Early and late complications of bariatric operation

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  1. Robert Limone,
  2. Alec Beekleyii,
  3. Dirk C Johnson3,
  4. Kimberly A Davis3
  1. 1 Department of Surgery, Tripler Ground forces Medical Center, Tripler, Honolulu, Hawaii, Usa
  2. 2 Section of Surgery, Sidney Kimmel Medical College at Thomas Jefferson Academy, Philadelphia, Pennsylvania, USA
  3. 3 Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA
  1. Correspondence to Kimberly A Davis, Partition of General Surgery, Trauma and Surgical Critical Care, Department of Surgery, Yale School of Medicine, New Haven, CT 06520-8062, Usa; kimberly.davis{at}yale.edu

Abstract

Weight loss surgery is one of the fastest growing segments of the surgical field of study. As with all medical procedures, postoperative complications will occur. Acute care surgeons need to exist familiar with the common problems and their management. Although full general surgical principles generally utilise, diagnoses specific to the various bariatric operations must be considered. At that place are anatomic considerations which alter direction priorities and options for these patients in many instances. These problems nowadays both early or late in the postoperative class. Bariatric operations, in many instances, result in permanent alteration of a patient's anatomy, which tin can atomic number 82 to complications at any time during the form of a patient's life. Acute care surgeons diagnosing surgical emergencies in postbariatric operation patients must be familiar with the type of surgery performed, as well equally the common postbariatric surgical emergencies. In add-on, surgeons must not overlook the mutual causes of an astute surgical abdomen—acute appendicitis, acute diverticulitis, acute pancreatitis, and gallstone affliction—for these are notwithstanding amidst the well-nigh common etiologies of abdominal pathology in these patients.

  • complications
  • morbid obesity
  • acute care surgery

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  • complications
  • morbid obesity
  • acute care surgery

Introduction

Weight loss surgery is ane of the fastest growing segments of the surgical discipline. As with all medical procedures, postoperative complications volition occur. Acute care surgeons demand to be familiar with the common problems and their direction. Although general surgical principles more often than not use, diagnoses specific to the various bariatric operations must be considered. There may be anatomic considerations which alter direction priorities and options for these patients in many instances. These bug nowadays both early or belatedly in the postoperative course.

Bariatric operations issue in permanent alteration of a patient's beefcake, which tin lead to complications at whatever fourth dimension during the course of a patient'south life. Knowledge of the resultant anatomy can guide the surgeon on the direction of potential problems. It is relatively rare that patients will know whatsoever anatomic details of their surgical procedure, such equally whether an alimentary (Roux) limb was placed in an antecolic or retrocolic position. It is therefore useful to obtain whatever operative reports relevant to the patient's previous bariatric operation if possible.

Acute care surgeons diagnosing surgical emergencies in postbariatric functioning patients must not overlook the common causes of an astute surgical abdomen—astute appendicitis, astute diverticulitis, acute pancreatitis, and gallstone illness—for these are still amongst the about common etiologies of abdominal pathology in bariatric operation patients. In cases of appendicitis and diverticulitis, a prior bariatric performance may have piffling bear upon on the handling plans or clinical course. Conversely, treatment of pancreatitis and gallstone disease may exist significantly impacted by a patient'due south resultant anatomy from a bariatric operation, limiting bachelor modalities.

Early on complications

Bariatric procedures are mostly prophylactic and constructive, merely can be associated with devastating complications, some of which may be fatal if not addressed quickly. Bariatric surgical procedures include sleeve gastrectomies (SG), Roux-en-Y gastric bypasses (RYGB), and gastric balloons. Early complications include leaks, stenoses, bleeding, and venous thromboembolic events (VTE). These principles also apply to less commonly performed bariatric operations such as the mini-gastric bypass, unmarried anastomosis duodenal ileal featherbed, and the duodenal switch (DS), also known as the biliopancreatic diversion with an SG.

Leaks

An anastomotic leak is the nearly dreaded complexity of any bariatric procedure because information technology increases overall morbidity to 61% and mortality to 15%.1 two Failures of anastomotic integrity prolong hospital stays and can result in gastroenteric and gastrobronchial fistulae, which may take months to resolve. Patients undergoing revisional bariatric operations, those who accept a body mass index (BMI) of >50 kg/grandii, and those with dysmetabolic syndrome X are most at risk for leaks.3–v A leak should be suspected and investigated in whatever patient with persistent tachycardia (>120 beats per minute (bpm)), dyspnea, fever, and abdominal pain. The average time for symptoms of a leak to present is approximately 3 days after the performance.6 Often these patients have been discharged home and may nowadays to the emergency room. Sustained heart rates over 120 bpm are a particularly worrisome sign and should be addressed quickly.

