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Complications of Bariatric Procedures William Bakhos,MD.

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1 Complications of Bariatric Procedures William Bakhos,MD

2 Mortality (30 Days) Overall: 0.1%-1% - Restrictive: 0.1% - GBP: 0.5% - BPD+DS: 1.1% - Higher: Male, Elderly, Surgeon experience Buchwald, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA Maggard, et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005.

3 Complications Focus: RYGB, LAGB. 3 categories: 1. Early complications (1-6wks). 2. Late complications(7wks-12mo). 3. Very late complications.

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5 Pulmonary Embolus: 0-3.3%  Accounts for 30% of mortality.  Prevent: pneumatic compression devices & subq heparin.  Dx: difficult.  Tx when high level of clinical suspicion. Bleeding: 0.6-4%  Early Bleeding: Staple lines / surgical anastamosis Mainly intraluminal PW:Melena, HR↑, HGB↓ Self limited Tx: PC, reverse anticoagulation, EGD, Surgery. Early Complications - RYGB

6 Leaks: 2-3% (VCU=No leak since july 2006)  Account for 50% of mortality.  PW: fever, HR↑, resp. fail.  Dx: UGIS, CT.  Tx: A. Urgent Exploratory surgery:  1. Irrigation.  2. Repair of the defect.  3. Wide ext. drainage. B. Abx. Early Complications - RYGB

7 Gastric remnant distention: rare  Potentially lethal (distention->rupture- >peritonitis)  Etlg: ileus or mech. obstruction.  pain, hiccups, LUQ tympany, shoulder pain, abdominal distension, tachycardia, or SOB.  X-Ray: large gastric air bubble.  Tx: decompression with gastrostomy (OR/Percutaneous) Early Complications - RYGB

8 Wound Infection:  Lap 3-4%  Open 10-15%  PW: fever, fluctuance, erythema, or drainage.  Tx: open and/or I&D, if cellulitis-> Abx. Early Complications - RYGB

9 Bleeding: 0.6-4%  Late Bleeding: rare Etlg: PUD Tx: conservative, partial gastrectomy. Stomal Stenosis: 6-20%  Etlg: tissue ischemia (poor perfusion, tension).  PW: 6-7wks post op, NV, dysphagia, GE reflux, inability to tolerate oral intake.  Dx: UGIS, EGD.  Tx: Balloon dilation, surgical revision(<0.05%). Late Complications - RYGB

10 Marginal Ulcers: %  Etlg: poor tissue perfusion, anastomotic tension, staple line disruption or gastrogastric fistulas (-> chronic exposure of the gastrojej to acid), or NSAID use.  Dx: EGD.  Tx: D/C NSAID, PPI, Stop Smoking,Sucralfate. Surgery revision (+truncal vagotomy) – rare. Late Complications - RYGB

11 Dumping Syndrome: 50%  PW: nausea, shaking, diaphoresis, diarrhea shortly after eating.  Tx: Dietary prohibitions. Cholelithiasis :  w/o proplxs – 38% (40% symp)  6mo post op w ursodeoxycholic acid – 2%  Risk factors: obesity, rapid weight loss.  ? benefit for simultaneous cholecystectomy for incidental gallstones at the time of RYGB (unless symptomatic). Villegas et al. Obes Surg Hamad, GG et al. Obes Surg Late Complications - RYGB

12 Choledocholithiasis: uncommon Dx: US, MRCP.  Tx: ERCP cannot be performed routinely. PTC. Surgery. Incisional Hernia: Lap – 0-1.8% ; Open – 24%.  PW: enlarging bulge, pain, or obstructive symptoms.  Tx: Postpone repair until significant weight loss (>1 year). Indications for early surgical repair include significant pain, bowel obstruction, and rapid enlargement of the hernia. Late Complications - RYGB

