Emergencies after bariatric surgery

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Emergencies after bariatric surgery

  1. 1. Emergencies After Bariatric Surgery AI Sarela MD FRCS Consultant Surgeon St James ’s University Hospital
  2. 2. Agenda <ul><li>Laparoscopic Bariatric Procedures </li></ul><ul><ul><li>Roux-en-Y gastric bypass </li></ul></ul><ul><ul><li>Adjustable gastric band </li></ul></ul><ul><ul><li>Sleeve gastrectomy </li></ul></ul><ul><li>Technical/mechanical complications </li></ul><ul><ul><li>Early </li></ul></ul><ul><ul><li>Late </li></ul></ul><ul><li>Case-scenarios </li></ul>
  3. 3. Difficulties in the Bariatric Patient <ul><li>The classical symptoms and signs of peritonitis are usually absent in the bariatric patient </li></ul><ul><li>Problematic venous access </li></ul><ul><li>Cuff measurement of BP is often inaccurate </li></ul><ul><li>May not fit into CT scanner </li></ul><ul><li>Unfamiliarity with anatomy of the operation </li></ul><ul><li>Immobile – patient transfer is not easy! </li></ul>
  4. 4. Complications of Laparoscopic Roux-en-Y gastric bypass <ul><li>Early (< 30 days after operation) </li></ul><ul><ul><li>Leakage – peritonitis </li></ul></ul><ul><ul><li>Acute distention of the gastric remnant </li></ul></ul><ul><ul><li>Bleeding </li></ul></ul><ul><li>Early or Late </li></ul><ul><ul><li>Intestinal obstruction </li></ul></ul><ul><ul><li>Stomal stenosis </li></ul></ul><ul><ul><li>Stomal ulceration </li></ul></ul><ul><ul><li>Gallstones </li></ul></ul>
  5. 5. Roux-en-Y Gastric Bypass Case Scenarios <ul><li>POD#1 Laparoscopic Bypass: Fresh rectal bleeding, tachycardia, hypotension </li></ul><ul><li>POD#4 Laparoscopic Bypass: A&E admission. Abdominal pain, tachycardia, not well. </li></ul><ul><li>POD#7 Laparoscopic Bypass: A&E admission. Vomiting. </li></ul><ul><li>POD#20 Laparoscopic Bypass. Abdominal pain, fever, tachycardia. </li></ul><ul><li>2 years after Laparoscopic Bypass. Abdominal pain. </li></ul>
  6. 6. GI Luminal Bleeding after Bypass <ul><li>Endoscopy – clipping of bleeder </li></ul><ul><li>Laparoscopy </li></ul><ul><ul><li>Bleeding from the J-J anastomosis? </li></ul></ul><ul><ul><ul><li>Open anastomosis to inspect staple-line </li></ul></ul></ul><ul><ul><ul><li>Evacuate blood clots – may obstruct bowel </li></ul></ul></ul><ul><ul><li>Bleeding from the gastric remanant? </li></ul></ul><ul><ul><ul><li>Gastrotomy - Evacuate blood </li></ul></ul></ul><ul><ul><ul><li>Oversew staple-lines </li></ul></ul></ul>
  7. 7. Acute Abdomen in the Bypass Patient <ul><li>Leakage – Peritonitis </li></ul><ul><li>Intra-peritoneal bleeding </li></ul><ul><li>Intestinal obstruction </li></ul>
  8. 8. Sites of Leakage after Gastric Bypass <ul><ul><li>Gastrojejunal anastomosis </li></ul></ul><ul><ul><li>Jejuno-jejunal anastomosis </li></ul></ul><ul><ul><li>Staple line on the residual stomach </li></ul></ul><ul><ul><li>Gastrotomy for insertion of anvil </li></ul></ul><ul><ul><li>Missed enterotomy </li></ul></ul>
  9. 9. Laparoscopic Roux-en-Y Gastric Bypass Normal Radiological Anatomy
  10. 10. Suspected Leak: Radiology or Re-Laparoscopy? <ul><li>Contrast swallow examination – beware the false-negative! </li></ul><ul><li>CT scan – timing of oral contrast; limited enhancement with IV contrast </li></ul><ul><li>Consider re-exploration for all patients with suspected GI leak – radiology may delay intervention </li></ul>
  11. 11. Causes of Obstruction after Gastric Bypass <ul><li>Internal hernia – Peterson ’s space </li></ul><ul><li>Internal hernia – small bowel mesenteric defect </li></ul><ul><li>Incorrect identification of small intestine </li></ul><ul><ul><li>Closed loop </li></ul></ul><ul><ul><li>Twisted loop </li></ul></ul><ul><li>Narrow/occluded jejuno-jejunal anastomosis </li></ul><ul><li>Blood clot at jejuno-jejunal anastomosis </li></ul><ul><li>Port-site hernia </li></ul><ul><li>Abdominal wall hernia </li></ul>
  12. 12. Anatomy of Intestinal Obstruction in the Bypass Patient <ul><li>Isolated obstruction of the biliopancreatic limb </li></ul><ul><ul><li>Upper abdominal pain </li></ul></ul><ul><ul><li>Deranged liver function tests </li></ul></ul><ul><ul><li>Distention of the gastric remanant </li></ul></ul><ul><li>Isolated obstruction of the alimentary limb </li></ul><ul><ul><li>Inability to tolerate oral intake </li></ul></ul><ul><li>Obstruction of the common channel </li></ul><ul><ul><li>Bilious vomiting </li></ul></ul>
