Complications of Bariatric Surgery

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• Complications of Bariatric Surgery
• Eran Sadot, MD.

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• Mortality(30d)
• - Overall 0.1-1
• - Restrictive 0.1
• - GBP 0.5
• - BPDDS 1.1
• - Higher Male, Elderly, Surgeon experience?
• Buchwald, et al. Bariatric surgery a systematic
  review and meta-analysis. JAMA 2004.
• Maggard, et al. Meta-analysis surgical
  treatment of obesity. Ann Intern Med 2005.

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• Focus RYGB, LAGB.
• 3 categories
• 1. Early complications (1-6wks).
• 2. Late complications(7wks-12mo).
• 3. Very late complications.

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• Early complications (1-6wks)

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Early Complications - LAGB

• Acute Stomal Stenosis (LAGB) 6
• - Etlg Perigastric fat, tissue edema.
• - PW NV, food intolerance.
• - Dx UGIS.
• - Tx conservativeif persist-gtrevision/removal.
• - Prevention perigastric fat removal.

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Early Complications - RYGB

• Pulmonary Embolus 0-3.3
• Accounts for 30 of mortality.
• Prevent pneumatic compression devices subq
  heparin.
• Dx difficult.
• Tx when high level of clinical suspicion.
• Bleeding 0.6-4
• Early Bleeding
• Etlg d/t staple lines / surgical anastamosis
• Mainly intraluminal
• PWMelena, HR?, HGB?
• Self limited
• Tx PC, reverse anticoagulation, EGD, Surgery.

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Early Complications - RYGB

• Leaks 2-3
• Account for 50 of mortality.
• PW fever, HR?, resp. fail.
• Dx UGIS, CT.
• Tx A. Urgent Exploratory surgery
• 1. Irrigation.
• 2. Repair of the defect.
• 3. Wide ext. drainage.
• B. Abx.

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Early Complications - RYGB

• Gastric remnant distention rare
• Potentially lethal (distention-gtrupture-gtperitonit
  is)
• Etlg Blind pouch distention d/t ileus or mech.
  obstruction.
• PW pain, hiccups, LUQ tympany, shoulder pain,
  abdominal distension, tachycardia, or SOB.
• X-Ray large gastric air bubble.
• Tx decompression with gastrostomy
  (OR/Percutaneous)

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Early Complications - RYGB

• Wound Infection
• Lap 3-4
• Open 10-15
• PW fever, fluctuance, erythema, or drainage.
• Tx open and/or ID, if cellulitis-gt Abx.

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• Late complications(7wks-12mo)

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Late Complications - LAGB

• Band Erosion 0-3
• Etlg gast wall ischemia (tight band, band buckle
  trauma).
• PW loss of restriction, fever, NV, Port site
  infection (B.K).
• Dx EGD.
• Tx removal.
• Band slippage/prolapse 2-14
• PW gastric obst (food intol, epig pain, NV).
• Dx UGIS (band malposition, dilated/prolapsed
  gast. pouch)
• Tx surgical reposition/removal.

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Late Complications - LAGB

• Port/tube Malfunction 0.4-7
• Etlg disconnection, port flips, leakage.
• PW weight regain.
• Tx surg repair/exchange hardware.
• Pouch/esophageal dilation (pseudoachalasia
  synd) 10
• Etlg tight band, food intake?, binge eating.
• Tx band deflation, band relocation/removal.
• Esophagitis rare
• Tx deflation, acid supp., removal.

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Late Complications - LAGB

• Port Infection 0.3-9
• 1st R/O Band erosion via EGD.
• Tx port removal.

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Late Complications - RYGB

• Bleeding 0.6-4
• Late Bleeding rare
• Etlg PUD
• Tx conservative, partial gastrectomy.
• Stomal Stenosis 6-20
• Etlg tissue ischemia (poor perfusion, tension).
• PW 6-7wks post op, NV, dysphagia, GE reflux,
  inability to tolerate oral intake.
• Dx UGIS, EGD.
• Tx Balloon dilation, surgical revision(lt0.05).

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Late Complications - RYGB

• Marginal Ulcers 0.6-13
• Etlg poor tissue perfusion, anastomotic tension,
  staple line disruption or gastrogastric fistulas
  (-gt chronic exposure of the gastrojej to acid),
  or NSAID use.
• Dx EGD.
• Tx
• D/C NSAID, PPI, Stop Smoking.
• Surgery revision (truncal vagotomy) rare.

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Late Complications - RYGB

• Dumping Syndrome 50
• PW nausea, shaking, diaphoresis, diarrhea
  shortly after eating.
• Tx Dietary prohibitions.
• Cholelithiasis
• w/o proplxs 38 (40 symp)
• 6mo post op w ursodeoxycholic acid 2
• Risk factors obesity, rapid weight loss.
• No benefit for simultaneous cholecystectomy for
  incidental gallstones at the time of RYGB (unless
  symptomatic).
• Villegas et al. Obes Surg 2004.
• Hamad, GG et al. Obes Surg 2003.

