3 Common Long-Term Complications of Gastric Bypass

Long-term complications of gastric bypass can include ulcers, scarring, narrowing of the anastomosis (where the intestine is connected to the gastric pouch), known as stenosis, and a drainage path through the skin called a fistula. Weight-loss surgery is one of the fastest growing segments of the surgical discipline. As with all medical procedures, post-operative complications will occur. Intensive care surgeons should be familiar with common problems and their treatment.

While general surgical principles generally apply, the specific diagnoses of different bariatric operations should be considered. There are anatomical considerations that, in many cases, alter the priorities and treatment options of these patients. These problems occur both at the beginning and at the end of the postoperative period. Bariatric operations, in many cases, cause a permanent alteration of the patient's anatomy, which can cause complications at any time in the patient's life.

Intensive care surgeons who diagnose surgical emergencies in patients after bariatric surgery should be familiar with the type of surgery performed, as well as with the most common post-bariatric surgical emergencies. In addition, surgeons should not overlook the common causes of acute abdominal surgery, acute appendicitis, acute diverticulitis, acute pancreatitis and gallstone disease, as these are still the most common etiologies of abdominal pathology in these patients. Bariatric surgical procedures include sleeve gastrectomies (SG), Roux-en-Y Y-shaped gastric bypass (RYGB), and gastric balloons. Initial complications include leaks, stenoses, bleeding, and venous thromboembolic events (VTE).

These principles also apply to bariatric operations that are performed less frequently, such as the minigastric bypass, the ileal duodenal bypass with a single anastomosis, and the duodenal switch (DS), also known as biliopancreatic bypass with an SG. In hemodynamically normal patients, the presence of other causes of postoperative tachycardia, such as postoperative bleeding, hypovolemia, and pneumonia, should be evaluated before reexploration. The evaluation of a leak should include an abdominal CT scan with oral contrast; patients should be instructed to drink approximately 100 cc of contrast just before the scan. Computed tomography can detect other diseases based on the differential diagnosis of tachycardia, such as bleeding and pneumonia.

The scintigraphy may be performed in conjunction with a CT lung angiogram to detect pulmonary ejaculation. The detection rate of leaks in gastroyejunal anastomosis (GJA) or in a computed angiography is 60 to 80%. An upper gastrointestinal tract (UGS) series can also be used to detect leaks, but it is less sensitive to a leak in the GJA than a CT scan. After RYGB, the gastric bag is a low-pressure system and therefore the incidence of leaks ranges from 0.6% to 4.4% of patients.

Because of this, surgical or non-surgical treatment strategies that control the leak but do not close or repair the perforation are effective in 72% of patients. Patients who have leaks that last more than 30 days can be treated with an endoluminal procedure to place clips, stents or a vacuum bandage to help close these chronic leaks. Nutrition is Can approach with distal enteral feeding of the GJA and is preferable to total parenteral nutrition. A feeding tube may be placed in the Roux limb, the biliopancreatic limb or the common canal.

Postoperative bleeding requiring intervention occurs in up to 11% of cases for both RYGB and SG operations. Fortunately, 85% of patients are likely to stop doing so without surgery. Patients with dysmetabolic syndrome X are at greater risk of bleeding. Routine supportive treatment should be instituted promptly and includes establishing adequate venous access, crystalloid resuscitation, transfusions of blood products, serial hematocrits, hemodynamic monitoring and correction of any coagulopathy as well as interruption of VTE chemoprophylaxis if it is being used.

An experienced endoscopist can safely evaluate an anastomosis in the early postoperative period and perform therapeutic endoluminal interventions such as tweezers or epinephrine injections as first-line treatment. Hemodynamic instability or failure of non-surgical treatment requires emergency surgical treatment. The via grappa is most commonly found as a site for bleeding after sprain surgery but a splenic injury is also possible. After ejaculation it is possible for intra-abdominal bleeding to occur in omentery or spleen if no obvious site is found for bleeding sources.

Enteric perforation and balloon migration leading to intestinal obstruction are two complications that may require acute treatment and result in death.

Genevieve Szulimowski
Genevieve Szulimowski

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