Complications of Gastric Restrictive Operations in Morbidly Obese Patients

Symposium on Complications of Common Procedures

Complications of Gastric Restrictive Operations in Morbidly Obese Patients

Edward W. Martin, Jr., M.D.,* Cathy Mojzisik, B.S., R.N.,t and Larry C. Carey, M.D.+

A widely accepted definition of morbid obesity is body weight that exceeds by 100 pounds or more the ideal weight adjusted for height, age, and sex established by the Metropolitan Life Insurance Tables. 8 · 9 It is estimated that 4.5 million Americans are morbidly obese, and that this presents a major health hazard to approximately 5 per cent of the population. 1 Among conditions suggested to be more common in the morbidly obese are hypertension, coronary artery disease, diabetes, degenerative arthritis, venous stasis, gynecologic disorders, and many less serious problems. Death rates in morbidly obese people under 40 years of age are considerably higher than in those of similar age but of normal weight, which may explain why there are fewer morbidly obese persons over 65 years of age. 3 The medical management of morbid obesity is far from satisfactory. Diet-induced weight loss is followed all too often by weight gain disheartening to both patient and physician. Diet regimens that employ contrived nourishment threaten the patient with grave metabolic consequences, and the use of appetite depressants is accompanied by serious side effects. Because of the low rate of success of the medical management of this serious health problem, surgeons have become involved in the care of morbidly obese persons, and over the past three decades, two approaches to treatment have been used. The first can be characterized as a procedure that creates malabsorption of food, the second as a procedure that restricts the volume of food that can be ingested. Operations designed to create From the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio *Associate Professor of Surgery tClinical Nurse Specialist tRobert M. Zollinger Professor of Surgery and Chairman

Surgical Clinics of North America-Val. 63, No. 6, December, 1983

1181

1182

EDWARD

W.

MARTIN,

JR., CATHY MOJZISIK AND LARRY C.

CAREY

Table 1. Gastric Restrictive Operations GASTRIC BYPASS

Loop Mason (1967) Alden (1977) Roux-en-Y Griffen (1977) Yale (1981) Miller (1982)

NO BYPASS

Gastroplasty Mason/Printen (1971) Gastrogastrostomy Alden/Jewell (1971) Gastric Partitioning TA-55, Pace/Carey (1977) TA-90, Martin/Carey (1978) DRTA-90 Total liquids, Martin/Carey (1979) Silastic collar, Carey/Martin (1981) Total liquids until goal, Martin/Carey (1981) Gastroplasty Reinforced Greater curvature, Gomez (1980) Lesser curvature horizontal, Fabito (1980) Lesser curvature vertical, O'Leary/Tretbar (1980) Silastic collar, Law (1981) Vertical banded, Mason/Doherty/Hess (1982) Gastric wrapping, Wilkinson (1981)

malabsorption have now been abandoned because of the severity of longterm sequelae. Various modifications of procedures to restrict the intake of food are currently employed, and the complications of these procedures will be addressed in this article. Gastric restrictive operations are designed to prevent the almost universally excessive caloric intake of morbidly obese persons. These procedures create a small upper gastric pouch so that only very small amounts of food can be eaten at one time; a small outlet (stoma) through which the stomach slowly empties prevents the patient from eating too frequently. Mason described the first of these procedures in 1967, i and during the ensuing years, many variations of the technique he described have been adopted (Table 1). One approach to restricting intake is to bypass the distal stomach and the upper small bowel; the other is to limit the capacity of the upper gastric pouch and slow the assimilation of food without opening the gastrointestinal tract or altering gastrointestinal continuity. Complications may follow either approach.

EARLY COMPLICATIONS In contrast to complications after small bowel bypass procedures, complications after gastric restrictive operations may occur immediately postoperatively. Painful lower esophageal distention results from eating too much too fast. The excessive production of mucus also presents problems. Small sips of antihistamine syrup or meat tenderizer are effective in facilitating passage of mucus from the small gastric reservoir, and the application of nitroglycerin paste on the skin has also been found helpful.

COMPLICATIONS OF GASTRIC RESTRICTIVE OPERATIONS IN OBESE PATIENTS

1183

Lesser Curvature Anterior LeaK SUBHEPATIC ABSCESS

SITE

Figure l. Perforation on the lesser curvature.

