Acute Bleeding After Gastric Bypass

by Candice Jensen, MD; Amir Mehran, MD; and Catherine Lewis, MD

All from the University of California, Los Angeles Medical Center, Department of General Surgery.

INTRODUCTION
Acute bleeding following laparoscopic Roux-en-Y gastric bypass (LRYGB) is an infrequently reported yet perplexing clinical dilemma, mainly due to the inaccessibility of the excluded stomach and the risks associated with early postoperative endoscopy.1 In the present communication, we address early or acute bleeding, defined as clinically significant bleeding within 48 hours of surgery; the incidence, prevention, diagnosis, and treatment options when faced with acute hemorrhage following LRYGB are described.

Incidence
Laparoscopic bariatric surgery has become the gold standard for most bariatric procedures over open surgery, as the benefits generally outweigh the risks. However, one area of documented increased risk in laparoscopic bariatric surgery as compared to open bariatric surgery is that of postoperative bleeding. The risk of bleeding after open gastric bypass is reported to be 0.6 percent,2 while the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGB) ranges from 1.1 to 4 percent.2 This wide range may be due to technical variations, reporting accuracy, and the threshold parameters used to differentiate bleeding from normal postoperative hemodilution.1
A variety of underlying mechanisms have been postulated as causes for the observed higher incidence of bleeding after laparoscopic procedures, including increased use of prophylactic anticoagulation, stapler use and stapler mechanics, and surgeon inexperience or the learning curve associated with laparoscopic gastric bypass.

Studies have documented more diligent use of antithrombotics for deep venous thrombosis prophylaxis during LRYGB as compared to open surgery.2 The reason behind this is unclear, as most surgeons agree that the benefit of prophylactic anticoagulation to decrease the incidence of pulmonary embolus outweighs the risk of postoperative bleeding, regardless of the technique used (open or laparoscopic). A comprehensive review by Spaw, et al., revealed no deaths due to postoperative bleeding in almost 3,000 patients,3 while fatal pulmonary embolism has been reported to claim the life of up to 1 in 500 bariatric patients.

During a standard LRYGB, up to 63cm of everted, visible staple lines are made, as well as 75cm of intraluminal staple lines.3 These staple lines may bleed either at the transected tissue edges or at sites where the staples penetrate the mucosa.4 Appropriate staple load size and height must be chosen based on manufacturer recommendations. In addition, manufacturer guidelines for product use, such as holding pressure for 30 seconds on the stapler before engaging the firing mechanism, must also be followed.3

The incidence of bleeding decreases as surgeons’ experience with LRYGB increases.3 Studies have shown that the learning curve for LRYGB is between 50 and 75 cases.5,6 Inexperienced surgeons may be unfamiliar with the anatomy on laparoscopic view or may have limited experience with endostaplers, leading to incorrect use or inappropriate sizing of staple loads.

Prevention
Various technical modifications have been described to decrease the incidence of postoperative bleeding, mainly directed at the staple-line sites and include appropriate choice of staple size/height, oversewing staple lines, performing handsewn anastomoses, application of pressure via stapling device prior to firing, staple-line reinforcements, buttressing, and use of hemostatic agents on staple lines.
Most bleeding following LRYGB is from areas along the staple lines; therefore, it is of utmost importance to select the appropriate staple size/height that will allow for hemostasis while avoiding tissue necrosis. Staple loads are referred to by color based on the size and height of staples. Table 1 shows stapler load characteristics and recommended uses.

Some authors recommend oversewing all staple lines and/or performing hand-sewn anastomoses4 as a means of decreasing the incidence of postoperative bleeding. Although these techniques may decrease the number of patients with postoperative bleeding, they also significantly increase the complexity of the case and time required in the operating room. There is also a theoretical risk of narrowing lumens in the case of oversewing.

There are several commercially available staple-line reinforcements and hemostatic agents that have been developed to decrease intraoperative and postoperative bleeding.8 Staple-line reinforcement products include Peri-Strips™ (BioVascular Inc., Saint Paul, Minnesota), which are composed of bovine pericardium, Peri-Strips Dry with Veritas™ (Synovis Surgical, Saint Paul, Minnesota), composed of a collagen matrix, and Seamguard™ (W.L. Gore & Associates Inc., Flagstaff, Arizona), which is composed of either ePTFE (first generation), or absorbable maxon (second generation). In a randomized prospective trial, staple-line reinforcement was shown to reduce staple-site bleeding, decrease blood loss, and possibly reduce the incidence of gastrointestinal hemorrhage.9 Other hemostatic agents, such as fibrin sealant placed around the anastomosis, may allow surgeons to achieve better hemostasis.10 Tiseel™ (Baxter, Westlake Village, California), approved by the FDA in 1998, has been used clinically as an adjunct to hemostasis during surgery.10 Although there is currently no such product available, a hemostatic gel that could be placed directly onto the staple load11 could potentially decrease the incidence of postoperative bleeding.