Postoperative patients who present with tachycardia and hypotension should be appropriately resuscitated and evaluated for myocardial infarction and pulmonary embolism (PE). Emergency operative exploration should follow if those are ruled out. The performance may exist done laparoscopically or open depending on the surgeon's experience and the severity of the hemodynamic instability. The priorities in the operating room are threefold: removal of contagion, placing closed suction drains to command the leak, and establishment of feeding access. If feasible, closing the leak may be attempted, but information technology is not required. If a repair is undertaken, interrupted sutures and a modified Graham patch may protect the repair.

In hemodynamically normal patients, evaluation for other causes of postoperative tachycardia, such as postoperative bleeding, hypovolemia, and pneumonia, should precede re-exploration. The evaluation of a leak should include an abdominal CT study with oral dissimilarity; patients should exist instructed to drinkable about 100 cc of dissimilarity just prior to the scan. A CT scan tin evaluate for other diseases on the differential diagnosis of the tachycardia, including bleeding and pneumonia. The browse tin can be performed along with a CT pulmonary angiogram to expect for a PE. The detection charge per unit for leaks at the gastrojejunal anastomosis (GJA) or in an SG by CT is threescore% to lxxx%.6 vii CT evidence of an abscess, phlegmon, or fluid collection should be considered a leak even if no extravasation of contrast is seen. An upper gastrointestinal series (UGS) can also be used to observe leaks but is less sensitive for a leak at the GJA than a CT,8 and neither study will effectively dominion out a leak at the jejuno-jejunal anastomosis (JJA) after an RYGB. Persistent tachycardia despite negative radiologic studies warrants surgical exploration if no other cause can be identified due to the poor sensitivities of diagnostic tests. In hemodynamically normal patients, control of a leak may also be done by image-guided drainage.

There are significant differences, however, betwixt the SG leak and the RYGB leak based on the typical endoluminal pressure. Afterwards RYGB, the gastric pouch is a low-pressure system, and thus the incidence of leaks ranges from about 0.six% to 4.iv% of patients.9 Because of this low pressure, operative or not-operative direction strategies that control the leak just do not close or repair the perforation are effective in 72% of patients.ten Patients who have leaks that last longer than 30 days can be treated with an endoluminal procedure to place clips, stents, or a vacuum dressing to help shut these chronic leaks.11 Nutrition can exist addressed with enteral feeding distal to the GJA and is preferable to full parenteral diet. A feeding tube can be placed in the Roux limb, the biliopancreatic limb, or the common channel.

Sleeve leaks, on the other hand, occur in a high-force per unit area system, are idea to exist more common, and range in incidence from i% to seven%.12–14 They are more difficult to treat. Most SG leaks occur at the uppermost extent of the sleeve, where blood supply is tenuous. The high pressure comes from the pyloric and lower esophageal sphincters, or mayhap due to a stenosis, twist in the SG, or kink. These anatomic narrowings must be addressed if the leak is to be treated successfully.

Stable patients with leaks after an SG tin can undergo image-guided drainage procedures. Endoluminal intervention with covered stenting may be placed before in the treatment grade to help command the leak. The stent should cover from the lower esophageal sphincter (LES) through the pyloric sphincter to let the leak to heal.13 Unfortunately, the most commonly available stents are not long enough (30 cm) to embrace this distance.

Stenosis, twists, or kinks

The loss of luminal caliber from stenosis causes patients to report the sensation of stuck food and the urge to regurgitate. These symptoms are similar esophageal dysphagia, with inability to pass food or liquid beyond the GJA or sleeve, and can effect in protein calorie malnutrition and nutrient deficiencies. Clinicians must address this when caring for patients with a stenosis, regardless of the cause. Thiamine deficiency tin can present with new-onset neurologic symptoms. All postsurgical bariatric patients presenting acutely with per bone (PO) intolerance should take a neurologic examination, biochemical testing for malnutrition, and diet replacement started empirically via an intravenous route because a new neurologic defect can go permanent if not addressed rapidly.15

