Early and late complications of bariatric operation

Leaks

An anastomotic leak is the most dreaded complication of any bariatric procedure because it increases overall morbidity to 61% and mortality to 15%.1 2 Failures of anastomotic integrity prolong hospital stays and can result in gastroenteric and gastrobronchial fistulae, which may take months to resolve. Patients undergoing revisional bariatric operations, those who have a body mass index (BMI) of >50 kg/m2, and those with dysmetabolic syndrome X are most at risk for leaks.3-5 A leak should be suspected and investigated in any patient with persistent tachycardia (>120 beats per minute (bpm)), dyspnea, fever, and abdominal pain. The average time for symptoms of a leak to present is approximately 3 days after the operation.6 Often these patients have been discharged home and may present to the emergency room. Sustained heart rates over 120 bpm are a particularly worrisome sign and should be addressed quickly.

Postoperative patients who present with tachycardia and hypotension should be appropriately resuscitated and evaluated for myocardial infarction and pulmonary embolism (PE). Emergency operative exploration should follow if those are ruled out. The operation may be done laparoscopically or open depending on the surgeon’s experience and the severity of the hemodynamic instability. The priorities in the operating room are threefold: removal of contamination, placing closed suction drains to control the leak, and establishment of feeding access. If feasible, closing the leak may be attempted, but it is not required. If a repair is undertaken, interrupted sutures and a modified Graham patch may protect the repair.

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In hemodynamically normal patients, evaluation for other causes of postoperative tachycardia, such as postoperative bleeding, hypovolemia, and pneumonia, should precede re-exploration. The evaluation of a leak should include an abdominal CT study with oral contrast; patients should be instructed to drink about 100 cc of contrast just prior to the scan. A CT scan can evaluate for other diseases on the differential diagnosis of the tachycardia, including bleeding and pneumonia. The scan can be performed along with a CT pulmonary angiogram to look for a PE. The detection rate for leaks at the gastrojejunal anastomosis (GJA) or in an SG by CT is 60% to 80%.6 7 CT evidence of an abscess, phlegmon, or fluid collection should be considered a leak even if no extravasation of contrast is seen. An upper gastrointestinal series (UGS) can also be used to detect leaks but is less sensitive for a leak at the GJA than a CT,8 and neither study will effectively rule out a leak at the jejuno-jejunal anastomosis (JJA) after an RYGB. Persistent tachycardia despite negative radiologic studies warrants surgical exploration if no other cause can be identified due to the poor sensitivities of diagnostic tests. In hemodynamically normal patients, control of a leak may also be done by image-guided drainage.

There are significant differences, however, between the SG leak and the RYGB leak based on the typical endoluminal pressure. After RYGB, the gastric pouch is a low-pressure system, and thus the incidence of leaks ranges from about 0.6% to 4.4% of patients.9 Because of this low pressure, operative or non-operative management strategies that control the leak but do not close or repair the perforation are effective in 72% of patients.10 Patients who have leaks that last longer than 30 days can be treated with an endoluminal procedure to place clips, stents, or a vacuum dressing to help close these chronic leaks.11 Nutrition can be addressed with enteral feeding distal to the GJA and is preferable to total parenteral nutrition. A feeding tube can be placed in the Roux limb, the biliopancreatic limb, or the common channel.

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Sleeve leaks, on the other hand, occur in a high-pressure system, are thought to be more common, and range in incidence from 1% to 7%.12-14 They are more difficult to treat. Most SG leaks occur at the uppermost extent of the sleeve, where blood supply is tenuous. The high pressure comes from the pyloric and lower esophageal sphincters, or possibly due to a stenosis, twist in the SG, or kink. These anatomic narrowings must be addressed if the leak is to be treated successfully.

Stable patients with leaks after an SG can undergo image-guided drainage procedures. Endoluminal intervention with covered stenting may be placed earlier in the treatment course to help control the leak. The stent should cover from the lower esophageal sphincter (LES) through the pyloric sphincter to allow the leak to heal.13 Unfortunately, the most commonly available stents are not long enough (30 cm) to cover this distance.

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