- Email: [email protected]
Complications of bariatric surgery: the acute care surgeon’s experience
The American Journal of Surgery (2015) -, -–-
Complications of bariatric surgery: the acute care surgeon’s experience Joel F. Bradley, III, M.D., Samuel W. Ross, M.D., M.P.H., Ashley Britton Christmas, M.D., F.A.C.S., Peter E. Fischer, M.D., F.A.C.S., M.S., Gaurav Sachdev, M.D., F.A.C.S., Brant Todd Heniford, M.D., F.A.C.S., Ronald F. Sing, D.O., F.A.C.S.* Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
KEYWORDS: Bariatric surgery; Acute care surgery; Bariatric emergencies; Bariatric complications; Bariatric outcomes
Abstract BACKGROUND: Complications of bariatric surgeries are common, can occur throughout the patient’s lifetime, and can be life-threatening. We examined bariatric surgical complications presenting to our acute care surgery service. METHODS: Records were reviewed from January 2007 to June 2013 for patients presenting with a complication after bariatric surgery. RESULTS: Laparoscopic Roux-en-Y gastric bypass was the most common index operation (n 5 20), followed by open Roux-en-Y gastric bypass (n 5 6), laparoscopic gastric band (n 5 4), and vertical banded gastroplasty (n 5 3). Diagnoses included internal hernia (n 5 10), small bowel obstruction (n 5 5), lap band restriction (n 5 4), biliary disease (n 5 3), upper GI bleeding or ulcer (n 5 3), ischemic bowel (n 5 2), marginal ulcer (n 5 2), gastric outlet obstruction (n 5 2), perforated ulcer (n 5 2), intussusception (n 5 1), and incarcerated ventral hernia (n 5 1). Operations were required in 91% of the patients. Laparoscopic outcomes were similar to open; however, open cases were more emergent (23.5% vs 69.2%) and had longer hospital length of stay (4.8 6 3.5 vs 11.0 6 10.3 days, P , .05). All patients survived. CONCLUSIONS: The acute care surgeon will encounter complications of bariatric surgery. Internal hernias or obstructive etiologies are the most common presentations and often require emergent or urgent surgery. Ó 2015 Elsevier Inc. All rights reserved.
Responding to the obesity epidemic in the United States and around the world has become a major focus of health care. The only proven, long-term approach to substantial weight loss and treatment of obesity-associated comorbidities is
The authors declare no conflicts of interest. Presented at the Southwestern Surgical Congress 2014. * Corresponding author. Tel.: 11-704-355-1311; fax: 11-704-355-5619. E-mail address: [email protected] Manuscript received August 22, 2014; revised manuscript January 21, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.03.004
bariatric surgery.1–3 Demand for bariatric procedures steadily increased from 1988 to 2008, when over 220,000 bariatric operations were performed in the United States and Canada4–6; demand has since leveled out to just over 100,000 cases per year.7,8 However, while the number of bariatric procedures performed remains stable, the incidence of complications arising from former bariatric surgery rises with each passing year as a higher percentage of the population are former bariatric patients. The significance of this growing volume of patients is that bariatric weight loss procedures have short- and long-term
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complications that are unique to the individual operation and that directly affect the practice of the acute care surgeon. Aside from the perioperative complications9 are the potentially serious postoperative complications of internal hernia, bowel obstruction, marginal ulcer, slipped bands, and strictures, among others,10 and risk for these complications persists without expiration, following bariatric patients for life. Complication rates following bariatric surgery, it should be noted, have been found to increase with patient age.11 National population data demonstrate that postoperative morbidity rates have been as high as 5.4% for gastric banding, 6.5% for sleeve gastrectomy, and 9.7% for Roux-en-Y gastric bypass patients (RYGB).10 Finally, because of the nature of bariatric surgery complications, patients are likely to present acutely and not necessarily to the center where the bariatric procedure was performed, especially as more time passes from the index procedure. Coupling this lifetime risk of complications with increasing prevalence of the procedure yields a greater number of potential patients presenting acutely to nonbariatric surgeons. The surgical literature is sparse regarding the presentation of bariatric surgery patients with acute complications to nonbariatric surgeons, and to our knowledge, there have been no studies on the surgical management of these patients by the acute care surgeon. Our objective was to describe a series of acute surgical complications in bariatric patients who presented to an acute care surgery service, and we hypothesized that the majority of complications could be managed with minimally invasive procedures.
approved by the Institutional Review Board of Carolinas Medical Center.
Methods Study design This study is a retrospective review of all bariatric surgery complications presenting to our acute care surgery service at a quaternary care hospital. A prospectively maintained complications log was queried for patients presenting with a surgical complication resulting from a bariatric surgery procedure from January 2007 to June 2013. Because our hospital system has a Bariatric Center of Excellence, and complications resulting from procedures performed by staff bariatric surgeons are managed by the index surgeon, those patients are not included in this review. Patients included in the series had their index surgery performed at another institution or by private surgeons who then transferred them to our center. Bariatric surgery procedures were defined as any surgical procedure for weight loss and included open or laparoscopic RYGB, vertical banded gastroplasty, duodenal switch, vertical sleeve gastrectomy, and gastric banding. Data collected included demographics, index bariatric procedure, diagnosis, treatment, surgical interventions, urgency of treatment, length of stay (LOS), disposition, and mortality. Patients were compared by surgical approach used for complication management. The study protocol was
Statistical analysis All data were stored and analyzed using SAS Software version 9.3 (SAS Institute, Inc, Cary, NC). Frequencies of categorical variables are expressed as a percentage of the group of origin, and continuous variables are reported as means 6 standard deviation. Laparoscopic and open surgical cases were compared using univariate tests, including Wilcoxon Mann–Whitney and Kruskal–Wallis tests to compare continuous and ordinal variables; Pearson chi-square and Fisher’s exact t tests were used for comparison of categorical variables. All group comparisons were unpaired. For all statistical analysis, significance was set at P value less than .05.
