Complications of bariatric surgery - www.iranobesitysociety.org

Complications of bariatric surgery
A.R. khalaj M.D. Minimal Invasive Surgery Research Center
university of Iran

MORTALITY
Overall mortality was estimated to be less than 1 percent Meta-analysis: surgical treatment of obesity.
AU - Maggard MA; Shugarman LR; Suttorp M; Maglione M; Sugarman HJ; Livingston EH; Nguyen NT; Li Z; Mojica WA; Hilton L; Rhodes S; Morton SC; Shekelle PG
SO - Ann Intern Med 2005 Apr 5;142(7):547-59
increasing mortality was associated with advancing age, male sex, and lower surgeon volume of bariatric procedures Surgical volume impacts bariatric surgery mortality: a case for centers of excellence.
AU - Hollenbeak CS; Rogers AM; Barrus B; Wadiwala I; Cooney RN
SO - Surgery. 2008 Nov;144(5):736-43. Epub 2008 Jul 21

MORTALITY
The introduction of laparoscopic RYGB has been associated with a significant reduction in perioperative mortality.0.17 percent as compared to 0.79 for open RYGB 30-day morbidity and mortality of bariatric surgical procedures as assessed by prospective, multi-center, risk-adjusted ACS-NSQIP data.
AU - Lancaster RT; Hutter MM
SO - SurgEndosc. 2008 Dec;22(12):2554-63. Epub 2008 Sep 20.

REHOSPITALIZATION RATES
the rates of unexpected reoperations ranged from 6 to 9 percent
AU - Santry HP; Gillen DL; Lauderdale DS
SO - JAMA 2005 Oct 19;294(15):1909-17.
20, 18, and 15 percent of patients required readmission at one, two, and three years, respectively SO - JAMA 2005 Oct 19;294(15):1918-24.
hospitalization in the year prior to surgery of approximately 8 percent.

COMPLICATIONS OF MALABSORPTIVE PROCEDURES
Jejunoileal bypass
JIB resulted in high rates of diarrhea, arthritis, hepatic failure, cirrhosis, nephrolithiasis, protein malnutritio and vitamin deficiencies - Am J Med 1978 Mar;64(3):461-75.n,
SurgClin North Am 1979; 59:1071.

COMPLICATIONS OF MALABSORPTIVE PROCEDURES
Biliopancreatic diversion and duodenal switch complications
significant protein calorie malnutrition, anemia, metabolic bone disease, deficiencies of fat-soluble vitamins and vitamin
B12- Gastroenterology 2001 Feb;120(3):669-81.

Vertical banded gastroplasty
staple line disruption 27-48%, stomalstenosis 20-33%, band erosion 1-7%, GERD, nausea/vomiting, marginal ulcers, and weight regain TI - Bariatric surgery. Surgery for weight control in patients with morbid obesity.
AU - Balsiger BM; Murr MM; Poggio JL; Sarr MG
SO - Med Clin North Am 2000 Mar;84(2):477-89.

Laparoscopic adjustable gastric band
Early complications include acute stomal obstruction 6%, band infection 0.3-9%, gastric perforation, hemorrhage, bronchopneumonia, and delayed gastric emptying.
GastrointestSurg 2003; 7:429.

Laparoscopic adjustable gastric band
Late complications include band erosion 7%, band slippage 2-14% or prolapse, port or tubing malfunction, leakage at the port site tubing or band, pouch or esophageal dilatation and esophagitis .
SO - Obes Surg 2002 Apr;12(2):254-60

Roux-en-Y gastric bypass
Pulmonary embolus up to 3.3%
Optimal strategies for preventing DVT/PE in the gastric bypass setting have not been established. However, most bariatric surgeons use both pneumatic compression devices in conjunction with subcutaneous heparin
TI - Current practices in the prophylaxis of venous thromboembolism in bariatric surgery.
AU - Wu EC; Barba CA
SO - ObesSurg 2000 Feb;10(1):7-13; discussion 14

Leaks 2 and 3 percent
TI - Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned?
AU - Higa KD; Boone KB; Ho T
SO - ObesSurg 2000 Dec;10(6):509-13.
exploratory surgery should be performed without delay, even if test results are not confirmatory.

