Sleeve surgery complications

1. Postoperative complications of sleeve gastrectomy
general surgery
Arshia Arabnia

2. Obesity
With well over half the U.S. population overweight and nearly one-third obese, weight and its effect
on health have become important topics of research and concern. Obesity is a chronic disease of
excess adipose tissue having multiple etiologies: genetic, environmental, behavioral, and
neurohormonal.
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4. Surgical intervention
• Surgery remains the only proven modality effective in inducing and maintaining weight loss and in
reducing lifetime obesity-related morbidities and mortality.
• In 1991, an NIH Consensus Development Conference established criteria by which patients
undergo consideration for operative treatment of obesity: individuals with a BMI of 40 kg/m2 or
greater and individuals with a BMI of 35 to 40 kg/m2 with significant obesity- related comorbidity.
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5. Sleeve gastrectomy
• SG is currently the most common operative intervention, recently having surpassed RNYGB, for
morbid obesity in the United States. It is a restrictive procedure, in which the surgeon removes
approximately 85% of the stomach laparoscopically so that the stomach takes the shape of a tube or
“sleeve”
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7. • SG results in excellent weight loss and comorbidity reduction that exceeds or is comparable to that
of other accepted bariatric procedures. Weight loss average in the first 2 years is from 60% to 75%
of excess body weight (EBW). Long-term data are limited, but the 5 and 10 year follow-up data
have demonstrated the durability and safety of the SG procedure.
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8. Post operative complications
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9. Early complications
• Anastomotic leak: Anastomotic leak occurs in procedures that require a staple line or anastomosis.
They can occur in between 1% and 5% of patients undergoing an SG, gastric bypass, or BPD/DS.
• The staple line near the GE junction is the most common site for the SG. Classic signs and
symptoms of peritonitis may not be present or may be difficult to recognize in the obese patient.
Abdominal pain, unexplained tachycardia, tachypnea, and hypoxia should raise suspicion of a leak.
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10. • Prompt imaging with an upper GI series or abdominal CT with oral contrast can lead to the
diagnosis. Conservative management with intravenous antibiotics, percutaneous drainage
(endoscopic stent for sleeve leaks), and parenteral nutrition in the hemodynamically stable patient is
an option
• If this is unsuccessful, or if the patient is clinically unstable, immediate operative exploration,
drainage, and repair (if possible) are undertaken.
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11. Postoperative bleeding
• Patients with hemorrhage may present with tachycardia, a drop in the hemoglobin level,
hematemesis, or melena. Patients with substantial postoperative hemorrhage that occurs in the first
few hours after surgery require operative exploration. In some cases, the diagnosis occurs after 24
hours, and if the patient is hemodynamically stable, nonoperative management is an option.
Postoperative bleeding after an SG occurs less frequently than the gastric bypass (0.5%) and is
mostly the type of bleeding that occurs in the abdominal cavity.
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12. Late complications
• Nutrition disturbances:
• Not surprisingly, the therapeutic nutrient restriction imposed by bariatric surgery may also lead to
significant nutritional deficiencies.
• Bariatric surgical patients should consume extra protein (60 to 80 g) on a daily basis to ensure that
the metabolic demands of the body are met.
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13. • Patients with preexisting iron deficiency and menstruating women should take 65 mg of elemental
iron daily, plus vitamin C, which improves absorption. Vitamin B12 deficiency is the next most
common; it can produce neurologic symptoms and megaloblastic anemia.For this reason, patients
are routinely administered intramuscular or sublingual vitamin B12.
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14. Marginal Ulcer:
• An ulcer occurring on the jejunal side of the gastrojejunostomy is termed a marginal ulcer.
• Such ulcers result from impaired perfusion of the jejunal mucosa because of interruption of the
blood supply by the staple line at the anastomosis. Smoking and the use of NSAIDs or steroids such
as prednisone may also contribute.
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15. • Marginal ulcers may occur as early as several weeks, or as late as 1 year postoperatively. Patients
present with abdominal pain, upper GI bleeding, nausea, and vomiting. Patients may lose weight
because of fear of eating, as food may worsen the symptoms.
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16. • Upper endoscopy provides the diagnosis, and treatment consists of protection of the GI mucosa
with PPIs and sucralfate. Total bowel rest with parenteral nutrition is sometimes necessary. If the
ulcer is recalcitrant to conservative management, revision of the gastrojejunostomy may be necessary.
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17. Stricture
• Sleeve patients can have a stricture anywhere along the length of the stapled stomach. A stricture
will occur within the first 3 months after surgery. Generally, a patient will complain of not being able
to advance their diet beyond liquids. They may have frequent vomiting episodes or night-time
regurgitation/reflux.
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18. • Upper endoscopy is the diagnostic procedure of choice. If a stricture is present, pneumatic balloon
dilation opens the affected region in gastric bypass and SG. Multiple dilations are sometimes
necessary.
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19. Cholelithiasis
• About a third of obese patients will develop cholelithiasis during the rapid weight loss following
gastric bypass surgery. The risk is lower with restrictive procedures.
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20. • This statistic has led to the routine administration of ursodeoxycholic acid, 300 mg twice daily, for
6 months postoperatively.
• This medication decreases the risk of developing cholelithiasis to around 2%. Side effects include
diarrhea, dyspepsia, and abdominal pain. Although screening for gallstones with ultrasound is not
performed for all patients, some surgeons will perform cholecystectomy at the time of initial
operation if patients have known preexisting cholelithiasis or symptoms of biliary colic.
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22. Thank you all for your attention
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