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Risk factors for postoperative bleeding in bariatric surgery. Surg Obes Relat Dis 2022; 18:1057-1065. [DOI: 10.1016/j.soard.2022.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/27/2022] [Accepted: 05/08/2022] [Indexed: 11/17/2022]
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Feng XC, Burch M. Management of Postoperative Complications Following Bariatric and Metabolic Procedures. Surg Clin North Am 2021; 101:731-753. [PMID: 34537140 DOI: 10.1016/j.suc.2021.05.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Bariatric and metabolic surgery is a safe and effective treatment of morbid obesity, a disease that continues to increase in prevalence in the United States and worldwide. The two most commonly performed operations are the sleeve gastrectomy and the gastric bypass. Early and late complications can occur, and although referral to a bariatric surgeon or center is ideal, emergency management of acute problems is relevant to all general surgeons. Bariatric surgery can have surgical and metabolic consequences. An understanding of the altered anatomy and physiology helps to guide management of morbidities. This article discusses surgical postoperative complications and metabolic complications.
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Affiliation(s)
- Xiaoxi Chelsea Feng
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA
| | - Miguel Burch
- General Surgery, Cedars Sinai Medical Center, 8635 West 3rd Street, Suite 650W, Los Angeles, CA 90048, USA.
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The Role of Relaparoscopy in the Management of Early Bariatric Surgery Complications and 30-Day Outcome: a Tertiary Centre Experience. Obes Surg 2021; 31:3462-3467. [PMID: 33881739 DOI: 10.1007/s11695-021-05401-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 12/11/2022]
Abstract
The laparoscopic approach for dealing with bariatric complications has become the gold standard of modern practice. The aim of this study is to assess the role of relaparoscopy as a diagnostic and therapeutic approach towards managing complications and improving 30-day outcome. MATERIALS AND METHODS A retrospective review of a prospectively maintained database was conducted in a tertiary bariatric unit. Data were collected on all bariatric surgical procedures performed between March 2013 and March 2019. Any patient who was returned to theatre for a suspected serious complication was identified and their outcome studied. RESULTS Over the 5-year study period, the total number of operations performed was 1660 (981 laparoscopic gastric bypass (LRYGB), 612 laparoscopic sleeve gastrectomy (LSG) and 67 revisional bariatric operations). Early postoperative complications (in hospital or within 30 days of surgery) that lead to reoperation were recorded in 33 patients (1.9%). These complications occurred after LRYGB in 26 patients (2.65%) and LSG in 7 patients (1.14%), respectively. Anastomotic leaks occurred in 1.1% of LRYGB, whilst 0.6% of patients have jejuno-jejunostomy obstruction. Obstruction at the gastro-jejunostomy anastomosis occurred in one patient. Following LSG, one mortality was recorded following bleeding from the staple line (0.06%) and five patients (0.3%) had leaks from the staple line. Thirty-one reoperations were performed laparoscopically, and two were converted to the open approach, whilst 2 operations were planned as open from the outset. CONCLUSION Relaparoscopy is an effective and safe approach to the management of clinically or radiologically suspected early complications after bariatric surgery. Graphical abstract.