Results Patient characteristics and complications A total of 33 patients presented over the study period. Patient characteristics are presented in Table 1. The majority of patients were middle-aged women, whose index bariatric procedure was a laparoscopic RYGB. The next most common index procedures were open RYGB, laparoscopic gastric banding, and vertical banded gastroplasty. In general, patients had significant weight loss after their bariatric surgery, and average body mass index on presentation (31.7 6 8.9 kg/m2) was in Class I obesity range. Patients’ presenting complications are listed in Table 2. Obstructive complications, as a whole, were the most common presentation, accounting for 25 (76%) patients. The most common diagnosis was an internal hernia, 2 cases of which resulted in bowel strangulation, ischemic and necrotic intestine, and subsequent resection. Next most common diagnosis was adhesive disease at the bariatric surgical site causing obstruction (15%), followed by gastric band slippage, and restriction (12%). Less common
Table 1 Patient characteristics of bariatric patients presenting to acute care surgeons* Number Age (years) Female Body mass index (kg/m2) Index bariatric procedure Laparoscopic Rou-en-Y gastric bypass Open Roux-en-Y gastric bypass Laparoscopic gastric banding Vertical banded gastroplasty
33 42.5 6 10.5 31 (94) 31.7 6 8.9 20 (61) 6 (19) 4 (12) 3 (9)
*Data are represented as number (percentage) for categorical variable and mean 6 standard deviation for continuous variables.
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3
Table 2 Presenting complications of bariatric patients to acute care surgeons* Internal hernia Ischemic bowel (secondary to internal hernia) Adhesive small bowel obstruction Laparoscopic band restriction Biliary disease Upper gastrointestinal bleed/ulcer Perforated ulcer Gastric outlet obstruction Intussusception Ventral incisional hernia
10 (30) 2 (6) 5 4 3 3 2 2 1 1
(15) (12) (9) (9) (6) (6) (3) (3)
*Data are represented as number (percentage).
diagnosis was unremitting symptomatic cholelithiasis after RYGB. There were 4 cases of marginal ulcer, 2 of which presented perforated and were in critical condition. One patient presented with delayed bleeding from a staple line after recent gastric bypass. Curiously, 1 patient presented with intussusception at the jejunojejunostomy, where the anastomosis acted as a lead point. Of note, all 3 patients with biliary disease also had internal hernias at Peterson’s defect that were closed at the time of cholecystectomy.
Management Operative intervention was required in 30 (91%) patients. Of the operative interventions, 17 (57%) were performed laparoscopically and 13 (43%) managed by open operations. Seven of the 13 (53.8%) open cases were started as diagnostic laparoscopy and were converted to open. Reasons for conversion included dense adhesions (3), gross perforation/ischemic bowel (2), or lack of working room secondary
Table 3
to bowel distension (2). An emergent operation (,4 hours) was required in 13 (43%) patients, while an additional 6 (20%) required an urgent operation (4 to 24 hours). Surgeries performed were specific to the complication diagnosis and patient condition. Internal hernias were reduced and mesenteric defect closed in all cases, and bowel resection was required in 2 cases. Gastric band restriction was managed with surgical removal in 3 cases (75%), and adhesive disease was managed with mass adhesiolysis. All 3 patients with a previous vertical banded gastroplasty presented with obstruction at the gatroplasty site and were converted to RYGB. The case of intussusception was managed with laparoscopic reduction and pexy of the proximal and distal bowel to the abdominal wall. Three patients with symptomatic cholelithiasis underwent laparoscopic cholecystectomy and incidental mesenteric defect closure. Nonoperative treatment included 2 upper endoscopies for bleeding or ulcer and 1 gastric band deflation for obstruction. There were no mortalities, and all patients were discharged home with a mean LOS of 7.3 6 7.7 days.
Laparoscopic versus open surgery When comparing the laparoscopic and open groups, there was no difference in age, body mass index, comorbidities, or index bariatric procedure (Table 3), and white blood cell count and hemoglobin levels were similar on admission. Outcomes between the 2 groups were also similar with no difference in complications (Table 4). However, the open cases had a longer LOS by an average of 6 days (P 5 .04). The open cases also had a higher urgency level with more emergent cases (P 5 .02). Open surgery was required for more critically ill patients and complex surgical pathology, including strangulated internal hernias, bleeding, perforations, and bowel ischemia.
Patient characteristics: laparoscopic versus open management
Age Female Body mass index (kg/m2) Comorbidities (%) Hypertension Diabetes CAD Index bariatric procedure Laparoscopic Rou-en-Y gastric bypass Open Roux-en-Y gastric bypass Laparoscopic gastric banding Vertical banded gastroplasty Admission WBC (mL) Admission hemoglobin (g/dL)
Laparoscopic n 5 17 (%)
Open n 5 13 (%)
P value
44.2 6 11.4 16 (94.1) 31.4 6 8.5
41.8 6 8.2 11 (84.6) 31.2 6 9.3
NS NS NS
4 (23.5) 4 (23.5) 2 (11.8)
4 (30.8) 3 (23.1) 0
NS NS NS
8 (47.2) 3 (17.6) 3 (17.6) 3 (17.6) 8.8 6 3.3 12.8 6 1.9
11 (84.6) 2 (15.4) 0 0 8.6 6 2.6 12.4 6 5.1
NS
CAD 5 coronary artery disease; NS 5 nonsignificant; WBC 5 white blood count.
NS NS
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4 Table 4
Patient outcomes: laparoscopic versus open management
Urgency Emergent Urgent Nonemergent/urgent Converted from laparoscopic Complications Surgical site infection Marginal ulcer Readmission Reoperation ICU length of stay (days) Hospital length of stay (days) Mortality
Laparoscopic n 5 17 (%)
Open n 5 13 (%)
4 (23.5) 3 (17.6) 10 (33.3)
9 (69.2) 3 (23.1) 1 (7.7) 7 (53.8) 9 (69.2) 2 (15.4) 1 (7.7) 4 (30.8) 2 (15.4) 3.4 6 9.2 11.0 6 10.3 0
6 (35.3) 2 (11.8) 2 (11.8) 2 (11.8) 0 0 4.8 6 3.5 0
P value .025
NS NS NS NS NS NS .040 NS
ICU 5 intensive care unit; NS 5 nonsignificant.
