Complications - Gastric bypass, laparoscopic

• Bleeding

Bleeding from the stapler lines on the stomach or also small intestine are the most common complications and can be almost completely avoided by using staple line reinforcements. Bleedings requiring transfusion occur in up to 8 %. Revisions are rarer with < 2 %.

• Contact of the active plate of the ultrasound device with the left gastric artery

This results in a puncture or sealing and a micro-pouch formation to prevent pouch necrosis. To avoid this procedure, a strict dissection close to the stomach wall should be performed.

• too short alimentary loop

To avoid the error of a too short loop, an initial check of the reachability of the pouch for the alimentary loop should be performed. If the loop is still too short once, a primary sleeve-like pouch shape and/or skeletonization of the alimentary loop or retrocolic retrogastric access is recommended.

• Loop rotation

To avoid a loop rotation (“blue loop syndrome), the loop is brought up under vision (mesentery points to the left). If it still comes to a rotation, the resolution and correction is performed.

• Loop mix-up

To avoid a loop mix-up, a consistent identification of the Treitz ligament must be performed. In an emergency, an immediate correction must be carried out, otherwise cardiac arrest threatens due to the overdistended stomach (distension). Important: short biliodigestive loops are technically difficult to reach in later revisions.

• further specifics

• Anastomotic Insufficiency

Anastomotic insufficiencies occur in primary bypass (no previous stomach surgery) in less than 5 % and can end lethally if reacted to too late. In patients with morbid obesity, this complication poses a particular risk, which is associated with high lethality. Tachycardia is often the only symptom. Every tachycardia (HR > 120) is reason to consider a relaparoscopy. An immediate relaparoscopy after laparoscopic primary operations has a good success prospect.

• Anastomotic Stenosis

Anastomotic stenoses immediately postoperatively are surgical technical errors. Late stenoses (1 -38 %) are mostly caused by local infections in the area of the circular staple line. After hand anastomoses and combined anastomoses, a stenosis in primary bypass is very rare. After conversion operations (e.g. Vertical Banded Gastroplasty (VBG) to Roux-en-Y-Gastric Bypass (RNYGB)) they are clearly more common (15 %). Endoscopic dilatation in one or two sessions is very effective.

• Anastomotic Ulcers

Anastomotic ulcers have become rarer in the era of laparoscopic bypass operations. The preoperatively known ulcer history requires subtle clarification (Helicobacter pylori, Gastrin) to prevent postoperative anastomotic ulcers.

• Herniation

Herniations of bowel loops through mesenteric openings are potential long-term complications. The retrocolic gastric bypass has the highest herniation risk. Relaparoscopy and CT are superior to all other diagnostic methods. For pain in the left upper abdomen: consistent relaparoscopy.
Mesenteric closure is standard in retrocolic and antecolic gastric bypass.

• Fistulas and Abscesses

Fistulas and abscesses occur after insufficiencies, especially after use of stapling devices. Abscesses with a frequency < 1 % are often combined with anastomotic insufficiencies and a late consequence. In gastro-gastric fistulas, there is a connection between the gastric pouch and the remnant stomach. These are mostly incomplete transections of the stomach, which necessitate a renewed surgical transection, as otherwise weight regain follows.

• Pouch Reservoir and Dumping Syndrome

If the loop is fixed too far cranially, it leads to the formation of a distal pouch reservoir with overflow phenomena; if the fixation is too far caudally, the risk for dumping syndrome increases. Therefore, the alimentary loop should be attached at the second staple line and adapted to pouch shape and size.