Non-surgical early complications, which particularly affects obese patients (high-risk patients).
- Acute renal failure caused by rhabdomyolysis with acute renal failure
- Deep venous thrombosis with resulting pulmonary embolisms
- Pneumonia
- Fluid and electrolyte deficiencies as a result of recurrent vomiting
- Avoided by ideal OR conditions with short operating time and appropriate perioperative management
Postoperative bleeding (0.6–15.8%):
Early postoperative bleeding:
- Bleeding from the gastric staple lines on the stomach or the anastomosis is the most common. Whether this can be avoided by the use of staple reinforcement lines is a topic of controversial discussion. Bleeding requiring transfusion is seen in up to 8% of patients. Less than 2% of patients require reoperation.
- Extra- and intraluminal sources of bleedings are possible.
Symptoms: Hb drop, hypotension, tachycardia, free fluid, hematemesis, melena
- Endoscopic procedure if necessary: clipping, oversewing, injection
- Postoperative staple line bleeding is the most common cause of bleeding → emergency laparoscopy and hemostasis by suture ligation or clips, if inspection is not possible → laparotomy
- For an unknown source of bleeding contrast enhanced, CT with IV contrast, interventional radiological coiling of suitable locations, otherwise re-laparoscopy and exploration.
Delayed postoperative bleeding:
- Erosional bleeding in patients with fistulas
- Rare: Anastomotic ulcers or ulcers in the gastric remnant (hematemesis, melena, chronic anemia)
- Endoscopic hemostasis, if not possible interventional radiological coiling/embolization, last resort re-laparoscopy with intraoperative gastroscopy for targeted suture ligation if necessary. In the gastric remnant that cannot be accessed endoscopically, re-laparoscopy with gastrotomy as the access for the gastroscope, or follow-up resection or removal of the gastric remnant.
Staple line/anastomotic failure (up to 5.1%):
- Anastomotic failures that occur in primary bypass (no previous gastric surgery) are seen in less than 5% of patients and can have a fatal outcome if the response is too late. In patients with morbid obesity, this complication poses a special risk, as it is associated with high mortality.
- The omission of foot-point anastomosis is an advantage over Roux-en-Y gastric bypass because this source of complications is lacking. Since mini gastric bypass does not require enteroanastomosis between the afferent and efferent limbs, a possible source of complications, this is an advantage compared to Roux-en-Y gastric bypass.
Clinical symptoms such as tachycardia, abdominal pain, hypotension, increased inflammatory parameters, fever, and new-onset shoulder pain should prompt an early re-laparoscopy, which is superior to imaging procedure modalities in extremely obese patients in terms of sensitivity and specificity in extremely obese patients.
Early leaks:
- Immediate re-laparoscopy following initial laparoscopic surgery with oversewing and draining the leakage site after initial laparoscopic surgeries has good prospects for success.
- With a tubular sleeve-like gastric pouch, fashioning of a new anastomosis is also a possible option in principle.
- Last resort: gastrectomy - with high mortality
- Antibiotic therapy is mandatory.
Late leaks (fistulas and abscesses) (1.5–6 %)
Usually only after discharge of the patient, often presenting as fistulas or abscesses.
Endoscopic techniques are favored when there is simultaneous drainage of extraluminal fluid accumulation by means of interventional radiology.
Small defects (< 0.5 mm) at the GE can be closed using OTS clips; larger defects with endoluminal vacuum systems (Esosponge); the polyurethane sponge is placed directly into the abscess cavity located posterior to the staple line failure.
Caution! Active explantation of the clips is not possible.
Gastrogastric fistulas involve a connection between the gastric pouch and the gastric remnant. They usually involve incomplete division of the stomach, and require another surgical division, because otherwise there will be further weight gain.
Strictures/stenoses (3–27%)
Anastomotic stenoses immediately postoperatively are surgical failures. Late stenoses (1–38%) are usually caused by local infections in the region of the staple line.