Comments Our study demonstrates that simple urgent and emergent complications are encountered by the general or acute care surgeon with some frequency. Over the 6-year period, 33 patients presented primarily to the acute care surgery service as transfers or referrals, and it is likely that at other facilities, where there are no staff bariatric surgeons, surgeons on call would encounter these issues even more commonly. While the authors cannot know how many patients presented to the emergency department with a bariatric surgery complaint, and thus derive the true incidence of these complications, general surgeons should still be familiar with the new bariatric anatomy and the subsequent complications and surgical management of these pathologies. This is highlighted by the fact that 39.4% of patients presented with an emergent etiology and required emergent, life-saving surgery, where there would not have been time to consult a bariatric surgeon or transfer to a bariatric center. The distribution of bariatric complications in this series is in concordance with results presented in previous publications on the topic and predominately features complications following RYGB and gastric banding.9,10,12 The most common acute presentation in our series was obstruction, most often because of internal hernia after RYGB (30%). Internal hernias are a well-known complication following RYGB and have been reported extensively.13–16 Thorough understanding of the new bariatric anatomy is essential for accurate and timely diagnosis. For instance, 4 different potential spaces for internal hernia can occur after RYGB: mesenteric (if retrocolic in position), mesojejunal, jejunojejunal, and Peterson’s, with the last 2 being most common.17,18 While the reports of bowel obstruction from internal hernias are low, ranging from .2% to 9%,19–21 the incidence of an obstruction leading to infarction and necrosis of large sections of small intestine can be devastating. Computed
tomography can help lead to diagnosis (through a swirl sign or evidence of ischemia) but can miss an internal hernia 11% to 9% of the time.22 Timely intervention for suspected internal hernia is fundamental to ensuring bowel viability, and diagnostic laparoscopy allows for quick assessment of the intestine. Evaluation of all potential internal hernia sites is essential, as some bariatric surgeons do not routinely close mesenteric defects,23,24 and, even when closed at the index surgery, as many as 83% of patients spontaneously open their jejunojejunostomy mesenteric defect after weight loss.25 Additional consideration for anastomotic leak (1.7% to 2.1%), marginal ulcer (.3% to 6%), gastrointestinal bleed (.6% to 1.9%), wound complications (3.0% to 6.6%), pulmonary embolism (.4% to .8%), and pneumonia should be considered in the acute postoperative period after RYGB, as it would be with any other major gastrointestinal operation.12,26 Adhesive disease (15%) and lap band restriction (12%) were the cause of other common presenting symptoms of obstruction. Adhesive disease at the bariatric surgical site (ie, anastomosis, band, etc) is an exceedingly rare cause of small bowel obstruction, and its incidence is reported between .7% and .9% with a mean follow-up of 21 to 43 months.14,27 However, adhesive disease persists with time and can present, over the lifetime of the patient, as a bowel obstruction at the site. Importantly, patients presenting with bowel obstruction from adhesive disease after RYGB are indiscernible from those with internal herniation and surgeons must have a low threshold to evaluate these patients with diagnostic laparoscopy. If a timely diagnosis is not performed, close attention must be given to monitoring the patient, as whole mid-gut volvulus is a potential devastating complication. Gastric banding has its own unique set of complications: band slippage (1% to 20%), which can cause dysphagia and, potentially, gastric outlet obstruction; port site infection (rare); and band erosion (,4%), which can
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cause perforation and lead to abdominal sepsis.12,28 When recognized early, these complications are amendable to management with minimally invasive techniques (77.8% either laparoscopic lysis of adhesions, gastric band removal, or conversion of vertical banded gastroplasty to RYGB), and conversion to open was only necessary when the degree of bowel distention made laparoscopy untenable. The above complications represent the bulk of emergencies encountered by a nonbariatric surgeon, but several other challenging complications were encountered in this series. Anastomotic ulcer disease (marginal ulcer) was present in 15% of patients and resulted in perforation and sepsis in 2 patients and gastrointestinal bleeding in 1 patient. While training in surgical and endoscopic management of these emergent complications is mandatory for acute care surgeons, these patients often present as consults for simple abdominal pain from the emergency department, so knowledge of medical management is also required.29 This knowledge begins with an understanding of the risk factors associated with marginal ulcer formation. These include smoking, non-steroidal anti-inflammatory drug use, Helicobacter Pylori infection, and foreign body (nonabsorbable suture, staples). Furthermore, knowledge of the new bariatric anatomy is crucial to understanding potential reasons for ulcers. A large pouch containing more parietal cells will create an acidic environment leading to ulcer formation. Most ulcers can be managed medically by removing the risk factors (stop non-steroidal anti-inflammatory drug, cease smoking, treat H. Pylori). However, if the underlying cause is anatomical (large pouch, foreign body, fistula), then a revision may be the best approach for treatment. Additionally, RYBG usually results in rapid weight loss, which can precipitate biliary cholesterol stones as fat energy reserves are mobilized, and symptomatic cholelithiasis can occur in 6.9% to 12% of patients.30,31 As our series indicates, when the abdomen is entered for any operation in a patient with a history of RYGB, it is important to visualize the entire abdomen and inspect any potential internal hernia site to close mesenteric defects (3/3 open defects during cholecystectomy). This series is also the first to compare bariatric complications management by acute care surgeons with surgical approach, and we were able to show that patients of all the index procedure types were successfully managed with minimally invasive techniques. Even though 43% of surgical patients ultimately required an open operation, only 6 (20%) had an open operation from the beginning, mandated by patient’s critical condition. Because the most common bariatric complications presenting to an acute care service are amendable to laparoscopic repair, all general, emergency, and acute care surgeons who take call should be facile with minimally invasive techniques and the unique anatomy of bariatric cases. Surgeons should be familiar with the new bariatric anatomy of RYGB, gastric banding, and sleeve gastrectomy, but also less popular procedures such as biliopancreatic diversion, banded gastroplasty, and duodenal switch.12,32 What may be a unique benefit to acute care surgeons, when compared with their
