Early Technical and Perioperative Complications of Bariatric Surgery

| May 1, 2015

by Tammy L. Kindel, MD, PhD and Corrigan L. McBride, MD
Drs. Kindel and McBride are from the Department of Surgery, Advanced Laparoscopic and Bariatric Surgery, University of Nebraska Medical Center,Omaha, Nebraska.

ABSTRACT
In this review, the authors discuss the presentation and suggested management of technical, perioperative complications of bariatric surgery. This discussion does not include the shared although rare postoperative complications (i.e., deep vein thrombosis, pulmonary embolism, rhabdomyolysis) seen in the patient population with morbid obesity. The acute complications discussed include postoperative leaks, obstruction, and bleeding encountered after Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric bypass.

Bariatric Times. 2015;12(5):8–12.


Introduction
The three most popular bariatric procedures performed in the United States as of 2012 are the Roux-en-y gastric bypass (RYGB, 59.6%), laparoscopic sleeve gastrectomy (LSG, 36.3%), and laparoscopic adjustable gastric band (LAGB, 4.1%).[1] With the increasing utilization of bariatric surgery for the treatment of morbid obesity comes an imperative need to understand the acute complications (<30 days) that accompany these procedures and the subsequent complication management. In this review, we discuss the presentation and suggested management of technical, perioperative complications of bariatric surgery. This discussion does not include the shared although rare postoperative complications (i.e., deep vein thrombosis, pulmonary embolism, rhabdomyolysis) seen in the patient population with morbid obesity. The acute complications discussed include postoperative leaks, obstruction, and bleeding encountered after RYGB, LSG, and LAGB.

Postoperative Leaks
The incidence of anastomotic or staple line leak after RYGB varies from 0.4 to 5.2 percent, primarily occurring at the gastrojejunal (GJ) anastomosis.[2,3] In gastric bypass patients, anastomotic or staple line leak is the strongest independent predictor in multivariate logistic regression analysis for postoperative mortality.[4] Although a rare postoperative complication, band-related gastric perforations may also be encountered.[5]

The staple line leak rate after sleeve gastrectomy varies in the literature from 0.3 to 7.8 percent. There are inconsistent published findings regarding the effect of staple line reinforcement or oversewing on the postoperative leak rate. While some studies, including two randomized controlled trials, have found no effect of staple line reinforcement on the postoperative leak rate, a recent systematic review found an average overall leak rate of 2.1 percent after LSG with a significantly reduced leak rate of 1.09 percent with the use of absorbable polymer staple line reinforcement compared to no reinforcement, over-sewing, or nonabsorbable reinforcement.[6–9] This is in comparison to a slightly larger systematic review that found no effect of staple line reinforcement on the leak rate, and rather that bougie size greater than 40 French may significantly decrease the postoperative leak rate.[10] Further randomized, controlled trials are needed to ultimately determine if staple line reinforcements significantly reduce staple line leaks after sleeve gastrectomy.

Patients presenting in the first 24 to 48 hours with an anastomotic or staple line leak may have symptoms of sustained tachycardia (greater than 120 beats pre minute [bpm]), tachypnea, and low urine output. If a surgical drain had been placed at the time of surgery, the output may be murky; however, prior to initiating oral intake, the output character may be normal and the patient may not be experiencing left upper quadrant (LUQ) abdominal pain. The presentation of a leak may only include sustained tachycardia without any other symptoms. It may be difficult to differentiate the initial symptoms of leak from other postoperative complications, such as a pulmonary embolism or acute myocardial infarction;2 however, a leak must always be considered in the postoperative patient with tachycardia. A postoperative leak presenting after 48 hours may also be seen with increasing LUQ abdominal pain, worse with oral intake as well as fevers and chills.[11]

When suspicion is high or the patient is ill, the first-line treatment of a leak is resuscitation and urgent re-exploration. An expedited imaging work up may be useful when the diagnosis is unclear and the patient is not in distress. An upper gastrointestinal (UGI) X-ray series with water-soluble contrast may show free extravasation of contrast from the GJ or sleeve staple line. As shown in Figure 1, 75 percent of the time the sleeve staple line leak is proximal, near the gastroesophageal junction or cardia.[12] An initial, well-placed, surgical drain may have contrast directly entering the drain tubing without free extravasation in the abdomen. An early perforation after a band often occurs posteriorly due to a technical error during the retro-gastric tunnel creation. It is important for the surgeon and managing team to evaluate the lateral UGI images to not miss this posterior leak.