MAJOR COMPLICATIONS

Peritonitis The most serious complication that may follow gastric restrictive procedures is perforation. There are many hypotheses about the cause of gastric perforation. The nasogastric tube may be the culprit, as its tip may press against the wall of the stomach for long periods of time. Ischemia present either above the staple lines or between them has also been suggested as contributing to perforation. 7 However, whatever the cause, the clinical manifestations of peritonitis are unique in the morbidly obese person. Most physicians recognize the traditional boardlike abdomen and grunting respirations of a patient with peritonitis, but morbidly obese patients have few of these classic findings. Abdominal rigidity is difficult to assess beneath several centimeters of subcutaneous fat, and abdominal pain may be minimal or absent. The clinical presentation depends on the location of the perforation, whether it is anterior medial on the lesser curvature or more laterally located on the posterior greater curvature (Figs. l and 2). Patients with an anteriorly situated perforation on the lesser curvature often manifest few physical findings until they begin to consume full liquids or pureed food, usually four or five days postoperatively. Symptoms may be delayed even longer, surfacing after the patient has left the hospital. Often, the first clinical indication of this catastrophic event is a vague feeling of abdominal fullness in the epigastric area to the right of the midline just above the

1184

EDWARD

W.

MARTIN,

}R., CATHY MOJZISIK AND LARRY C. CAREY

Figure 2. Perforation on the greater curvature.

umbilicus. Incisional pain or a wound problem may be suspected because the vital signs are often not typical. The characteristic rapid tachycardia and the short, shallow respirations are absent. Diagnosis of perforations in this location is challenging. Case Study. A 26-year-old woman weighing 309 pounds underwent the gastric restrictive operation. Her medical history included chronic bronchitis. The patient complained of mild shortness of breath and nausea on the day after the operation. The nasogastric tube was removed on the third postoperative day, and the patient received nothing by mouth for the next 24 hr. On the fourth postoperative day, she was instructed to sip 30 ml of clear liquid over 1 hr, and if this was tolerated, to advance the rate to 30 ml over 5 min until she felt full. Because clear liquids were tolerated, her diet was advanced to a liquid/pureed diet on the fifth postoperative day. She tolerated small amounts of juices, had cereal thinned with milk, and finely pureed meat thinned with soup. In the late evening, she complained of excruciating left upper quadrant pain radiating to the back and tenderness of the left lower quadrant and pelvic area. Gastrografin swallow roentgenograms demonstrated a possible extravasation; chest x-ray film was normal. The leukocyte count was 15,000 at the onset of her discomfort and rose to 20,000 within 12 hr, when she was transferred to the operating room for oversewing of a perforation on the medial side of the stoma in the distal anterior row of staples and drainage of a subphrenic abscess. Cultures of the abscess fluids showed growth of oral flora. More commonly, gastric perforation is laterally located on the greater curvature, and the mucus and gastric contents are spilled posteriorly and

COMPLICATIONS OF GASTRIC RESTRICTIVE OPERATIONS IN OBESE PATIENTS

1185

superiorly beneath the left hemidiaphragm and along the left colic gutter. Tachycardia exceeding 120 beats per min, often in the range of 160 to 180 beats per min, occurs within the first 48 hr and is associated with left shoulder pain; short, shallow respirations; and more subtle left-sided and pelvic pain. The chest film shows a left pleural effusion, and the leukocyte count climbs steadily. Roentgenograms made after Gastrografin swallow are often not diagnostic. Common incorrect diagnoses include pulmonary embolism, atelectasis, and left lung pneumonia. A fall in blood gas levels further adds to confusion. Prompt diagnosis and equally prompt treatment are important. Case Study. A 30-year-old woman weighed 300 pounds before undergoing the gastric restrictive operation. Her medical history contributed no relevant information. Less than 48 hr after the operation, she reported left shoulder and left upper quadrant pain, which she was reluctant to report to the doctor because she associated the pain with the use of the trapeze bar. Approximately 5 hr after voicing her complaint of mild discomfort, she suffered acute onset of tachycardia, tachypnea, and fever. Her temperature was 101.6 F, pulse 160/min, respirations 40/min, and blood pressure 110/ 70 mmHg. The nasogastric tube remained in place, and the patient reported that "something popped" inside. Her leukocyte count was elevated (22,000); blood gases were abnormal (pH 7.42, pC0 2 41 mmHg, p0 2 48 mmHg, bicarbonate 26 mEq/L). Chest roentgenograms demonstrated an effusion or infiltrate in the left lung. The patient was returned to the operating room where a gastric perforation at the staple line was oversewn, and a subphrenic abscess was drained. When the clinical findings in the obese patient are characteristic of gastric perforation, the leukocyte count and the vital signs should be monitored closely. The patient should be transferred to the intensive care unit, and intravenous fluids and the appropriate broad-spectrum antibiotics should be given. Unless improvement is rapid, the patient should be returned to the operating room, the abdomen opened through the previous incision, and the abscess drained. If the leak can be closed quickly, this should be done. If this is not possible, the major concern is to provide adequate drainage of the left upper quadrant and, if possible, to place a gastrostomy tube in the distal stomach. Early reoperation will dramatically reduce both the morbidity and mortality of gastric perforation. Stomal Obstruction