Diagnosis
The most challenging aspect of diagnosing acute hemorrhage following Roux-en-Y gastric bypass is differentiating between intraluminal and extraluminal bleeding sources. Most authors agree that there is little or no role for localization studies such as tagged red cell scans.1,2,4 Computed tomography (CT) scan may prove helpful, especially in the case of bleeding into the excluded remnant stomach. Spaw, et al.,3 support the use of arteriography to localize bleeding as a diagnostic maneuver, but assert that embolization is contraindicated due to the hazard of devascularizing fresh staple lines. The clinical picture, along with the timing and color of the blood (hematemesis, melena, blood per rectum) may also help clarify the bleeding site. Clinical signs of hypotension, tachycardia, bright red hemorrhage, early reduction in the hematocrit, and presentation within 6 to 12 hours after the procedure generally signify active surgical bleeding. In contrast, delayed gastrointestinal (GI) evacuation of old blood clots that have accumulated following the primary procedure generally do not represent active bleeding.2,4,11

The diagnosis of intra-abdominal, extraluminal bleeding may be elusive and manifest as a decreasing hemotocrit and hemodynamic compromise without overt GI symptoms. Common sites of extraluminal postoperative bleeding include the mesentery surrounding the jejunojejunostomy, perigastric tissue, and the splenic area near the angle of His. The diagnosis is driven by clinical parameters, such as persistently large bloody output from drains, along with tachycardia, hypotension, oliguria, and a decreasing hematocrit.1

Previous studies cited drain output as one indicator of extraluminal bleeding, but it is important to note that none relied on this data alone to make the diagnosis or guide therapy, and some authors question the usefulness of a surgical drain. In a recent series of 352 consecutive LRYGB cases by Dallal, et al.,12 in which drains were not routinely placed, six patients had clinically significant bleeding (5 from GI tract). All cases were manifested by tachycardia and treated successfully with transfusion. Dallal, et al., therefore concluded that clinical indicators for bleeding were obvious without the additional data from a drain.12 Furthermore, even proponents of drains note that clotted drains may fail to alert potential active bleeding, giving a false sense of security.3

A common credo is that the origin of GI hemorrhage after LRYGB is from a GI staple line until proven otherwise.2, 4, 11 There are four staple lines to consider when determining the site of postoperative bleeding: the gastrojejunostomy, gastric pouch, excluded remnant stomach, and jejunojejunostomy. One study found that the incidence of bleeding from a staple line was approximately 62 percent (21% each from the gastric pouch, GJ, or JJ) compared with a 14-percent incidence of intraluminal gastric remnant bleeding.13 Clinical manifestations often point to the offending staple line; for example, hematemesis suggests bleeding at the gastrojejunostomy or pouch, severe left upper quadrant pain, back and shoulder pain, intractable hiccups, or severe nausea with retching and melena suggests bleeding in the excluded remnant stomach, and bright red blood per rectum or melena suggests bleeding from the jejunojejunostomy.4 It is also possible to have a mixed clinical picture with multiple sites of bleeding.

Management
The initial management of acute hemorrhage following gastric bypass is guided by clinical parameters and consists of fluid resuscitation, discontinuation of all anticoagulation, evaluation of blood count and coagulation profile, and possible transfusion. The need for operative intervention depends on the clinical presentation and the timing of presentation.4 In the comprehensive review by Spaw, et al., of acute bleeding after LRYGB, 89 of 2,895 total patients had clinically significant postoperative hemorrhage, and only 20 percent required reoperation.3 The remainder of patients were successfully managed with observation, resuscitation with fluid and/or blood, and, in some cases, endoscopy. Of those patients who were managed nonoperatively, 20 percent were managed with observation alone, without the need for blood transfusion.3 These patients remained clinically stable, and the bleeding resolved spontaneously, though the source of bleeding in these patients could not be confirmed.3 Another 55 percent of patients required fluid and blood replacement, but did not undergo diagnostic or therapeutic interventions.3 The remaining 15 percent of patients presented with clinical evidence of severe bleeding that prompted urgent upper endoscopy which was diagnostic in five cases, therapeutic in six cases, and used to guide operative intervention in two cases.3

Endoscopy can be valuable in assessing the gastric and enteric anastomoses for evidence of active bleeding and can provide for less invasive treatment of the bleeding. A recent article by Fernandez reported successful early (within 24 hours of surgery) endoscopic identification of post-LRYGB bleeding and treatment by injection of epinephrine in all patients in the series. There were no complications, and patients were spared the need for reoperation.14 If the surgeon is not performing the endoscopy, he or she should be present or available nearby when bariatric patients undergo early postoperative endoscopy. Furthermore, it may be advisable for these patients to undergo endoscopy in the operating room in the event that surgical intervention to address the bleeding becomes necessary.

Early reoperation should be performed for patients with hemodynamic instability and possibly patients with early onset of hemorrhage (12 hours) after surgery.11 Some authors propose initial laparoscopy to treat complications1, 15 with timely progression to laparotomy if laparoscopy fails. Others assert that urgent laparotomy is the safest option.3 Operative therapy is guided by the site of bleeding and may include oversewing of one or all staple lines, gastrotomy (for pouch or excluded stomach) or enterotomy with evacuation of clot, and revision of anastomotic sites.

In the future, natural orifice transluminal endoscopic surgery (NOTES) may become another option for the treatment of postoperative bleeding. As with endoscopy, this procedure would allow for minimally invasive diagnosis and treatment of upper GI hemorrhage, but would also provide the advantage of extraluminal visualization and additional therapeutic capabilities.

Conclusion
Postoperative bleeding occurs in up to four percent of LRYGB cases and may be due in part to increased use of prophylactic anticoagulation and use of staplers for transection or anastamoses. Even when additional modalities are used or technical steps are taken to prevent postoperative bleeding, bariatric surgeons must maintain a high index of suspicion to identify postoperative bleeding in a timely fashion in order to take the appropriate action. With clinical vigilance and careful management, the majority of patients can be successfully treated without the need for reoperation.

References
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Category: Commentary, Past Articles