Abdominal computed tomography (CT) scans with water-soluble contrast have an evolving role in the diagnosis of a leak, and are the diagnostic modality of choice at some high-volume bariatric centers. A recent retrospective review of sleeve gastrectomy patients found that CT had a sensitivity of 95 percent and specificity of 100 percent in diagnosing postoperative leaks compared to 79.4 percent sensitive and 95 percent specific for UGI studies.[13] An abdominal CT scan has the additional benefit of helping to differentiate between a leak and other postoperative complications, such as an obstruction, hematoma or abscess. CT findings of an early leak can be subtle, including a left pleural effusion or dotting of air along the falciform ligament. Delayed leaks on CT may have an associated LUQ fluid collection or evolving abscess.

The management of an early postoperative anastomotic leak, perforation, or staple line leak, regardless of the bariatric surgery type, shares the need for early operative intervention if the leak is uncontained or the patient is unstable. Repair can be done with either laparoscopy or laparotomy depending on the surgeon’s comfort level with reoperation. The perforation should be identified and repaired when possible and patched with omentum. Despite reoperation, many leaks continue postoperatively, thus, adequate closed-suction drainage is critical for ongoing leak management and to minimize the need for additional re-operations. Consideration must be given at the time of initial reoperation for postoperative nutrition. Anticipating a prolonged recovery period, enteral nutrition is preferred. A gastrostomy tube should be placed in the gastric remnant for GJ leaks and a jejunostomy tube for a leak from the jeju-jejunostomy (JJ), sleeve staple line, or a band perforation. Broad-spectrum antibiotics are used in conjunction with operative intervention, the duration depending on the individual patient’s ongoing contamination and abscess formation. In addition to broad-spectrum antibiotics, antifungal therapy should be administered for leaks originating from the stomach or gastroesophageal junction.

Nonoperative management and endoscopic stenting has an evolving role in the management of stable or contained leaks after sleeve gastrectomy. This is generally more appropriate for patients who are at least one week postoperative. Endoscopic placement of a covered, self-expandable stent for planned 3 to 6 weeks of treatment has been successfully described.[14,15] These patients still need drainage of intra-abdominal fluid collections, which can be done laparoscopically or percutaneously in conjunction with intravenous antibiotics and acid suppression. Enteral feeding access can be considered at the time of endoscopy and stent placement with a post-pyloric feeding tube. There are increasing reports of GJ anastomosis leaks being successfully treated endoscopically with variable combinations of expandable stents, over-the-scope clips, and fibrin glue.[16–17]

Postoperative Obstructions
Obstruction of the GJ after RYGB can present as early as the first postoperative day with intolerance of liquids and nonbilious emesis to severe obstruction and intolerance of secretions. Patients may note epigastric pain and fullness relieved with emesis. This early obstruction is generally due to edema or clot at the GJ. While rarely due to a technical mistake with construction of the GJ, this error should be prevented with routine use of intraoperative endoscopy. Radiographically evident obstruction occurs at a reported rate of 0.97 percent.[18] A UGI series will show filling of the pouch with delayed passage of contrast through the GJ in a partial obstruction to non-emptying of the pouch and often reproduction of symptoms during the UGI with a complete obstruction (Figure 2). Management includes nothing per os (NPO) status until symptoms improve followed by a trial of liquids; if prolonged NPO status is needed, total parenteral nutrition (TPN) should be initiated by Postoperative Day 5 or placement of a fluoroscopically guided GJ or G tube in the remnant stomach. Operative intervention is rarely required.

Obstruction of the RYGB JJ may present as Roux limb obstruction with symptoms of nausea, vomiting, and epigastric fullness. Acute biliopancreatic (BP) remnant obstruction can present with more subtle findings than Roux limb obstruction, including epigastric abdominal pain and tachycardia or bradycardia (due to gastric distention). Laboratory findings may suggest biliary and pancreatic duct stasis, such as elevated alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, and total and direct bilirubin or lipase.[19] A CT scan can be helpful in diagnosing BP limb obstruction, as a plain abdominal X-ray can miss a fluid-filled and distended BP limb.

The reasons for early JJ obstruction may be due to narrowing or kinking of the anastomosis or a coagulated blood clot with edema of the staple line resulting in proximal limb obstruction. If the JJ obstruction is causing acute obstruction of the BP limb, early and rapid decompression is critical regardless of the etiology. Delayed decompression places the patient at risk of staple line blow-out and remnant perforation.[20] Decompression can be managed most easily with placement of a gastric tube into the gastric remnant.