The second major complication that may follow gastric restrictive procedures with or without stomal reinforcement is stomal narrowing. The problem is manifested early, within the first postoperative month. The incidence of stomal obstruction has been about 5 per cent in most studies. The ingestion of semisolid food becomes increasingly difficult, and finally even liquids cause a major problem for the patient. Dehydration and continual vomiting necessitate readmission to the hospital. An upper gastrointestinal series demonstrates the degree of obstruction. A nasogastric tube is passed, and nothing is ingested by mouth for the next 48 hr. The tube is then removed, and liquids are administered orally at the rate of 30 ml!hr. If the liquids are tolerated, the diet is advanced to pureed food, the (j

1186

EDWARD

W.

MARTIN,

JR., CATHY MOJZISIK AND LARRY C.

CAREY

rate is increased to ad libitum, and the patient is discharged. In a few cases, this program must be repeated several times before success is achieved. In many cases of stomal obstruction, more vigorous, invasive, but still nonsurgical techniques are required. After the barium swallow has demonstrated stomal narrowing but not total obstruction, the pediatric gastroscope (P-3) is passed into the upper pouch and the stenotic opening inspected. If a small-caliber Teflon guide wire can be passed through the opening, dilation with Eder-Puestow dilators is performed. Case Study. A 41-year-old woman weighed 284 lb before undergoing a gastric restrictive operation. The nasogastric tube passed through the stoma remained in place for three days postoperatively. The patient tolerated both clear liquids and thinned, pureed foods at a controlled rate. At discharge, she tolerated all liquids without emesis. Approximately two weeks after her discharge from the hospital, she said she was vomiting mucus and could not tolerate clear liquids without vomiting. An antihistamine was prescribed. The patient was instructed to sip clear liquids as tolerated. Within 48 hr, she was admitted to the hospital for dehydration secondary to persistent vomiting. After 48 hr without oral intake, she could tolerate small amounts of clear liquids. Upper gastrointestinal roentgenograms demonstrated a stricture of the gastric stoma. Dilation of the stoma was postponed until eight weeks had elapsed since the operation, and the patient was discharged on a regimen of antihistamine medication and weekly intravenous fluid replacement. Although vomiting continued, she consumed clear liquids and very small amounts of blenderized foods until she returned to the hospital for the dilation procedure. Endoscopic identification of the small stoma was made through the pediatric endoscope. A 240 em Teflon wire was threaded through the endoscope and through the stoma. Fluoroscopic confirmation of the position of the guidewire was established, and the endoscope was removed. A 16 Fr modified nasogastric tube was then passed over the guidewire under fluoroscopic observation. The Teflon guidewire was replaced by an Eder-Puestow guidewire, and the nasogastric wire was removed. Serial Eder-Puestow dilators up to 25 Fr were used, and a nasogastric tube was reinserted. The dilation procedure was repeated in 48 hr, and the nasogastric tube remained in place for 48 hr. Mter the tube was removed, the patient tolerated clear liquids and advanced to thinned, pureed foods. Within four weeks after dilation, she tolerated solid foods well. In other patients, a guidewire is passed through the stomal opening under fluoroscopic observation by the radiologist. A small amount of contrast material is introduced so that the stoma can be inspected. The guidewire is advanced through the stoma, and then a Gruntzig catheter is passed over the guidewire, the balloon inflated, and the stoma dilated. Case Study. A 33-year-old woman weighed 232lb when she underwent a gastric restrictive procedure. Within four months, the patient returned for a second operation because of a failed gastric partition. A small, iatrogenic posterior gastric tear was repaired during the second operation. The nasogastric tube was removed on the third postoperative day. The patient tolerated both clear liquids and thinned, pureed foods at a controlled