5 laparoscopic or bariatric cohorts, is their early recognition of shock and ability to make a quick shift in mentality to a damage control operation. Conversely, they must also work harder to maintain their laparoscopic skill set if their primary case load does not contain complex laparoscopic cases. Many general and acute care surgeons may think that these complications are rare and do not pertain to their practice; however, as bariatric procedures have regionalized, patients’ emergent complications are often seen by the local surgeon not at the regional center. Regardless of data that indicate patient outcomes are similar between bariatric centers and community practice,33,34 bariatric surgeries have centralized to centers of excellence because of Centers for Medicare and Medicaid reimbursement policies. Patients from rural areas then return to their communities and when emergent complications arise, it is the local general surgeon who must triage and appropriately treat these complications. As healthcare costs increase, many patients are also turning to surgery in low-income countries to reduce personal costs expecting local surgeons to manage any complications arising from their medical tourism, which is often an incorrect or ill-performed surgery.35 These trends and our series highlight the need for those who take unassigned call to be well versed in bariatric complications and have an ability to diagnose, triage, and treat emergent and urgent conditions with a versatile skill set. There are obvious limitations to our study because of its retrospective nature and design as a case series. While we cannot estimate the incidence of bariatric complications presenting to our center, or have the patient or operative data from the index surgery, our experience provides a valuable context and comparison for what other similar services can expect to experience. Additionally, our institution is renowned for the permeation of minimally invasive techniques throughout all surgical divisions, and this skill set may not be the same at other centers, although an argument can be made that it should be mandatory for all acute care surgeons. Indeed, as our senior author can attest, extensive experience with laparoscopic and bariatric procedures comprises an invaluable knowledge base for treating these and many other complications in trauma and acute care surgery.
Conclusions Bariatric surgery is a commonplace in the United States and can result in a unique set of complications and emergencies that all general surgeons should be familiar with. Complications can be managed by laparoscopy or endoscopy in many cases, but patient’s condition, individual diagnosis, and surgeon level of comfort should guide treatment decisions. Additionally, severe surgical pathologies such as bleeding, perforation, strangulation, and ischemia are less likely to be managed with minimally
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invasive techniques. We recommend that when diagnosis is unclear for former bariatric surgery patients, diagnostic laparoscopy be performed to answer definitively if a surgical complication is present.
18. Hussain A, El-Hasani S. Bariatric emergencies: current evidence and strategies of management. World J Emerg Surg 2013;8:58. 19. Elms L, Moon RC, Varnadore S, et al. Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution. Surg Endosc 2014;28:1624–8. 20. Rodriguez A, Mosti M, Sierra M, et al. Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced? Obes Surg 2010;20:1380–4. 21. Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87–91. 22. Lockhart ME, Tessler FN, Canon CL, et al. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR Am J Roentgenol 2007;188: 745–50. 23. Finnell CW, Madan AK, Tichansky DS, et al. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007;17: 145–8. 24. Madan AK, Lo Menzo E, Dhawan N, et al. Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009;19:549–52. 25. Hope WW, Sing RF, Chen AY, et al. Failure of mesenteric defect closure after Roux-en-Y gastric bypass. JSLS 2010;14:213–6. 26. Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138: 957–61. 27. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13: 596–600. 28. Kirshtein B, Lantsberg L, Mizrahi S, et al. Bariatric emergencies for non-bariatric surgeons: complications of laparoscopic gastric banding. Obes Surg 2010;20:1468–78. 29. Kalaiselvan R, Exarchos G, Hamza N, et al. Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis 2012;8:423–8. 30. Tucker ON, Fajnwaks P, Szomstein S, et al. Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery? Surg Endosc 2008;22:2450–4. 31. D’Hondt M, Sergeant G, Deylgat B, et al. Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass? J Gastrointest Surg 2011;15: 1532–6. 32. Cossu ML, Meloni GB, Alagna S, et al. Emergency surgical conditions after biliopancreatic diversion. Obes Surg 2007;17:637–41. 33. Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg 2004;188:105–10. 34. Dimick JB, Nicholas LH, Ryan AM, et al. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 2013;309:792–9. 35. Birch DW, Vu L, Karmali S, et al. Medical tourism in bariatric surgery. Am J Surg 2010;199:604–8.
References 1. Adams TD, Davidson LE, Litwin SE, et al. Health benefits of gastric bypass surgery after 6 years. JAMA 2012;308:1122–31. 2. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567–76. 3. Jimenez A, Casamitjana R, Flores L, et al. Long-term effects of sleeve gastrectomy and Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus in morbidly obese subjects. Ann Surg 2012;256:1023–9. 4. Nguyen NT, Masoomi H, Laugenour K, et al. Predictive factors of mortality in bariatric surgery: data from the Nationwide Inpatient Sample. Surgery 2011;150:347–51. 5. Davis MM, Slish K, Chao C, et al. National trends in bariatric surgery, 1996-2002. Arch Surg 2006;141:71–4; discussion, 75. 6. Trus TL, Pope GD, Finlayson SR. National trends in utilization and outcomes of bariatric surgery. Surg Endosc 2005;19:616–20. 7. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427–36. 8. Livingston EH. The incidence of bariatric surgery has plateaued in the U.S. Am J Surg 2010;200:378–85. 9. Longitudinal Assessment of Bariatric Surgery (LABS) Consortium, Flum DR, Belle SH, King WC, et al. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med 2009;361: 445–54. 10. Chebli JE, Schindler R. The results of a surgical complication protection program (BLIS, Inc.) for private pay bariatric patients in the U.S.: 2006-2011. Obes Surg 2012;22:1798–801. 11. Scozzari G, Passera R, Benvenga R, et al. Age as a long-term prognostic factor in bariatric surgery. Ann Surg 2012;256:724–8; discussion, 728–9. 12. Campanile FC, Boru CE, Rizzello M, et al. Acute complications after laparoscopic bariatric procedures: update for the general surgeon. Langenbecks Arch Surg 2013;398:669–86. 13. Capella RF, Iannace VA, Capella JF. Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity. J Am Coll Surg 2006;203:328–35. 14. Hwang RF, Swartz DE, Felix EL. Causes of small bowel obstruction after laparoscopic gastric bypass. Surg Endosc 2004;18:1631–5. 15. Nelson LG, Gonzalez R, Haines K, et al. Spectrum and treatment of small bowel obstruction after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006;2:377–83; discussion, 383. 16. Nguyen NT, Huerta S, Gelfand D, et al. Bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2004;14:190–6. 17. Monkhouse SJ, Morgan JD, Norton SA. Complications of bariatric surgery: presentation and emergency managementda review. Ann R Coll Surg Engl 2009;91:280–6.