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Late Complications - RYGB

• Choledocholithiasis uncommon
• Dx US, MRCP.
• Tx
• ERCP cannot be performed routinely.
• PTC.
• Surgery.
• Incisional Hernia Lap 0-1.8 Open 24.
• PW enlarging bulge, pain, or obstructive
  symptoms.
• Tx
• Postpone repair until significant weight loss (gt1
  year).
• Indications for early surgical repair include
  significant pain, bowel obstruction, and rapid
  enlargement of the hernia.

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Late Complications - RYGB

• Internal Hernias 0-5
• Three potential areas of internal herniation are
  between
• Mesenteric defect at the jejuno-jejunostomy.
• The space between the transverse mesocolon and
  Roux-limb mesentery (Peterson's hernias).
• The defect in transverse mesocolon if the
  Roux-limb is passed retrocolic most common.
• If a patient is suspected of an internal hernia,
  urgent surgical exploration is indicated !
• Prevention all previously mentioned defects are
  usually closed.

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Late Complications - RYGB

• Failure to lose weight
• d/t maladaptive eating patterns.
• Weight regain up to 20
• noncompliant eating and other behavioral habits.
• functional gastrogastric fistula
• Dx UGIS.
• Tx surg rep. Endo stent/suture.
• Dilation of gastric pouch or the gastrojej.
  anastomosis
• d/t excessive food intake.
• Endoscopic suture reduction.

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• Very Late Complications

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Very Late Complications

• Nutritional Defficiency
• After RYGB
• Bloomberg RD, Fleishman A, Nalle JE, Herron DM,
  Kini S. Nutritional deficiencies following
  bariatric surgery what have we learned? Obes
  Surg. 2005. Review.
• Poitou Bernert C. Nutritional deficiency after
  gastric bypass diagnosis, prevention and
  treatment. Diabetes Metab. 2007. Review.
• Shah M. Review long-term impact of bariatric
  surgery on body weight, comorbidities, and
  nutritional status. J Clin Endocrinol Metab.
  2006. Review.
• Alvarez-Leite JI. Nutrient deficiencies secondary
  to bariatric surgery. Curr Opin Clin Nutr Metab
  Care. 2004. Review.
• Fujioka K. Follow-up of nutritional and metabolic
  problems after bariatric surgery. Diabetes Care.
  2005. Review.

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Nutritional Defficiency

• The mechanisms
• Insufficient intake d/t dietary restrictions and
  food intolerance (meat, milk, fiber)
• The exclusion of the stomachs inferior part
  results in a decreased secretion of gastric acid,
  sometimes required to absorb vitamins and
  minerals (B12 and iron).
• Duodeno-jejunal malabsorption related to the
  short-circuit. The duodenum is the main
  absorption site for calcium, iron and vitamin B1
  (thiamin).
• Asynergia occurs between the bolus and the
  bilio-pancreatic secretions in the common portion
  of the intestine.

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Proteins

• Albumin lt3.5 g/dL.
• Mechanism
• 50 duodenal absorption
• Intake def (intolerance to meat)
• Decreased pancreatic enzyme secretion
• Contact time?
• Clinical deterioration of general state of
  health, muscle weakness with loss of muscle mass,
  anomalies of the skin, mucosa and nails (alopecy,
  striated nails, dermatitis, hypopigmentation),
  edema.
• Prevalence
• Distal RYGB 6-13
• Standard RYGB (Shorter R limb lt150cm) none.
• Peak incidence 1-2yr post op.

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Vitamin B12 (cobalamin)

• lt250 pg/ml.
• Mechanism
• ?acid secretion (cleavage B12 food proteins).
• Delayed/no link to IF (parietal c.).
• Schilling test after RYGB abnrl in 50 of B12
  def.
• Prevalence (no pre-op def. , despite advised
  MVI)
• From 1yr post op. 12-70.
• In the first 2 yr 25.
• Post-op MVI use was shown to prevent folate and
  B12 deficiency when taken regularly.
• Clinical Macrocytosis 0.8. Megaloblastic
  anemia rare. No neurologic symp.

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Vitamin B9 (folates)

• lt3 ng/ml
• Mechanism
• ?dietary intake (fruits and vegetables).
• Because folates may be absorbed throughout the
  whole intestine.
• Prevalence (no pre-op deff. , despite advised
  MVI)
• 20 at 1 yr.
• Post-op MVI use was shown to prevent folate and
  B12 deficiency when taken regularly.
• Clinical NTD, Anemia, apathy, fatigue,
  headaches, insomnia,, weakness, Diarrhea, loss of
  appetite.