RYGB stenosis is common, easy to diagnose, and treatable without some other operation. The incidence of stenosis after RYGB is 8% to xix% and is more common after anastomoses done with an end-to-end anastomosis stapler. Comparatively, linear stapled or handsewn anastomoses take fewer strictures.sixteen A UGS volition confirm stenosis, showing a failure of contrast to pass through the GJA. Typical management is endoscopic balloon dilation, which tin can safely be washed past an experienced endoscopist within the first week after surgery. The target diameter of the GJA anastomosis later an RYGB is 15 mm in bore, so patients volition accept some restrictions when they consume. Anastomoses that are 9 mm or less are stenotic. Serial dilations should be endeavored to achieve optimal size. The bore should not exist increased more 3 to 4 mm with each treatment, and endoscopists should expect that the dilated bore will decrease with time. Consequently, most patients will need two to three dilations until they can consume comfortably.17

Stenosis later an SG differs from RYGB stenosis in frequency, diagnosis, and therapy. Afterwards an SG, true stenosis or stricture occurs infrequently, befalling but 0.69% to 2% of patients.18–20 The therapy for a focal stenosis is the aforementioned as RYGB stenosis with series balloon dilations; typically two to three treatments are needed prior to achieving the desired diameter.xx Rarely, there is an extensive length of stenosis, which would do good from 6 weeks of stenting. If this fails to maintain the diameter, a myotomy, either endoscopic or laparoscopic, is the adjacent treatment pick.21

However, "stenosis" or dysphagia symptoms may develop as a result of a kink in the SG or a volvulus around the SG's longitudinal centrality. Collectively these may occur in up to ix% of patients.22 Patients present unable to tolerate PO intake, but the UGS may be completely normal and may not ever capture the sleeve in a twist or kink morphology. Additionally, an upper endoscopy may also be normal and allow passage of a x mm endoscope because the telescopic or insufflation air straightens out the twist or kink. Endoscopic interventions will not care for a kink or a volvulus. In these patients, conversion to an RYGB may exist the all-time selection, although there are a few reports of using repeat balloon dilation to give the patient a chance to avoid another surgery.18 Some SG obstructions are associated with a leak, and as such may affect the timing of operative management. Information technology would exist hard, for case, to perform a conversion RYGB in the operative field total of inflammatory tissue. One may have to stent for 6 weeks to command the leak before attempting a conversion.

Bleeding

Postoperative bleeding that requires intervention occurs in upwards to eleven% of cases in both the RYGB and SG.23 Fortunately, 85% of patients are probable to stop without surgical intervention.24 Patients with dysmetabolic syndrome Ten take a higher risk for haemorrhage. Usual supportive treatment should be instituted promptly and includes establishing adequate venous admission, crystalloid resuscitation, claret product transfusions, series hematocrits, hemodynamic monitoring, correction of whatsoever coagulopathies, and stoppage of VTE chemoprophylaxis if information technology is being used. An experienced endoscopist can safely evaluate an anastomosis in the early on postoperative flow and perform therapeutic endoluminal interventions like clips or epinephrine injections as first-line treatment.

Hemodynamic instability or failure of non-operative management mandates emergency surgical direction. The staple line is the nearly mutual site of bleeding after an SG, merely splenic injury is too possible. After RYGB, the anastomoses are probable sites of bleeding, but intra-abdominal hemorrhage from the omentum, mesentery, and spleen are besides potential areas. If no obvious site is found, the surgeon must evaluate inside the gastric remnant, the biliopancreatic limb, and the Roux limb for bleeding sources.

Venous thromboembolism

The rate of a VTE after bariatric functioning is low, merely a PE is still the well-nigh common cause of mortality after these procedures.25 Most occur 3 weeks later the process,25 but at that place is no indication or consensus virtually the optimal duration of chemoprophylaxis prescription. There is debate over the risk to these patients, but there is consensus on who the highest run a risk patients for VTE are: those undergoing revision bariatric operation or open procedures, those with a BMI >50 kg/m2, those with surgery elapsing >four hours, those with hypercoagulable states, and those with obesity hypoventilation syndrome.25–27 When postoperative bariatric patients present acutely in distress, a PE should e'er be in the differential diagnosis. Screening can be washed with a CT angiogram. Handling consists of systemic anticoagulation, and if a massive embolus is found then a catheter-directed lytic therapy is probable the all-time handling choice.28

