Emergencies After Bariatric Surgery AI Sarela MD FRCS Consultant Surgeon St James’s University Hospital
Nov 03, 2014
Emergencies After Bariatric Surgery
AI Sarela MD FRCS
Consultant Surgeon
St James’s University Hospital
Agenda
• Laparoscopic Bariatric Procedures– Roux-en-Y gastric bypass– Adjustable gastric band– Sleeve gastrectomy
• Technical/mechanical complications– Early– Late
• Case-scenarios
Difficulties in the Bariatric Patient
• The classical symptoms and signs of peritonitis are usually absent in the bariatric patient
• Problematic venous access• Cuff measurement of BP is often
inaccurate• May not fit into CT scanner• Unfamiliarity with anatomy of the operation• Immobile – patient transfer is not easy!
Complications of Laparoscopic Roux-en-Y gastric bypass
• Early (< 30 days after operation)– Leakage – peritonitis– Acute distention of the gastric remnant– Bleeding
• Early or Late– Intestinal obstruction– Stomal stenosis– Stomal ulceration– Gallstones
Roux-en-Y Gastric BypassCase Scenarios
• POD#1 Laparoscopic Bypass: Fresh rectal bleeding, tachycardia, hypotension
• POD#4 Laparoscopic Bypass: A&E admission. Abdominal pain, tachycardia, not well.
• POD#7 Laparoscopic Bypass: A&E admission. Vomiting.
• POD#20 Laparoscopic Bypass. Abdominal pain, fever, tachycardia.
• 2 years after Laparoscopic Bypass. Abdominal pain.
GI Luminal Bleeding after Bypass
• Endoscopy – clipping of bleeder
• Laparoscopy– Bleeding from the J-J anastomosis?
• Open anastomosis to inspect staple-line• Evacuate blood clots – may obstruct bowel
– Bleeding from the gastric remanant?• Gastrotomy - Evacuate blood• Oversew staple-lines
Acute Abdomen in the Bypass Patient
• Leakage – Peritonitis
• Intra-peritoneal bleeding
• Intestinal obstruction
Sites of Leakage after Gastric Bypass
– Gastrojejunal anastomosis
– Jejuno-jejunal anastomosis
– Staple line on the residual stomach
– Gastrotomy for insertion of anvil
– Missed enterotomy
Laparoscopic Roux-en-Y Gastric BypassNormal Radiological Anatomy
Suspected Leak: Radiology or Re-Laparoscopy?
• Contrast swallow examination – beware the false-negative!
• CT scan – timing of oral contrast; limited enhancement with IV contrast
• Consider re-exploration for all patients with suspected GI leak – radiology may delay intervention
Causes of Obstruction after Gastric Bypass
• Internal hernia – Peterson’s space• Internal hernia – small bowel mesenteric defect• Incorrect identification of small intestine
– Closed loop– Twisted loop
• Narrow/occluded jejuno-jejunal anastomosis• Blood clot at jejuno-jejunal anastomosis• Port-site hernia• Abdominal wall hernia
Anatomy of Intestinal Obstruction in the Bypass Patient
• Isolated obstruction of the biliopancreatic limb– Upper abdominal pain– Deranged liver function tests– Distention of the gastric remanant
• Isolated obstruction of the alimentary limb– Inability to tolerate oral intake
• Obstruction of the common channel– Bilious vomiting
Massively Dilated Gastric Remnant
• Acute Dilatation– Obstruction at J-J, BP limb or CC– Clot due to staple-line bleeding. Technical
error in construction of the anastomosis.– CT guided or operative decompression of
remnant.
• Chronic Dilatation– Peptic ulcer, vagotomy, cancer,
gastroparesis- in all these cases duodenum will remain collapsed
Intestinal Obstruction with Distened Gastric Remnant
Dysphagia with Bypass
• Stomal stenosis
• Early post-operative presentation
• Dilatation
• Routine post-operative PPI therapy
• Smoking cessation
Marginal Ulcer
• Incidence up to 15%• Barium study – gastro-gastric fistula• Non-operative management
– Smoking cessation– NSAID cessation– Endoscopic removal of retained sutures– PPI
• Operation– Excision and revision of anastomosis
Gallstone & Biliary Sepsis
• Risk of gallstones may double during rapid weight loss (from 15 to 30%)
• Combined cholecystectomy is controversial
• Post-bypass – how to manage choledocholithiasis?– Laparoscopic bile duct exploration– Trans-gastric ERCP– Percutaneous trans-hepatic biliary drainage
Dysphagia with a Band
• Slippage
• Over-inflation
• Fluid Shifts
– “Auto-fill”
– Gastric wall oedema
Band Slippage
• Cephalad migration of the gastric wall such that band is displaced
• Symptoms– Pain– Dysphagia – Gastric outlet obstruction
• Danger: Gastric wall necrosis
Band SlippageRadiology – Contrast Swallow
• Enlarged pouch that is obstructed at the
level of the band
• Change in the orientation of the band on
contrast swallow or plain radiograph
Band in Good Position
Slipped Band
Slipped Band
Operations for Band Slippage
• Reduction of prolapsed stomach without opening the band
• Opening the band, reduction of prolapsed stomach, repositioning of the band.
• Removal of the band
• Avoid cutting – expensive!
• If opened, can leave it in the tunnel – do not have to remove.
Band Erosion
• Inadequate weight loss or weight regain
• Intra-abdominal abscess
• Port-site infection
Re-operation on the Bariatric Patient Positioning
• Abduction of both thighs on “split leg” table
• Foot supports
• No chest straps
• Arms “tucked in” at sides
• Extension arm-boards for retraction clamps
• Maximum head-up incline
Re-operation on the Bariatric PatientEquipment
• Extra-long laparoscopic ports and instruments
• Liver retractor with Fastclamp
• Methylene blue solution (two ampoules in 1 litre of sterile water/NS)
• NG tube – introduce under laparoscopic vision
Bariatric Surgery Emergencies
• Scary!!
• Try to contact the operating surgeon
• Determine the anatomy of the procedure
• Radiology is not usually helpful
• Very low threshold for RE-LAPAROSCOPY
• Ensure availability of correct equipment
• LAVAGE & DRAIN