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Hess DT, Beesley H, Carter CO, Carmine BJ, Pernar LIM. Surgical management of obstructing clot at the jejunojejunostomy after gastric bypass: a single center experience and literature review. Surg Obes Relat Dis 2020; 17:765-770. [PMID: 33414097 DOI: 10.1016/j.soard.2020.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/01/2020] [Accepted: 11/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass is a proven treatment for morbid obesity and its sequelae. Gastric bypass has a safe risk profile, but postoperative complications can be seen. We report on 10 cases of postoperative bleeding causing an obstructing clot at the jejunojejunostomy (JJ) occurring over a 9-year period. OBJECTIVES The aim was to document presenting symptoms of obstructing clots at the JJ and to suggest a treatment approach to minimize complications. SETTING University Hospital, United States METHODS: The local Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for all patients undergoing reoperation after Roux-en-Y gastric bypass, from July 2009 until December 2019. All patients who were found to have postoperative bleeding causing an obstructing clot at the JJ were selected for retrospective medical-record review. RESULTS The most common presenting symptoms were Hematocrit drop (10 of 10), nausea (9 of 10), abdominal pain (7 of 10), and hematemesis (4 of 10). There were 12 reoperations in the 10 patients, 10 of which were completed laparoscopically. Infectious complications were the most frequent morbidity in our patients; 4 patients developed abscesses. In all of these, the operative notes described gross spillage into the peritoneal cavity. In later cases, the remnant stomach was decompressed before reoperation, reducing spillage. CONCLUSIONS Despite the low rate of obstructing clots at the JJ, without rapid recognition and reoperation, there is a risk for serious complications. Typical presenting symptoms include nausea and abdominal pain, which help differentiate it from other causes of decreased hematocrit. Diagnosis is commonly made with computerized tomographic (CT) scan. Decompression of a dilated remnant stomach before addressing the clot can prevent intraperitoneal spillage and subsequent abscess formation. Enterotomy creation and removal of clot is recommended, without fear of continued bleeding.
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Affiliation(s)
- Donald T Hess
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.
| | - Hassan Beesley
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Cullen O Carter
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Brian J Carmine
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Luise I M Pernar
- Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
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Peña ME, Schlottmann F, Laxague F, Sadava EE, Buxhoeveden R. Usefulness of Abdominal Drain in Laparoscopic Roux-en-Y Gastric Bypass: A Randomized Controlled Trial. J Laparoendosc Adv Surg Tech A 2020; 30:538-541. [PMID: 32013717 DOI: 10.1089/lap.2019.0783] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common procedures to treat morbid obesity. Abdominal drains are often placed during the operation to detect complications earlier. The aim of this study was to assess the benefit of routine drain placement during laparoscopic RYGB. Materials and Methods: A consecutive series of patients undergoing laparoscopic RYGB between 2017 and 2018 was analyzed. The sample was randomized before the procedure into two groups: with abdominal drain (G1) and without abdominal drain placement (G2). Patients with intraoperative complications were excluded from the randomization. Postoperative complications and pain (visual analogue scale) were compared between groups. Results: A total of 84 patients were included; 45 belonged to G1 and 39 to G2. Mean age (G1 44 years versus G2 48 years) and body mass index (G1 43 kg/m2 versus G2 44 kg/m2) were similar in both groups. There were no significant differences between groups in preoperative comorbidities. Mean operative time was 92 minutes in both groups. Mean pain score at postoperative day 0 was similar in both groups (G1 3.2 versus G2 3.5, P = .58), but was higher in G1 at postoperative day 1 (G1 3.1, G2 1.1, P = .02). Postoperative Clavien-Dindo I-II complications were similar in both groups (G1 9% versus G2 1%, P = .37). No major complications, reoperations, or 30-day mortality occurred in the entire cohort. Conclusions: Drain placement in laparoscopic RYGB was associated with greater postoperative pain and did not show benefits in early detection of postoperative complications. Routine placement of abdominal drain in laparoscopic RYGB might not be recommended.