13 Internal Hernias: 0-5%  Three potential areas 1-Mesenteric defect at the jejuno-jejunostomy 2-The space between the transverse mesocolon and Roux-limb mesentery (Peterson's hernias). 3-The defect in transverse mesocolon if the Roux-limb is passed retrocolic – most common.  If a patient is suspected of an internal hernia, urgent surgical exploration is indicated !  Prevention: all previously mentioned defects are usually closed. Late Complications - RYGB

14 Failure to lose weight :  Maladaptive eating patterns. Weight regain: up to 20% Noncompliant eating. Functional gastrogastric fistula: Dx: UGIS. Tx: surg rep. Endo stent/suture.  Dilation of gastric pouch or the gastrojej. anastomosis: Excessive food intake. Endoscopic suture reduction. Late Complications - RYGB

15 Nutritional Defficiency after RYGB Bloomberg RD, Fleishman A, Nalle JE, Herron DM, Kini S. Nutritional deficiencies following bariatric surgery: what have we learned? Obes Surg Review. Poitou Bernert C. Nutritional deficiency after gastric bypass: diagnosis, prevention and treatment. Diabetes Metab Review. Shah M. Review: long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. J Clin Endocrinol Metab Review. Alvarez-Leite JI. Nutrient deficiencies secondary to bariatric surgery. Curr Opin Clin Nutr Metab Care Review. Fujioka K. Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care Review. Very Late Complications

16 Nutritional Defficiency The mechanisms: 1. Insufficient intake d/t dietary restrictions and food intolerance (meat, milk, fiber) 2. The exclusion of the stomach’s inferior part results in a decreased secretion of gastric acid, sometimes required to absorb vitamins and minerals (B12 and iron). 3. Duodeno-jejunal malabsorption related to the short-circuit. The duodenum is the main absorption site for calcium, iron and vitamin B1 (thiamin). 4. Asynergia occurs between the bolus and the bilio-pancreatic secretions in the common portion of the intestine.

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18 Proteins Albumin <3.5 g/dL. Mechanism:  50% duodenal absorption  Intake def (intolerance to meat)  Decreased pancreatic enzyme secretion  Contact time↓ Clinical: deterioration of general state of health, muscle weakness with loss of muscle mass, anomalies of the skin, mucosa and nails (alopecy, striated nails, dermatitis, hypopigmentation), edema. Prevalence:  Distal RYGB – 6-13%  Standard RYGB (Shorter R limb <150cm) – none.  Peak incidence – 1-2yr post op.

19 Vitamin B12 (cobalamin) <250 pg/ml. Mechanism :  ↓acid secretion (cleavage B12 – food proteins).  Delayed/no link to IF (parietal c.).  Schilling test after RYGB – abnrl in 50% of B12 def. Prevalence: (no pre-op def., despite advised MVI)  From 1yr post op. : 12-70%.  In the first 2 yr – 25%.  Post-op MVI use was shown to prevent folate and B12 deficiency when taken regularly. Clinical : Macrocytosis – 0.8%. Megaloblastic anemia – rare. No neurologic symp.

20 Vitamin B9 (folates) <3 ng/ml Mechanism:  ↓dietary intake (fruits and vegetables).  Because folates may be absorbed throughout the whole intestine. Prevalence: (no pre-op deff., despite advised MVI)  20% at 1 yr.  Post-op MVI use was shown to prevent folate and B12 deficiency when taken regularly. Clinical: NTD, Anemia, apathy, fatigue, headaches, insomnia,, weakness, Diarrhea, loss of appetite.

21 Vitamin B1 (thiamin) Mechanism:  Absorbed in the duodenum  ↓intake (fruits, meat, cereals..)  Vomiting Prevalence:  1%  No def. when MVI Clinical:  CVS: CHF  Neuro: Wernicke's encephalopathy, confusion, irritability, memory loss, nervousness, numbness of hands and feet, pain sensitivity, poor coordination, weakness.  GI: Constipation, intestinal disturbances, loss of appetite In all cases - administration of IV Vit B1 (50–100 mg) corrects the deficit.

