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Cheng V, Samakar K, Dobrowolsky AB, Nguyen JD, Abel SA, Pakula A, Bernard A, Martin MJ. Common postbariatric surgery emergencies for the acute care surgeon: What you need to know. J Trauma Acute Care Surg 2023; 95:817-831. [PMID: 37982794 DOI: 10.1097/ta.0000000000004125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
ABSTRACT The field of bariatric and metabolic surgery has changed rapidly over the past two decades, with an exponential increase in case volumes being performed because of its proven efficacy for morbid obesity and obesity-related comorbidities. Although this increased volume of procedures has been accompanied by significant decrease in postoperative complication rates, there are numerous potential complications after bariatric surgery that may require urgent or emergent surgical evaluation or interventions. Many of these risks extend well beyond the early postoperative period and can present months to years after the index procedure. Acute care surgeons are increasingly covering most or all of the emergency general surgery services at many centers and must be familiar with the numerous bariatric surgical procedures being performed and their individual complication profile to provide optimal care for these frequently challenging patients. This article provides a focused and concise review of the common bariatric procedures being performed, their early and late complication profiles, and a practical guide to the optimal diagnostic evaluations, surgical interventions, and perioperative management options. The author group includes both acute care surgeons and bariatric surgeons with significant experience in the emergency management of the complicated postbariatric surgical patient. LEVEL OF EVIDENCE Literature Synthesis and Expert Opinion; Level V.
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Affiliation(s)
- Vincent Cheng
- From the Division of Trauma and Surgical Critical Care (V.C., M.J.M.), Los Angeles County + USC Medical Center, University of Southern California; Division of Upper GI and General Surgery (V.C., K.S., A.B.D., J.D.N., S.A.A., M.J.M.), Keck School of Medicine of the University of Southern California, Los Angeles; Surgical Specialties (A.P.), Simi Valley Adventist Hospital, Simi Valley, California; and Division of Acute Care Surgery and Trauma (A.B.), University of Kentucky-Lexington, Lexington, Kentucky
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Salame M, Jawhar N, Belluzzi A, Al-Kordi M, Storm AC, Abu Dayyeh BK, Ghanem OM. Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management. J Clin Med 2023; 12:4336. [PMID: 37445371 DOI: 10.3390/jcm12134336] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 06/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.
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Affiliation(s)
- Marita Salame
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Noura Jawhar
- Division of Pediatric Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Endoscopic and histopathological assessment of individuals undergoing one anastomosis gastric bypass: a 2-year follow-up. Surg Endosc 2023; 37:3720-3727. [PMID: 36650354 DOI: 10.1007/s00464-023-09884-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/08/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is much debate over the occurrence of biliary reflux to the gastric pouch after one anastomosis gastric bypass (OAGB) and its potential risks. OBJECTIVE To assess endoscopic and histopathological findings following a standardized protocol of biopsy collection two years after OAGB. METHODS A historical cohort study was conducted, based on a prospectively collected database, which involved 39 participants who underwent OAGB. Participants underwent clinical evaluation and esophagogastroduodenoscopy at the time of surgery and 24 months afterward. Post-operatively, biopsy specimens in esophagogastric junction, pouch, and anastomosis were systematically collected. RESULTS 92.3% of the participants were female and the mean age was 37 ± 8.5 years. The mean body mass index (BMI) significantly decreased from 37.6 ± 5.7 kg/m2 to 27 ± 4.1 kg/m2 after 2 years (p < 0.001). The mean %TWL was 27.2 ± 10.5%. The prevalence of non-erosive gastritis significantly increased from 25.6 to 51.3% (p = 0.02). Erosive gastritis significantly decreased from 28.2 to 10.3% (p = 0.04). Four cases of marginal ulcers were identified (10.3%). The commonest histopathological finding was mild inflammation in 74.3% (esophagogastric junction), 58.9% (pouch), and 71.8% (anastomosis). There was one case of focal intestinal metaplasia in each site of interest and no cases of dysplasia or severe inflammation. CONCLUSIONS Using a standardized protocol of post-operative biopsy collection, low rates of severe endoscopic and histopathological abnormalities were observed two years after OAGB. Nevertheless, as most patients have histologically proven inflammation, bile in the gastric pouch, and endoscopic gastritis, long-term surveillance is essential because of the uncertain risk of these abnormalities.
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Goudarzi H, Obney JR, Hemmatizadeh M, Anbara T. Endoscopic Self-Expanding Metallic Stent Placement in the Management of Post Laparoscopic Sleeve Gastrectomy Complications. JOURNAL OF DIGESTIVE ENDOSCOPY 2022. [DOI: 10.1055/s-0042-1754333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Introduction Endoscopic treatments have become popular by providing the best solution for healing complications while allowing oral nutrition. In this study, we aim to evaluate outcomes of the endoscopic-covered stents for staple line complications following bariatric surgery.