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Affiliation(s)
- María E Peña
- Department of General Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Schlottmann
- Department of General Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Laxague
- Department of General Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | | | - Rudolf Buxhoeveden
- Department of General Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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Zafar SN, Miller K, Felton J, Wise ES, Kligman M. Postoperative bleeding after laparoscopic Roux en Y gastric bypass: predictors and consequences. Surg Endosc 2019; 33:272-280. [PMID: 30232617 DOI: 10.1007/s00464-018-6365-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/20/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, safe and effective bariatric procedure. Bleeding is a significant source of postoperative morbidity. We aimed to determine the incidence, outcomes, and predictors of postoperative bleeding after LRYGB. METHODS LRYGB patients included in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 dataset were identified. Preoperative and intraoperative factors were tested for associations with bleeding using univariable and multivariable logistic regression analysis. Outcomes of length of stay, in-hospital mortality, 30-day mortality, discharge disposition, and 30-day complications among patients with and without clinically significant postoperative bleeding were compared using multivariable regression. RESULTS In the 43,280 LRYGB patients included in this analysis, postoperative bleeding occurred in 652 (1.51%) patients. Of these, 165 (25.3%) underwent a re-operation and 97 (14.9%) underwent an unplanned endoscopy for 'bleeding'. Postoperative bleeding was associated with a longer median postoperative length of stay (4 vs. 2 days), higher in-hospital mortality (1.23 vs. 0.04%), higher 30-day mortality (1.38 vs. 0.15%), discharge to an extended-care facility (3.88 vs. 0.6%), and higher rates of major complications (all P < 0.05). Independent predictors of postoperative bleeding included; a history of renal insufficiency (OR 2.55, 95% CI 1.43-4.52), preoperative therapeutic anticoagulation (OR 2.44, 95% CI 1.69-3.53), and revisional surgery (OR 1.45, 95% CI 1.06-1.97). Intraoperative associated factors included conversions (OR 3.37, 95% CI 1.42-7.97), and drain placement (OR 1.40, 95% CI 1.18-1.67). Robotic approaches resulted in independently lower postoperative bleeding rates (OR 0.50, 95% CI 0.32-0.77). CONCLUSIONS Postoperative bleeding occurs in 1.5% of patients undergoing a LRYGB and is associated with significantly increased morbidity and mortality. We have identified patient and operative factors that are independently associated with postoperative bleeding.
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Affiliation(s)
- Syed Nabeel Zafar
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Kaylie Miller
- School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Jessica Felton
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Eric S Wise
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mark Kligman
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA. .,Center for Weight Management & Wellness, University of Maryland Medical Center, 29 South Greene Street, Suite 105, Baltimore, MD, 21201, USA.
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Mason Hedberg H, Ujiki M. Endoscopic Best Practices. QUALITY IN OBESITY TREATMENT 2019:101-109. [DOI: 10.1007/978-3-030-25173-4_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Laparoscopic Sleeve Gastrectomy has a Lower Risk of Postoperative Bleeding Than Laparoscopic Roux-en-Y Gastric Bypass. Surg Laparosc Endosc Percutan Tech 2018; 29:53-57. [PMID: 30499889 DOI: 10.1097/sle.0000000000000598] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Measures to reduce postoperative bleeding (POB) after bariatric surgery is skewed toward laparoscopic sleeve gastrectomy (LSG). We use 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to characterize the differences in bleeding rates between LSG and laparoscopic Roux-en-Y gastric bypasses (LRYGB). Propensity score matching and multivariable logistic regressions tested for independent differences in POB rates. A total of 168,093 patients from 742 centers were identified in the data set. After selection 36,925 patients with LRYGB and 20,020 patients with LSG were included in the analysis. A total of 710 (1.25%) patient suffered a POB. The independent odds of POB were 38% lower for patients having LSG compared with those having LRYGB (odds ratio, 0.62; 95% confidence interval=0.51-0.76). This difference is more pronounced with intraoperative securing of the staple line. Appropriate measures to reduce POB after each type of bariatric procedure is warranted.
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Bowles-Cintron RJ, Perez-Ginnari A, Martinez JM. Endoscopic management of surgical complications. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Souto-Rodríguez R, Alvarez-Sánchez MV. Endoluminal solutions to bariatric surgery complications: A review with a focus on technical aspects and results. World J Gastrointest Endosc 2017; 9:105-126. [PMID: 28360973 PMCID: PMC5355758 DOI: 10.4253/wjge.v9.i3.105] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/12/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023] Open
Abstract
Obesity is a growing problem in developed countries, and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients. Despite the advances in surgical techniques, some patients still develop acute and late postoperative complications, and an endoscopic evaluation is often required for diagnosis. Moreover, the high morbidity related to surgical reintervention, the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery, and, in many cases, a suitable first-line treatment of bariatric surgery complications. There is now evidence in the literature supporting endoscopic management for some of these complications, such as gastrointestinal bleeding, stomal and marginal ulcers, stomal stenosis, leaks and fistulas or pancreatobiliary disorders. However, endoscopic treatment in this setting is not standardized, and there is no consensus on its optimal timing. In this article, we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment. Based on a thorough review of the literature, we evaluated the performance and safety of different endoscopic options for every type of complication, highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.