COMPLICATIONS OF GASTRIC RESTRICTIVE OPERATIONS IN OBESE PATIENTS

1187

rate. Before discharge from the hospital, an upper gastrointestinal roentgenogram demonstrated passage of barium through the stoma. Within two weeks of discharge, the patient reported frequent vomiting with intermittent tolerance of very thin blenderized foods. She received weekly intravenous therapy to maintain hydration for approximately eight weeks after the operation. Dilation with the pediatric endoscope failed but was accomplished with the passage and distention of a balloon catheter. The catheter was manipulated through the stoma. After this procedure, she tolerated clear liquids without emesis, and her diet was advanced to solid foods within four weeks. Repeated dilation was not necessary. Very rarely, it may be necessary to correct the stomal obstruction surgically. Case Study. A 26-year-old woman weighed 378lb when she underwent a gastric restrictive operation. During the procedure, the nasogastric tube was passed without difficulty through the stoma. A small hematoma was noted on the lesser curvature. The nasogastric tube was removed on the third postoperative day, and the patient received nothing by mouth for the next 24 hr. After this, she tolerated clear liquids and thinned, pureed foods at a controlled rate of 30 ml over 5 min until she felt full. She was discharged six days after the operation, tolerating liquid oral intake without nausea or vomiting. Twelve days after discharge, the patient reported a build-up of mucus in the pouch and vomiting. She tolerated small amounts of milk and blenderized foods. She was advised to discontinue all dairy products and to sip small amounts of dissolved meat tenderizer in warm water for the mucus. In the following weeks, the "post-nasal drip" intensified with the onset of hay fever. She reported increased frequency of vomiting and a decreased fluid intake. She was readmitted to the hospital 30 days after the operation because of dehydration. An upper gastrointestinal roentgenogram demonstrated a complete obstruction of the stomach at the staple line. No barium passed to the distal stomach when she was examined under the fluoroscope 45 min after drinking the barium. She was returned to the operating room where gastrogastrostomy was performed, and a gastrostomy tube inserted in the distal portion of the stomach. She was discharged with the gastrostomy tube for supplementary feedings. During the following nine months, she continued to experience daily vomiting of mucus secondary to a post-nasal drip exacerbated by allergies. Antihistamines were helpful. She tolerated small amounts of liquids by mouth and supplemented her diet with water via the gastrostomy tube. Approximately six months postoperatively, this patient began to tolerate small amounts of soft foods. Nine months after operation, the tube "fell out." At present, she is eating small amounts of food and experiences intermittent vomiting related to the accumulation of mucus in the pouch. During the nine-month period, this patient lost a total of 131 pounds. Stomal Ulcers The occurrence of stomal ulcers has been reported by major university obesity centers to be as high as 3.1 per cent. 11 Since the gastric pouch has

1188

EDWAHD

w.

~AHTIN,

JR,

CATHY MOJZISIK AND LAHHY C. CAHEY

been made even smaller and has been routinely measured, the incidence is less (1 per cent). 11 Older patients appear to be more likely than younger patients to develop stomal ulcers. Thomboembolism Thomboembolism is the most feared complication of gastric restrictive procedures and merits much preoperative, operative, and postoperative attention. Prophylactic heparin (5000 U subcutaneously every 8 to 12 hr) is given before operation and continued until the patient is fully ambulatory and ready for discharge. During the surgical procedure, the head of the operating room table is tilted up 15 to 20° to enhance upper abdominal exposure, but every 30 min the position of the table should be reversed to accomplish emptying of blood from the legs and help to prevent venous pooling, lessening the possibility of clot formation. Postoperatively, early ambulation is mandatory, and vigorous attention must be paid to averting formation of blood clots. Pulmonary embolism is the leading cause of postoperative death in most large series. In our series of over 500 procedures, four of the seven deaths resulted from pulmonary emboli. Atelectasis and Pneumonia Among early postoperative problems that must be watched for and prevented are atelectasis and pneumonia. It is important that the patient be instructed preoperatively in the use of the Respirex and that he be taught proper deep breathing and coughing techniques. Preoperative levels of blood gases should be determined to serve as base line information. Despite the institution of active pulmonary physiotherapy, the incidence of pneumonia has been shown to be 3. 5 per cent in most large series of patients undergoing gastric restrictive procedures. 10 Wound Infection and Hernia Prompt recognition and treatment quickly solve problems of wound infection. Pain, erythema, and induration are sometimes far more subtle in the obese patient than in those of normal weight. Most wound infections can be treated by opening the wound, removing the skin staples, and irrigating the wound with Betadine solution or a similar preparation. This is a procedure that usually can be carried out at the patient's bedside. In contrast to the expected rate of occurrence of wound infection of 13 per cent 6 in patients undergoing gastric bypass when the gastrointestinal tract is entered and the procedure is longer, the rate of occurrence of wound infection in patients undergoing gastric restrictive procedures has been 16.4 per cent in our series of over 500 patients. 2 The rate of ventral hernia occurrence has been 12.2 per cent. Metabolic Sequelae Late complications after gastric restrictive procedures are just emerging, and careful observation will be required over the next few years to assess them accurately. Symptoms of malnutrition may be delayed and subtle, and they are only now being recognized and reported. Neurologic symptoms vary from severe, resembling Guillain-Barre or Wernicke's

