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GI Complications of Gastric Bypass Caroline R. Tadros, MD May 15 th 2013.

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Presentation on theme: "GI Complications of Gastric Bypass Caroline R. Tadros, MD May 15 th 2013."— Presentation transcript:

1 GI Complications of Gastric Bypass Caroline R. Tadros, MD May 15 th 2013

2 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.

3 Bariatric Procedures Lap band http://www.nationalbariatric Sleeve Gastrectomy

4 Roux-en-Y Anatomy

5 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)

6 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

7 Mechanical Complications Gastric Remnant Distention Stomal Stenosis Marginal Ulcers Ulcers in excluded stomach Cholelithiasis/Choledocholi thiasis Fistulas – Gastro-gastric – Gastro-intestinal

8 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

9 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.

10 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

11 Stomal Stenosis ( cont’d ) Diagnosis – EGD – Upper GI series Treatment 12,13,14 – Endoscopic balloon dilation (perforation rate 3%) – Surgical revision (<0.05%)

12 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

13 Marginal Ulcers Etiology ( cont’d ) – Helicobacter pylori infection 21-24 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

14 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)

15 Ulcers Within the Excluded Stomach Endoscopy is limited due to the post surgical anatomy Pancreatitis If suspected operative management/intraoperative endoscopy 25

16 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

17 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

18 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

19 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

20 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.

21 Mesenteric Swirl Sign Rev. Col. Bras. Cir. vol.39 no.3 Rio de Janeiro May/June 2012

22 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

23 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

24 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.

25 Excessive Weight Loss Bacterial Overgrowth Gastro-intestinal fistula

26 References 1.Oxalate nephropathy complicating Roux-en-Y Gastric Bypass: an underrecognized cause of irreversible renal failure. Nasr SH, D'Agati VD, Said SM, Stokes MB, Largoza MV, Radhakrishnan J, Markowitz GS Clin J Am Soc Nephrol. 2008;3(6):1676. 2.Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. Service GJ, Thompson GB, Service FJ, Andrews JC, Collazo-Clavell ML, Lloyd RV N Engl J Med. 2005;353(3):249. 3.Severe hypoglycaemia post-gastric bypass requiring partial pancreatectomy: evidence for inappropriate insulin secretion and pancreatic islet hyperplasia. Patti ME, McMahon G, Mun EC, Bitton A, Holst JJ, Goldsmith J, Hanto DW, Callery M, Arky R, Nose V, Bonner-Weir S, Goldfine AB Diabetologia. 2005;48(11):2236. 4.Bowel habits after bariatric surgery. Potoczna N, Harfmann S, Steffen R, Briggs R, Bieri N, Horber FF Obes Surg. 2008;18(10):1287. 5.Dumping syndrome: pathophysiology and treatment. Ukleja A Nutr Clin Pract. 2005;20(5):517. 6.Change in effective circulating volume during experimental dumping syndrome. MATHEWS DH, LAWRENCE W Jr, POPPELL JW, VANAMEE P, RANDALL HT Surgery. 1960;48:185. 7.Jacobs, DO, Robinson, MK. Morbid obesity and operations for morbid obesity. In: Maingot's abdominal operations, 11th ed, Zinner, MJ, Ashley, SW (Eds), McGraw Hill, New York 2007. p. 471. 8.Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases.Lee S, Carmody B, Wolfe L, Demaria E, Kellum JM, Sugerman H, Maher JW J Gastrointest Surg. 2007;11(6):708. 9.Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan RJ, Landreneau RJ, GagnéDJ Obes Surg. 2003;13(5):797. 10.Perforation in the bypassed stomach following laparoscopic Roux-en-Y gastric bypass. Papasavas PK, Yeaney WW, Caushaj PF, Keenan RJ, Landreneau RJ, GagnéDJ Obes Surg. 2003;13(5):797. 11.Laparoscopic gastric bypass surgery: outcomes. Schneider BE, Villegas L, Blackburn GL, Mun EC, Critchlow JF, Jones DBJ Laparoendosc Adv Surg Tech A. 2003;13(4):247.

