Complications - Laparoscopic gastric bypass

• Bleeding

The most common complication is bleeding from the gastric/EE staple line, which can be prevented almost completely by reinforcing the staple lines with sutures. Bleeding requiring blood transfusion is seen in up to 8% of patients. With <2% revision surgery is much less common.

• Contact between the active plate of the ultrasound device and the left gastric artery

Oversew or seal the defect and fashion a micropouch to prevent pouch necrosis. Best prevent the latter by strictly dissecting close to the gastric wall.

• Efferent limb too short

To avoid fashioning a limb that is too short, first check that the efferent limb is long enough to reach the pouch. If the limb proves to be too short nevertheless, it is recommended to fashion a primary gastric sleeve-like pouch and/or skeletonize the efferent limb or bring the limb up via a retrocolic retrogastric route.

• Blue loop syndrome

To avoid a twisted limb (“blue limb” syndrome), bring up the limb under direct vision (with the mesentery pointing to the left). Correct and eliminate any limb rotation.

• Limb misidentification

Consistent identification of the ligament of Treitz is crucial to also ensure that the limbs are not misidentified. Any misidentification of the limbs must be corrected immediately since otherwise the overstretched stomach (distension) carries the risk of cardiac arrest. Caution: Gaining access to short afferent limbs during revision surgery is technically challenging.

• Other special features

• Suture line failure

Suture/staple line failure occurs in less than 5% of primary bypass cases (no previous gastric surgery) and can be fatal if treatment is delayed. This complication poses a particular risk to morbidly obese patients since it is associated with high mortality. Often, tachycardia is the only symptom. In the event of any tachycardia (HF > 120) always consider relaparoscopy. Immediate relaparoscopy after initial laparoscopic surgery has a good chance of success.

• Anastomotic stricture

Anastomotic stricture presenting in the immediate postoperative course is indicative of technical mistakes. Most often late stricture (1%-38%) is due to local infections near the EEA staple line. Stricture is very rarely seen following hand sewn anastomosis and combined anastomosis in primary gastric bypass. It is significantly more common after conversion operations (e.g., vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RNYGB)) (15%). Endoscopic dilation performed in one or two sessions is very effective.

• Anastomotic ulcers

Anastomotic ulcers have become less common in the age of laparoscopic bypass surgery. Any preoperative history of ulcers must be clarified in detail (heliobacter pylori, gastrin) to prevent postoperative anastomotic ulcers.

• Herniation

Herniation of intestinal loops through mesenteric openings is a potential long-term complication. Retrocolic gastric bypass has the highest risk of herniation. Relaparoscopy and CT are superior to all other diagnostic modalities. In left upper quadrant pain: Mandatory relaparoscopy.

Closure of mesenteric defects is standard practice in retrocolic and antecolic gastric bypass.

• Fistulas and abscesses

Fistulas and abscesses arise in leakage, especially in stapled anastomoses. Abscess formation with a frequency of <1% is often combined with suture/staple failure and is a late sequela.  Gastrogastric fistulas connect the gastric pouch with the gastric remnant. These fistulas are mainly due to incomplete division of the stomach and necessitate revision surgery to correct them since otherwise the patient’s weight will increase again.

• Pouch reservoir and dumping syndrome

If the limb is anchored too far craniad, this will result in a distal pouch reservoir with overflow phenomenon; if the limb is anchored too far caudad, this will increase the risk of a dumping syndrome. The efferent limb should therefore be placed at the second staple line and tailored to the shape and size of the pouch.