22 Liposoluble vitamins (A, E, K) Mechanism: ↓fat breakdown(limited/short time with biliary sec.) Prevalence:  very low after RYGB.  BPD(4yr): A-69%, K-68%, E-4%. Despite MVI. Clinical (BPD):  Vit A - night blindness or ocular xerosis.  Vit E – non.  Vit K – non. Prudence recommends that patients taking anticoagulants (antivitamin K) must be closely monitored !

23 Calcium and vitamin D Mechanism:  Ca: ↓ intake, ↓absorption (duodenum & prox jej).  Vit D: ↓absorption (lipid malabsorption).  HyperPTH: Ca ↓ ->PTH↑ ->hyperPTH-> bone loss. Prevalence:  Distal RYGB: Ca: 10% at 2yr Vit D: 51% at 2yr  BPD: Ca: 25-50% Vit D: 17-50%  HyperPTH: RYGB: ↑risk in post menopausal. BPD: 69% at 4 yr, 3% ↑ bone resorption. Clinical: osteoporosis, osteomalacia.

24 Iron & Anemia Iron deficiencies are the most frequent deficiencies after RYGB. Mechanism:  ↓intake (red meat).  ↓ HCL -> ↓ transformation ferric form (Fe3+) to ferrous form (Fe2+), which is the absorbable form.  ↓ absorbed in the duodenum. Prevalence: (despite MVI)  at 2 yr 33%  ↑ 50% among women of childbearing age. Anemia:  Def. anemias (vitamin B12, iron, folates) ~ 30%.  Microcytic anemia in 63% of patients with an iron deficit Other Clinical: tinnitus, hair loss.

25 Potassium and magnesium Halverson JD. Am Surg 1986:  56% hypokalemia with diuretic.  34% hypomagnesemia. Amaral JF. Ann Surg 1985:  6.3% severe hypokalemia (<3).  No hypomagnesemia.

26 Zinc The absorption of zinc is dependent on the absorption of lipids which is reduced after RYGB. Prevalence:  BPD: 10-50%.  RYGB: rare. Clinical:  Hair loss is frequently observed among women mo after the RYGB.: Mechanisms: iron, protein and zinc deficiencies, post surgical stress and significant weight loss. Only one study described an improvement of alopecia after treatment with high zinc sulfate supplements.

27 Selenium Only in BPD:  %  No clinical repercussion. Potential Symptoms:  Increased incidence of cancer.  Pancreatic insufficiency.  Immune impairment.  Liver impairment  Male sterility.

28 Prevention and treatment of the nutritional deficiencies after RYGB

29 No controlled trial exists to determine the type of supplements and the dosages to be prescribed after RYGB. The majority of the reviews published on post-RYGB deficiencies recommend a multivitamin supplement providing 100% of the RDA.

30 Pregnancy Iron def. anemia ~ prematurity, LBW. Vit D def. ~ Rickets, Neonatal hypoCa. Iodine def. ~ Goiter, intellectual impairment. FA def. ~ NTD, Cleft palate. An increase in cases of malformations of the neural tube was reported: Haddow JE. Neural tube defects after gastric bypass. Lancet Knudsen LB. Gastric bypass, pregnancy, and neural tube defects. Lancet Martin L. Gastric bypass surgery as maternal risk factor for neural tube defects. Lancet Ladipo OA. Nutrition in pregnancy: mineral and vitamin supplements. Am J Clin Nutr 2000.