Gastric remnant distension
Clinical features include pain, hiccups, left upper quadrant tympany, shoulder pain, abdominal distension, tachycardia, or shortness of breath. Radiographic assessment may demonstrate a large gastric air bubble
Treatment consists of emergent operative decompression with a gastrostomy tube or percutaneousgastrostomy
TI - Laparoscopic reoperative bariatric surgery: experience from 27 consecutive patients.
AU - Gagner M; Gentileschi P; de Csepel J; Kini S; Patterson E; Inabnet WB; Herron D; Pomp A
SO - ObesSurg 2002 Apr;12(2):254-60.

Marginal ulcers0.6 to 16%
Causes of marginal ulcers include :
Poor tissue perfusion due to tension or ischemia at the anastomosis
Presence of foreign material, such as staples or nonabsorbable suture
Excess acid exposure in the gastric pouch due to gastrogastric fistulas
Nonsteroidalantiinflammatory drug use
Helicobacter pylori infection
Smoking
medical treatment

Cholelithiasis
Without prophylaxis, cholelithiasis develops in as many as 38 percent of patients within six months of surgery, and up to 41 percent of such patients become symptomatic .
Am J Gastroenterol 1991 Aug;86(8):1000-5.
The high frequency of cholelithiasis can be reduced to as low as 2 percent with a six month course of ursodeoxycholic acid (a synthetic bile salt) given prophylactically after surgery .
Am J Surg 1995 Jan;169(1):91-6; discussion 96-7.

Wound infection
Rates of wound infection are significantly greater with open (10 to 15 percent) than laparoscopic (3 to 4 percent) gastric bypass procedures .
SO - Ann Surg 2000 Oct;232(4):515-29
The incidence of wound infections can be decreased by perioperative administration of antibiotics (usually cefazolin) .

Stomalstenosis6 to 20 percent
Endoscopic balloon dilation is usually successful .
Repeat dilation sessions may be required for some patients
[
The complication rate for dilation is approximately 3 percent
Surgical revision (required in less than 0.05 percent of patients) is reserved for those who have persistent stenosis despite repeated dilations.

Bleeding
Bleeding after gastric bypass has been described in 0.6 to 4.0 percent of patient
Ann Surg 2001 Sep;234(3):279-89; discussion 289-91
A higher rate of postoperative gastrointestinal bleeding was observed following laparoscopic versus open GBP in a prospective randomized study
Ann Surg 2001 Sep;234(3):279-89; discussion 289-91.

Ventral incisional hernia

Ventral incisional hernias occur with a frequency of 0 to 1.8 percent in laparoscopic series and as high as 24 percent in open series, underscoring a clear advantage of the laparoscopic approach in this regard
SO - Ann Surg 2001 Sep;234(3):279-89; discussion 289-91.

Failure to lose weight and weight regain
Progressive noncompliant eating and other behavioral habits .
Development of a functional gastrogastric fistula.
Gradual enlargement of the gastric pouch.
Dilation of the gastrojejunalanastomosis.

Metabolic and nutritional derangements
Iron, vitamin B12, and folate. Hyperoxaluria and nephrolithiasis have been reported following roux-en-Y gastric bypass surgery.

Internal hernias
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
Internal hernias have been described in 0 [64] and 5 [73] percent of patients undergoing laparoscopic bariatric surgery.
If a patient is suspected of an internal hernia, urgent surgical exploration is indicated

Postoperative hypoglycemia and
Dumping
A small number of patients develop blackouts and seizures after weight loss surgery due to a severe form of recurrent hyperinsulinemic hypoglycemia . TI - Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery.
AU - Service GJ; Thompson GB; Service FJ; Andrews JC; Collazo-Clavell ML; Lloyd RV
SO - N Engl J Med 2005 Jul 21;353(3):249-54

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