Complications of bariatric surgery A.R. khalaj M.D. Minimal
Invasive Surgery Research Center university of Iran
Slide 3
MORTALITY Overall mortality was estimated to be less than 1
percent Meta-analysis: surgical treatment of obesity. AU - Maggard
MA; Shugarman LR; Suttorp M; Maglione M; Sugarman HJ; Livingston
EH; Nguyen NT; Li Z; Mojica WA; Hilton L; Rhodes S; Morton SC;
Shekelle PG SO - Ann Intern Med 2005 Apr 5;142(7):547-59 increasing
mortality was associated with advancing age, male sex, and lower
surgeon volume of bariatric procedures Surgical volume impacts
bariatric surgery mortality: a case for centers of excellence. AU -
Hollenbeak CS; Rogers AM; Barrus B; Wadiwala I; Cooney RN SO -
Surgery. 2008 Nov;144(5):736-43. Epub 2008 Jul 21
Slide 4
MORTALITY The introduction of laparoscopic RYGB has been
associated with a significant reduction in perioperative mortality.
0.17 percent as compared to 0.79 for open RYGB 30-day morbidity and
mortality of bariatric surgical procedures as assessed by
prospective, multi-center, risk-adjusted ACS-NSQIP data. AU -
Lancaster RT; Hutter MM SO - Surg Endosc. 2008 Dec;22(12):2554-63.
Epub 2008 Sep 20.
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REHOSPITALIZATION RATES the rates of unexpected reoperations
ranged from 6 to 9 percent AU - Santry HP; Gillen DL; Lauderdale DS
SO - JAMA 2005 Oct 19;294(15):1909-17. 20, 18, and 15 percent of
patients required readmission at one, two, and three years,
respectively SO - JAMA 2005 Oct 19;294(15):1918-24. hospitalization
in the year prior to surgery of approximately 8 percent.
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COMPLICATIONS OF MALABSORPTIVE PROCEDURES Jejunoileal bypass
JIB resulted in high rates of diarrhea, arthritis, hepatic failure,
cirrhosis, nephrolithiasis, protein malnutritio and vitamin
deficiencies - Am J Med 1978 Mar;64(3):461- 75.n, Surg Clin North
Am 1979; 59:1071.
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COMPLICATIONS OF MALABSORPTIVE PROCEDURES Biliopancreatic
diversion and duodenal switch complications significant protein
calorie malnutrition, anemia, metabolic bone disease, deficiencies
of fat-soluble vitamins and vitamin B12- Gastroenterology 2001
Feb;120(3):669-81.
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Vertical banded gastroplasty staple line disruption 27-48%,
stomal stenosis 20-33%, band erosion 1-7%, GERD, nausea/vomiting,
marginal ulcers, and weight regain TI - Bariatric surgery. Surgery
for weight control in patients with morbid obesity. AU - Balsiger
BM; Murr MM; Poggio JL; Sarr MG SO - Med Clin North Am 2000
Mar;84(2):477-89.
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Laparoscopic adjustable gastric band Early complications
include acute stomal obstruction 6%, band infection 0.3-9%, gastric
perforation, hemorrhage, bronchopneumonia, and delayed gastric
emptying. Gastrointest Surg 2003; 7:429.
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Laparoscopic adjustable gastric band Late complications include
band erosion 7%, band slippage 2-14% or prolapse, port or tubing
malfunction, leakage at the port site tubing or band, pouch or
esophageal dilatation and esophagitis. SO - Obes Surg 2002
Apr;12(2):254-60
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Roux-en-Y gastric bypass Pulmonary embolus up to 3.3% Optimal
strategies for preventing DVT/PE in the gastric bypass setting have
not been established. However, most bariatric surgeons use both
pneumatic compression devices in conjunction with subcutaneous
heparin TI - Current practices in the prophylaxis of venous
thromboembolism in bariatric surgery. AU - Wu EC; Barba CA SO -
Obes Surg 2000 Feb;10(1):7-13; discussion 14
Slide 12
Leaks 2 and 3 percent TI - Complications of the laparoscopic
Roux-en-Y gastric bypass: 1,040 patients-- what have we learned? AU
- Higa KD; Boone KB; Ho T SO - Obes Surg 2000 Dec;10(6):509-13.
exploratory surgery should be performed without delay, even if test
results are not confirmatory.
