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Complications of bariatric surgery – What the general surgeon needs to know
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Review
Complications of bariatric surgery e What the general surgeon needs to know Paul Healy*, Christopher Clarke, Ian Reynolds, Mayilone Arumugasamy, Deborah McNamara Department of Surgery, Beaumont Hospital and The Royal College of Surgeons in Ireland, Ireland
article info
abstract
Article history:
Obesity is an important cause of physical and psychosocial morbidity and it places a sig-
Received 28 March 2015
nificant burden on health system costs and resources. Worldwide an estimated 200 million
Received in revised form
people over 20 years are obese and in the UK the Department of Health report that 61.3% of
13 July 2015
people in the UK are either overweight or obese. Surgery for obesity (bariatric surgery) is
Accepted 12 August 2015
being performed with increasing frequency in specialist centres both in the UK and Ireland
Available online xxx
and abroad due to the phenomenon of health tourism. Its role and success in treating medical conditions such as diabetes mellitus and hypertension in obese patients will likely
Keywords:
lead to an even greater number of bariatric surgery procedures being performed. Patients
Bariatric surgery
with early postoperative complications may be managed in specialist centres but patients
Obesity
with later complications, occurring months or years after surgery, may present to local
Late complications
surgical units for assessment and management. This review will highlight the late com-
Emergency
plications of the 3 most commonly performed bariatric surgery procedures that the emergency general surgeon may encounter. It will also highlight the complications that require urgent intervention by the emergency general surgeon and those that can be safely referred to a bariatric surgeon for further management after initial assessment and investigations. © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Obesity as defined by the World Health Organisation is an abnormal or excessive fat accumulation that may impair health.1 More objectively it is defined as a Body Mass Index (BMI) over 30 where BMI ¼ weight in (kg)/height in (m2).2
However this is not a direct measurement of adiposity and NICE recommend that waist circumference is used in conjunction with BMI.3 Worldwide an estimated 900 million over 20 years are overweight and 500 million people over 20 years are obese. In the United Kingdom the Department of Health suggest that 61.3% of UK adults are either overweight or obese4 with 24% of males and 26% of females being obese.5
* Corresponding author. Suite 18, Beaumont Hospital Private Clinic, Beaumont Road, Dublin 9, Ireland. Tel.: þ353 1 857 4885. E-mail address: [email protected] (P. Healy). http://dx.doi.org/10.1016/j.surge.2015.08.003 1479-666X/© 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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Irish figures from the National Task Force on Obesity estimate that 39% of Irish adults are overweight and 18% obese.6 Obesity impacts physical, psychological and social heath and it is a major risk factor for death from ischaemic heart disease, diabetes mellitus and cancer. The economic burden is substantial with an estimated 2e4% of health budgets in the EU being spent on adult obesity.7 Obesity cost the NHS £5.1 billion in 2006/79 and data from Ireland estimated a spend of V1.13 billion in 2009 on direct and indirect obesity related costs.8 It has been reported that obesity costs the US economy over $100 billion annually.2 Lifestyle modifications form the basis of interventions for obesity with adjuvants such as pharmacotherapy and surgery being employed in selected individuals. Despite advances in health promotion initiatives and pharmacotherapy, surgery has been shown to be superior to non-surgical interventions in reducing weight.10 Consequently there has been a trend towards an increase in surgical interventions targeting obesity and worldwide over 340000 bariatric procedures were performed in 201111 with 8000 performed in the UK in the same period.12 These procedures are increasingly provided in specialist centres and there is a further group of patients who seek such interventions abroad where follow up and aftercare can be limited or even non-existent. A morbidity rate of 2.4%e10% has been reported internationally depending on the type of procedure13 and recently The National Bariatric Surgery Registry (UK) reported an overall complication rate of 2.6%.14 Should complications arise many individuals may present to local and nonspecialist centres. Therefore general non-bariatric specialist surgeons should have knowledge of the commonly performed procedures and associated complications in order to safely manage such patients. This review aims to look at the common surgical procedures performed for obesity with a focus on the associated late complications and their management that can present to emergency general surgeons.
Bariatric surgery
procedures including laparoscopic adjustable gastric banding, sleeve gastrectomy and Roux-en-Y gastric bypass and their potential late complications.12
Laparoscopic adjustable gastric banding (LAGB) Description LAGB is a restrictive procedure involving the placement of an adjustable silicone ring below the gastro-oesophageal junction to create a pouch. It is connected to a port that is placed in the subcutaneous tissue and can be inflated or deflated to increase or decrease the degree of restriction. It is reversible and generally considered a safer procedure as the GI tract is not entered and there is no anastomosis.17 Never the less late complications do arise and a reoperation rate of 10e20% has been reported.18 Band slippage, pouch enlargement, band erosion and port site complications are the most common problems associated with LAGB (Table 1).