Complications of bariatric surgery: the acute care surgeon’s experience Joel F. Bradley, III, M.D., Samuel W. Ross, M.D., M.P.H., Ashley Britton Christmas, M.D., F.A.C.S., Peter E. Fischer, M.D., F.A.C.S., M.S., Gaurav Sachdev, M.D., F.A.C.S., Brant Todd Heniford, M.D., F.A.C.S., Ronald F. Sing, D.O., F.A.C.S.* Department of General Surgery, Carolinas Medical Center, Charlotte, NC, USA
KEYWORDS: Bariatric surgery; Acute care surgery; Bariatric emergencies; Bariatric complications; Bariatric outcomes
Abstract BACKGROUND: Complications of bariatric surgeries are common, can occur throughout the patient’s lifetime, and can be life-threatening. We examined bariatric surgical complications presenting to our acute care surgery service. METHODS: Records were reviewed from January 2007 to June 2013 for patients presenting with a complication after bariatric surgery. RESULTS: Laparoscopic Roux-en-Y gastric bypass was the most common index operation (n 5 20), followed by open Roux-en-Y gastric bypass (n 5 6), laparoscopic gastric band (n 5 4), and vertical banded gastroplasty (n 5 3). Diagnoses included internal hernia (n 5 10), small bowel obstruction (n 5 5), lap band restriction (n 5 4), biliary disease (n 5 3), upper GI bleeding or ulcer (n 5 3), ischemic bowel (n 5 2), marginal ulcer (n 5 2), gastric outlet obstruction (n 5 2), perforated ulcer (n 5 2), intussusception (n 5 1), and incarcerated ventral hernia (n 5 1). Operations were required in 91% of the patients. Laparoscopic outcomes were similar to open; however, open cases were more emergent (23.5% vs 69.2%) and had longer hospital length of stay (4.8 6 3.5 vs 11.0 6 10.3 days, P , .05). All patients survived. CONCLUSIONS: The acute care surgeon will encounter complications of bariatric surgery. Internal hernias or obstructive etiologies are the most common presentations and often require emergent or urgent surgery. Ó 2015 Elsevier Inc. All rights reserved.
Responding to the obesity epidemic in the United States and around the world has become a major focus of health care. The only proven, long-term approach to substantial weight loss and treatment of obesity-associated comorbidities is
The authors declare no conflicts of interest. Presented at the Southwestern Surgical Congress 2014. * Corresponding author. Tel.: 11-704-355-1311; fax: 11-704-355-5619. E-mail address: [email protected] Manuscript received August 22, 2014; revised manuscript January 21, 2015 0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.03.004
bariatric surgery.1–3 Demand for bariatric procedures steadily increased from 1988 to 2008, when over 220,000 bariatric operations were performed in the United States and Canada4–6; demand has since leveled out to just over 100,000 cases per year.7,8 However, while the number of bariatric procedures performed remains stable, the incidence of complications arising from former bariatric surgery rises with each passing year as a higher percentage of the population are former bariatric patients. The significance of this growing volume of patients is that bariatric weight loss procedures have short- and long-term
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complications that are unique to the individual operation and that directly affect the practice of the acute care surgeon. Aside from the perioperative complications9 are the potentially serious postoperative complications of internal hernia, bowel obstruction, marginal ulcer, slipped bands, and strictures, among others,10 and risk for these complications persists without expiration, following bariatric patients for life. Complication rates following bariatric surgery, it should be noted, have been found to increase with patient age.11 National population data demonstrate that postoperative morbidity rates have been as high as 5.4% for gastric banding, 6.5% for sleeve gastrectomy, and 9.7% for Roux-en-Y gastric bypass patients (RYGB).10 Finally, because of the nature of bariatric surgery complications, patients are likely to present acutely and not necessarily to the center where the bariatric procedure was performed, especially as more time passes from the index procedure. Coupling this lifetime risk of complications with increasing prevalence of the procedure yields a greater number of potential patients presenting acutely to nonbariatric surgeons. The surgical literature is sparse regarding the presentation of bariatric surgery patients with acute complications to nonbariatric surgeons, and to our knowledge, there have been no studies on the surgical management of these patients by the acute care surgeon. Our objective was to describe a series of acute surgical complications in bariatric patients who presented to an acute care surgery service, and we hypothesized that the majority of complications could be managed with minimally invasive procedures.
approved by the Institutional Review Board of Carolinas Medical Center.