COMPLICATIONS OF GASTRIC RESTRICTIVE OPERATIONS IN OBESE PATIENTS

1189

syndromes with neurologic sequelae, to subtle dizziness, weakness, peripheral neuropathy, postural hypotension, double vision, and varying degrees of mental confusion. 5 Whether this syndrome results from a vitamin deficiency, possibly vitamin B1, or a combination of metabolic abnormalities such as ketosis, mineral and protein depletion, carnitine deficiency, or hyperuricemia, is not known at present. However, when neurologic symptoms are recognized, action should be prompt. We have administered Betalin and B12 intramuscularly, oral thiamine, 100 mg daily, and multiple oral vitamins to patients exhibiting vague neurologic symptoms. When more severe neurologic problems occur, patients should be hospitalized, and intramuscular injections of B complex and B 12 , intravenous thiamine, 400 mg, and total parenteral nutrition begun immediately. Rapid attention to neurologic sequelae is mandatory.

SUMMARY After gastric restrictive procedures in morbidly obese persons, the reported morbidity is 15 per cent, and mortality is 1 per cent. Pulmonary embolism continues to be the most serious complication, and subcutaneous heparin and early ambulation remain mandatory in its prevention. Gastric perforations must be recognized early and treated promptly, as must the more common postoperative complications, namely pneumonia, atelectasis, and wound infection. Late metabolic sequelae are being recognized more frequently, and major neurologic Wernicke-like and Guillain-Barre-like syndromes are being reported. Less dramatic neurologic conditions are also being recognized more frequently. Early recognition and prompt nutritional therapy are essential. Lessening the failure rate after gastric restrictive procedures and attaining an acceptable weight loss (within 50 per cent of the ideal body weight sustained for more than two years) remains the major goal of the surgical treatment of morbid obesity, with the hope that more successful medical intervention will obviate the surgical treatment of morbidly obese persons.

REFERENCES l. Abraham, S., and Johnson, C. L.: Prevalence of severe obesity in adults in the United States. Am. J. Clin. Nutr., 33:364, 1980. 2. Carey, L. C., Martin, E. W. Jr., and Mojzisik C: The surgical treatment of morbid obesity. Curr. Probl. Surg., in press. 3. Drenick, E. J., Bale, G. S., Seltzer, F., et a!.: Excessive mortality and causes of death in morbidly obese men. J.A.M.A., 243:443, 1980. 4. Eskino, S. J., Massie, J. D., Born, M. L., eta!.: Experimental study of double staple lines in gastric partitions. Surg. Gynecol. Obstet., 152:751, 1981. 5. Feit, H., Glasberg, M., Ireton, C., eta!.: Peripheral neuropathy and starvation after gastric partitioning for morbid obesity. Ann. Intern. Med., 96:453, 1982. 6. Mason, E. E.: Surgical Treatment of Obesity. Philadelphia, W. B. Saunders, 1981. 7. Mason, E. E., and Ito, C.: Gastric bypass in obesity. SuRe. CUI'\. NORTH AM., 47:1345, 1967.

1190

EDWARD

w.

MARTIN,

JR., CATHY MOJZISIK AND LARRY c.

CAREY

8. Metropolitan Life Insurance Company: Mortality among overweight women. Stat. Bull. Metropol. Life Insur., Co., 41:1, 1960. 9. Metropolitan Life Insurance Company: Mortality among overweight men. Bull. Metropol. Life Insur. Co., 41:6, 1960. 10. Peltier, G., Hermrech, A. S., Moffat, R. E., et a!.: Complications following gastric bypass procedures for morbid obesity. Surgery, 86:648, 1979. 11. Printen, J. J., Scott, D., and Mason, E. E.: Stomal ulcers after gastric bypass. Arch. Surg., 115:525, 1981. Department of Surgery The Ohio State University College of Medicine 410 West Tenth Avenue Columbus, OH 43210