Airship complications

Astute care surgery providers should probably be familiar with the direction of acute complications of balloons used for weight loss. Airship placements account for less than 1% of bariatric procedures. They are placed endoscopically in the stomach and restrict food intake. They are meant to stay for 6 months or less. Patients will frequently study symptoms of reflux, nausea, and abdominal discomfort even when the airship is in proper position. About 4% to seven% of patients request early on removal because they cannot tolerate these symptoms.29 30

Enteric perforation and migration of the airship leading to a bowel obstacle are two complications which may require acute management and may consequence in death. Data is thin, merely there does not appear to be anything unique about the presentation of balloon patients with a perforation or bowel obstruction. Deflating a balloon for removal is commonly done endoscopically with specialized equipment to puncture the balloon, aspirate the saline, and deflate the balloon. In the instance of migration, the balloon is probable deflated already, but fifty-fifty in the deflated country these balloons are big and may require a sizeable enterotomy to remove them from the intestines. Of note, balloons are inflated with blue-dyed saline, then patients could note blue or green urine if the airship spontaneously deflates and the blue dye is captivated from the alimentary canal.31 Balloons left in place longer than 6 months are at a college chance for perforation.32

Perforations commonly result from force per unit area necrosis and ulceration from the airship, and treatment starts with deflating the balloon. In an unstable patient, any big bore needle tin exist used to deflate the balloon, just a gastrotomy may be needed to gain admission to the balloon. The balloon tin be decompressed with a big bore endoscopic needle and a snare to excerpt the balloon. This may cause the dyed saline to spill, making visualization difficult. After the airship(s) is deflated and removed, the perforation must still be addressed, which can be done with a Graham patch or resection.

Tardily complications

Adjustable gastric band complications

Nigh ring complications are related to mechanical issues with the band itself (eg, band slippage and band, balloon, or tubing breakage). Other and more serious late complications include band erosion, astute obstacle, ischemia, and megaesophagus or pseudoachalasia. Including patients who require band removal for insufficient weight loss, the cumulative incidence of patients requiring reoperation is nigh 25%.33

Band slippage

Band slippage occurs when ane wall or side of the stomach slips through the orifice of the band, resulting in a larger than normal gastric pouch superior to the band. The usual anatomic derangement is characterized as 'cephalad prolapse of the trunk of the stomach or caudal movement of the band.'34 Slippage is considered the about mutual complexity after laparoscopic adjustable gastric band35 and occurs in 8% of patients.36 Although fundoplication around the band and the pars flaccida technique for placement of the ring are thought to reduce the likelihood of ring slippage,37 information technology may still occur even after these technical precautions are done at the time of band placement.38 Band slippage presents as a dilated gastric pouch superior to the band. These patients frequently report symptoms of immediate or delayed vomiting after meals, a feeling of fullness merely relieved by vomiting, and occasional pain or irritation in the upper abdomen.

Workup should include a evidently intestinal X-ray. The expected band position is to the left of the spinal column with an oblique bending of approximately fifteen°. This is from 8 o'clock to 2 o'clock when scanning the X-ray from the patient's right to the left. The "phi angle," the bending betwixt the vertical spinal column and the ring, is commonly between 45° and 58° (figure ane). Phi angles greater than 58° usually indicate a slipped band. Seeing the entire ring of band on a plain anterior-posterior intestinal Ten-ray (the "O sign")39 should too enhance suspicion for a slipped ring. Boosted radiographic signs sensitive for band slippage are inferior deportation of the superior lateral band margin more than two.4 cm from the diaphragm and the presence of an air-fluid level in a higher place the gastric band.40

In more than astringent cases of band slippage, the backlog stomach wall herniated through the band orifice may result in swelling and obstruction at the ring outlet, resulting in severe dilation and ischemia of the stomach wall above the ring. This is like a strangulated hernia. These patients often are completely obstructed and have severe, unrelenting pain, tachycardia, fever, and leukocytosis.

The start handling footstep when dealing with a patient with a suspected ring complication is to completely empty the ring of fluid. In many circumstances, this intervention may resolve the slippage and relieve symptoms. Resolution of band slippage (return of the breadbasket to its normal position) can be confirmed with a follow-up UGS. Patients who experience relief of symptoms and resolution of band slippage with emptying of the band should be temporarily restricted to a liquid nutrition and referred to a bariatric surgeon for elective retrieval. Patients who keep to accept abdominal pain, systemic signs, or in whom follow-up contrast UGS reveals the ring remaining in a slipped position will likely require emergency surgery for band removal and perchance resection of ischemic or necrotic stomach.