Methods Study design This study is a retrospective review of all bariatric surgery complications presenting to our acute care surgery service at a quaternary care hospital. A prospectively maintained complications log was queried for patients presenting with a surgical complication resulting from a bariatric surgery procedure from January 2007 to June 2013. Because our hospital system has a Bariatric Center of Excellence, and complications resulting from procedures performed by staff bariatric surgeons are managed by the index surgeon, those patients are not included in this review. Patients included in the series had their index surgery performed at another institution or by private surgeons who then transferred them to our center. Bariatric surgery procedures were defined as any surgical procedure for weight loss and included open or laparoscopic RYGB, vertical banded gastroplasty, duodenal switch, vertical sleeve gastrectomy, and gastric banding. Data collected included demographics, index bariatric procedure, diagnosis, treatment, surgical interventions, urgency of treatment, length of stay (LOS), disposition, and mortality. Patients were compared by surgical approach used for complication management. The study protocol was
Statistical analysis All data were stored and analyzed using SAS Software version 9.3 (SAS Institute, Inc, Cary, NC). Frequencies of categorical variables are expressed as a percentage of the group of origin, and continuous variables are reported as means 6 standard deviation. Laparoscopic and open surgical cases were compared using univariate tests, including Wilcoxon Mann–Whitney and Kruskal–Wallis tests to compare continuous and ordinal variables; Pearson chi-square and Fisher’s exact t tests were used for comparison of categorical variables. All group comparisons were unpaired. For all statistical analysis, significance was set at P value less than .05.
Results Patient characteristics and complications A total of 33 patients presented over the study period. Patient characteristics are presented in Table 1. The majority of patients were middle-aged women, whose index bariatric procedure was a laparoscopic RYGB. The next most common index procedures were open RYGB, laparoscopic gastric banding, and vertical banded gastroplasty. In general, patients had significant weight loss after their bariatric surgery, and average body mass index on presentation (31.7 6 8.9 kg/m2) was in Class I obesity range. Patients’ presenting complications are listed in Table 2. Obstructive complications, as a whole, were the most common presentation, accounting for 25 (76%) patients. The most common diagnosis was an internal hernia, 2 cases of which resulted in bowel strangulation, ischemic and necrotic intestine, and subsequent resection. Next most common diagnosis was adhesive disease at the bariatric surgical site causing obstruction (15%), followed by gastric band slippage, and restriction (12%). Less common
Table 1 Patient characteristics of bariatric patients presenting to acute care surgeons* Number Age (years) Female Body mass index (kg/m2) Index bariatric procedure Laparoscopic Rou-en-Y gastric bypass Open Roux-en-Y gastric bypass Laparoscopic gastric banding Vertical banded gastroplasty
33 42.5 6 10.5 31 (94) 31.7 6 8.9 20 (61) 6 (19) 4 (12) 3 (9)
*Data are represented as number (percentage) for categorical variable and mean 6 standard deviation for continuous variables.
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3
Table 2 Presenting complications of bariatric patients to acute care surgeons* Internal hernia Ischemic bowel (secondary to internal hernia) Adhesive small bowel obstruction Laparoscopic band restriction Biliary disease Upper gastrointestinal bleed/ulcer Perforated ulcer Gastric outlet obstruction Intussusception Ventral incisional hernia
10 (30) 2 (6) 5 4 3 3 2 2 1 1
(15) (12) (9) (9) (6) (6) (3) (3)
*Data are represented as number (percentage).
diagnosis was unremitting symptomatic cholelithiasis after RYGB. There were 4 cases of marginal ulcer, 2 of which presented perforated and were in critical condition. One patient presented with delayed bleeding from a staple line after recent gastric bypass. Curiously, 1 patient presented with intussusception at the jejunojejunostomy, where the anastomosis acted as a lead point. Of note, all 3 patients with biliary disease also had internal hernias at Peterson’s defect that were closed at the time of cholecystectomy.
Management Operative intervention was required in 30 (91%) patients. Of the operative interventions, 17 (57%) were performed laparoscopically and 13 (43%) managed by open operations. Seven of the 13 (53.8%) open cases were started as diagnostic laparoscopy and were converted to open. Reasons for conversion included dense adhesions (3), gross perforation/ischemic bowel (2), or lack of working room secondary
Table 3
to bowel distension (2). An emergent operation (,4 hours) was required in 13 (43%) patients, while an additional 6 (20%) required an urgent operation (4 to 24 hours). Surgeries performed were specific to the complication diagnosis and patient condition. Internal hernias were reduced and mesenteric defect closed in all cases, and bowel resection was required in 2 cases. Gastric band restriction was managed with surgical removal in 3 cases (75%), and adhesive disease was managed with mass adhesiolysis. All 3 patients with a previous vertical banded gastroplasty presented with obstruction at the gatroplasty site and were converted to RYGB. The case of intussusception was managed with laparoscopic reduction and pexy of the proximal and distal bowel to the abdominal wall. Three patients with symptomatic cholelithiasis underwent laparoscopic cholecystectomy and incidental mesenteric defect closure. Nonoperative treatment included 2 upper endoscopies for bleeding or ulcer and 1 gastric band deflation for obstruction. There were no mortalities, and all patients were discharged home with a mean LOS of 7.3 6 7.7 days.
Laparoscopic versus open surgery When comparing the laparoscopic and open groups, there was no difference in age, body mass index, comorbidities, or index bariatric procedure (Table 3), and white blood cell count and hemoglobin levels were similar on admission. Outcomes between the 2 groups were also similar with no difference in complications (Table 4). However, the open cases had a longer LOS by an average of 6 days (P 5 .04). The open cases also had a higher urgency level with more emergent cases (P 5 .02). Open surgery was required for more critically ill patients and complex surgical pathology, including strangulated internal hernias, bleeding, perforations, and bowel ischemia.
Patient characteristics: laparoscopic versus open management
Age Female Body mass index (kg/m2) Comorbidities (%) Hypertension Diabetes CAD Index bariatric procedure Laparoscopic Rou-en-Y gastric bypass Open Roux-en-Y gastric bypass Laparoscopic gastric banding Vertical banded gastroplasty Admission WBC (mL) Admission hemoglobin (g/dL)
Laparoscopic n 5 17 (%)
Open n 5 13 (%)
P value
44.2 6 11.4 16 (94.1) 31.4 6 8.5
41.8 6 8.2 11 (84.6) 31.2 6 9.3
NS NS NS
4 (23.5) 4 (23.5) 2 (11.8)
4 (30.8) 3 (23.1) 0
NS NS NS
8 (47.2) 3 (17.6) 3 (17.6) 3 (17.6) 8.8 6 3.3 12.8 6 1.9
11 (84.6) 2 (15.4) 0 0 8.6 6 2.6 12.4 6 5.1
NS
CAD 5 coronary artery disease; NS 5 nonsignificant; WBC 5 white blood count.