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Vitamin B1 (thiamin)

• Mechanism
• Absorbed in the duodenum
• ?intake (fruits, meat, cereals..)
• Vomiting
• Prevalence
• 1
• No def. when MVI
• Clinical
• CVS CHF
• Neuro Wernicke's encephalopathy, confusion,
  irritability, memory loss, nervousness, numbness
  of hands and feet, pain sensitivity, poor
  coordination, weakness.
• GI Constipation, intestinal disturbances, loss
  of appetite
• In all cases - administration of IV Vit B1
  (50100 mg) corrects the deficit.

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Liposoluble vitamins (A, E, K)

• Mechanism ?fat breakdown(limited/short time with
  biliary sec.)
• Prevalence
• very low after RYGB.
• BPD(4yr)
• A-69, K-68, E-4.
• Despite MVI.
• Clinical (BPD)
• Vit A - night blindness or ocular xerosis.
• Vit E non.
• Vit K non.
• Prudence recommends that patients taking
  anticoagulants (antivitamin K) must be closely
  monitored !

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Calcium and vitamin D

• Mechanism
• Ca ? intake, ?absorption (duodenum prox jej).
• Vit D ?absorption (lipid malabsorption).
• HyperPTH Ca ? -gtPTH? -gthyperPTH-gt bone loss .
• Prevalence
• Distal RYGB
• Ca 10 at 2yr
• Vit D 51 at 2yr
• BPD
• Ca 25-50
• Vit D 17-50
• HyperPTH
• RYGB ?risk in post menopausal.
• BPD 69 at 4 yr , 3 ? bone resorption.
• Clinical osteoporosis, osteomalacia.

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Iron Anemia

• Iron deficiencies are the most frequent
  deficiencies after RYGB.
• Mechanism
• ?intake (red meat).
• ? HCL -gt ? transformation ferric form (Fe3) to
  ferrous form (Fe2), which is the absorbable
  form.
• ? absorbed in the duodenum.
• Prevalence (despite MVI)
• at 2 yr 33
• ? 50 among women of childbearing age.
• Anemia
• Def. anemias (vitamin B12, iron, folates) 30.
• Microcytic anemia in 63 of patients with an
  iron deficit
• Other Clinical tinnitus, hair loss.

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Potassium and magnesium

• Halverson JD. Am Surg 1986
• 56 hypokalemia with diuretic.
• 34 hypomagnesemia.
• Amaral JF. Ann Surg 1985
• 6.3 severe hypokalemia (lt3).
• No hypomagnesemia.

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Zinc

• The absorption of zinc is dependent on the
  absorption of lipids which is reduced after RYGB.
• Prevalence
• BPD 10-50.
• RYGB rare.
• Clinical
• Hair loss is frequently observed among women 3 -
  6 mo after the RYGB.
• Mechanisms iron, protein and zinc deficiencies,
  post surgical stress and significant weight loss.
• Only one study described an improvement of
  alopecia after treatment with high zinc sulfate
  supplements.

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Selenium

• Only in BPD
• 3-14.5
• No clinical repercussion.
• Potential Symptoms
• Increased incidence of cancer.
• Pancreatic insufficiency.
• Immune impairment.
• Liver impairment
• Male sterility.

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• Diagnosis
• of the deficiencies
• nutritional Follow-up

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• Prevention and treatment
• of the nutritional deficiencies
• after RYGB

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• No controlled trial exists to determine the type
  of supplements and the dosages to be prescribed
  after RYGB.
• The majority of the reviews published on
  post-RYGB deficiencies recommend a multivitamin
  supplement providing 100 of the RDA.

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Pregnancy

• Iron def. anemia prematurity, LBW.
• Vit D def. Rickets, Neonatal hypoCa.
• Iodine def. Goiter, intellectual impairment.
• FA def. NTD, Cleft palate.
• An increase in cases of malformations of the
  neural tube was reported
• Haddow JE. Neural tube defects after gastric
  bypass. Lancet 1986.
• Knudsen LB. Gastric bypass, pregnancy, and neural
  tube defects. Lancet 1986.
• Martin L. Gastric bypass surgery as maternal risk
  factor for neural tube defects. Lancet 1988.
• Ladipo OA. Nutrition in pregnancy mineral and
  vitamin supplements. Am J Clin Nutr 2000.

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• It is recommended that women wait approximately
  at least 18 months after surgery before beginning
  a pregnancy.
• There is no data on the monitoring and the
  supplements to be prescribed for pregnant women
  after RYGB.

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Take Home

• Bariatric surgery can be life-saving for the
  right patient.
• Attention to adequate nutrition and vitamin
  supplementation is key.
• Lifelong monitoring is essential !