Complications Band slippage resulting in gastric prolapse, occurs with cephalad prolapse of the body of the stomach or caudal movement of the band. Features suggestive of band slippage include acute dysphagia, vomiting, regurgitation and pain (epigastric, left upper quadrant and chest).20,21 If left untreated the incarcarated stomach pouch may be at risk of ischaemia. Investigations that can help in the diagnosis of band slippage include plain radiographs of the lower chest/upper abdomen which shows a shift in the band from a normally angled 2 to 8 o clock position (see Fig. 1) to a 4 to 10 o clock position (see Fig. 2). The centre ring of the band may also be visible and there will be dilation and prolapse of the gastric pouch. An
Table 1 e Summary of gastric band complications including symptoms and treatment. Complication
Indications for surgery in adults include a BMI over 40 or BMI 35e40 in the presence of co morbidities such as type 2 diabetes mellitus, hypertension, sleep apnoea or polycystic ovarian syndrome that could improve with weight loss. Other criteria include a failure of diet and exercise provided the patient will receive intensive specialist management, they are fit for anaesthesia and that they will commit to long term follow up.15 The British Obesity and Metabolic Surgery Society have detailed criteria that organisations should fulfil in order to provide bariatric surgery. These recommendations centre on facilities (equipment, imaging, and theatre), specialist staff (surgeons, physicians, nurses and dieticians) and care pathways (referral and assessment, follow up).16 Procedures for obesity are classified as restrictive, malabsorptive or both. Restrictive procedures include laparoscopic adjustable gastric banding or sleeve gastrectomy; malabsorptive procedures such as biliopancreatic diversion or combined procedures such as Roux-en-Y gastric bypass. This review will discuss the 3 most commonly performed
Symptoms
Treatment
Band slippage
i Acute dysphagia i. Deflate band urgently ii. Vomiting ii. If no improvement iii. Upper abdominal consider laparoscopy pain and band removal or iv. Reflux unbuckling with/without resection Pouch i. Reduced satiety i. Full band deflation enlargement ii. Dyspepsia ii. Smaller portion sizes iii. Reflux iii. Low calorie diet iv. Chest pain Band erosion i. No satiety i. Consider referral to ii. Gastrointestinal bariatric surgeon for bleeding further management but iii. Epigastric pain if unwell may need iv. Port site infection intervention by general surgeon ii. Laparoscopy/laparotomy or endoscopic removal iii. Remove band iv. Excise any necrotic tissue v. Closure of gastrostomy
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Fig. 3 e Gastric pouch enlargement associated with band slippage.
Fig. 1 e Normal positioned gastric band in 2e8 o clock position on plain radiograph.
upper GI contrast series or CT abdomen with water soluble contrast can be helpful in identifying a dilated incarcerated gastric pouch. The dilated portion of GI tract proximal to the band with band slippage is differentiated from pouch dilation by this abnormally positioned band and acute symptoms (see Figs. 2 and 3 from same patient). Urgent intervention is required to deflate the band (typically found in the left upper quadrant or over the sternum) using a Huber or spinal needle as complications can include gastric perforation and stomach necrosis.
Fig. 2 e Abnormally positioned gastric band in a 4 to 10 o'clock position on plain radiograph.
The port site can be deflated in a similar way to a Portacath. If access to the port is difficult it can also be accessed via ultrasound guidence. If symptoms fail to improve with full desufflation of the band or if there is no fluid aspirated, exploration via laparoscopy is mandatory to release the slippage and possibly remove the band. The band and surrounding capsule should be identified (Fig. 4) and the capsule divided. The buckle is identifed and unbuckled (see Figs. 5 and 6) and the slippage reduced. It is important to identify and divide any remaining constricting capsule to prevent any further problems (see Fig. 7). The presence of any necrosis requires resection. Pouch enlargement is dilation of the proximal gastric pouch with or without a change in the band angle and without obstruction. The patient may present with a lack of satiety, heartburn, regurgitation and occasional chest pain19 and is diagnosed with an upper GI contrast series. It occurs due to over inflation or over eating and non-operative management includes band deflation, a low calorie diet and reduced portion sizes. This approach is successful in up to 77% of patients19 but if unsuccessful (pouch remains enlarged) surgical removal or replacement is needed. Band slippage and pouch enlargement can be managed by the emergency general surgeon by complete band deflation. Being familiar with the technique to deflate the port can remedy both clinical problems particularly band slippage and prevent complications such as necrosis or perforation.
Fig. 4 e Gastric band with enlarged pouch at laparoscopy.
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Fig. 5 e Identification of band buckle during laparoscopic removal.
an excessively tight band.23 Band erosion may manifest with a loss of restriction, epigastric pain, gastrointestinal bleeding, an intra-abdominal abscess or port site infection.20 At endoscopy the white gastric band is visible within the gastric lumen on retroflexion (see Fig. 8) and management involves band removal via laparoscopy or laparotomy and excision of necrotic tissue with closure of the gastrostomy. It may also be possible to remove the band at endoscopy. If the patient is not acutely unwell then referral to a bariatric surgeon for further management is appropriate. Port site complications include infection and malfunctions such as breakage or disconnection of the tubing. Infection may manifest in the early post-operative course as localised erythema, swelling and pain and may be successfully treated with antibiotics. If unsuccessful and infection is limited to the port, it can be removed and the tubing tied off with Prolene and reinserted once the infection resolves.20 Late port site infection may be due to band erosion and loss of restriction may also be present in such a scenario. Port malfunction can occur due to the disconnection of the tubing (see Fig. 9) or when leakage occurs and may be suspected if weight regain occurs. Disconnection can be assessed by plain radiograph or fluoroscopy examination and leakage will be evident by a discrepancy in the volume of saline injected and subsequently aspirated.24 It is also indicated if injection of saline does not result in any restriction. Both band erosion and port site complications can generally be safely referred back to bariatric surgeons or an upper gastrointestinal surgeon for further management. However if the patient is unwell the emergency general surgeon may need to intervene sooner.
Fig. 6 e Unbuckling of gastric band prior to removal.
Roux-en-Y gastric bypass However if the patient is unwell or symptoms fail to resolve operative interention needs to be considered. Band erosion can occur early or even years after surgery and following a review of 15,775 patients it has a reported incidence rate of 1.46% but varies in some series between 0.2% and 33%.22 Early erosion may occur due to intra operative injury to the stomach or a micro perforation that initiates a chronic inflammatory process and eventual erosion. Late erosions are believed to result from chronic ischaemia due to
Fig. 7 e Remaining capsule after removal of gastric band.