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da Rocha L, Ayub Pérez O, Arantes V. Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2015.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol 2015; 12:701-10. [PMID: 26347162 DOI: 10.1038/nrgastro.2015.151] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Leaks are the most frequent early postoperative complication in the two most popular bariatric procedures, Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy. Multimodal therapy based on self-expandable stent insertion 'to cover' the defect is the most widely documented technique to date with a reported success rate >80%. Additional experimental techniques 'to close' the defect or 'to drain' the paradigestive cavity have been reported with encouraging results. The role of endoscopy in early postoperative bleeding is limited to management of bleeds arising from fresh sutures and the diagnosis of chronic sources of bleeding such as marginal ulcer after RYGB. Post-RYGB stricture is a more delayed complication than leaks and the role of endoscopic dilation as a first-line treatment in this indication is well documented. Ring and band placement are outdated procedures for obesity treatment, but might still be an indication for endoscopic removal, a technique which does not compromise further surgery, if needed.
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Affiliation(s)
- Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Jacques Deviere
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
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Endoscopic management of bariatric surgery complications: what the gastroenterologist should know. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2015; 81:35-47. [PMID: 26552500 DOI: 10.1016/j.rgmx.2015.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/16/2015] [Accepted: 06/18/2015] [Indexed: 12/11/2022]
Abstract
Obesity is a serious disorder in almost the entire world. It is an important risk factor for a series of conditions that affect and threaten health. Currently, bariatric surgery is the most effective treatment for morbid obesity, and in addition to the resulting weight loss, it reduces morbidity in this population. There has been a significant increase in the number of obese patients operated on. Despite the success of bariatric surgery, an important group of patients still present with major postoperative complications. In order for endoscopy to effectively contribute to the diagnosis and treatment of complications deriving from obesity surgery, the gastroenterologist must be aware of the particularities involved in bariatric surgery. The present article is a review of the resulting anatomic aspects of the main surgical techniques employed, the most common postoperative symptoms, the potential complications, and the possibilities that endoscopic diagnosis and treatment offer. Endoscopy is a growing and continuously evolving method in the treatment of bariatric surgery complications. The aim of this review is to contribute to the preparation of gastroenterologists so they can offer adequate endoscopic diagnosis and treatment to this high-risk population.
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García-García ML, Martín-Lorenzo JG, Torralba-Martínez JA, Lirón-Ruiz R, Miguel Perelló J, Flores Pastor B, Pérez Cuadrado E, Aguayo Albasini JL. Emergency endoscopy for gastrointestinal bleeding after bariatric surgery. Therapeutic algorithm. Cir Esp 2014; 93:97-104. [PMID: 25438773 DOI: 10.1016/j.ciresp.2014.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/07/2014] [Accepted: 05/07/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Gastrointestinal bleeding (GB) is a potential complication after bariatric surgery and its frequency is around 2-4% according to the literature. The aim of this study is to present our experience with GB after bariatric surgery, its presentation and possible treatment options by means of an algorithm. PATIENTS AND METHOD From January 2004 to December 2012, we performed 300 consecutive laparoscopic bariatric surgeries. A total of 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of a gastrojejunal anastomosis using a circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. Demographics, clinical presentation, diagnostic evaluation and treatment were reviewed. A total of 20 patients underwent a sleeve gastrectomy. RESULTS Twenty-seven cases (9%) developed GB. Diagnosis and therapeutic endoscopy was required in 13 patients. The onset of bleeding occurred between the 1(st)-6(th) postop days in 10 patients, and the origin was at the gastrojejunostomy staple-lines, and 3 patients had bleeding from an anastomotic ulcer 15-20 days after surgery. All other patients were managed non-operatively. CONCLUSION Conservative management of gastrointestinal bleeding is effective in most cases, but endoscopy with therapeutic intent should be considered in patients with severe or recurrent bleeding. Multidisciplinary postoperative follow- up is very important for early detention and treatment of this complication.