31 Laparoscopic Adjustable Gastric Band complications

32 Normal Position Normal position of gastric band. Phi angle, corresponding to angle between vertical axis and gastric band, is estimated at 55°. Note large width (2 cm) of Swedish Adjustable Gastric Band

33 Normal Position/adjustment

34 Adjustment Restriction/losing restriction

35 Over-Restriction Reflux/Regurgitation Dilated esophagus. Tertiary non peristaltic waves. Big concentric pouch.

36 Over-Restriction/Esophageal Dilatation. Milone et al from Columbia University,NY in their series Of 440 patients,reported 121 patients who had follow-up with a clinic visit and Barium Swallow performed at 1 year. Seventeen patients (10 women and 7 men) (14%) were found to have esophageal dilation with an average diameter of /- 4.6 mm Esophageal dilation after laparoscopic adjustable gastric banding. Milone L et al. Surg Endosc Jun;22(6):

37 Over-Restriction/Esophageal Dilatation Esophageal dilation after laparoscopic adjustable gastric banding. Milone L et al. Surg Endosc Jun;22(6):

38 Over-Restriction/Pouch Dilatation Brown et al from Melbourne Australia reported 17 cases of symmetrical pouch dilatation (SPD) within their series of 425 LAGB procedure all performed by pars flaccida technique (4.4 %). Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management. Brown WA et al. Obes Surg Sep;18(9).

39 Misplacement Band was placed in perigastric fat. Failure to loose weight.

40 Band Slippage Acute pain and Vomiting unrelated to band fill

41 Band Slippage Manganiello et al from Loyola university reported their series of 660 LAGB patients, 34 (5%) experienced band slippage and required 40 subsequent operative procedures. Of the 34 patients, 6 underwent multiple procedures for their slipped band. Overall, 10 removals, 13 gastric reductions, and 17 replacements were performed Management of slipped adjustable gastric bands. Manganiello M et al. Surg Obes Relat Dis Jul-Aug;4(4):534-8; discussion 538.

42 Acute Erosion/Infection after placement Fever and chills. 2 weeks s/p Band

43 Erosion Port Infection

44 Erosion Acute abdominal pain upon filling the band

45 Erosion Tube infection

46 Port and Tube complications Flipped reservoir/Disconnection

47 Port and Tube complications In a series of 2191 morbidly obese patients treated by LAGB, Boris Kirshtein et al reported 29 patients (1.3%) with port disconnection. Presentattion was sudden loss of restriction, failure to adjust the band and regaining weight. Presentation and management of port disconnection after laparoscopic adjustable gastric banding. Boris Kirshtein et al. Surg Endosc Mar 25.

48 Port and Tube complications Disconnection Boris Kirshtein et al. Surg Endosc Mar 25

49 Port and Tube complications Disconnection Parameter Value Mean age, years (range)38.5 (18–63) Sex, % female79 BMI at primary bariatric surgery, mean ± SD (kg/m 2 )43.7 ± 6.6 Mean time after primary surgery, months (range)12.1 (3–41) Type of band (SAGB/LapBand ® )23/5 Excess BMI loss at disconnection, mean ± SD (%)42 ± 24.4 Excess weight loss at disconnection, mean ± SD (%)52 ± 33.9 Boris Kirshtein et al. Surg Endosc Mar 25

50 Port and Tube complications Chronic leak

51 Table 2 Incidence of tube breakage or disconnection in relation to different bands and need of laparoscopic operations to retrieve the tube PatientsTube breakageTube disconnectionLap operations Heliogast®26928 (10.4%)3 (1.1%)1 (0.3%) Lap-band®22019 (8.6%)4 (1.8%)3 (1.3%) (χ 2 analysis) p = 0.50p = 0.51 Port and Tube complications Injection Port and Connecting Tube Complications after Laparoscopic Adjustable Gastric Banding. Lattuada E et al Obes Surg Jun 10.

52 Port and Tube complications Debris with one way valve effect Thrombosis of the Lap-Band system. Sherwinter DA et al. Surg Endosc Feb 23.

53 Table 1 Complications of port and connecting tube in 489 patients Complication PatientsOperations Tube breakage4754 Tube disconnection77 Port-site infection37 Port rotation77 Port prominence with skin erosion44 Tube kinking11 Port-site hernia + tube breakage11 Small bowel obstruction by the tube11 Total7182 Port and Tube complications Lattuada E et al Obes Surg Jun 10.

54 Mixed complications

55 Volvulus around the tube

56 THANK YOU


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