Laparoscopic band removal can exist challenging. The surgeon will often encounter extensive adhesions of the left lobe of the liver to the upper third of the tum and a band which appears completely engulfed in breadbasket tissue. The surgeon's only indication of the presence of a ring may exist the ring tubing coursing into this expanse. Careful, persistent autopsy allows the left lobe of the liver to be mobilized off the upper stomach and unremarkably is accomplished easily. The side by side step is identification of the band buckle, which can generally be establish on the medial or lesser curvature side of the stomach. Since the ring tubing enters nearly the buckle, following the band tubing will lead to the buckle. Dissection on the buckle itself is necessary to get the band mobile, as there is normally ingrowth of scar tissue in and around the buckle. The silastic balloon portion of the band itself usually resists extensive adhesion formation and volition be relatively mobile and piece of cake to slide around the tum once the buckle is gratuitous. Because the buckle is non typically covered with the gastric plication, it is also the expanse of dissection that is to the lowest degree likely to result in a gastric wall injury.

Once the gastric band is complimentary of adhesions and can be freely rotated around the tum, it may simply be cutting with scissors and removed. The cutting band can usually exist extracted either through a xv mm port or via dilation of a smaller port. The tubing and subcutaneous port should too be entirely removed. Prior to completing the exploration, inspection of the posterior gastric wall for ischemia or perforation may place the need for additional procedures. Plications do non necessarily need to be taken down in the acute setting, although doing then may assist assess stomach tissue integrity and potential demand for resection. Takedown of the plication in the setting of normal gastric tissue tin can be safely done either with careful sharp autopsy or the utilise of a linear stapler, with the anvil or narrow side of the stapler placed in the "tunnel" created by the fundoplication and the cartridge side exterior the tunnel. The functioning is completed with removal of the ring's port in the subcutaneous tissue of the abdominal wall.

Band erosion

Although band erosion sounds like an ominous complication, it is rarely a surgical emergency. Erosions occur in a relatively pocket-sized pct of patients, ranging from 0.31% to ane.96%.41 42 Symptom onset is frequently insidious, vague, and non-specific. Patients may depict upper abdominal or back pain, loss of food restriction, melena, new onset of reflux, or "spontaneous" infection of the subcutaneous ring port (from bacteria from the gastric erosion tracking along the band tubing to the subcutaneous port). Manifestly abdominal X-rays can sometimes document band malposition, and CT scan or upper abdominal contrast series may advise an intraluminal ring and inflammatory changes in the upper stomach. Because the process is slow, adhesion formation around the site of erosion usually limits contamination of the belly or peritonitis. Upper endoscopy may certificate fractional or complete erosion of the band into the stomach. When such patients present without sepsis, which is typically the case, they may be started on antibiotics and referred to a bariatric surgeon for management.

Options for treatment depend on the degree of erosion. Complete or well-nigh-complete intraluminal bands can be removed endoscopically by cut the tubing and extracting the ring from the mouth.43 44 The resultant erosion almost invariably seals quickly due to the slow nature of the erosion and the amount of inflammation present. Similarly, patients with partial erosion may have laparoscopic removal of the band as described above. If a hole is visible, patching with omentum or fundus is unremarkably sufficient to seal it. If a hole is non visible, closed suction drainage, intravenous antibiotics, and a period of nothing by mouth is ordinarily sufficient to seal the erosion. Follow-upwards UGS can confirm no leak prior to resuming oral intake.

Megaesophagus or pseudoachalasia

Megaesophagus or pseudoachalasia rarely requires acute handling. Patients typically present with worsening dysphagia, regurgitation, or airsickness. Plain 10-rays often prove the band in normal position, but UGS reveals an esophagus dilated across the outer limit of the band. The dilation is attributed to chronic overeating despite having a band to limit intake. As the esophagus expands and the capacity increases, patients describe loss of brake, which may prompt augmenting the band fill up. Additional make full worsens the outlet obstacle and increases the chronic stretching of the esophagus. Initial evaluation and treatment for patients presenting acutely should consist of patently films and UGS to document the problem. Treatment is emptying of the band. These patients should undergo elective band removal.

