Gastrointestinal Bleeding after Roux-en-Y Gastric Bypass

| February 18, 2010

by Ninh T. Nguyen, MD; Marcelo W. Hinojosa, MD;
James Gray, BS; and Brian R. Smith, MD

Drs. Nguyen, Hinojosa, and Smith and Mr. Gray are from the Department of Surgery, University of California, Irvine Medical Center, Orange, California.

Bariatric Times. 2010;7(2):20–22

Abstract
Gastrointestinal hemorrhage is a potential complication after both open and laparoscopic gastric bypass. This article discusses the clinical presentation of gastrointestinal bleeding, its etiology, options for treatment, and methods of prevention.

Introduction
Gastrointestinal (GI) hemorrhage is a potential complication after both open and laparoscopic gastric bypass. The incidence of GI hemorrhage after laparoscopic gastric bypass ranges from 1.1 to 4 percent.[1–6] Although the incidence is low, this complication can be life-threatening if not recognized expeditiously and treated correctly. In this article we discuss the clinical presentation of GI bleeding, its etiology, options for treatment, and methods of prevention.

Clinical Presentation
Patients with GI hemorrhage usually present either early (within several hours after surgery) or up to several days after the index procedure. The initial manifestation consists of hematemesis, bright red, bloody bowel movement, tachycardia, low urine output and/or hypotension. The timing of GI hemorrhage is one of the most important factors in deciding if the patient should proceed with operative intervention or watchful waiting. Gastrointestinal hemorrhage occurring within the first six hours after the index procedure is an indication of active and likely persistent surgical bleeding. Operative intervention in this scenario should be entertained. Additionally, the color of blood may help to decipher between old bleeding and active bleeding. Bright red blood normally signifies active bleeding. Gastrointestinal hemorrhage with bright red hematemesis or bowel movement in combination with tachycardia and hypotension is a particularly strong indicator of massive bleeding and an expeditious operative intervention is of utmost importance. Depending on the clinical presentation, the source of GI hemorrhage may not be immediately apparent. In contrast to early hemorrhage, the clinical presentation of GI hemorrhage occurring several days after gastric bypass usually consists of passage of dark blood (melena), often without other signs of blood loss such as a changes in the blood count or vital signs.[2] Delayed GI hemorrhage may represent evacuation of old blood clots accumulating from the primary procedure and do not represent active bleeding. In summary, clinical signs of hypotension, tachycardia, bright red hemorrhage, early reduction in the hematocrit, and presentation within six hours after the index procedure signify active bleeding and are factors that should be used as consideration for reoperative intervention.

Etiology and Diagnostic Methods
The etiology of GI hemorrhage after gastric bypass is from the gastrointestinal staple lines until proven otherwise. The four potential sites of staple line hemorrhage are staple lines of the gastric pouch, the gastrojejunal anastomosis, the jejuno-jejunal anastomosis, and the gastric remnant. Bleeding from the staple-lines may occur at the transected tissue edges or at the sites where the staples penetrate the mucosa. Bleeding at the staple lines may result in either GI or intraabdominal bleeding.

It is not necessary to perform any diagnostic work up to localize the site of bleeding, as the patient’s clinical presentation can be used as a guide to the possible site of bleeding. Hematemesis normally points to bleeding at the gastrojejunal anastomosis or the gastric pouch. In contrast, bright red blood per rectum usually implies bleeding at either the gastric remnant or the jejunal anastomosis.

Management
Initial management of GI hemorrhage consists of fluid resuscitation, discontinuation all anticoagulation, evaluation of blood count and coagulation profile, and possible blood transfusion. The need for operative intervention depends on the clinical presentation and the timing of presentation. Bright red hematemesis or bowel movement suggests active bleeding. Hypotension, persistent tachycardia despite fluid challenge, and decreasing blood count despite transfusion are also indicators of active rapid bleeding requiring urgent operative intervention. The timing of the bleeding presentation is also an important factor. Bleeding within the first six hours after the operation usually indicate active bleeding.

Postoperative bleeding interventions consist of either endoscopic therapy, laparoscopic or open reexploration, or both. Endoscopic therapy is most successful in patients with bleeding arising either from the gastric pouch or gastrojejunal anastomosis. The role of endoscopy is to evacuate the intraluminal blood clots and obtain hemostasis. Possible endoscopic methods for controlling staple-line bleeding include injection of epinephrine solution, clipping of bleeders, and thermal coagulation. A contrast study should be performed after any endoscopic therapy to rule out the potential for perforations. Endoscopy has limited application for management of bleeding at the jejuno-jejunal anastomosis because of the long length of the roux limb, particularly in patients with a 150-cm roux limb, and the large amount of intraluminal clot often prohibits good visualization. Nevertheless, successful endoscopic management of bleeding at the jejuno-jejunal anastomosis has been described.[7] There is no possible role for endoscopic management of staple-line bleeding arising from the gastric remnant in the acute setting.

