Chaar and Gersin. J Obes Weight-Loss Medic 2015, 1:1 Journal of Obesity and Weight-loss Medication Review Article: Open Access Management of Immediate Complications Following Bariatric Surgery: Clinical Pearls for the Clinician Managing Bariatric Patients Maher El Chaar1* and Keith Gersin2 1School of Medicine, Temple University, St Luke’s University Hospital and Health Network, USA 2Chief Bariatric Surgery, Carolinas Medical Center, University of North Carolina, USA *Corresponding author: Maher El Chaar, Clinical Associate Professor, School of Medicine, Temple University, St Luke’s University Hospital and Health Network, Co-Medical Director of Bariatric Surgery, Allentown, Pennsylvania, USA, E-mail: [email protected] reflux disease, strictures, stenosis, weight regain and nutritional Abstract deficiencies. Although venous thromboembolic diseases and Bariatric surgery is the only effective long term treatment of morbid cardiac complications are not unique to weight loss surgery, they obesity. With the establishment of an accreditation process for may occur with greater frequency in the morbidly obese and are bariatric centers and the development of laparoscopic approaches to bariatric surgery, in addition to fellowship training, bariatric therefore included here [3]. In this review article we will focus on surgery became a role model for other surgical specialties in the immediate complications occurring after bariatric surgery and terms of efficacy and safety. Bariatric surgery has now a long track provide general guidelines as to the work-up and management of record of safety and a very low morbidity and mortality rates. In those complications. addition, the number of bariatric procedures being performed is increasing dramatically. Health care providers caring for bariatric Gastrointestinal Leakage patients will encounter on occasions certain complications specific to bariatric patients in the immediate postoperative period. The Gastrointestinal (GI) leakage is one of the most devastating objective of this review is to illustrate some of the immediate complications that can be encountered following bariatric surgery. postoperative complications following bariatric surgery to provide The possible sites of leakage are primarily from staple lines however general guidelines for a timely diagnosis and management of postoperative patients. These bariatric specific complications leaks can result from any anastomosis whether stapled, hand sewn include gastrointestinal leakage, gastrointestinal bleeding and or a combination of the two (Figure 1). In addition, missed serosal small bowel obstruction. We will also discuss the diagnosis of injuries or enterotomies at the time of surgery are another likely postoperative thromboembolic and cardiac diseases in bariatric source. GI leakage usually occurs in the immediate postoperative patients. period but rarely may present several weeks following surgery and Introduction Bariatric surgery is the only effective and proven long-term solution for the treatment for morbid obesity [1]. The number of patients undergoing bariatric surgery has increased dramatically in the past two decades due in part to the adoption of laparoscopic techniques [2]. It is imperative that clinicians caring for post- operative bariatric patients have a clear understanding and high index of suspicion for the potential complications that may arise following weight loss surgery. Failure to quickly and correctly diagnose these complications may lead to devastating outcomes, including death. Post-operative bariatric complications may be arbitrarily grouped into those occurring immediately following surgery (within the first 24-72 hours following surgery) and those occurring later (months to years). Immediate complications related to the surgical technique itself and occurring immediate after surgery include gastrointestinal leakage, bleeding, small bowel obstructions (intra-luminal or extra- luminal in origin) venous thromboembolic disease and cardiac Figure 1: UGI demonstrating a leak from the gastrojejunostomy anastomosis 1 day following a Laparoscopic Roux-en-Y-Gastric Bypass. Patient signs and events. Complications occurring later include hernias (internal symptoms include fever, tachycardia and abodominal pain. and incisional), symptomatic cholelithiasis, gastroesophageal Citation: Chaar ME, Gersin K (2015) Management of Immediate Complications Following Bariatric Surgery: Clinical Pearls for the Clinician Managing Bariatric Patients. J Obes Weight-Loss Medic 1:003 ClinMed Received: March 01, 2015: Accepted: March 13, 2015: Published: March 16, 2015 International Library Copyright: © 2015 Chaar ME. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. usually results in increased morbidity and mortality. The incidence of GI leakage following gastric bypass surgery ranges between 1% and 5% with rates following revisional bariatric surgery even higher. [5- 7]. The incidence of GI leakage following sleeve gastrectomy ranges from 1.2% to 2.7% usually resulting from failure of the gastric sleeve staple line [8]. The differences in leakage rates between open and laparoscopic techniques remain controversial. Some authors have suggested that the leakage rates after laparoscopic roux-en-y-gastric bypass (LRYGB) are higher than when performed in an open fashion possibly due to surgeon experience and learning curve [9]. DeMaria et al. demonstrated a reduction in leakage rates from 6.8% to 1.8% after performing their first 102 LRYGB cases [10]. When performed by experienced surgeons, Nguyen et al. found no difference in the rate of postoperative anastomotic leakage rates between open and laparoscopic groups [11]. The use of routine post-operative contrast studies to rule out GI leakage remains controversial. Selective imaging based upon the patient’s clinical situation is acceptable [12]. Unstable patients with a suspicion of GI leakage should be explored immediately without the Figure 2: CT scan demonstrating hemoperitoneum 1 day following a need of any additional testing or radiographic studies. Two commonly Laparoscopic Roux-en-Y-Gastric Bypass (LRYGB). The patient developed abdominal pressure, tachycardia and a drop in hemoglobin following LRYGB performed diagnostic procedures include upper gastrointestinal series (UGI) and computerized axial tomography (CT) scanning. The sensitivity of these modalities varies depending upon patient related postoperative period patients may be managed by endoscopic stent factors and the experience of the interpreting radiologist. Limitations placement combined with laparoscopic or percutaneous drainage of of UGI series involve the inability to visualize all potential sources of abdominal collections [15,16]. Gastric outlet obstruction secondary GI leaks and therefore CT scanning is more sensitive in this regard. A to a leak and subsequent stenosis may require a revision to a roux- recent retrospective analysis of prospectively collected data on 3,018 en-y gastric bypass [17]. patients, demonstrated that leaks were detected in 17 of 56 patients (30%) when UGI series were used and in 28 of 50 patients (56%) In stable patients with a controlled leak, non-operative when CT scans were used [6]. Another advantage of abdominal management may be considered. These patients may have had a and pelvic CT scanning is the ability to reveal other intra-abdominal drain placed at the time of initial operation or subsequently via pathology that share similar clinical symptoms to GI leakage such interventional radiologic techniques. Patients who are managed as small bowel obstruction or intra-abdominal bleeding. A potential non-operatively are treated with antibiotic administration and limitation of CT scans is the inability to perform the procedure due parenteral nutrition and should be explored immediately if they fail to weight limitations or inability of patients to fit inside the scanners. to improve clinically, develop new symptoms or any signs of sepsis [18]. Endoscopic means to manage leaks following bariatric surgery Clinicians should not rely on radiographic studies alone in are preferentially performed in specialized large volume, tertiary determining which patients require operative interventions. A care centers under approved clinical trials and are not currently negative UGI or CT scan does not rule out the presence of GI leakage considered standards of care. ad in the appropriate clinical setting in the presence of signs and symptoms suggestive of GI leakage, a diagnostic laparoscopy or Gastrointestinal Bleeding laparotomy should be performed [9]. Patients with GI leakage may The rate of gastrointestinal bleeding (GIB) following bariatric present with one or more of the following signs and symptoms: surgery varies in the literature between 1 and 4% [5]. GIB usually fever, tachycardia, tachypnea, hypoxia, oliguria, abdominal, back or arises from staple lines, however may also be the result of injury to shoulder pain, feeling of impending doom and hypotension. intra-abdominal organs including the liver and spleen. A potential Basic surgical tenants should be followed to appropriately manage mechanism of staple line bleeding is the penetration of the mucosa by these patients requiring exploration. Exploration can be performed the stapler or the transaction of a vessel traversing the serosal layer of laparoscopically