Gastric bypass

RYGB results in permanent amending of anatomy, which provides both the potential for unique complications and can confound the usual treatment options. Afterward ruling out common causes of non-bariatric performance-related complications (appendicitis, diverticulitis and and then on), the top four conditions to consider are gallstone disease, marginal ulceration, internal hernia, and intussusception.

Gallstone disease

Patients who have had bariatric operation develop gallstones at a higher incidence than the boilerplate population.45 Alterations in enterohepatic circulation, hormonal changes associated with weight loss, and perchance increased biliary stasis contribute to the development of cholelithiasis. RYGB results in rerouting of food through the comestible limb and may alter or delay the release of the usual gut hormones that stimulate gallbladder contraction, resulting in atypical symptoms or non-postprandial pain. Symptomatic cholelithiasis and cholecystitis can be treated with laparoscopic cholecystectomy. However, the direction of choledocholithiasis is complicated considering the usual route to the ampulla of Vater for endoscopic retrograde cholangiopancreatography (ERCP) is bypassed. Pediatric colonoscopes or double-airship endoscopy can allow highly skilled endoscopists to pass a scope all the mode downward the alimentary limb through the JJA and back up the biliopancreatic limb to the ampulla of Vater, but this is time-consuming and not ever in the armamentarium of the endoscopist.

Hence, the three options bachelor to the surgeon for treatment of choledocholithiasis afterward gastric bypass are percutaneous transhepatic cholangiography, surgical mutual bile duct exploration, or the so-called "rendezvous" process where the surgeon laparoscopically provides access to the bypassed stomach remnant to permit the gastroenterologist to arroyo the ampulla of Vater with a standard side-viewing ERCP scope. Biliopancreatic diversion/DS patients have only the first two options, equally these patients typically practise not have retained stomach for this access. Some institutions have created algorithms to treat these patients that require complex multidisciplinary procedures.46

Marginal ulceration

Merely under 5% of patients develop marginal ulceration after RYGB.47 It typically occurs at or near the GJA, although typical peptic ulcers in the first portion of the duodenum have also been described.48 The nearly frequent symptoms are epigastric called-for pain occurring in approximately 57% of patients, followed past bleeding in fifteen%.47

Perforation

Patients may nowadays with spontaneous perforations (one%–2% of patients). Some may take no warning symptoms, although a detailed history may reveal antecedent symptoms of postprandial pain and nausea or recent increased employ of either non-steroidal anti-inflammatory drugs (NSAIDs) or tobacco. Hazard factors for perforation include smoking, NSAID use, and anastomosis with non-absorbable suture fabric.49

In the setting of astute perforation in a patient with a remote history of bariatric operation, the diagnosis is often suspected based on the history and physical examination solitary. Patients who have fever, tachycardia, and peritonitis on examination may need no boosted workup (or at nearly a plain abdominal X-ray demonstrating free air) before committing them to operating exploration. Patients may be managed laparoscopically or open; the priorities are to reduce contagion and control the leak. Omental patch repair of the defect is acceptable with or without primary closure of the perforation and closed suction drainage. In this setting major revision operations should be avoided, if possible.

Patients with less clear-cut presentations may crave abdominal CT. Similar hemodynamically stable patients with early leaks, localized or independent perforations in patients without sepsis and intact allowed systems can be managed not-operatively with intravenous antibiotics, proton pump inhibitors, bowel rest, and careful observation for the development of sepsis. Like early leaks from the GJA or gastric pouch staple line, tardily marginal ulcer perforations can also be managed with endoscopic placement of intraluminal stents and percutaneous and prototype-guided drainage of attainable intra-intestinal fluid collections in selected patients.

Haemorrhage

Mild to moderate bleeding from marginal ulcers occurs in 5% of patients; massive hemorrhage is substantially less common.50 Presentation is like any patient with upper gastrointestinal bleeding and includes melena or hematochezia, hematemesis, and near-syncope or syncope. Initial management should focus on resuscitation with crystalloid or blood products if advisable, reversal of antiplatelet agents or anticoagulants, and intravenous proton pump inhibitors. Upper endoscopy is diagnostic and ordinarily therapeutic. Bleeding is usually identified at the GJA site, and the bulk can be controlled with standard endoscopic techniques. In ane report, surgery was only required in 4% of patients with bleeding marginal ulcer.51 Since most patients who require operative management accept pathology not acquiescent to endoscopic therapy, surgical treatment should consist of resection of the ulcer site (usually the GJA) with revision of the anastomosis in healthy tissue. Combined laparoscopic and endoscopic procedures, where an endoscopically identified isolated bleeding vessel is laparoscopically oversewn without opening the lumen, accept been successfully performed.