Description Roux-en-Y gastric bypass initially involves the formation of a gastric pouch of approximately 30 ml volume from the proximal stomach and the division of small bowel at a point 50e100 cm from the duodenojejunal flexure. The distal small
Fig. 8 e Endoscopic (J Maneuver) view of gastric band erosion.
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Fig. 9 e Port site disconnection diagnosed on plain radiograph.
bowel (Roux limb) is then anastomosed to the newly formed pouch to create a gastro-jejunostomy. The bypassed segment of stomach and proximal small bowel (biliopancreatic limb) is then anastomosed to the small bowel 100e150 cm for the newly formed gastro-jejunostomy (see Fig. 10). Overall the procedure produces weight loss by both restriction of intake and malabsorption.25
Complications Surgical complications occur due to physiological changes and the alteration in anatomy and include obstruction (gastric
5
remnant distension, anastomotic stenosis) haemorrhage, and choleithiasis. Other complications include short bowel syndrome, dumping syndrome and nutritional deficiencies but may not present as primary surgical emergencies. Small bowel obstruction can occur at any point from the newly formed gastrojejunal anastomosis to the terminal ileum. In a review of 2395 patients the incidence of small bowel obstruction has been reported at 3.9%. It occurs more commonly with a laparoscopic approach and causes include adhesions (48.4%), internal hernias (28%) and kinking of the jejunojejunal anastomosis (13%).26 Symptoms vary depending on the level of obstruction and include colicky abdominal pain, nausea and vomiting, distension and absolute constipation.27 Despite vomiting being a well associated feature of small bowel obstruction it may be absent if the level of obstruction involves the biliopancreatic limb. CT is useful in ruling out mechanical obstruction and if obstruction is identified it can highlight a transition point. Obstruction of any aetiology distal to the jejunojejunal anastomosis can result in dilation of the biliopancreatic limb, Roux limb and gastric remnant. Bilious vomiting is a feature and insertion of a nasogastric tube may decompress the proximal small bowel. Obstruction of the biliopancreatic limb results in a dilated biliopancreatic limb, duodenum and gastric remnant and can result in abnormal liver function tests and a raised serum amylase level. An isolated dilation of the Roux limb occurs in obstruction proximal to the jejunojejunal anastomosis and bilious vomiting is unusual in this scenario.28 However in identifying obstruction, the sensitivity of CT following gastric bypass is less favourable compared to the general population (51% versus 80e90%).27 Despite the well documented benefits of laparoscopic surgery its use in Roux en Y gastric bypass is associated with
Fig. 10 e Roux-en-Y gastric bypass-post operative anatomy. ©Ethicon, Inc. (2006). Reproduced with permission. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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Fig. 11 e Potential sites of internal herniation following Roux en Y gastric bypass. ©Elsevier 2006. Reproduced with permission.
an increase in internal hernia formation. This is believed to be due to fewer adhesions that develop following a laparoscopic approach.29 Sites of potential herniation include (a) the defect in the transverse mesocolon if the Roux limb is placed in a retrocolic position (mesocolic) (b) the space between the Roux limb mesentery and transverse mesocolon (Peterson's hernia) and (c) the mesenteric defect at the site of the jejunojejunostomy (see Fig. 11). They can present acutely due to strangulation or with recurrent episodes of colicky abdominal pain. Imaging may be non-diagnostic and contrast reaching the colon does not outrule an internal hernia. The presence of swirls in the mesentry or multiple loops of unopacified bowel
abnormally located in the right side of the abdomen raises the suspicion of an internal hernia. Due to the risk of strangulation there should be a low threshold for surgical exploration in an emergency setting.29 Port site hernias can also develop and these can be remedied by the general surgery. Gastric remnant syndrome is a rare sequel of obstruction but failure to recognise its occurrence can lead to perforation, peritonitis and subsequently death. Features include epigastric pain, distension, hiccups, a distended and tympanic upper abdomen, dyspnoea or tachycardia. A plain abdominal radiograph may show a gastric air bubble and diagnosis can be confirmed on CT imaging with oral contrast. A dilated gastric remnant with a collapsed duodenum can indicate an obstruction in the pyloric region but this will not be amenable to standard interventions such as nasogastric tube decompression. Urgent decompression with a gastrostomy tube (operative or percutaneous) is warranted in such cases. Stomal (anastomotic) stenosis has been documented in up to 6% in one series and may present with symptoms of nausea, vomiting, gastro oesophageal reflux or dysphagia. Diagnosis can be established with an upper GI contrast series although endoscopy is both diagnostic and therapeutic. Endoscopic dilatation has been shown to be safe and effective but some may require more than one dilation and perforation can occur.30,31 It is appropriate that if an anastomatic stenosis is identified and requires dilation it should be referred back to the initial bariatric surgeon or upper gastrointestinal surgeon as it usually does not require emergency intervention. Upper gastrointestinal haemorrhage is rare following Roux en Y gastric bypass and occurs more commonly in the early post-operative period due to marginal ulcers at the gastrojejunostomy.32 Suspected upper GI haemorrhage should be managed according to local and national guidelines such as NICE and an upper gastrointestinal endoscopy performed. If the source of haemorrhage is not identified further
Fig. 12 e Sleeve gastrectomy-post operative anatomy. ©Ethicon, Inc. (2006). Reproduced with permission. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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investigations include colonoscopy and angiography. In the context of ongoing haemorrhage without a definitive source the gastric remnant and duodenum may need to be explored.33
Laparoscopic sleeve gastrectomy (LSG) Description
changes that occur following surgery will facilitate an understanding of these presentations and aid in the interpretation of appropriate investigations. General surgeons should be aware of the potential late complications of the common bariatric surgical procedures to ensure that patients are investigated and managed appropriately. The specific complications of band slippage, pouch enlargement, bowel obstruction, internal hernia and gastric remanant syndrome should be recognised and managed by the emergency general surgeon while complications such as band erosion and stomal stenosis may be referred to a bariatric surgeon for further management.
