Emergencies after bariatric surgery

Emergencies After Bariatric Surgery AI Sarela MD FRCS Consultant Surgeon St James ’s University Hospital

Agenda
Laparoscopic Bariatric Procedures
Roux-en-Y gastric bypass
Adjustable gastric band
Sleeve gastrectomy
Technical/mechanical complications
Early
Late
Case-scenarios

Difficulties in the Bariatric Patient
The classical symptoms and signs of peritonitis are usually absent in the bariatric patient
Problematic venous access
Cuff measurement of BP is often inaccurate
May not fit into CT scanner
Unfamiliarity with anatomy of the operation
Immobile – patient transfer is not easy!

Complications of Laparoscopic Roux-en-Y gastric bypass
Early (< 30 days after operation)
Leakage – peritonitis
Acute distention of the gastric remnant
Bleeding
Early or Late
Intestinal obstruction
Stomal stenosis
Stomal ulceration
Gallstones

Roux-en-Y Gastric Bypass Case Scenarios
POD#1 Laparoscopic Bypass: Fresh rectal bleeding, tachycardia, hypotension
POD#4 Laparoscopic Bypass: A&E admission. Abdominal pain, tachycardia, not well.
POD#7 Laparoscopic Bypass: A&E admission. Vomiting.
POD#20 Laparoscopic Bypass. Abdominal pain, fever, tachycardia.
2 years after Laparoscopic Bypass. Abdominal pain.

GI Luminal Bleeding after Bypass
Endoscopy – clipping of bleeder
Laparoscopy
Bleeding from the J-J anastomosis?
Open anastomosis to inspect staple-line
Evacuate blood clots – may obstruct bowel
Bleeding from the gastric remanant?
Gastrotomy - Evacuate blood
Oversew staple-lines

Acute Abdomen in the Bypass Patient
Leakage – Peritonitis
Intra-peritoneal bleeding
Intestinal obstruction

Sites of Leakage after Gastric Bypass
Gastrojejunal anastomosis
Jejuno-jejunal anastomosis
Staple line on the residual stomach
Gastrotomy for insertion of anvil
Missed enterotomy

Laparoscopic Roux-en-Y Gastric Bypass Normal Radiological Anatomy

Suspected Leak: Radiology or Re-Laparoscopy?
Contrast swallow examination – beware the false-negative!
CT scan – timing of oral contrast; limited enhancement with IV contrast
Consider re-exploration for all patients with suspected GI leak – radiology may delay intervention

Causes of Obstruction after Gastric Bypass
Internal hernia – Peterson ’s space
Internal hernia – small bowel mesenteric defect
Incorrect identification of small intestine
Closed loop
Twisted loop
Narrow/occluded jejuno-jejunal anastomosis
Blood clot at jejuno-jejunal anastomosis
Port-site hernia
Abdominal wall hernia

Anatomy of Intestinal Obstruction in the Bypass Patient
Isolated obstruction of the biliopancreatic limb
Upper abdominal pain
Deranged liver function tests
Distention of the gastric remanant
Isolated obstruction of the alimentary limb
Inability to tolerate oral intake
Obstruction of the common channel
Bilious vomiting

Massively Dilated Gastric Remnant
Acute Dilatation
Obstruction at J-J, BP limb or CC
Clot due to staple-line bleeding. Technical error in construction of the anastomosis.
CT guided or operative decompression of remnant.
Chronic Dilatation
Peptic ulcer, vagotomy, cancer, gastroparesis- in all these cases duodenum will remain collapsed

Intestinal Obstruction with Distened Gastric Remnant

Dysphagia with Bypass
Stomal stenosis
Early post-operative presentation
Dilatation
Routine post-operative PPI therapy
Smoking cessation

Marginal Ulcer
Incidence up to 15%
Barium study – gastro-gastric fistula
Non-operative management
Smoking cessation
NSAID cessation
Endoscopic removal of retained sutures
PPI
Operation
Excision and revision of anastomosis

Gallstone & Biliary Sepsis
Risk of gallstones may double during rapid weight loss (from 15 to 30%)
Combined cholecystectomy is controversial
Post-bypass – how to manage choledocholithiasis?
Laparoscopic bile duct exploration
Trans-gastric ERCP
Percutaneous trans-hepatic biliary drainage

Dysphagia with a Band
Slippage
Over-inflation
Fluid Shifts
“ Auto-fill”
Gastric wall oedema

Band Slippage
Cephalad migration of the gastric wall such that band is displaced
Symptoms
Pain
Dysphagia
Gastric outlet obstruction
Danger: Gastric wall necrosis

Band Slippage Radiology – Contrast Swallow
Enlarged pouch that is obstructed at the level of the band
Change in the orientation of the band on contrast swallow or plain radiograph

Band in Good Position

Slipped Band

Operations for Band Slippage
Reduction of prolapsed stomach without opening the band
Opening the band, reduction of prolapsed stomach, repositioning of the band.
Removal of the band
Avoid cutting – expensive!
If opened, can leave it in the tunnel – do not have to remove.

Band Erosion
Inadequate weight loss or weight regain
Intra-abdominal abscess
Port-site infection

Re-operation on the Bariatric Patient Positioning
Abduction of both thighs on “split leg” table
Foot supports
No chest straps
Arms “tucked in” at sides
Extension arm-boards for retraction clamps
Maximum head-up incline

Re-operation on the Bariatric Patient Equipment
Extra-long laparoscopic ports and instruments
Liver retractor with Fastclamp
Methylene blue solution (two ampoules in 1 litre of sterile water/NS)
NG tube – introduce under laparoscopic vision

Bariatric Surgery Emergencies
Scary!!
Try to contact the operating surgeon
Determine the anatomy of the procedure
Radiology is not usually helpful
Very low threshold for RE-LAPAROSCOPY
Ensure availability of correct equipment
LAVAGE & DRAIN

Emergencies after bariatric surgery

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Emergencies after bariatric surgery Presentation Transcript