After control of the hemorrhage, patients should be counseled that strict abstinence from smoking and NSAIDs is mandatory to minimize the risk of recurrence. Patients with non-healing ulcers or big/dilated gastric pouches may need to be referred to a bariatric surgeon for elective revision operation.

Small bowel obstacle

RYGB patients may develop pocket-sized bowel obstructions related to internal hernias or postoperative adhesions. More rarely, stenosis of the JJA, small bowel bezoars, and small bowel intussusception (often at the jejuno-jejunostomy site) may atomic number 82 to obstructions in these patients. Archetype presentation is with diffuse intestinal pain, distension, bloating, nausea, and vomiting. Vomiting may be less pronounced than non-gastric featherbed patients. Bowel obstruction related to adhesions is more mutual after open procedures. In patients who have had a prior laparoscopic gastric bypass, over 50% of small bowel obstructions are acquired by internal hernias.52

Internal hernia

Maybe the most difficult to place only potentially catastrophic late complication in mail service-RYGB patients is an internal hernia with small bowel volvulus. Symptoms may be non-specific and intermittent. Centric imaging may be read as negative or normal in about 30% of patients.53 Vital signs and laboratory values may be relatively normal unless vascular compromise of abdominal tissue has already occurred.

Internal hernias after bariatric operation tin occur at anastomotic sites, but can also occur through the transverse mesocolic defect in the setting of a retrocolic alimentary or Roux limb arrangement. The defect that occurs between the comestible (Roux) limb mesentery and the transverse mesocolon is known as the Petersen'south defect (figure 2). There is also a defect at the mesentery of the JJA. Closure of these defects at the time of initial operation is thought to reduce their incidence, simply even with rubber closure, internal herniation and volvulus can withal occur. The overall incidence of internal hernias after RYGB is 2.5%, with the bulk (87%) of hernias occurring at either the transverse mesocolic defect or Petersen'southward defect.54

Patients with internal hernia and pocket-size bowel volvulus typically nowadays with mid-epigastric or periumbilical intestinal pain, oft of relatively sudden onset. Their pain may be unremitting and radiate to the back. Eating can ofttimes worsen symptoms, and in avant-garde cases symptoms of a bowel obstacle with obstipation and vomiting may be reported. Symptoms may be general enough that providers evaluating the patients may consider marginal ulcers or symptomatic gallstones in their differential diagnoses, leading to evaluations with upper endoscopy or abdominal ultrasounds and potentially delaying therapy.55 56 Cross-sectional imaging may reveal telltale signs of internal hernia, such equally mesenteric swirl or obstructive patterns and engorged mesenteric nodes.57 However, CT imaging has a suboptimal sensitivity for internal hernias in patients with a history of bariatric operation and may be read as normal in up to 30% of patients.54

Mail-RYGB patients in whom small bowel obstructive symptoms are present, or in whom imaging reveals a minor bowel obstacle, should by and large not accept a trial of non-operative direction. Bullheaded nasogastric tube placement can easily event in perforation of the bullheaded end of the alimentary limb, but typically will non correct a bowel obstruction related to an internal hernia. These patients should exist taken expeditiously to the operating room.58

As with all postbariatric performance problems, cognition of the patient's operative anatomy prior to exploration is helpful (eg, antecolic vs. retrocolic alimentary limb). Patients with small bowel volvulus through an internal hernia defect will often have what appears to be a "knot" or twist of bowel loops in the infracolic abdomen, and it can be hard to ascertain which direction to run the bowel to get it reduced. This conundrum can be addressed by starting at the terminal ileum and running the bowel retrograde. This will usually both reduce the volvulus and allow articulate delineation of the problem. If all the bowel is viable, simple closure of the internal defect should suffice. Surgeons should audit all possible mesenteric defects for adequate closure. Typically, nearly lxx% of internal hernias tin exist corrected laparoscopically, but surgeons should not hesitate to convert to open performance if laparoscopic reduction and repair of an internal hernia is non progressing safely. Devitalized bowel should be resected.

Conclusion

Acute care surgeons can safely care for bariatric patients, including many of the complications related to their weight loss process. The threshold to operate to in these patients, in general, should be lower when they present with acute symptoms but not without understanding the specific circumstances.

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