NS NS
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4 Table 4
Patient outcomes: laparoscopic versus open management
Urgency Emergent Urgent Nonemergent/urgent Converted from laparoscopic Complications Surgical site infection Marginal ulcer Readmission Reoperation ICU length of stay (days) Hospital length of stay (days) Mortality
Laparoscopic n 5 17 (%)
Open n 5 13 (%)
4 (23.5) 3 (17.6) 10 (33.3)
9 (69.2) 3 (23.1) 1 (7.7) 7 (53.8) 9 (69.2) 2 (15.4) 1 (7.7) 4 (30.8) 2 (15.4) 3.4 6 9.2 11.0 6 10.3 0
6 (35.3) 2 (11.8) 2 (11.8) 2 (11.8) 0 0 4.8 6 3.5 0
P value .025
NS NS NS NS NS NS .040 NS
ICU 5 intensive care unit; NS 5 nonsignificant.
Comments Our study demonstrates that simple urgent and emergent complications are encountered by the general or acute care surgeon with some frequency. Over the 6-year period, 33 patients presented primarily to the acute care surgery service as transfers or referrals, and it is likely that at other facilities, where there are no staff bariatric surgeons, surgeons on call would encounter these issues even more commonly. While the authors cannot know how many patients presented to the emergency department with a bariatric surgery complaint, and thus derive the true incidence of these complications, general surgeons should still be familiar with the new bariatric anatomy and the subsequent complications and surgical management of these pathologies. This is highlighted by the fact that 39.4% of patients presented with an emergent etiology and required emergent, life-saving surgery, where there would not have been time to consult a bariatric surgeon or transfer to a bariatric center. The distribution of bariatric complications in this series is in concordance with results presented in previous publications on the topic and predominately features complications following RYGB and gastric banding.9,10,12 The most common acute presentation in our series was obstruction, most often because of internal hernia after RYGB (30%). Internal hernias are a well-known complication following RYGB and have been reported extensively.13–16 Thorough understanding of the new bariatric anatomy is essential for accurate and timely diagnosis. For instance, 4 different potential spaces for internal hernia can occur after RYGB: mesenteric (if retrocolic in position), mesojejunal, jejunojejunal, and Peterson’s, with the last 2 being most common.17,18 While the reports of bowel obstruction from internal hernias are low, ranging from .2% to 9%,19–21 the incidence of an obstruction leading to infarction and necrosis of large sections of small intestine can be devastating. Computed
tomography can help lead to diagnosis (through a swirl sign or evidence of ischemia) but can miss an internal hernia 11% to 9% of the time.22 Timely intervention for suspected internal hernia is fundamental to ensuring bowel viability, and diagnostic laparoscopy allows for quick assessment of the intestine. Evaluation of all potential internal hernia sites is essential, as some bariatric surgeons do not routinely close mesenteric defects,23,24 and, even when closed at the index surgery, as many as 83% of patients spontaneously open their jejunojejunostomy mesenteric defect after weight loss.25 Additional consideration for anastomotic leak (1.7% to 2.1%), marginal ulcer (.3% to 6%), gastrointestinal bleed (.6% to 1.9%), wound complications (3.0% to 6.6%), pulmonary embolism (.4% to .8%), and pneumonia should be considered in the acute postoperative period after RYGB, as it would be with any other major gastrointestinal operation.12,26 Adhesive disease (15%) and lap band restriction (12%) were the cause of other common presenting symptoms of obstruction. Adhesive disease at the bariatric surgical site (ie, anastomosis, band, etc) is an exceedingly rare cause of small bowel obstruction, and its incidence is reported between .7% and .9% with a mean follow-up of 21 to 43 months.14,27 However, adhesive disease persists with time and can present, over the lifetime of the patient, as a bowel obstruction at the site. Importantly, patients presenting with bowel obstruction from adhesive disease after RYGB are indiscernible from those with internal herniation and surgeons must have a low threshold to evaluate these patients with diagnostic laparoscopy. If a timely diagnosis is not performed, close attention must be given to monitoring the patient, as whole mid-gut volvulus is a potential devastating complication. Gastric banding has its own unique set of complications: band slippage (1% to 20%), which can cause dysphagia and, potentially, gastric outlet obstruction; port site infection (rare); and band erosion (,4%), which can
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cause perforation and lead to abdominal sepsis.12,28 When recognized early, these complications are amendable to management with minimally invasive techniques (77.8% either laparoscopic lysis of adhesions, gastric band removal, or conversion of vertical banded gastroplasty to RYGB), and conversion to open was only necessary when the degree of bowel distention made laparoscopy untenable. The above complications represent the bulk of emergencies encountered by a nonbariatric surgeon, but several other challenging complications were encountered in this series. Anastomotic ulcer disease (marginal ulcer) was present in 15% of patients and resulted in perforation and sepsis in 2 patients and gastrointestinal bleeding in 1 patient. While training in surgical and endoscopic management of these emergent complications is mandatory for acute care surgeons, these patients often present as consults for simple abdominal pain from the emergency department, so knowledge of medical management is also required.29 This knowledge begins with an understanding of the risk factors associated with marginal ulcer formation. These include smoking, non-steroidal anti-inflammatory drug use, Helicobacter Pylori infection, and foreign body (nonabsorbable suture, staples). Furthermore, knowledge of the new bariatric anatomy is crucial to understanding potential reasons for ulcers. A large pouch containing more parietal cells will create an acidic environment leading to ulcer formation. Most ulcers can be managed medically by removing the risk factors (stop non-steroidal anti-inflammatory drug, cease smoking, treat H. Pylori). However, if the underlying cause is anatomical (large pouch, foreign body, fistula), then a revision may be the best approach for treatment. Additionally, RYBG usually results in rapid weight loss, which can precipitate biliary cholesterol stones as fat energy reserves are mobilized, and symptomatic cholelithiasis can occur in 6.9% to 12% of patients.30,31 As our series indicates, when the abdomen is entered for any operation in a patient with a history of RYGB, it is important to