Operative intervention is often required with clinical findings of a JJ obstruction as this is generally a technical failure and requires surgical correction to relieve the obstruction.[21] Nguyen et al[22] described five patients with early Roux limb obstruction with 80 percent requiring operative treatment with proximal bypass of the obstructed entero-enterostomy. We similarly prefer not to redo the anastomosis but to bypass the obstructed limb (whether the Roux or BP) to the common channel. A Roux limb obstruction at the retrocolic mesenteric tunnel can often be corrected with takedown of the mesenteric closure only and ensuring proper orientation of the limb through the defect. Hematoma or clot at the JJ is a rare cause of postoperative obstruction. Operative treatment has been described laparoscopically with clot evacuation by enterostomy with revision of the anastomosis.[23]

Narrowing or edema, most commonly at the incisura angularis, can present acutely after sleeve gastrectomy with the presentation of nausea, vomiting, and oral intolerance. A UGI series is the initial diagnostic test of choice. Treatment is similar to GJ obstruction after RYGB with supportive management and parenteral nutrition if needed. If symptoms become chronic in nature, a stricture can be treated safely at 6 to 8 weeks after surgery with endoscopy and balloon dilation.[24]

Obstructive symptoms after LAGB placement are prototypical for gastric outlet obstruction. The frequency has decreased over the past decade with the use of the pars flaccida technique;[25] however, acute obstruction has still been reported due to use of a smaller diameter band in higher BMI patients.[26] A UGI series will adequately diagnose the obstruction and evaluate for band slippage, which would require re-operation. If complete band deflation and conservative measure fail to relieve the edema and allow adequate oral intake, the LAGB may need to be replaced for a longer size.

Postoperative Bleeding
Significant (requiring blood-transfusion) postoperative bleeding occurs in approximately 1 to 4 percent of RYGB patients. This complication is significantly more common in patients with type 2 diabetes mellitus (T2DM) as well as in patients who have undergone a previous abdominal operation.[27] Operative intervention is required in 21 to 25 percent of early postoperative bleeding events.[27,28]  The first step in management of bleeding after bariatric surgery is the somewhat challenging diagnosis, and determination if the bleeding is intraluminal or extraluminal into the peritoneal cavity. Symptoms of bleeding include a hematocrit drop, which occurs universally to some extent for all postoperative patients, and tachycardia, which often draws the clinician to concern for a leak. More definitive evidence for bleeding are melena, hematochezia or, hematemesis signifying an intraluminal bleed or sanguineous drain output representing bleeding into the peritoneal cavity. Blood per rectum usually suggests a more distal source like the gastric remnant or JJ in RYGB patients.

For the stable patient, the management of bleeding begins with discontinuation of anticoagulants, volume resuscitation with blood transfusion if indicated, and serial monitoring of the hematocrit. If the bleeding is ongoing and believed to be intraluminal, an EGD should be performed after intubation in the operating room for confirmation of diagnosis and endoscopic treatment. If endoscopic intervention fails or the bleeding is extraluminal, the patient should then be surgically explored. For unstable patients, the patient should be transferred to the intensive care unit (ICU), resuscitated by blood transfusion, and then taken to the operating room as stated previously with intubation followed by EGD and emergent laparoscopy, if needed for bleeding control. If operative exploration is required for a staple line bleed, including concern for bleeding from the gastric remnant staple line, consideration should always be given that bleeding is due to a staple line disruption, and exploration for a simultaneous leak should be undertaken.[29] Fortunately, in the majority of patients, significant bleeding after RYGB is self-limited and can be managed with transfusion alone, close-monitoring, and discontinuation of any anti-coagulants. There is some evidence that staple line reinforcements with RYGB reduce operative blood loss and significantly improve postoperative hemoglobin levels.[30]

Postoperative bleeding occurs 1 to 6 percent of the time after LSG, with a reduced bleeding risk reported with staple line reinforcements.[6,24] Fibrin sealant is another option to reduce staple line leakage after LSG. One randomized controlled trial found the intra-operative use of fibrin sealant significantly reduced postoperative bleeding.[31] Bleeding after a sleeve if intraluminal from the long staple line generally presents as hematemesis. If signs of bleeding persist, these patients should undergo urgent endoscopy in the operating room, similar to RYGB patients, rather than the bedside or ICU to maximize airway control and resuscitation. Intra-peritoneal bleeding can be from the spleen, divided short gastric vessels, the mesentery, or trocar related. While operative intervention is generally not required, diagnostic laparoscopy should be immediately undertaken in patients with persistent transfusion requirements or signs of hemodynamic compromise. Bleeding after LAGB is rare, but if encountered, will usually be intra-peritoneal and from the lesser curve or retrogastric tunnel. Intraoperative visualization can be difficult, necessitating mobilization of the greater curve with division of the short gastric vessels to fully rotate the stomach medially and expose the posterior surface and lesser sac.

Conclusion
Early technical, postoperative complications after bariatric surgery include postoperative anastomotic or staple line leaks, iatrogenic perforation, obstruction and/or bleeding. Although the rate of these shared complications is low and many can be managed nonoperatively, it is imperative for the bariatric surgeon to have a robust understanding of the presentation of these potentially life-threatening complications to enable rapid detection, diagnosis, and operative management when indicated to minimize morbidity and mortality.

References
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FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.

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