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Affiliation(s)
- María Luisa García-García
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España.
| | - Juan Gervasio Martín-Lorenzo
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | | | - Ramón Lirón-Ruiz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Joana Miguel Perelló
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Benito Flores Pastor
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - Enrique Pérez Cuadrado
- Sección de Gastroenterología y Endoscopia, Hospital Universitario J. M. Morales Meseguer, Murcia, España
| | - José Luis Aguayo Albasini
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario J. M. Morales Meseguer, Murcia, España; Departamento de Cirugía, Campus de Excelencia Internacional «Campus Mare Nostrum», Universidad de Murcia, Murcia, España
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De Palma GD, Forestieri P. Role of endoscopy in the bariatric surgery of patients. World J Gastroenterol 2014; 20:7777-7784. [PMID: 24976715 PMCID: PMC4069306 DOI: 10.3748/wjg.v20.i24.7777] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2013] [Revised: 12/31/2013] [Accepted: 03/08/2014] [Indexed: 02/06/2023] Open
Abstract
Obesity is an increasingly serious health problem in nearly all Western countries. It represents an important risk factor for several gastrointestinal diseases, such as gastroesophageal reflux disease, erosive esophagitis, hiatal hernia, Barrett's esophagus, esophageal adenocarcinoma, Helicobacter pylori infection, colorectal polyps and cancer, non-alcoholic fatty liver disease, cirrhosis, and hepatocellular carcinoma. Surgery is the most effective treatment to date, resulting in sustainable and significant weight loss, along with the resolution of metabolic comorbidities in up to 80% of cases. Many of these conditions can be clinically relevant and have a significant impact on patients undergoing bariatric surgery. There is evidence that the chosen procedure might be changed if specific pathological upper gastrointestinal findings, such as large hiatal hernia or Barrett's esophagus, are detected preoperatively. The value of a routine endoscopy before bariatric surgery in asymptomatic patients (screening esophagogastroduodenoscopy) remains controversial. The common indications for endoscopy in the postoperative bariatric patient include the evaluation of symptoms, the management of complications, and the evaluation of weight loss failure. It is of critical importance for the endoscopist to be familiar with the postoperative anatomy and to work in close collaboration with bariatric surgery colleagues in order to maximize the outcome and safety of endoscopy in this setting. The purpose of this article is to review the role of the endoscopist in a multidisciplinary obesity center as it pertains to the preoperative and postoperative management of bariatric surgery patients.
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Gill RS, Whitlock KA, Mohamed R, Sarkhosh K, Birch DW, Karmali S. The role of upper gastrointestinal endoscopy in treating postoperative complications in bariatric surgery. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:37-41. [PMID: 22586549 DOI: 10.4161/jig.20133] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 12/21/2011] [Accepted: 12/23/2011] [Indexed: 12/17/2022]
Abstract
There are an estimated 500 million obese individuals worldwide. Currently, bariatric surgery has been shown to result in clinically significant weight loss. With increasing demand for bariatric surgery, endoscopic techniques used intra and postoperatively continue to evolve. Endoscopic evaluation of anastomotic integrity following RYGB allows for early detection of anastomotic leaks. Furthermore, endoscopy is a valuable tool to diagnose and treat RYGB postoperative surgical complications such as anastomotic leakage, hemorrhage and stricture formation. Early evidence suggests that endoscopic management of upper gastrointestinal hemorrhage following RYGB is effective. In addition, endoscopic balloon dilatation is able to effectively treat obstruction in the setting of gastrojejunal anastomotic strictures. With successful endoscopic management of these complications, bariatric patients may avoid more invasive surgical procedures.