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Gastric remnant distension Clinical features include pain,
hiccups, left upper quadrant tympany, shoulder pain, abdominal
distension, tachycardia, or shortness of breath. Radiographic
assessment may demonstrate a large gastric air bubble Treatment
consists of emergent operative decompression with a gastrostomy
tube or percutaneous gastrostomy TI - Laparoscopic reoperative
bariatric surgery: experience from 27 consecutive patients. AU -
Gagner M; Gentileschi P; de Csepel J; Kini S; Patterson E; Inabnet
WB; Herron D; Pomp A SO - Obes Surg 2002 Apr;12(2):254-60.
Slide 14
Marginal ulcers 0.6 to 16% Causes of marginal ulcers include :
Poor tissue perfusion due to tension or ischemia at the anastomosis
Presence of foreign material, such as staples or nonabsorbable
suture Excess acid exposure in the gastric pouch due to
gastrogastric fistulas Nonsteroidal antiinflammatory drug use
Helicobacter pylori infection Smoking medical treatment
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Cholelithiasis Without prophylaxis, cholelithiasis develops in
as many as 38 percent of patients within six months of surgery, and
up to 41 percent of such patients become symptomatic. Am J
Gastroenterol 1991 Aug;86(8):1000-5. The high frequency of
cholelithiasis can be reduced to as low as 2 percent with a six
month course of ursodeoxycholic acid (a synthetic bile salt) given
prophylactically after surgery. Am J Surg 1995 Jan;169(1):91-6;
discussion 96-7.
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Wound infection Rates of wound infection are significantly
greater with open (10 to 15 percent) than laparoscopic (3 to 4
percent) gastric bypass procedures. SO - Ann Surg 2000
Oct;232(4):515-29 The incidence of wound infections can be
decreased by perioperative administration of antibiotics (usually
cefazolin).
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Stomal stenosis 6 to 20 percent Endoscopic balloon dilation is
usually successful. Repeat dilation sessions may be required for
some patients [ The complication rate for dilation is approximately
3 percent Surgical revision (required in less than 0.05 percent of
patients) is reserved for those who have persistent stenosis
despite repeated dilations.
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Bleeding Bleeding after gastric bypass has been described in
0.6 to 4.0 percent of patient Ann Surg 2001 Sep;234(3):279-89;
discussion 289-91 A higher rate of postoperative gastrointestinal
bleeding was observed following laparoscopic versus open GBP in a
prospective randomized study Ann Surg 2001 Sep;234(3):279-89;
discussion 289-91.
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Ventral incisional hernia Ventral incisional hernias occur with
a frequency of 0 to 1.8 percent in laparoscopic series and as high
as 24 percent in open series, underscoring a clear advantage of the
laparoscopic approach in this regard SO - Ann Surg 2001
Sep;234(3):279-89; discussion 289-91.
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Failure to lose weight and weight regain Progressive
noncompliant eating and other behavioral habits. Development of a
functional gastrogastric fistula. Gradual enlargement of the
gastric pouch. Dilation of the gastrojejunal anastomosis.
Slide 21
Metabolic and nutritional derangements Iron, vitamin B12, and
folate. Hyperoxaluria and nephrolithiasis have been reported
following roux-en- Y gastric bypass surgery.
Slide 22
Internal hernias Three potential areas of internal herniation
are between: Mesenteric defect at the jejuno-jejunostomy The space
between the transverse mesocolon and Roux-limb mesentery
(Peterson's hernias) The defect in transverse mesocolon if the
Roux-limb is passed retrocolic Internal hernias have been described
in 0 [64] and 5 [73] percent of patients undergoing laparoscopic
bariatric surgery. If a patient is suspected of an internal hernia,
urgent surgical exploration is indicated
Slide 23
Postoperative hypoglycemia and Dumping A small number of
patients develop blackouts and seizures after weight loss surgery
due to a severe form of recurrent hyperinsulinemic hypoglycemia. TI
- Hyperinsulinemic hypoglycemia with nesidioblastosis after
gastric-bypass surgery. AU - Service GJ; Thompson GB; Service FJ;
Andrews JC; Collazo-Clavell ML; Lloyd RV SO - N Engl J Med 2005 Jul
21;353(3):249-54