- Staged management of stenosis: endoscopic dilation – stent implantation – re-laparoscopy and conversion surgery, if necessary
Anastomotic ulcers (1–16%) and pouchitis (0,6–8%):
A preoperative history of ulcers requires a thorough work-up (Helicobacter pylori, gastrin) to prevent postoperative anastomotic ulcers. Ulcers can lead may result in perforation and penetration.
- Risk factors/causes: foreign body reactions, microfailures, local ischemia, peptic lesions due to increased acid production in the gastric pouch, untreated Helicobacter infections, nicotine abuse, herpes infection, and NSAID abuse.
Most ulcers usually occur in the first year; on average, ulcer perforations occur 13.5 months after surgery.
- Location: Bypassed gastric remnant, duodenum, jejunum, usually jejunal marginal zone of the GE.
- Healing can normally be achieved with pharmacotherapy medication. General ulcer therapy treatment with elimination cessation of nicotine- and NSAID-related risk factors, pharmacotherapy with PPIs.
- If bleeding occurs, the usual standard endoscopic therapeutic treatment techniques should be implemented.
- Perforated ulcers are an emergency indication and are oversewn and drained.
- Untreated ulcers may result in stenosies and dysphagia.
- Therapy-refractory ulcers are an indication for surgical revision with the fashioning of a new anastomosis.
Internal hernias:
- Low incidence of internal hernias compared with Roux-en-Y gastric bypass
- Significantly fewer adhesions occur after laparoscopic surgeries. The increased mobility of the intestine could predispose to the formation of internal hernias. The excessive postoperative weight loss reduces intraperitoneal fat and thus may thereby lead to expansion of small mesenteric gaps.
- Herniations of bowel loops through openings in the mesentery are potential long-term complications. Re-laparoscopy and CT are superior to all other diagnostic procedure.
- Treatment must be conducted promptly and includes exploration of the entire small intestine. If left untreated, herniations can lead to small intestine necrosis.
Dumping syndrome (up to 75%):
- Dumping syndrome is a complex of symptoms that develops physiologically as a result of sudden gastric emptying followed by rapid exposure of the small intestine to undigested food.
- Grading of dumping syndrome ranges from mild gastrointestinal symptoms to vasomotor disorders to severe therapy-refractory hypoglycemia.
- Early dumping (10–30 min after eating) results in non physiologically high influx of interstitial fluid into the intestinal lumen caused by the hyperosmolar chyme with distension of the intestinal wall and vasomotor disorders.
- Late dumping (1–3 hours after eating) is caused by overly rapid absorption of water-soluble carbohydrates with initial hyperglycemia followed by a counter-regulatory, often excessive insulin response with hypoglycemia and its typical symptoms.
Management:
- Dietary measures
- Pharmacological: acarbose, somatostatin analogs, e.g., octreotide 50–100 μg s.c. 3–4 times daily
- Surgical techniques such as pancreatic resection should be reserved for special therapy-refractory cases.
Treatment failure/failure to reach the therapeutic goal: inadequate weight loss/de novo weight gain (BMI >35 kg/m22)
Causes:
- Pouch dilation can result in treatment failure. The pouch may have been fashioned too large initially, or it might have subsequently dilated due to inappropriate eating behavior or a gastroenterostomy that is too narrow.
- If the anastomosis is too wide, the downstream jejunal loops may dilate and function as a replacement stomach.
Management:
- pouch downsizing, tangential resection of the dilated part
- concurrent nutritional and psychological care
- conversion surgery if necessary
Excessive weight loss with malnutrition (0.1-1.3%)
- Iron deficiency anemia (3.9-–12.7%) caused by the duodenumal bypass
- Vitamin D deficiency (32%)
- Biliary reflux (0.9–1.6%)
- Malnutrition especially if the BPL (biliopancreatic limb) is >200 cm
Management:
- Initially, attempt at conservative pharmacological management with medication/substitution
- As a last resort, redo (conversion) surgery
Potential biliary reflux in the gastric pouch: Effects unknown thus far
