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Complications of Bariatric Procedures

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Complications of Bariatric Procedures William Bakhos,MD Mortality (30 Days) Complications Pulmonary Embolus: 0-3.3% Accounts for 30% of mortality. – PowerPoint PPT presentation

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Title: Complications of Bariatric Procedures


1
Complications of Bariatric Procedures
  • William Bakhos,MD

2
Mortality (30 Days)
  • Overall 0.1-1
  • - Restrictive 0.1
  • - GBP 0.5
  • - BPDDS 1.1
  • - Higher Male, Elderly, Surgeon experience
  • Buchwald, et al. Bariatric surgery a systematic
    review and meta-analysis. JAMA 2004.
  • 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.

4
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5
Early Complications - RYGB
  • 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
  • PWMelena, HR?, HGB?
  • Self limited
  • Tx PC, reverse anticoagulation, EGD, Surgery.

6
Early Complications - RYGB
  • Leaks 2-3 (VCUNo 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.

7
Early Complications - RYGB
  • Gastric remnant distention rare
  • Potentially lethal (distention-gtrupture-gtperitonit
    is)
  • 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)

8
Early Complications - RYGB
  • Wound Infection
  • Lap 3-4
  • Open 10-15
  • PW fever, fluctuance, erythema, or drainage.
  • Tx open and/or ID, if cellulitis-gt Abx.

9
Late Complications - RYGB
  • 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(lt0.05).

10
Late Complications - RYGB
  • Marginal Ulcers 0.6-13
  • Etlg poor tissue perfusion, anastomotic tension,
    staple line disruption or gastrogastric fistulas
    (-gt 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.

11
Late Complications - RYGB
  • 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 2004.
  • Hamad, GG et al. Obes Surg 2003.

12
Late Complications - RYGB
  • 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 (gt1
    year).
  • Indications for early surgical repair include
    significant pain, bowel obstruction, and rapid
    enlargement of the hernia.

13
Late Complications - RYGB
  • 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.

14
Late Complications - RYGB
  • 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.

15
Very Late Complications
  • 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. 2005. Review.
  • Poitou Bernert C. Nutritional deficiency after
    gastric bypass diagnosis, prevention and
    treatment. Diabetes Metab. 2007. Review.
  • Shah M. Review long-term impact of bariatric
    surgery on body weight, comorbidities, and
    nutritional status. J Clin Endocrinol Metab.
    2006. Review.
  • Alvarez-Leite JI. Nutrient deficiencies secondary
    to bariatric surgery. Curr Opin Clin Nutr Metab
    Care. 2004. Review.
  • Fujioka K. Follow-up of nutritional and metabolic
    problems after bariatric surgery. Diabetes Care.
    2005. Review.

16
Nutritional Defficiency
  • The mechanisms
  • Insufficient intake d/t dietary restrictions and
    food intolerance (meat, milk, fiber)
  • The exclusion of the stomachs inferior part
    results in a decreased secretion of gastric acid,
    sometimes required to absorb vitamins and
    minerals (B12 and iron).
  • Duodeno-jejunal malabsorption related to the
    short-circuit. The duodenum is the main
    absorption site for calcium, iron and vitamin B1
    (thiamin).
  • Asynergia occurs between the bolus and the
    bilio-pancreatic secretions in the common portion
    of the intestine.

17
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18
Proteins
  • Albumin lt3.5 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 lt150cm) none.
  • Peak incidence 1-2yr post op.

19
Vitamin B12 (cobalamin)
  • lt250 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)
  • lt3 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
    (50100 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 ? -gtPTH? -gthyperPTH-gt 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 -gt ? 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 (lt3).
  • 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 3 -
    6 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
  • 3-14.5
  • 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 1986.
  • Knudsen LB. Gastric bypass, pregnancy, and neural
    tube defects. Lancet 1986.
  • Martin L. Gastric bypass surgery as maternal risk
    factor for neural tube defects. Lancet 1988.
  • 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 40.9 /- 4.6 mm
  • Esophageal dilation after laparoscopic
    adjustable gastric banding.
  • Milone L et al. Surg Endosc. 2008
    Jun22(6)1482-6.

37
Over-Restriction/Esophageal Dilatation
Esophageal dilation after laparoscopic adjustable
gastric banding. Milone L et al. Surg Endosc.
2008 Jun22(6)1482-6.
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. 2008 Sep18(9).

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

40
Band SlippageAcute 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. 2008
    Jul-Aug4(4)534-8 discussion 538.

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

43
ErosionPort Infection
44
ErosionAcute abdominal pain upon filling the band
45
ErosionTube 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. 2008
    Mar 25.

48
Port and Tube complicationsDisconnection
Boris Kirshtein et al. Surg Endosc. 2008 Mar 25
49
Port and Tube complicationsDisconnection
Boris Kirshtein et al. Surg Endosc. 2008 Mar 25
50
Port and Tube complications Chronic leak
51
Port and Tube complications
Table 2 Incidence of tube breakage or
disconnection in relation to different bands and
need of laparoscopic operations to retrieve the
tube
  • Injection Port and Connecting Tube Complications
    after Laparoscopic Adjustable Gastric Banding.
  • Lattuada E et al Obes Surg. 2008 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. 2008 Feb 23.
53
Port and Tube complications
Table 1 Complications of port and connecting tube
in 489 patients
  • Lattuada E et al Obes Surg. 2008 Jun 10.

54
Mixed complications
55
Volvulus around the tube
56
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