Methods A prospective evaluation was performed for all patients treated for staple line complications after bariatric surgery. Bariatric patients with acute leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after sleeve gastrectomy were included in this survey.
Results From January 2019 to June 2020, 41 patients (12 with acute leaks, 16 with chronic fistulas, and 13 with strictures) were treated with endoscopic silicone-covered stents (polyester or nitinol). The mean follow-up was 3.5 months. Immediate symptomatic improvement occurred in 95.2% (91.7% of acute leaks, 81.2% of fistulas, and 92.3% of strictures). In addition, 87.8% of patients initiated oral feeding immediately after stenting. There was no mortality case in this population.
Conclusion Although stent migration rarely occurs in subjects, the endoscopic silicone-covered stents strategy is one of the best treatments for anastomotic complications after bariatric surgery, providing rapid healing while simultaneously allowing for oral nutrition.
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Affiliation(s)
| | - Jacob R. Obney
- Department of Biology, Texas Tech University, Lubbock, Texas, United States
| | | | - Taha Anbara
- Department of Surgery, Erfan Niayesh Hospital, Tehran, Iran
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Early Bleeding After Laparoscopic Roux-en-Y Gastric Bypass: Incidence, Risk Factors, and Management - a 21-Year Experience. Obes Surg 2022; 32:3232-3238. [PMID: 35932414 PMCID: PMC9532327 DOI: 10.1007/s11695-022-06173-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/26/2022]
Abstract
Purpose Morbidity and mortality associated with bariatric surgery are considered low. The aim of this study is to assess the incidence, clinical presentation, risk factors, and management of early postoperative bleeding (POB) after laparoscopic Roux-en-Y gastric by-pass (RYGB). Materials and Methods Retrospective analysis of prospectively collected data of consecutive patients who underwent RYGB in 2 expert bariatric centers between January 1999 and April 2020, with a common bariatric surgeon. Results A total of 2639 patients underwent RYGB and were included in the study. POB occurred in 72 patients (2.7%). Intraluminal bleeding (ILB) was present in 52 (72%) patients and extra-luminal bleeding (ELB) in 20 (28%) patients. POB took place within the first 3 postoperative days in 79% of patients. The most frequent symptom was tachycardia (63%). Abdominal pain was more regularly seen with ILB, compared to ELB (50% vs. 20%, respectively, p = 0.02). Male sex was an independent risk factor of POB on multivariate analysis (p < 0.01). LOS was significantly longer in patients who developed POB (8.3 vs. 3.8 days, p < 0.01). Management was conservative for most cases (68%). Eighteen patients with ILB (35%) and 5 patients with ELB (25%) required reoperation. One patient died from multiorgan failure after staple-line dehiscence of the excluded stomach (mortality 0.04%). Conclusion The incidence of POB is low, yet it is the most frequent postoperative complication after RYGB. Most POB can be managed conservatively while surgical treatment is required for patients with hemodynamic instability or signs of intestinal obstruction due to an intraluminal clot. Graphical abstract ![]()
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Safety and Efficacy of One Anastomosis Gastric Bypass on Patients with Severe Obesity Aged 65 Years and Above. Obes Surg 2022; 32:1610-1616. [PMID: 35277792 DOI: 10.1007/s11695-022-05994-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/06/2022] [Accepted: 03/09/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE With the global increase in life expectancy and the subsequent impaired quality of life in older obese adults, modalities such as bariatric surgery become crucial to help lose excess weight. This study was conducted to evaluate the effectiveness and safety of one anastomosis gastric bypass (OAGB) in patients 65 years old and above. MATERIALS AND METHODS This retrospective cohort study was conducted on 61 patients with severe obesity aged ≥ 65 years through Iran National Obesity Surgery Database. The patients had undergone OAGB and were followed up for 12 to 60 months. The required data was extracted through national database. RESULTS Mean age and BMI of the patients were 67.62 ± 2.03 years and 46.42 ± 5.46 kg/m2, respectively. Regarding gender, 90.1% of the participants were female. Mean operative time and length of hospital stay were 41.37 ± 13.91 min and 1.16 ± 0.61 days, respectively. Five patients (8.19%) required ICU admission. The changes in %TWL after 3, 6, 12, 24, 36, 48, and 60 month follow-up was 18.62%, 25.51%, 32.84%, 35.86%, 38.49%, 31.41%, and 29.52%, respectively. The resolution of gastroesophageal reflux disease, diabetes mellitus, dyslipidemia, obstructive sleep apnea, and hypertension after 24 month was about 100%, 65%, 73.33%, 100%, and 76%, respectively. The postoperative early and late complications were 6.53% and 11.46%, respectively. We did not find significant difference in above results between two age groups of 65-70 and > 70 years. CONCLUSIONS OAGB can be a good choice in older obese adults because of its shorter operative time, higher potency, and low complication rate.