Operative intervention is indicated in patients presenting with hemodynamic instability, specifically hypotension and tachycardia with decreasing hematocrit, or patients presenting with GI hemorrhage within the initial six hours from the index procedure. Hemodynamic instability represents rapid bleeding and prolonged observation can lead to adverse outcome.

Intraabdominal hemorrhage should be considered in patients presenting with hypotension and decreasing hematocrit without obvious gastrointestinal hemorrhage. Laparoscopic reexploration is an option if the index procedure was performed laparoscopically and without the presence of hemodynamic instability. If the patient is hemodynamically unstable, laparoscopy is contraindicated as the increased intraabdominal pressure during insufflation of pneumoperitoneum can worsen hemodynamics by decreasing cardiac venous return. The goals at the time of reoperation are to rule out an intraabdominal source of bleeding, evacuate intraluminal clot, and oversewing all potential sites of staple line bleeding. For example, a distended gastric remnant will require a gastrotomy on the greater curvature for removal of intraluminal blood and clot. Upon decompression, the entire gastric remnant staple line should be oversewn with a running suture, keeping in mind that identification of a specific site of bleeding is difficult. In summary, the primary goals of reexploration are luminal decompression of blood clots and oversewing of all staple lines.

Prevention
Several innovative methods have been devised to prevent staple line bleeding. The use of linear staplers with a shorter staple height may be helpful. For example, use of the white stapler load (2.5mm staple height) for construction of the jejuno-jejunal anastomosis rather than a blue stapler load (3.5mm staple height) is a common practice.  Similarly, the blue stapler load is used for construction of the gastric pouch rather than a green stapler load (4.8mm staple height). The shorter staple height provides more compression of the tissue resulting in improved hemostasis, but does not completely eliminate staple line bleeding.

Another method for prevention of staple line bleeding is the use of reinforcement products. The Peri-Strips Dry® (Synovis, St Paul, Minnesota) are composed of two strips of biological tissue derived from bovine pericardium that are applied to the linear stapler and act as a buttressing material at the staple lines. Bioabsorbable Seamguard® (WL Gore & Associates, Inc., Flagstaff, Arizona) staple line reinforcement product works in a similar fashion but is completely absorbable. Composed of absorbable Maxon®-like material, the material is degraded within six months after surgery.

Lastly, some surgeons attempt to prevent GI bleeding by routine oversewing of all staple lines at the primary operation, a time consuming task. In the future, we can likely look forward to development of a hemostatic gel applied to the stapler before its application. Unfortunately, no such adjunct is yet available.

Conclusion
Gastrointestinal hemorrhage remains a potentially serious complication after laparoscopic gastric bypass. Diagnostic evaluation is of limited value since the sites of intraluminal hemorrhage are typically from the staple lines. Operative intervention should be based on the patient’s clinical status including vital signs, changes in hematocrit, and other indications of ongoing hemorrhage. Endoscopic therapy should be used for bleeding arising from the gastric pouch or gastrojejunal anastomosis. Laparoscopic reexploration will rule out intraperitoneal bleeding and clot evacuation with oversewing of all staple lines may be accomplished if the patient is not unstable. Preventive measures include the use of stapler loads with shorter staple height, routine suture oversewing of staple lines, and the use of staple line reinforcement products.

References
1.    Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg. 2000;232:515–529.
2.     Nguyen NT, Ryan Rivers, Wolfe BM. Early gastrointestinal hemorrhage after laparoscopic gastric bypass. Obes Surg. 2003;13:62–65.
3.     Papasavas PK, Hayetian FD, Caushaj PF, et al. Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Endosc. 2002;16:1653–1657.
4.     Perugini RA, Mason R, Czerniach DR, et al. Predictors of complication and suboptimal weight loss after laparoscopic Roux-en-Y gastric bypass: A series of 188 patients. Arch Surg. 2003;138:541–545.
5.     Kligman MD, Thomas C, Saxe J. Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass. Am Surg. 2003;69:304–310.
6.     Podnos YD, Jiminez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass. Arch Surg. 2003;138:957–961.
7.     Moreto M, Mottin CC, Padoin AV, et al. Endoscopic management of bleeding after gastric bypass: A therapeutic alternative [correspondence]. Obes Surg. 2003;13:466–467.

Editors note:
This article was excerpted from Weight Loss Surgery: A Multidisciplinary Approach by Drs. Raul J. Rosenthal and Daniel B. Jones. Copyright © 2008 Matrix Medical Communications.

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