Long-Term Complications of Bariatric Surgery

Educational Objectives

The goal of this program is to improve diagnosis and management of long-term complications associated with bariatric surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Cite common long-term complications associated with bariatric surgery procedures.
2. Manage common long-term complications of bariatric surgery.

Summary

Obesity treatment: involves lifestyle modifications, endoscopic therapies, and pharmacotherapy; surgery has generally been recommended for patients with a body mass index (BMI) ≥40 or ≥35 with comorbidities, but updated guidelines support bariatric surgery for patients with a BMI of ≥35 (with or without comorbidities) and a BMI of ≥30 with comorbidities; a BMI of ≥27.5 may be considered for Asian populations

Surgical procedures: adjustable gastric banding is infrequently performed (most current surgeries involving bands are removals with conversion to other procedures); sleeve gastrectomy is the most common procedure, accounting for 60% to 70% of cases; Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno–ileal (SADI) bypass (variation of the duodenal switch) are other options; SADI involves creating a sleeve gastrectomy, followed by an anastomosis from ≈300 cm proximal to the ileocecal valve to the first portion of the duodenum; this omits the risk for marginal ulcers and yields a total weight loss of ≈40%; postoperative care recommendations — patients who have undergone malabsorptive procedures (eg, SADI, duodenal switch) need higher levels of vitamins A, D, E, and K, as well as additional calcium and iron; close follow-up is needed during the first year after the procedure and annually thereafter

Long-Term Complications

Weight recurrence: incidence is common; increase of ≈5% from the lowest postoperative weight is expected 2 to 10 yr after surgery, but anything more than that requires assessment; long-term rates of weight remission depend on the index procedure; malabsorptive procedures have better rates of remission (especially gastric bypass and duodenal switch) than purely restrictive procedures; ≤60% of patients experience some degree of weight recurrence after adjustable gastric banding; reasons — lifestyle, dietary choices, and exercise play a role; anatomic and psychosocial reasons occasionally contribute; workup — order an upper gastrointestinal series for sleeve gastrectomy, sleeve dilation, or gastrojejunostomy dilation after bypass; a fistula to the remnant stomach can cause weight recurrence; hiatal hernia can lead to maladaptive food choices and thus weight recurrence; treatment — dietary and behavior modification is the foundation; medically supervised weight loss, medications, and endoscopic or surgical revision may be considered

Endoscopic revision: transoral outlet reduction (ie, decrease in the size of the gastrojejunostomy) has shown promise in stabilization of weight or additional weight loss

Surgical options: include conversion to a malabsorptive procedure (RYGB or SADI) after sleeve gastrectomy; complication rates are low, especially with increased use of robots and laparoscopy; for patients with gastroesophageal reflux disease (GERD), conversion to bypass is preferred; patients with weight recurrence after gastric bypass may be eligible for limb distalization (increases the risk for protein-calorie malnutrition); ensure the common channel is ≥350 cm long

GERD and Barrett esophagus: the rates of de novo GERD and Barrett esophagus are ≤40% and ≤12%, respectively, after sleeve gastrectomy; causes — disruption of sling fibers or the lower esophageal sphincter affects gastric compliance; patients may have hiatal hernia, underlying motility abnormalities, or anatomic obstruction of the sleeve; recommended tests — include endoscopic evaluation, pH manometry, and an upper GI study; guidelines suggest routine screening endoscopy ≤3 yr after sleeve gastrectomy, even in the absence of GERD; management — conversion to RYGB may be considered for patients with a high BMI; for patients with a BMI <30, consider hiatal hernia repair, magnetic sphincter augmentation (eg, LINX), or advanced endoscopic procedures; multidisciplinary discussion is warranted

Abdominal pain: gallstones are a common cause; marginal ulcers and internal hernias are specific to patients with bypass and duodenal switch; symptomatic cholelithiasis requiring surgery — observed in 3% to 25% after surgery; ursodiol (Actigall) is used for ≈1 yr after surgery to decrease the risk for gallstone formation; assess using ultrasonography; in patients with RYGB, cholelithiasis can be challenging to treat because of the increased distance to the duodenum for endoscopic evaluation; laparoscopic cholecystectomy combined with a common bile duct exploration may be considered for patients who have a gallbladder; laparoscopy-assisted transgastric endoscopic retrograde cholangiopancreatography (ERCP) has fallen out of favor; lumen-apposing metal stents is now placed into the remnant stomach and used as access for ERCP

Marginal ulceration: occurs at the gastrojejunostomy and occurs in 5% to 12% of patients after gastric bypass; rates are higher after conversion from sleeve gastrectomy to gastric bypass (similar to retained antrum syndrome); ischemia of the anastomosis may occur with crossing staple lines, or the larger pouch may lead to increased acid production; perform endoscopic evaluation; treatment with open-capsule proton pump inhibitors (PPIs) leads to faster healing compared with closed-capsule PPIs; sucralfate (Carafate) and misoprostol are recommended if tolerated; refractory cases may require surgical revision of the anastomosis or remnant gastrectomy

Internal hernia: occurs in 1% to 5% of patients with RYGB or duodenal switch and causes abdominal pain and obstructive symptoms; patients with persistent obstructive symptoms and a negative computed tomography should undergo operative evaluation

Slippage, mechanical obstruction, and erosion after adjustable gastric banding: may cause obstructive symptoms and severe GERD; if the band is in the correct position but too tight, deflating the balloon in the office is first-line treatment; surgery is indicated if x-ray shows displacement; erosion can cause cellulitis at the port site or new-onset GERD; assess endoscopically

Readings

Abboud DM, Yao R, Rapaka B, et al. Endoscopic management of weight recurrence following bariatric surgery. Front Endocrinol. 2022 July 14; Volume 13. https://doi.org/10.3389/fendo.2022.946870; Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) indications for metabolic and bariatric surgery. Obes Surg. 2023 Jan;33(1):3-14; Gulinac M, Miteva DG, Peshevska-Sekulovska M, et al. Long-term effectiveness, outcomes and complications of bariatric surgery. World J Clin Cases. 2023 Jul 6;11(19):4504–4512; Meira MD, Oliveira FDESC, Coutinho LR, et al. Long-term evaluation of patients with BMI = 50kg/m2 who underwent bariatric surgery. Rev Col Bras Cir. 2023 Apr 28;50:e20233397.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Tatarian was recorded at the 41st Advances in Gastroenterology Conference, held on June 17, 2023, in Atlantic City, NJ, and presented by Sidney Kimmel Medical College at Thomas Jefferson University. For information on future CME activities from this presenter, please visit jefferson.cloud-cme.com. Audio Digest thanks the speakers and Sidney Kimmel Medical College at Thomas Jefferson University 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 0.50 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 0.50 CE contact hours.

Lecture ID:

GE380202

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.