visualize the entire abdomen and inspect any potential internal hernia site to close mesenteric defects (3/3 open defects during cholecystectomy). This series is also the first to compare bariatric complications management by acute care surgeons with surgical approach, and we were able to show that patients of all the index procedure types were successfully managed with minimally invasive techniques. Even though 43% of surgical patients ultimately required an open operation, only 6 (20%) had an open operation from the beginning, mandated by patient’s critical condition. Because the most common bariatric complications presenting to an acute care service are amendable to laparoscopic repair, all general, emergency, and acute care surgeons who take call should be facile with minimally invasive techniques and the unique anatomy of bariatric cases. Surgeons should be familiar with the new bariatric anatomy of RYGB, gastric banding, and sleeve gastrectomy, but also less popular procedures such as biliopancreatic diversion, banded gastroplasty, and duodenal switch.12,32 What may be a unique benefit to acute care surgeons, when compared with their
5 laparoscopic or bariatric cohorts, is their early recognition of shock and ability to make a quick shift in mentality to a damage control operation. Conversely, they must also work harder to maintain their laparoscopic skill set if their primary case load does not contain complex laparoscopic cases. Many general and acute care surgeons may think that these complications are rare and do not pertain to their practice; however, as bariatric procedures have regionalized, patients’ emergent complications are often seen by the local surgeon not at the regional center. Regardless of data that indicate patient outcomes are similar between bariatric centers and community practice,33,34 bariatric surgeries have centralized to centers of excellence because of Centers for Medicare and Medicaid reimbursement policies. Patients from rural areas then return to their communities and when emergent complications arise, it is the local general surgeon who must triage and appropriately treat these complications. As healthcare costs increase, many patients are also turning to surgery in low-income countries to reduce personal costs expecting local surgeons to manage any complications arising from their medical tourism, which is often an incorrect or ill-performed surgery.35 These trends and our series highlight the need for those who take unassigned call to be well versed in bariatric complications and have an ability to diagnose, triage, and treat emergent and urgent conditions with a versatile skill set. There are obvious limitations to our study because of its retrospective nature and design as a case series. While we cannot estimate the incidence of bariatric complications presenting to our center, or have the patient or operative data from the index surgery, our experience provides a valuable context and comparison for what other similar services can expect to experience. Additionally, our institution is renowned for the permeation of minimally invasive techniques throughout all surgical divisions, and this skill set may not be the same at other centers, although an argument can be made that it should be mandatory for all acute care surgeons. Indeed, as our senior author can attest, extensive experience with laparoscopic and bariatric procedures comprises an invaluable knowledge base for treating these and many other complications in trauma and acute care surgery.
Conclusions Bariatric surgery is a commonplace in the United States and can result in a unique set of complications and emergencies that all general surgeons should be familiar with. Complications can be managed by laparoscopy or endoscopy in many cases, but patient’s condition, individual diagnosis, and surgeon level of comfort should guide treatment decisions. Additionally, severe surgical pathologies such as bleeding, perforation, strangulation, and ischemia are less likely to be managed with minimally
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invasive techniques. We recommend that when diagnosis is unclear for former bariatric surgery patients, diagnostic laparoscopy be performed to answer definitively if a surgical complication is present.
18. Hussain A, El-Hasani S. Bariatric emergencies: current evidence and strategies of management. World J Emerg Surg 2013;8:58. 19. Elms L, Moon RC, Varnadore S, et al. Causes of small bowel obstruction after Roux-en-Y gastric bypass: a review of 2,395 cases at a single institution. Surg Endosc 2014;28:1624–8. 20. Rodriguez A, Mosti M, Sierra M, et al. Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced? Obes Surg 2010;20:1380–4. 21. Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87–91. 22. Lockhart ME, Tessler FN, Canon CL, et al. Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR Am J Roentgenol 2007;188: 745–50. 23. Finnell CW, Madan AK, Tichansky DS, et al. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007;17: 145–8. 24. Madan AK, Lo Menzo E, Dhawan N, et al. Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009;19:549–52. 25. Hope WW, Sing RF, Chen AY, et al. Failure of mesenteric defect closure after Roux-en-Y gastric bypass. JSLS 2010;14:213–6. 26. Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138: 957–61. 27. Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13: 596–600. 28. Kirshtein B, Lantsberg L, Mizrahi S, et al. Bariatric emergencies for non-bariatric surgeons: complications of laparoscopic gastric banding. Obes Surg 2010;20:1468–78. 29. Kalaiselvan R, Exarchos G, Hamza N, et al. Incidence of perforated gastrojejunal anastomotic ulcers after laparoscopic gastric bypass for morbid obesity and role of laparoscopy in their management. Surg Obes Relat Dis 2012;8:423–8. 30. Tucker ON, Fajnwaks P, Szomstein S, et al. Is concomitant cholecystectomy necessary in obese patients undergoing laparoscopic gastric bypass surgery? Surg Endosc 2008;22:2450–4. 31. D’Hondt M, Sergeant G, Deylgat B, et al. Prophylactic cholecystectomy, a mandatory step in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass? J Gastrointest Surg 2011;15: 1532–6. 32. Cossu ML, Meloni GB, Alagna S, et al. Emergency surgical conditions after biliopancreatic diversion. Obes Surg 2007;17:637–41. 33. Livingston EH. Procedure incidence and in-hospital complication rates of bariatric surgery in the United States. Am J Surg 2004;188:105–10. 34. Dimick JB, Nicholas LH, Ryan AM, et al. Bariatric surgery complications before vs after implementation of a national policy restricting coverage to centers of excellence. JAMA 2013;309:792–9. 35. Birch DW, Vu L, Karmali S, et al. Medical tourism in bariatric surgery. Am J Surg 2010;199:604–8.
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