LSG results in the formation of a narrow tubular stomach by dividing and excising a significant portion of the stomach (see Fig. 12). Its effects as a weight loss procedure are mediated through both restriction and hormonal changes. These changes are believed to be related to a reduced serum ghrelin levels which normally stimulate hunger.34 The procedure maintains a functioning pylorus, avoids an anastomosis and insertion of a foreign body and preserves normal intestinal absorption.35
Conflict of interest
Complications
Acknowledgements
Long term complications relate to stenosis, which can occur at the gastrooesophageal junction or incisura angularis and manifest with dysphagia and vomiting. As with stomal stenosis, investigation is with an upper GI contrast study or endoscopy and can be treated with endoscopic dilation.36 However if dilation is required it should be ideally be done by the bariatric surgeon or upper gastrointestinal surgeon (Table 2).
Illustrations provided by Ethicon and Elsevier.
Conclusion Obesity is reaching epidemic proportions worldwide despite increasing health promotion initiatives and interventions aimed at lifestyle modification. Surgery is currently the only proven intervention in achieving and sustaining long term weight loss and impacting positively on obesity related co morbidities such as diabetes mellitus. With an increasing number of these procedures being performed in specialist centres early post-operative complications are addressed by specialist bariatric surgeons. However patients with late complications will more commonly present to non-specialist centres. An understanding of the post-operative anatomical
Table 2 e Summary of procedures and main late complications (Bold to hightlight those that need intervention by emergency general surgeon). Procedure Laparoscopic assisted gastric band
Roux en Y gastric bypass
Sleeve gastrectomy
Main complications i. Band slippage ii. Pouch enlargement iii. Band necrosis iv. Port site complications i. Bowel obstruction ii. Gastric remnant syndrome iii. Gastrointestinal haemorrhage iv. Stomal (anastomotic) stenosis i. Stomal stenosis
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None.
references
1. World Health Organization. Factsheet: Obesity and overweight (Internet). Geneva: World Health Organisation; (updated 2013). Available from: http://www.who.int/mediacentre/factsheets/ fs311/en/index.html. 2. American College of Surgeons. Recommendations for facilities performing bariatric surgery (Internet). Chicago: American College of Surgeons; 2000. Available from: http://www.facs. org/fellows_info/statements/st-34.html. 3. Carter R, Mouralidarane A, Ray S, Soeda J, Oben J. Recent advancements in drug treatment of obesity. Clin Med 2012;12(5):456e60. 4. Department of Health (England). Reducing obesity and improving diet. London: Stationary Office; 2013. 5. Health and Social Care Information Centre. Statistics on obesity, physical activity and diet e England, 2013. Leeds: Health and Social Care Centre; 2013. 6. Obesity the policy challenges the report of the national taskforce on obesity. National Task Force on Obesity; 2005. Available from: http://www.hse.ie/eng/health/child/healthyeating/ taskforceonobesity.pdf. 7. The Challenge of obesity in the WHO European region and the strategies for response. In: Branca F, Nikogosian H, Lobstein T, editors. WHO regional office for Europe: Copenhagen; 2007. 8. SafeFood The cost of overweight and obesity on the Island of Ireland e executive summary. 2012. Available from:, http:// www.safefood.eu/SafeFood/media/SafeFoodLibrary/ Documents/Publications/Research%20Reports/Final-ExecSummary-The-Economic-Cost-of-Obesity.pdf. 9. Scarborough P, Bhatnagar P, Wickramasinghe KK, Allender S, Foster C, Rayner M. The economic burden of ill health due to diet, physical inactivity, smoking, alcohol and obesity in the UK: an update to 2006e07 NHS costs. J Public Health Oxf 2011;33(4):527e535.. 10. Colquitt J, Clegg A, Loveman E, Royle P, Sidhu MK. Surgery for morbid obesity. Cochrane Database Syst Rev 2005;(4):Cd003641.
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11. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23(4):427e36. 12. National Confidential Enquiry into Patient Outcome and Death. Too lean a service? A review of the care of patients who underwent bariatric surgery. NCEPOD; 2012. Available at: www. ncepod.org.uk. 13. Carlin AM, Zeni TM, English WJ, Hawasli AA, Genaw JA, Krause KR, et al. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg 2013;257(5):791e7. 14. UK National Bariatric Surgery Registry. First registry report to March 2010. Dendrite: Oxfordshire; 2011. Available from: www.augis.org/pdf/audits. 15. National Institute for Health and Clinical Excellence. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children, NICE guideline. London: NICE; 2006. 16. British Obesity and Metabolic Surgery Society. Providing bariatric surgery: BOMSS service standards for clinical services and guidance on commissioning. Report of a working party. London: BOMSS; 2012. F, Douard R, Blanche JP, Berta JL, 17. Chevallier JM, Zinzindohoue Altman JJ, et al. Complications after laparoscopic adjustable gastric banding for morbid obesity: experience with 1,000 patients over 7 years. Obes Surg 2004;14(3):407e14. 18. Lancaster RT, Hutter MM. Bands and bypasses: 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACSNSQIP data. Surg Endosc 2008;22(12):2554e63. 19. Moser F, Gorodner MV, Galvani CA, Baptista M, Chretien C, Horgan S. Pouch enlargement and band slippage: two different entities. Surg Endosc 2006;20(7):1021e9. 20. Eid I, Birch DW, Sharma AM, Sherman V, Karmali S. Complications associated with adjustable gastric banding for morbid obesity: a surgeon's guides. Can J Surg 2011;54(1):61e6. 21. Spivak H, Rubin M. Laparoscopic management of lap-band slippage. Obes Surg 2003;13(1):116e20. 22. Brown WA, Egberts KJ, Franke-Richard D, Thodiyil P, Anderson ML, O'Brien PE. Erosions after laparoscopic adjustable gastric banding: diagnosis and management. Ann Surg 2013;257(6):1047e52. 23. Abu-Abeid S, Keidar A, Gavert N, Blanc A, Szold A. The clinical spectrum of band erosion following laparoscopic adjustable silicone gastric banding for morbid obesity. Surg Endosc 2003;17(6):861e3.