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Affiliation(s)
- Richdeep S Gill
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
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Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies. Obes Surg 2011; 21:413-20. [PMID: 21240659 DOI: 10.1007/s11695-011-0354-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N=19). Hematocrit decreased significantly from preoperative values (-5.2 ± 3.1 without bleeding vs. -14.8 ± 4.7 with, p<0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p=0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.
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Evaluating the Safety and Efficacy of BMI-Based Preoperative Administration of Low-Molecular-Weight Heparin in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery. Obes Surg 2011; 22:47-51. [DOI: 10.1007/s11695-011-0397-y] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Ferreira LEVV, Song LMWK, Baron TH. Management of acute postoperative hemorrhage in the bariatric patient. Gastrointest Endosc Clin N Am 2011; 21:287-94. [PMID: 21569980 DOI: 10.1016/j.giec.2011.02.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is one of the treatment options for achieving and preserving weight loss and managing medical complications related to obesity. After bariatric surgery, early or late adverse events, such as intraluminal or extraluminal gastrointestinal hemorrhage, can occur. Early gastrointestinal bleeding is more often a complication associated with Roux-en-Y gastric bypass surgery than other bariatric procedures and usually arises from the gastrojejunal anastomosis. Early postoperative bleeding may be potentially life threatening, although death after postbariatric surgery as a consequence of acute bleeding is uncommon. Although early postoperative intraluminal bleeding can usually be managed conservatively, endoscopic therapy may be required.
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Affiliation(s)
- Lincoln E V V Ferreira
- Department of Medicine, Digestive Endoscopy Unit, Hospital Universitario da Universidade Federal de Juiz de Fora, Unidade de Endoscopia Digestiva-Avenida Eugenio do Nascimento s/no. Bairro: Dom Bosco - CEP:36038-330, Juiz de Fora, Minas Gerais, Brasil
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Finks JF, Carlin A, Share D, O'Reilly A, Fan Z, Birkmeyer J, Birkmeyer N. Effect of surgical techniques on clinical outcomes after laparoscopic gastric bypass--results from the Michigan Bariatric Surgery Collaborative. Surg Obes Relat Dis 2010; 7:284-9. [PMID: 21126927 DOI: 10.1016/j.soard.2010.10.004] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 09/27/2010] [Accepted: 10/05/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND The techniques used with laparoscopic gastric bypass (LGB) and their association with patient outcomes remain largely unexplored. METHODS We analyzed the data from the Michigan Bariatric Surgery Collaborative, which maintains a state-wide prospective clinical registry of bariatric surgery patients. Participating surgeons were surveyed regarding their use of specific techniques during LGB. The survey data were linked with the registry data from patients undergoing LGB from June 2006 to January 2010. The gastrojejunostomy technique and the use of staple-line reinforcement were evaluated for their effects on patient outcomes. RESULTS During the study period, 9904 patients underwent LGB. A total of 44 surgeons (86%) completed the survey. When performing gastrojejunostomy, most surgeons used a circular stapler (CS) technique (66%), followed by the hand-sewn (HS) (18%) and linear stapler (LS) (16%). Also, 48% of surgeons reported using staple-line buttressing when creating the gastric pouch. The rate of anastomotic leak at the gastrojejunostomy was not affected by the surgical technique (CS .6%, LS .3%, HS .6%, P = .38). However, the CS technique was associated with a greater rate of postoperative hemorrhage (CS 2.9%, LS 1.2%, HS 1.6%, P <.0001) and wound infection (CS 4.7%, LS 1.6%, HS .6%, P <.0001). The use of staple-line reinforcement was associated with a lower rate of postoperative hemorrhage (1.9% versus 2.7%, P = .012). CONCLUSION With LGB, the use of the CS technique was associated with greater rates of postoperative hemorrhage and wound infection than the use of the LS or HS technique. Furthermore, the use of staple-line reinforcement was associated with a reduction in the rates of postoperative hemorrhage.
