The most serious early complications are anastomotic leak and pulmonary embolus. Anastomotic leaks can occur at any of the sites where the GI tract is entered or reconstructed, although it most commonly occurs at the gastrojejunostomy. Leakage has been described at the gastrotomy site used in the vertical banded gastroplasty. Peritonitis secondary to anastomotic leakage is the most common cause of death after bariatric surgery. The initial signs and symptoms may be minimal. Patients with unexplained tachycardia, dyspnea, restlessness, or oxygen desaturation should be evaluated carefully because these may be early warning signs of an anastomotic disruption. Depending on the procedure that was performed, Gastrografin x-rays of the upper GI tract or abdominal computed tomography scanning may be indicated. A high index of suspicion is warranted and emergent re-exploration may be indicated in patients with otherwise unexplained septic physiology.
Although obstruction of the Roux-en-Y limb is rare after gastric bypass surgery (<1%), it may cause acute distention of the gastric remnant. These patients often complain of severe bloating and persistent hiccups. Plain films of the abdomen may show dilatation of the remnant stomach. Emergent reoperation may be necessary, although percutaneous decompression has been described and may be successful. Internal hernias and adhesion formation are also rare causes of intestinal obstruction. Obstruction of the gastric pouch outlet in patients who have undergone vertical banded gastroplasty has been described and may be due to edema or other technical errors when it occurs early in the postoperative period.
Pulmonary complications may be observed even in patients who have their procedures performed laparoscopically. These complications include pneumonia and atelectasis. Pulmonary embolism is the second most frequent cause of death, with an incidence of approximately 1%. Besides wound infections that usually become immediately evident, other wound complications are usually detected within 1 month of surgery, with a reported frequency of between 20% and 30% after open procedures and 5% or less after laparoscopic procedures. Most wound complications occur within 1 month of operation.
Gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass. (Reprinted with permission from Cleveland Clinic Center for Medical Art & Photography © 2005-2009. All Rights Reserved.)
Board Review Questions
1. Which of the following procedures has the highest rate of nutritional complications?
A. Laparoscopic adjustable banding
B. Roux-en-Y gastric bypass
C. Sleeve gastrectomy
D. Duodenal switch
2. Which of the following is the most common emergent complication of laparoscopic adjustable gastric bands?
A. Band slippage
B. Dysfunction or leak from the reservoir or tubing
3. A postoperative marginal ulcer in a patient who has undergone a Roux-en-Y gastric bypass is best initially treated by
A. Triple therapy for Helicobacter pylori
B. Proton pump inhibitors
C. Endoscopic dilation with post-dilation proton pump inhibitors
D. Resection of the ulcer with surgical revision of the gastrojejunostomy
1. The correct answer is D. Duodenal switch
2. The correct answer is C. Prolapse
3. The correct answer is B. Proton pump inhibitors