Various complications may develop after bariatric surgery (Table 3.5).
Table 3.5. Postoperative complications of gastric restrictive surgery.
Gastric perforation Staple line dehiscence Channel obstruction
Distal gastric or afferent limb obstruction Late
Staple line dehiscence Channel widening Channel stenosis
Distal gastric and afferent limb obstruction Pouch dilatation Gastric or jejunal ulcer Small bowel obstruction internal hernia Adhesions
Leakage may occur from any stapled or sutured anastomosis, partition site, or area of channel reinforcement. The overall risk of leakage is higher in the morbidly obese than in the nonobese population . Leaks are serious complications usually requiring urgent surgery. The incidence of leakage increases with gastric transections as opposed to stapling. Leaks usually occur at the anterior aspect of the staple or suture line and may be difficult to demonstrate with the patient in the supine position . Abscesses may develop as a consequence of leakage. It may be impossible to perform CT because of weight limitations of the equipment, and ultrasonography has limitations in severe obesity. Nuclear scintigraphy may be used to identify abscesses in obese patients; in the early postoperative period, however, normal postsurgical sites will demonstrate increased uptake. To obtain an accurate assessment it is necessary to have a one-week interval from the time of surgery for leukocytes labeled with indium-111 (mIn) and a two-week interval for 67[Ga] citrate, unless the site of abscess is remote from the surgical bed.
Perforation of the gastric pouch may occur remote from staple lines or anastomoses. The etiology is unclear but has been attributed to hyperacidity, ischemia, and the use of large nasogastric tubes. The prophylactic use of medications that block or neutralize acid production is advocated to prevent this potential complication.
Early staple line dehiscence is generally attributed to technical failure (i.e., misfiring of the stapling device). Delayed dehiscence is due to staples pulling away from the wall of the stomach, which may be secondary to food impaction in the pouch (Figs. 3.73 and 3.74). For this reason, a diet of liquids only is recommended for 8 weeks following surgery. With partial suture line disruption, an additional channel or channels may form, and subsequent weight gain may ensue. With regard to gastroplasty, staple line dehiscence is more common with horizontal partitioning than with the vertical orientation.
Channel Obstruction and Stenosis
Early channel obstruction is usually due to edema and is usually temporary. Late stenosis, or obstruction may be secondary to food impaction, fibrosis, or channel angulation (Fig. 3.75). Channel stenosis may in turn lead to vomiting and gastroesophageal reflux and/or secondary pouch dilatation and weight gain. Stenosis may be treated by endoscopic dilatation.
After gastroplasty, channel widening may occur over time, possibly leading to weight gain. The incidence of channel widening has diminished with the standard channel reinforcements now in use and with the creation of smaller channels.
Pouch size may increase over time, and the change may be identified radiographically. Pouch dilatation may be a cause of weight gain. Numerical measurements of pouch size based on contrast studies have been generally abandoned because of unreliable data. Problems with data are related to difficulties associated with variable magnification and variable distensibility depending on patient cooperation.
Gastritis and gastric ulcers may rarely develop in the proximal gastric pouch. Gastric ulceration after GBP is a rare complication. Ulcers have also been reported to occur in the distal stomach and may lead to perforation (Fig. 3.76). The classic sign of free intraperitoneal air may not
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