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Affiliation(s)
- Jonathan F Finks
- Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Ozaslan E, Purnak T, Tenlik I, Yildiz A, Haznedaroglu IC. An alternative hemostatic method for early GI bleeding caused by anastomotic ulcer. Gastrointest Endosc 2010; 72:902-3. [PMID: 20883870 DOI: 10.1016/j.gie.2010.01.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 01/12/2010] [Indexed: 02/08/2023]
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Nguyen NT, Dakin G, Needleman B, Pomp A, Mikami D, Provost DA, Scott DJ, Jones DB, Gallagher S, Gagner M, Murr M. Effect of staple height on gastrojejunostomy during laparoscopic gastric bypass: a multicenter prospective randomized trial. Surg Obes Relat Dis 2010; 6:477-82. [DOI: 10.1016/j.soard.2010.03.294] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 10/06/2009] [Accepted: 03/29/2010] [Indexed: 11/30/2022]
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Standardization of the fully stapled laparoscopic Roux-en-Y gastric bypass for obesity reduces early immediate postoperative morbidity and mortality: a single center study on 2606 patients. Obes Surg 2009; 19:1355-64. [PMID: 19685100 PMCID: PMC2762050 DOI: 10.1007/s11695-009-9933-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 07/28/2009] [Indexed: 01/14/2023]
Abstract
Background Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality. Methods We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%). Results There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14–73), mean BMI 41.44 kg/m2 (range, 23–75.5). The mean hospital stay was 3.35 days (range 2–71). Mean total operative time was 63 min (range 35–150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n = 89, 3.42%), intestinal obstruction (n = 9, 0.35%), anastomotic leak (n = 5, 0.19%) and others (n = 47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure. Conclusion The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.
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Borkgren-Okonek MJ, Hart RW, Pantano JE, Rantis PC, Guske PJ, Kane JM, Gordon N, Sambol NC. Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration, dose stratification, and antifactor Xa activity. Surg Obes Relat Dis 2008; 4:625-31. [DOI: 10.1016/j.soard.2007.11.010] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2007] [Revised: 11/15/2007] [Accepted: 11/21/2007] [Indexed: 01/08/2023]
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Fernández-Esparrach G, Bordas JM, Pellisé M, Gimeno-García AZ, Lacy A, Delgado S, Cárdenas A, Ginès A, Sendino O, Momblán D, Zabalza M, Llach J. Endoscopic management of early GI hemorrhage after laparoscopic gastric bypass. Gastrointest Endosc 2008; 67:552-555. [PMID: 18294521 DOI: 10.1016/j.gie.2007.10.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 10/08/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Early upper GI hemorrhage (UGH) is a potential complication after laparoscopic Roux-en-Y gastric bypass (RYGBP), and early reoperative intervention is the most accepted treatment. Experience with endoscopic treatment is limited. OBJECTIVE Our purpose was to describe the role of endoscopy and injection therapy in the management of early UGH after laparoscopic RYGBP. DESIGN Case series study. SETTING Endoscopy Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain. PATIENTS We describe the endoscopic treatment of 6 patients with early UGH within 24 hours after a RYGBP. INSTRUMENTATION Upper endoscopy was performed in all 6 cases. The origin of the bleeding was identified at the staple line in all cases, and epinephrine alone or combined with polidocanol was successfully injected in 5 of 6 patients. RESULTS Endoscopic therapy arrested active bleeding without any complications in all cases without the need for further surgery or endoscopic treatments. LIMITATION Our experience is limited to 6 cases. CONCLUSION Early postoperative UGH after RYGBP may be adequately controlled with endoscopic treatment and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.