27 References 12.Endoscopic dilation of gastroesophageal anastomosis stricture after gastric bypass. Barba CA, Butensky MS, Lorenzo M, Newman R Surg Endosc. 2003;17(3):416. 13.Stomal complications of gastric bypass: incidence and outcome of therapy. Sanyal AJ, Sugerman HJ, Kellum JM, Engle KM, Wolfe L Am J Gastroenterol. 1992;87(9):1165. 14.Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass. Go MR, Muscarella P 2nd, Needleman BJ, Cook CH, Melvin WS Surg Endosc. 2004;18(1):56. 15.Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Higa KD, Boone KB, Ho T Obes Surg. 2000;10(6):509. 16.Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Gumbs AA, Duffy AJ, Bell RL Surg Obes Relat Dis. 2006;2(4):460. 17.Marginal ulcer after gastric bypass: a prospective 3-year study of 173 patients. Sapala JA, Wood MH, Sapala MA, Flake TM Jr Obes Surg. 1998;8(5):505. 18.Ulcer disease after gastric bypass surgery.Dallal RM, Bailey LA Surg Obes Relat Dis. 2006;2(4):455. 19.Strictures following gastric stapling for morbid obesity. Results of endoscopic dilatation. Sataloff DM, Lieber CP, Seinige Am Surg. 1990;56(3):167. 20.Changes in gallbladder bile composition following gallstone formation and weight reduction. Shiffman ML, Sugerman HJ, Kellum JM, Moore EW Gastroenterology. 1992;103(1):214. 21.Marginal ulceration after laparoscopic gastric bypass: an analysis of predisposing factors in 260 patients. Rasmussen JJ, Fuller W, Ali MR Surg Endosc. 2007;21(7):1090. 22.Flexible endoscopy in the management of patients undergoing Roux-en-Y gastric bypass. Schirmer B, Erenoglu C, Miller A Obes Surg. 2002;12(5):634. 23.Endoscopic and histologic findings of the foregut in 426 patients with morbid obesity. Csendes A, Burgos AM, Smok G, Beltran M Obes Surg. 2007;17(1):28. 24.Early effects of Helicobacter pylori infection in patients undergoing bariatric surgery. Ramaswamy A, Lin E, Ramshaw BJ, Smith CD Arch Surg. 2004;139(10):1094. 25.Bleeding Duodenal Ulcer After Roux-en-Y Gastric Bypass Surgery Marc Zerev,, MD, FRCSC;Lee B. Sigmon, BS; Timothy S. Kuwada, MD; B. Todd Heniford, MD; Ronald F. Sing, DOJ Am Osteopath Assoc January 1, 2008 vol. 108 no. 1 25-27

28 References 26.Is routine cholecystectomy required during laparoscopic gastric bypass? Villegas L, Schneider B, Provost D, Chang C, Scott D, Sims T, Hill L, Hynan L, Jones D Obes Surg. 2004;14(2):206. 27.Elective cholecystectomy during laparoscopic Roux-en-Y gastric bypass: is it worth the wait? Hamad GG, Ikramuddin S, Gourash WF, Schauer PR Obes Surg. 2003;13(1):76. 28.Surgical gastrostomy placement as access for diagnostic and therapeutic ERCP. Baron TH, Vickers SM Gastrointest Endosc. 1998;48(6):640. 29.ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Wright BE, Cass OW, Freeman ML Gastrointest Endosc. 2002;56(2):225. 30.Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Champion JK, Williams M Obes Surg. 2003;13(4):596. 31.Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, Wolfe BM Ann Surg. 2001;234(3):279. 32.Sensitivity and specificity of eight CT signs in the preoperative diagnosis of internal mesenteric hernia following Roux-en-Y gastric bypass surgery. Iannuccilli JD, Grand D, Murphy BL, Evangelista P, Roye GD, Mayo-Smith W Clin Radiol. 2009;64(4):373. 33.Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls.Lockhart ME, Tessler FN, Canon CL, Smith JK, Larrison MC, Fineberg NS, Roy BP, Clements RHAJR Am J Roentgenol. 2007;188(3):745. 34.Binge eating among gastric bypass patients at long-term follow-up. Kalarchian MA, Marcus MD, Wilson GT, Labouvie EW, Brolin RE, LaMarca LB Obes Surg. 2002;12(2):270. 35.Gastro-gastric fistulas and marginal ulcers in gastric bypass procedures for weight reduction. Capella JF, Capella RF Obes Surg. 1999;9(1):22. 36.Management of gastrogastric fistulas after divided Roux-en-Y gastric bypass surgery for morbid obesity: analysis of 1,292 consecutive patients and review of literature. Carrodeguas L, Szomstein S, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Villares A, Zundel N, Rosenthal R Surg Obes Relat Dis. 2005;1(5):467. 37.Stomal ulcer after gastric bypass.MacLean LD, Rhode BM, Nohr C, Katz S, McLean AP J Am Coll Surg. 1997;185(1):1. 38.Treatment of dilated gastrojejunostomy with sclerotherapy. Spaulding L Obes Surg. 2003;13(2):254. 39.Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Thompson CC, Slattery J, Bundga ME, Lautz DB Surg Endosc. 2006;20(11):1744.

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