24. Keidar A, Carmon E, Szold A, Abu-Abeid S. Port complications following laparoscopic adjustable gastric banding for morbid obesity. Obes Surg 2005;15(3):361e5. 25. McNatt SS, Longhi JJ, Goldman CD, McFadden DW. Surgery for obesity: a review of the current state of the art and future directions. J Gastrointest Surg 2007;11(3):377e97. 26. Elms L, Rena C, Moon RC, Varnadore S, Teixeira AF, Jawad MA. 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(5):1624e8. 27. Husain S, Ahmed AR, Johnson J, Thad Boss T, William O'Malley W. Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management. Arch Surg 2007;142(10):988e93. 28. Tucker ON, Escalante-Tattersfield T, Szomstein S, Rosenthal RJ. The ABC System: a simplified classification system for small bowel obstruction after laparoscopic Rouxen-Y gastric bypass. Obes Surg 2007;17(12):1549e54 [Epub 2007 Nov 27]. 29. Paroz A, Calmes JM, Giusti V, Suter M. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery. Obes Surg 2006;16(11):1482e7. 30. Ukleja A, Afonso BB, Pimentel R, Szomstein S, Rosenthal R. Outcome of endoscopic balloon dilation of strictures after laparoscopic gastric bypass. Surg Endosc 2008;22(8):1746e50. 31. Ahmad J, Martin J, Ikramuddin S, Schauer P, Slivka A. Endoscopic balloon dilation of gastroenteric anastomotic stricture after laparoscopic gastric bypass. Endoscopy 2003;35(9):725e8. 32. Jamil LH, Krause KR, Chengelis DL, Jury RP, Jackson CM, Cannon ME, et al. Endoscopic management of early upper gastrointestinal hemorrhage following laparoscopic Roux-enY gastric bypass. Am J Gastroenterol 2008;103(1):86e91. 33. Braley SC, Nguyen NT, Wolfe BM. Late gastrointestinal hemorrhage after gastric bypass. Obes Surg 2002;12(3):404e7. 34. Langer FB, Reza Hoda MA, Bohdjalian A, Felberbauer FX, Zacherl J, Wenzl E, et al. Sleeve gastrectomy and gastric banding: effects on plasma ghrelin levels. Obes Surg 2005;15(7):1024e9. 35. Shi X, Karmali S, Sharma AM, Birch DW. A review of laparoscopic sleeve gastrectomy for morbid obesity. Obes Surg 2010;20(8):1171e7. 36. Dapri G, Cadiere GB, Himpens J. Laparoscopic seromyotomy for long stenosis after sleeve gastrectomy with or without duodenal switch. Obes Surg 2009;19(4):495e9.
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ScienceDirect The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
Complications of bariatric surgery e What the general surgeon needs to know Paul Healy*, Christopher Clarke, Ian Reynolds, Mayilone Arumugasamy, Deborah McNamara Department of Surgery, Beaumont Hospital and The Royal College of Surgeons in Ireland, Ireland
article info
abstract
Article history:
Obesity is an important cause of physical and psychosocial morbidity and it places a sig-
Received 28 March 2015
nificant burden on health system costs and resources. Worldwide an estimated 200 million
Received in revised form
people over 20 years are obese and in the UK the Department of Health report that 61.3% of
13 July 2015
people in the UK are either overweight or obese. Surgery for obesity (bariatric surgery) is
Accepted 12 August 2015
being performed with increasing frequency in specialist centres both in the UK and Ireland
Available online xxx
and abroad due to the phenomenon of health tourism. Its role and success in treating medical conditions such as diabetes mellitus and hypertension in obese patients will likely
Keywords:
lead to an even greater number of bariatric surgery procedures being performed. Patients
Bariatric surgery
with early postoperative complications may be managed in specialist centres but patients
Obesity
with later complications, occurring months or years after surgery, may present to local
Late complications
surgical units for assessment and management. This review will highlight the late com-
Emergency
plications of the 3 most commonly performed bariatric surgery procedures that the emergency general surgeon may encounter. It will also highlight the complications that require urgent intervention by the emergency general surgeon and those that can be safely referred to a bariatric surgeon for further management after initial assessment and investigations. © 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Obesity as defined by the World Health Organisation is an abnormal or excessive fat accumulation that may impair health.1 More objectively it is defined as a Body Mass Index (BMI) over 30 where BMI ¼ weight in (kg)/height in (m2).2
However this is not a direct measurement of adiposity and NICE recommend that waist circumference is used in conjunction with BMI.3 Worldwide an estimated 900 million over 20 years are overweight and 500 million people over 20 years are obese. In the United Kingdom the Department of Health suggest that 61.3% of UK adults are either overweight or obese4 with 24% of males and 26% of females being obese.5
* Corresponding author. Suite 18, Beaumont Hospital Private Clinic, Beaumont Road, Dublin 9, Ireland. Tel.: þ353 1 857 4885. E-mail address: [email protected] (P. Healy). http://dx.doi.org/10.1016/j.surge.2015.08.003 1479-666X/© 2015 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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Irish figures from the National Task Force on Obesity estimate that 39% of Irish adults are overweight and 18% obese.6 Obesity impacts physical, psychological and social heath and it is a major risk factor for death from ischaemic heart disease, diabetes mellitus and cancer. The economic burden is substantial with an estimated 2e4% of health budgets in the EU being spent on adult obesity.7 Obesity cost the NHS £5.1 billion in 2006/79 and data from Ireland estimated a spend of V1.13 billion in 2009 on direct and indirect obesity related costs.8 It has been reported that obesity costs the US economy over $100 billion annually.2 Lifestyle