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Tang SJ, Rivas H, Tang L, Lara LF, Sreenarasimhaiah J, Rockey DC. Endoscopic hemostasis using endoclip in early gastrointestinal hemorrhage after gastric bypass surgery. Obes Surg 2008; 17:1261-7. [PMID: 18074504 DOI: 10.1007/s11695-007-9206-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Roux-en-Y gastric bypass (RYGBP) is the most commonly performed bariatric operation in the USA. In the early postoperative stage, gastrointestinal (GI) bleeding is an infrequent but potentially serious complication that usually results from bleeding at the gastrojejunostomy staple-line. Observant management with transfusion for stable patients and surgical exploration for unstable patients is typically recommended for early GI bleeding. We hypothesized that use of endoclips, which do not cause thermal injury to the surrounding tissues (or anastomosis), may be preferable to thermal approaches which could cause tissue injury. We report 2 cases of early GI bleeding after RYGBP that were successfully managed with endoclip application to bleeding lesions. Emergent endoscopy was performed, and major stigmata such as active spurting vessel and adherent clot were noted at the gastrojejunostomy staple-lines. Endoscopic hemostasis using endoclips was readily applied to bleeding lesions at staple-lines. Primary hemostasis was achieved, and there was no recurrent bleeding or complication. We conclude that therapeutic endoscopy can be performed safely for early bleeding after RYGBP. In patients with early bleeding after RYGBP, use of endoclips is mechanistically preferable to other options.
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Affiliation(s)
- Shou-Jiang Tang
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390-8887, USA.
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Jamil LH, Krause KR, Chengelis DL, Jury RP, Jackson CM, Cannon ME, Duffy MC. Endoscopic management of early upper gastrointestinal hemorrhage following laparoscopic Roux-en-Y gastric bypass. Am J Gastroenterol 2008; 103:86-91. [PMID: 17941960 DOI: 10.1111/j.1572-0241.2007.01588.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Upper gastrointestinal hemorrhage (UGIH) is an infrequent complication (1-3.8%) following laparoscopic Roux-en-Y gastric bypass (LRYGB). The safety and efficacy of endoscopic management of immediate postoperative bleeding is unknown. We sought to determine how frequently UGIH complicates LRYGB and whether endoscopic management is successful in controlling hemorrhage. METHODS Retrospective chart review of all patients who developed UGIH following LRYGB from November 2001 to July 2005 at a large suburban teaching hospital. RESULTS Of 933 patients who underwent LRYGB, 30 (3.2%) developed postoperative UGIH. An endoscopic esophagogastroduodenoscopy (EGD) was performed in 27/30 patients (90%). All were found to have bleeding emanating from the gastrojejunostomy (GJ) staple line. Endoscopic intervention was performed in 24/30 (80%) with epinephrine injection and heater probe cautery being used most commonly. Endoscopic therapy was ultimately successful in controlling all hemorrhage, with 5 patients (17%) requiring a second EGD for rebleeding. No patient required surgery to control hemorrhage. One patient aspirated during the endoscopic procedure with subsequent anoxic encephalopathy and died 5 days postoperatively. Twenty-one patients (70%) developed UGIH in the intraoperative or immediate postoperative period (<4 h postoperative). The mean length of stay was significantly longer in these patients (2.84 vs 4.1, P= 0.001). CONCLUSIONS (a) UGIH complicates LRYGB in a small but significant number of patients. (b) Bleeding usually occurs at the GJ site. (c) EGD is safe and effective in controlling hemorrhage with standard endoscopic techniques. (d) UGIH occurs most commonly in the immediate postoperative period and may be best managed in the operating room with the patient intubated to prevent aspiration.
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Affiliation(s)
- Laith H Jamil
- Division of Gastroenterology/Hepatology, William Beaumont Hospital, Royal Oak, Michigan, USA
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A comparison of thromboembolic and bleeding events following laparoscopic gastric bypass in patients treated with prophylactic regimens of unfractionated heparin or enoxaparin. Am J Surg 2007; 194:709-11. [DOI: 10.1016/j.amjsurg.2007.08.018] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 08/13/2007] [Accepted: 08/13/2007] [Indexed: 11/19/2022]
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