Presentation on theme: "GI Complications of Gastric Bypass Caroline R. Tadros, MD May 15 th 2013."— Presentation transcript:
GI Complications of Gastric Bypass Caroline R. Tadros, MD May 15 th 2013
Disclaimer This presentation has no commercial content, promotes no commercial vendor and has not been supported financially by any commercial vendor. I have not received financial remuneration from any commercial vendor related to this presentation.
Bariatric Procedures Lap band link.org Sleeve Gastrectomy
Medical Complications of Roux-en-Y Metabolic and nutritional derangements – Iron, calcium, vitamin B12, thiamine, and folate Nephrolithiasis/Renal Failure 1 – Hyperolaxuria Post-operative hypoglycemia 2,3 – Pancreatic nesidioblastosis (beta islet cell hypertrophy)
Medical Complications of Roux-en-Y Change in bowel habits 4 Steatorrhea – Excessive fat intake – Lactose intolerance Dumping Syndrome 5 – Early 6 Onset within 15 minutes Colicky abdominal pain, nausea, tachycardia, diarrhea Usually self limited and resolves 7-12 weeks post operatively – Late Onset 2-3 hours Dizziness, fatigue, diaphoresis, and weakness
Gastric Remnant Distention Etiology 7,8 – paralytic ileus – distal mechanical obstruction – Iatrogenic injury to vagal fibers along the lesser curvature – Progressive distension can ultimately lead to rupture Presentation 9 – Abdominal pain – Hiccups – Shoulder pain – Abdominal distension – Tachycardia – Shortness of breath
Gastric Remnant Distention Diagnosis – Left upper quadrant tympany – Gastric air bubble on imaging Treatment 10 – emergent decompression with a gastrostomy tube or percutaneous gastrostomy – Immediate operative exploration and decompression are required if percutaneous drainage is not feasible, or if perforation is suspected.
Stomal Stenosis Etiology 11 – Tissue ischemia – Increased tension on the gastro-jejunal anastamosis Presentation – Several weeks postop – Nausea, vomiting, dysphagia, decreased oral intake, weight loss
Marginal Ulcers Etiology 15,16 – Poor tissue perfusion due to tension or ischemia at the anastomosis – Presence of foreign material, such as staples or non- absorbable suture – Excess acid exposure in the gastric pouch due to gastro- gastric fistulas – Non-steroidal anti-inflammatory drug use
Marginal Ulcers Etiology ( cont’d ) – Helicobacter pylori infection High prevalence of H. pylori in bariatric patients Preoperative treatment of HP decreased marginal ulcer rate form 6.8 to 2.4% – Smoking Presentation – nausea, abdominal pain, bleeding and/or perforation
Treatment of Marginal Ulcers 13 Gastric acid suppression Sucralfate Discontinuation of NSAIDS Smoking cessation H. pylori therapy Calcium channel blockers Endoscopy/ IR embolization Surgery (gastro-jejunostomy revision with truncal vagotomy)
Ulcers Within the Excluded Stomach Endoscopy is limited due to the post surgical anatomy Pancreatitis If suspected operative management/intraoperative endoscopy 25
Cholelithiasis Rapid weight loss increases lithogenicity of bile 20 Frequency can be reduced with a six month course of ursodiol given post-operatively Cholecystectomy at the time of bypass in those with symptomatic cholelithiasis 26,27 Cholecystectomy in asymptomatic patients is controversial
Choledocholithiasis ERCP is of limited benefit Typically requires PTC or surgery Placement of a gastrostomy tube into bypassed stomach at the time of surgery or as necessary for pancreatobiliary/ duodenal access 28,29
Internal Hernias Occur in up to 5 % of patients undergoing laparoscopic bariatric surgery Hernias through the transverse mesocolon are the most common and require operative repair 30
Internal Hernias Three potential areas of internal herniation 31,15 – Mesenteric defect at the jejuno-jejunostomy – The space between the transverse mesocolon and Roux- limb mesentery (Peterson's hernias) – The defect in the transverse mesocolon if the Roux-limb is passed retrocolic
Internal Hernias ( cont’d ) Intermittent, difficult to detect radiographically 32,33 If suspected, urgent surgical exploration is indicated strangulated hernia may result in short bowel syndrome.
Mesenteric Swirl Sign Rev. Col. Bras. Cir. vol.39 no.3 Rio de Janeiro May/June 2012
Persistent Obesity Failure to lose weight 34 – rare and is often due to maladaptive eating patterns during the early postoperative period Weight Regain 34 – Occurs in up to 20% of patients, especially those with super-obesity (BMI>50 ) at the time of surgery
Differential Diagnosis of Weight Regain Progressive noncompliant eating development of a gastro-gastric fistula 35,36,37 gradual enlargement of the gastric pouch 38,39 dilatation of the gastro-jejunal anastomosis
Weight Regain Management Fistula 35, 36,37 – UGIS if persistent or new onset GERD symptoms – surgical repair may be indicated Dilatation of gastric pouch or the gastro-jejunal anastomosis – Repeated overdistention of the pouch from excessive food intake – No benefit of revisional surgery.
Excessive Weight Loss Bacterial Overgrowth Gastro-intestinal fistula
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