modifications form the basis of interventions for obesity with adjuvants such as pharmacotherapy and surgery being employed in selected individuals. Despite advances in health promotion initiatives and pharmacotherapy, surgery has been shown to be superior to non-surgical interventions in reducing weight.10 Consequently there has been a trend towards an increase in surgical interventions targeting obesity and worldwide over 340000 bariatric procedures were performed in 201111 with 8000 performed in the UK in the same period.12 These procedures are increasingly provided in specialist centres and there is a further group of patients who seek such interventions abroad where follow up and aftercare can be limited or even non-existent. A morbidity rate of 2.4%e10% has been reported internationally depending on the type of procedure13 and recently The National Bariatric Surgery Registry (UK) reported an overall complication rate of 2.6%.14 Should complications arise many individuals may present to local and nonspecialist centres. Therefore general non-bariatric specialist surgeons should have knowledge of the commonly performed procedures and associated complications in order to safely manage such patients. This review aims to look at the common surgical procedures performed for obesity with a focus on the associated late complications and their management that can present to emergency general surgeons.
Bariatric surgery
procedures including laparoscopic adjustable gastric banding, sleeve gastrectomy and Roux-en-Y gastric bypass and their potential late complications.12
Laparoscopic adjustable gastric banding (LAGB) Description LAGB is a restrictive procedure involving the placement of an adjustable silicone ring below the gastro-oesophageal junction to create a pouch. It is connected to a port that is placed in the subcutaneous tissue and can be inflated or deflated to increase or decrease the degree of restriction. It is reversible and generally considered a safer procedure as the GI tract is not entered and there is no anastomosis.17 Never the less late complications do arise and a reoperation rate of 10e20% has been reported.18 Band slippage, pouch enlargement, band erosion and port site complications are the most common problems associated with LAGB (Table 1).
Complications Band slippage resulting in gastric prolapse, occurs with cephalad prolapse of the body of the stomach or caudal movement of the band. Features suggestive of band slippage include acute dysphagia, vomiting, regurgitation and pain (epigastric, left upper quadrant and chest).20,21 If left untreated the incarcarated stomach pouch may be at risk of ischaemia. Investigations that can help in the diagnosis of band slippage include plain radiographs of the lower chest/upper abdomen which shows a shift in the band from a normally angled 2 to 8 o clock position (see Fig. 1) to a 4 to 10 o clock position (see Fig. 2). The centre ring of the band may also be visible and there will be dilation and prolapse of the gastric pouch. An
Table 1 e Summary of gastric band complications including symptoms and treatment. Complication
Indications for surgery in adults include a BMI over 40 or BMI 35e40 in the presence of co morbidities such as type 2 diabetes mellitus, hypertension, sleep apnoea or polycystic ovarian syndrome that could improve with weight loss. Other criteria include a failure of diet and exercise provided the patient will receive intensive specialist management, they are fit for anaesthesia and that they will commit to long term follow up.15 The British Obesity and Metabolic Surgery Society have detailed criteria that organisations should fulfil in order to provide bariatric surgery. These recommendations centre on facilities (equipment, imaging, and theatre), specialist staff (surgeons, physicians, nurses and dieticians) and care pathways (referral and assessment, follow up).16 Procedures for obesity are classified as restrictive, malabsorptive or both. Restrictive procedures include laparoscopic adjustable gastric banding or sleeve gastrectomy; malabsorptive procedures such as biliopancreatic diversion or combined procedures such as Roux-en-Y gastric bypass. This review will discuss the 3 most commonly performed
Symptoms
Treatment
Band slippage
i Acute dysphagia i. Deflate band urgently ii. Vomiting ii. If no improvement iii. Upper abdominal consider laparoscopy pain and band removal or iv. Reflux unbuckling with/without resection Pouch i. Reduced satiety i. Full band deflation enlargement ii. Dyspepsia ii. Smaller portion sizes iii. Reflux iii. Low calorie diet iv. Chest pain Band erosion i. No satiety i. Consider referral to ii. Gastrointestinal bariatric surgeon for bleeding further management but iii. Epigastric pain if unwell may need iv. Port site infection intervention by general surgeon ii. Laparoscopy/laparotomy or endoscopic removal iii. Remove band iv. Excise any necrotic tissue v. Closure of gastrostomy
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Fig. 3 e Gastric pouch enlargement associated with band slippage.
Fig. 1 e Normal positioned gastric band in 2e8 o clock position on plain radiograph.
upper GI contrast series or CT abdomen with water soluble contrast can be helpful in identifying a dilated incarcerated gastric pouch. The dilated portion of GI tract proximal to the band with band slippage is differentiated from pouch dilation by this abnormally positioned band and acute symptoms (see Figs. 2 and 3 from same patient). Urgent intervention is required to deflate the band (typically found in the left upper quadrant or over the sternum) using a Huber or spinal needle as complications can include gastric perforation and stomach necrosis.
Fig. 2 e Abnormally positioned gastric band in a 4 to 10 o'clock position on plain radiograph.