  13. 13. Massively Dilated Gastric Remnant <ul><li>Acute Dilatation </li></ul><ul><ul><li>Obstruction at J-J, BP limb or CC </li></ul></ul><ul><ul><li>Clot due to staple-line bleeding. Technical error in construction of the anastomosis. </li></ul></ul><ul><ul><li>CT guided or operative decompression of remnant. </li></ul></ul><ul><li>Chronic Dilatation </li></ul><ul><ul><li>Peptic ulcer, vagotomy, cancer, gastroparesis- in all these cases duodenum will remain collapsed </li></ul></ul>
  14. 14. Intestinal Obstruction with Distened Gastric Remnant
  15. 15. Dysphagia with Bypass <ul><li>Stomal stenosis </li></ul><ul><li>Early post-operative presentation </li></ul><ul><li>Dilatation </li></ul><ul><li>Routine post-operative PPI therapy </li></ul><ul><li>Smoking cessation </li></ul>
  16. 16. Marginal Ulcer <ul><li>Incidence up to 15% </li></ul><ul><li>Barium study – gastro-gastric fistula </li></ul><ul><li>Non-operative management </li></ul><ul><ul><li>Smoking cessation </li></ul></ul><ul><ul><li>NSAID cessation </li></ul></ul><ul><ul><li>Endoscopic removal of retained sutures </li></ul></ul><ul><ul><li>PPI </li></ul></ul><ul><li>Operation </li></ul><ul><ul><li>Excision and revision of anastomosis </li></ul></ul>
  17. 17. Gallstone & Biliary Sepsis <ul><li>Risk of gallstones may double during rapid weight loss (from 15 to 30%) </li></ul><ul><li>Combined cholecystectomy is controversial </li></ul><ul><li>Post-bypass – how to manage choledocholithiasis? </li></ul><ul><ul><li>Laparoscopic bile duct exploration </li></ul></ul><ul><ul><li>Trans-gastric ERCP </li></ul></ul><ul><ul><li>Percutaneous trans-hepatic biliary drainage </li></ul></ul>
  18. 18. Dysphagia with a Band <ul><li>Slippage </li></ul><ul><li>Over-inflation </li></ul><ul><li>Fluid Shifts </li></ul><ul><ul><li>“ Auto-fill” </li></ul></ul><ul><ul><li>Gastric wall oedema </li></ul></ul>
  19. 19. Band Slippage <ul><li>Cephalad migration of the gastric wall such that band is displaced </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Dysphagia </li></ul></ul><ul><ul><li>Gastric outlet obstruction </li></ul></ul><ul><li>Danger: Gastric wall necrosis </li></ul>
  20. 20. Band Slippage Radiology – Contrast Swallow <ul><li>Enlarged pouch that is obstructed at the level of the band </li></ul><ul><li>Change in the orientation of the band on contrast swallow or plain radiograph </li></ul>
  21. 21. Band in Good Position
  22. 22. Slipped Band
  23. 23. Slipped Band
  24. 24. Operations for Band Slippage <ul><li>Reduction of prolapsed stomach without opening the band </li></ul><ul><li>Opening the band, reduction of prolapsed stomach, repositioning of the band. </li></ul><ul><li>Removal of the band </li></ul><ul><li>Avoid cutting – expensive! </li></ul><ul><li>If opened, can leave it in the tunnel – do not have to remove. </li></ul>
  25. 25. Band Erosion <ul><li>Inadequate weight loss or weight regain </li></ul><ul><li>Intra-abdominal abscess </li></ul><ul><li>Port-site infection </li></ul>
  26. 26. Re-operation on the Bariatric Patient Positioning <ul><li>Abduction of both thighs on “split leg” table </li></ul><ul><li>Foot supports </li></ul><ul><li>No chest straps </li></ul><ul><li>Arms “tucked in” at sides </li></ul><ul><li>Extension arm-boards for retraction clamps </li></ul><ul><li>Maximum head-up incline </li></ul>
  27. 27. Re-operation on the Bariatric Patient Equipment <ul><li>Extra-long laparoscopic ports and instruments </li></ul><ul><li>Liver retractor with Fastclamp </li></ul><ul><li>Methylene blue solution (two ampoules in 1 litre of sterile water/NS) </li></ul><ul><li>NG tube – introduce under laparoscopic vision </li></ul>
  28. 28. Bariatric Surgery Emergencies <ul><li>Scary!! </li></ul><ul><li>Try to contact the operating surgeon </li></ul><ul><li>Determine the anatomy of the procedure </li></ul><ul><li>Radiology is not usually helpful </li></ul><ul><li>Very low threshold for RE-LAPAROSCOPY </li></ul><ul><li>Ensure availability of correct equipment </li></ul><ul><li>LAVAGE & DRAIN </li></ul>

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