, vitamin B₁₂ deficiency, and folate deficiency can cause anemia; thiamine deficiency — administer thiamine in all patients who have undergone MBS, including those with SIBO; severe vitamin B₁ deficiency can cause beriberi; wet beriberi causes cardiac failure; dry beriberi causes neurologic complications; vitamin D deficiency — can be exacerbated after surgery; order a dual-energy x-ray absorptiometry scan if the patient meets criteria for fracture risk caused by osteoporosis; supplement calcium to prevent calcium deficiency; other deficiencies — monitor fat-soluble vitamins (eg, vitamins A, K, E); vitamin A deficiency presents as vision changes; vitamin E helps from a cardiometabolic standpoint; vitamin K is involved in the coagulation cascade and bone metabolism; selenium is important for thyroid hormone production; zinc deficiency can present with growth impairment, sexual dysfunction, inflammation, GI symptoms, and cutaneous symptoms; recommendations — it is important to take bariatric multivitamins with iron and calcium citrate; if patients do not tolerate those, try patches and liquid vitamins, although absorption is poorer than oral supplements; more frequent laboratory assessments are recommended in patients on alternate modalities

Laparoscopic gastric banding: GERD and dysphagia — band de-filling, removing, or repositioning can help improve symptoms; band slippage — managed in the emergency department by removing fluid from the band to improve pain using a Huber needle; if the patient improves, perform interval band removal; if symptoms persist after de-fill, perform band removal; erosion — a chronic issue that causes port site erythema, induration, and pain; de-fill and remove the band

Band adjustment: obtain pre-adjustment imaging to confirm the band location; perform a physical examination to palpate the port, usually in the left upper quadrant overlying the rectus muscle or below the largest incision; use a Huber needle to adjust the amount of saline in the band; if the silicone center of the port is difficult to access, the port may have flipped; perform an ultrasound-guided port adjustment; consider removal if there is no access; a band phi angle of 0° to 60° is acceptable

Band removal: the speaker prefers removal of the port first; make an incision and retract the port (cut the fascial stitches); mobilize the port and cut the tubing at an angle, preferable over an arrow; do not enter the abdomen at the site where the port was placed; cautery should be performed only over the band itself; unbuckle or cut the mobilized band; use endoscopy to check for dissection injuries, signs of erosion, and narrowness of the tract of the band; if the capsule is not too tight, the likelihood of dysphagia is very low; if the tract is very tight, consider cutting the capsule to release tension

Band erosion: discoloration of the band is indicative of erosion; the band can be removed endoscopically, depending on degree of erosion; a band cutter or lithotripter can be used; ensure complete removal of the band and the connector tubing

History of RYGB and choledocholithiasis: minimally invasive treatment options are available; 15-mm balloon trocars can be used to perform laparoscopy-assisted endoscopic retrograde cholangiopancreatography for direct access to the stomach to remove the stones

Perioperative management of anti-obesity medication: hold phentermine 1 wk before surgery as it can cause hypotension unresponsive to vasopressors; abrupt withdrawal of topiramate can induce seizures; continue or taper topiramate throughout the perioperative process; hold semaglutide or any glucagon-like peptide-1 agonist 1 wk before surgery; hold gliflozins for 3 days; hold metformin and glipizide on day of surgery

Readings

Bahardoust M, Eghbali F, Shahmiri SS, et al. B1 Vitamin deficiency after bariatric surgery, prevalence, and symptoms: a systematic review and meta-analysis. Obesity Surgery. 2022;32(9):3104-3112. doi:https://doi.org/10.1007/s11695-022-06178-7; Joosten JJ, Longchamp G, Khan MF, et al. The use of fluorescence angiography to assess bowel viability in the acute setting: an international, multi-centre case series. Surgical Endoscopy. 2022;36(10):7369-7375. doi:https://doi.org/10.1007/s00464-022-09136-7; Lanzetta MM, Masserelli A, Addeo G, et al. Internal hernias: a difficult diagnostic challenge. Review of CT signs and clinical findings. Acta Biomed. 2019;90(5-S):20-37. Published 2019 Apr 24. doi:10.23750/abm.v90i5-S.8344; Malik S, Mitchell JE, Steffen K, et al. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract. 2016;10(1):1-14. doi:10.1016/j.orcp.2015.07.003; Sheehan A, Patti ME. Hypoglycemia after upper gastrointestinal surgery: clinical approach to assessment, diagnosis, and treatment. Diabetes Metab Syndr Obes. 2020;13:4469-4482. Published 2020 Nov 19. doi:10.2147/DMSO.S233078; Strong AT, Guerrón AD. Revisional bariatric surgery for chronic complications necessitates custom surgical solutions. Mini-invasive Surgery. 2022; 6:37. http://dx.doi.org/10.20517/2574-1225.2021.137; Varbanova M, Maggard B, Lenhardt R. Preoperative preparation and premedication of bariatric surgical patient. Saudi J Anaesth. 2022;16(3):287-298. doi:10.4103/sja.sja_140_22; Wilson RB. Pathophysiology, prevention, and treatment of beriberi after gastric surgery. Nutr Rev. 2020;78(12):1015-1029. doi:10.1093/nutrit/nuaa004

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:

GS700802

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.