The port site can be deflated in a similar way to a Portacath. If access to the port is difficult it can also be accessed via ultrasound guidence. If symptoms fail to improve with full desufflation of the band or if there is no fluid aspirated, exploration via laparoscopy is mandatory to release the slippage and possibly remove the band. The band and surrounding capsule should be identified (Fig. 4) and the capsule divided. The buckle is identifed and unbuckled (see Figs. 5 and 6) and the slippage reduced. It is important to identify and divide any remaining constricting capsule to prevent any further problems (see Fig. 7). The presence of any necrosis requires resection. Pouch enlargement is dilation of the proximal gastric pouch with or without a change in the band angle and without obstruction. The patient may present with a lack of satiety, heartburn, regurgitation and occasional chest pain19 and is diagnosed with an upper GI contrast series. It occurs due to over inflation or over eating and non-operative management includes band deflation, a low calorie diet and reduced portion sizes. This approach is successful in up to 77% of patients19 but if unsuccessful (pouch remains enlarged) surgical removal or replacement is needed. Band slippage and pouch enlargement can be managed by the emergency general surgeon by complete band deflation. Being familiar with the technique to deflate the port can remedy both clinical problems particularly band slippage and prevent complications such as necrosis or perforation.
Fig. 4 e Gastric band with enlarged pouch at laparoscopy.
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Fig. 5 e Identification of band buckle during laparoscopic removal.
an excessively tight band.23 Band erosion may manifest with a loss of restriction, epigastric pain, gastrointestinal bleeding, an intra-abdominal abscess or port site infection.20 At endoscopy the white gastric band is visible within the gastric lumen on retroflexion (see Fig. 8) and management involves band removal via laparoscopy or laparotomy and excision of necrotic tissue with closure of the gastrostomy. It may also be possible to remove the band at endoscopy. If the patient is not acutely unwell then referral to a bariatric surgeon for further management is appropriate. Port site complications include infection and malfunctions such as breakage or disconnection of the tubing. Infection may manifest in the early post-operative course as localised erythema, swelling and pain and may be successfully treated with antibiotics. If unsuccessful and infection is limited to the port, it can be removed and the tubing tied off with Prolene and reinserted once the infection resolves.20 Late port site infection may be due to band erosion and loss of restriction may also be present in such a scenario. Port malfunction can occur due to the disconnection of the tubing (see Fig. 9) or when leakage occurs and may be suspected if weight regain occurs. Disconnection can be assessed by plain radiograph or fluoroscopy examination and leakage will be evident by a discrepancy in the volume of saline injected and subsequently aspirated.24 It is also indicated if injection of saline does not result in any restriction. Both band erosion and port site complications can generally be safely referred back to bariatric surgeons or an upper gastrointestinal surgeon for further management. However if the patient is unwell the emergency general surgeon may need to intervene sooner.
Fig. 6 e Unbuckling of gastric band prior to removal.
Roux-en-Y gastric bypass However if the patient is unwell or symptoms fail to resolve operative interention needs to be considered. Band erosion can occur early or even years after surgery and following a review of 15,775 patients it has a reported incidence rate of 1.46% but varies in some series between 0.2% and 33%.22 Early erosion may occur due to intra operative injury to the stomach or a micro perforation that initiates a chronic inflammatory process and eventual erosion. Late erosions are believed to result from chronic ischaemia due to
Fig. 7 e Remaining capsule after removal of gastric band.
Description Roux-en-Y gastric bypass initially involves the formation of a gastric pouch of approximately 30 ml volume from the proximal stomach and the division of small bowel at a point 50e100 cm from the duodenojejunal flexure. The distal small
Fig. 8 e Endoscopic (J Maneuver) view of gastric band erosion.
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Fig. 9 e Port site disconnection diagnosed on plain radiograph.
bowel (Roux limb) is then anastomosed to the newly formed pouch to create a gastro-jejunostomy. The bypassed segment of stomach and proximal small bowel (biliopancreatic limb) is then anastomosed to the small bowel 100e150 cm for the newly formed gastro-jejunostomy (see Fig. 10). Overall the procedure produces weight loss by both restriction of intake and malabsorption.25
Complications Surgical complications occur due to physiological changes and the alteration in anatomy and include obstruction (gastric
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remnant distension, anastomotic stenosis) haemorrhage, and choleithiasis. Other complications include short bowel syndrome, dumping syndrome and nutritional deficiencies but may not present as primary surgical emergencies. Small bowel obstruction can occur at any point from the newly formed gastrojejunal anastomosis to the terminal ileum. In a review of 2395 patients the incidence of small bowel obstruction has been reported at 3.9%. It occurs more commonly with a laparoscopic approach and causes include adhesions (48.4%), internal hernias (28%) and kinking of the jejunojejunal anastomosis (13%).26 Symptoms vary depending on the level of obstruction and include colicky abdominal pain, nausea and vomiting, distension and absolute constipation.27 Despite vomiting being a well associated feature of small bowel obstruction it may be absent if the level of obstruction involves the biliopancreatic limb. CT is useful in ruling out mechanical obstruction and if obstruction is identified it can highlight a transition point. Obstruction of any aetiology distal to the jejunojejunal anastomosis can result in dilation of the biliopancreatic limb, Roux limb and gastric remnant. Bilious vomiting is a feature and insertion of a nasogastric tube may decompress the proximal small bowel. Obstruction of the biliopancreatic limb results in a dilated biliopancreatic limb, duodenum and gastric remnant and can result in abnormal liver function tests and a raised serum amylase level. An isolated dilation of the Roux limb occurs in obstruction proximal to the jejunojejunal anastomosis and bilious vomiting is unusual in this scenario.28 However in identifying obstruction, the sensitivity of CT following gastric bypass is less favourable compared to the general population (51% versus 80e90%).27 Despite the well documented benefits of laparoscopic surgery its use in Roux en Y gastric bypass is associated with
Fig. 10 e Roux-en-Y gastric bypass-post operative anatomy. ©Ethicon, Inc. (2006). Reproduced with permission. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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Fig. 11 e Potential sites of internal herniation following Roux en Y gastric bypass. ©Elsevier 2006. Reproduced with permission.