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Laparoscopic Handsewn Gastrojejunostomy Revision of Gastrojejunal Anastomosis with Takedown of Gastro-gastric Fistula. Obes Surg 2022; 32:1403-1404. [PMID: 35230603 DOI: 10.1007/s11695-022-05941-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 01/30/2022] [Accepted: 02/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Marginal ulcer (MU) and gastro-gastric fistula (GGF) are well-described complications following Roux-en-Y gastric bypass (RYGB). The incidence of MU ranges from 0.6 to 25% and the incidence of GGF following divided RYGB has been reported as high as 6%. MU has been shown to be associated with GGF with a 53% incidence of MU in patients with GGF versus 4% in patients without GGF. Other risk factors for developing GGF previously identified in the literature include incomplete gastric transection, staple-line leak, and foreign body erosion. Management of GGF begins with aggressive medical therapy aimed at decreasing acid production, and surgical intervention is indicated for persistent symptoms such as weight gain or persistent ulcers. Endoscopic therapy is not recommended given risk of failure in setting of chronic inflammation. METHODS To demonstrate the operative management of gastro-gastric fistula from chronic marginal ulcer. A 52-year-old female who had previous robotic RYGB in 2012 developed a chronic marginal ulcer and was diagnosed with a gastro-gastric fistula in 2017. She had a suspected perforation of her marginal ulcer in 2018, although no ulcer was found on laparoscopic exploration. She was taken to the OR for revision in 2018 for chronic marginal ulcer and strictures. Two gastro-gastric fistulas were found and resected, and a redo gastrojejunostomy was performed. RESULTS We used a handsewn RYGB technique in this patient, and other options include circular or linear techniques to create the gastrojejunal anastomosis [GJA]. We have found the rate of both stricture and marginal ulcer higher after circular stapled GJA technique. She did well post-operatively and did not have any further issues with marginal ulcers or strictures. CONCLUSIONS A significant number of patients with GGF will fail maximal medical therapy and will require surgical treatment. Laparoscopic resection of GGF is the most well-described surgical technique, with or without revision of the gastrojejunostomy depending on presence of anastomotic stricture, marginal ulcer, or involvement with GG fistula. Surgical therapy has been shown to lead to good outcomes.
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Ayuso SA, Robinson JN, Okorji LM, Thompson KJ, McKillop IH, Kuwada TS, Gersin KS, Barbat SD, Bauman RW, Nimeri A. Why Size Matters: an Evaluation of Gastric Pouch Size in Roux-en-Y Gastric Bypass Using CT Volumetric Analysis and its Effect on Marginal Ulceration. Obes Surg 2022; 32:587-592. [PMID: 34985616 DOI: 10.1007/s11695-021-05850-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/26/2021] [Accepted: 12/13/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Marginal ulceration (MU) is a common long-term complication following Roux-en-Y gastric bypass (RYGB). The causes of MU after RYGB are multifactorial and include surgical technique of constructing the gastrojejunal anastomosis (GJA). The purpose of this study is to evaluate the relationship between gastric pouch size in RYGB and MU using CT volumetrics. MATERIAL AND METHODS Patients were retrospectively identified who underwent esophagogastroduodenoscopy (EGD) following RYGB at a tertiary care teaching hospital. Measurement of gastric pouch size was performed using 3-D CT software. Standard statistical methods were used, a univariate comparison was performed between MU and non-MU patients followed by a propensity-matched comparison to control for factors known to affect MU, and a propensity-matched subgroup analysis was also performed. RESULTS In total, 122 patients met criteria, 57 of which had MU on EGD and 65 who did not. The MU group had more smokers and patients with PPI use than the non-MU group, and the mean time from operation to CT scan was 26.6 months (range: 0-108 months). The MU group had a larger gastric pouch size than the non-MU group (34.1 ± 11.8 versus 20.1 ± 6.8 cm3). When analyzed for matched patient cohorts, this difference remained for the MU group that included smokers and PPI use. When stratified for pouch size, for each 5 cm3 increase in pouch size, patients had 2.4 times odds increase of MU formation. CONCLUSIONS CT volumetric analysis demonstrated that a larger gastric pouch size was associated with MU following RYGB.
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Affiliation(s)
- Sullivan A Ayuso
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA.
| | - Jordan N Robinson
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Leslie M Okorji
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Kyle J Thompson
- Division of Research, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Iain H McKillop
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Timothy S Kuwada
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Keith S Gersin
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Selwan D Barbat
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Roc W Bauman
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
| | - Abdelrahman Nimeri
- Atrium Health Weight Management, Section of Bariatric and Metabolic Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, 28204, USA
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