an increase in internal hernia formation. This is believed to be due to fewer adhesions that develop following a laparoscopic approach.29 Sites of potential herniation include (a) the defect in the transverse mesocolon if the Roux limb is placed in a retrocolic position (mesocolic) (b) the space between the Roux limb mesentery and transverse mesocolon (Peterson's hernia) and (c) the mesenteric defect at the site of the jejunojejunostomy (see Fig. 11). They can present acutely due to strangulation or with recurrent episodes of colicky abdominal pain. Imaging may be non-diagnostic and contrast reaching the colon does not outrule an internal hernia. The presence of swirls in the mesentry or multiple loops of unopacified bowel
abnormally located in the right side of the abdomen raises the suspicion of an internal hernia. Due to the risk of strangulation there should be a low threshold for surgical exploration in an emergency setting.29 Port site hernias can also develop and these can be remedied by the general surgery. Gastric remnant syndrome is a rare sequel of obstruction but failure to recognise its occurrence can lead to perforation, peritonitis and subsequently death. Features include epigastric pain, distension, hiccups, a distended and tympanic upper abdomen, dyspnoea or tachycardia. A plain abdominal radiograph may show a gastric air bubble and diagnosis can be confirmed on CT imaging with oral contrast. A dilated gastric remnant with a collapsed duodenum can indicate an obstruction in the pyloric region but this will not be amenable to standard interventions such as nasogastric tube decompression. Urgent decompression with a gastrostomy tube (operative or percutaneous) is warranted in such cases. Stomal (anastomotic) stenosis has been documented in up to 6% in one series and may present with symptoms of nausea, vomiting, gastro oesophageal reflux or dysphagia. Diagnosis can be established with an upper GI contrast series although endoscopy is both diagnostic and therapeutic. Endoscopic dilatation has been shown to be safe and effective but some may require more than one dilation and perforation can occur.30,31 It is appropriate that if an anastomatic stenosis is identified and requires dilation it should be referred back to the initial bariatric surgeon or upper gastrointestinal surgeon as it usually does not require emergency intervention. Upper gastrointestinal haemorrhage is rare following Roux en Y gastric bypass and occurs more commonly in the early post-operative period due to marginal ulcers at the gastrojejunostomy.32 Suspected upper GI haemorrhage should be managed according to local and national guidelines such as NICE and an upper gastrointestinal endoscopy performed. If the source of haemorrhage is not identified further
Fig. 12 e Sleeve gastrectomy-post operative anatomy. ©Ethicon, Inc. (2006). Reproduced with permission. Please cite this article in press as: Healy P, et al., Complications of bariatric surgery e What the general surgeon needs to know, The Surgeon (2015), http://dx.doi.org/10.1016/j.surge.2015.08.003
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investigations include colonoscopy and angiography. In the context of ongoing haemorrhage without a definitive source the gastric remnant and duodenum may need to be explored.33
Laparoscopic sleeve gastrectomy (LSG) Description
changes that occur following surgery will facilitate an understanding of these presentations and aid in the interpretation of appropriate investigations. General surgeons should be aware of the potential late complications of the common bariatric surgical procedures to ensure that patients are investigated and managed appropriately. The specific complications of band slippage, pouch enlargement, bowel obstruction, internal hernia and gastric remanant syndrome should be recognised and managed by the emergency general surgeon while complications such as band erosion and stomal stenosis may be referred to a bariatric surgeon for further management.
LSG results in the formation of a narrow tubular stomach by dividing and excising a significant portion of the stomach (see Fig. 12). Its effects as a weight loss procedure are mediated through both restriction and hormonal changes. These changes are believed to be related to a reduced serum ghrelin levels which normally stimulate hunger.34 The procedure maintains a functioning pylorus, avoids an anastomosis and insertion of a foreign body and preserves normal intestinal absorption.35
Conflict of interest
Complications
Acknowledgements
Long term complications relate to stenosis, which can occur at the gastrooesophageal junction or incisura angularis and manifest with dysphagia and vomiting. As with stomal stenosis, investigation is with an upper GI contrast study or endoscopy and can be treated with endoscopic dilation.36 However if dilation is required it should be ideally be done by the bariatric surgeon or upper gastrointestinal surgeon (Table 2).
Illustrations provided by Ethicon and Elsevier.
Conclusion Obesity is reaching epidemic proportions worldwide despite increasing health promotion initiatives and interventions aimed at lifestyle modification. Surgery is currently the only proven intervention in achieving and sustaining long term weight loss and impacting positively on obesity related co morbidities such as diabetes mellitus. With an increasing number of these procedures being performed in specialist centres early post-operative complications are addressed by specialist bariatric surgeons. However patients with late complications will more commonly present to non-specialist centres. An understanding of the post-operative anatomical
Table 2 e Summary of procedures and main late complications (Bold to hightlight those that need intervention by emergency general surgeon). Procedure Laparoscopic assisted gastric band
Roux en Y gastric bypass
Sleeve gastrectomy
Main complications i. Band slippage ii. Pouch enlargement iii. Band necrosis iv. Port site complications i. Bowel obstruction ii. Gastric remnant syndrome iii. Gastrointestinal haemorrhage iv. Stomal (anastomotic) stenosis i. Stomal stenosis
7
None.
references
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