How Do You Know You Have.an Ulcer in Your Stomach After.gastric Bypass Sleeve

Arq Bras Cir Dig. 2015 Apr-Jun; 28(2): 139–143.

Language: English | Portuguese

Late surgical complications after gastric by-pass: a literature review

Complicações cirúrgicas tardias após bypass gástrico: revisão da literatura

Mariano PALERMO

¹Division of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the University of Buenos Aires, Buenos Aires, Argentina

Pablo A. ACQUAFRESCA

ⁱSectionalisation of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the University of Buenos Aires, Buenos Aires, Argentina

Tomasz ROGULA

²Cleveland Dispensary Foundation, Bariatric and Metabolic Institute, Cleveland, OH, USA.

Guillermo E. DUZA

¹Sectionalisation of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the University of Buenos Aires, Buenos Aires, Argentina

Edgardo SERRA

ⁱDivision of Bariatric Surgery - CIEN-DIAGNOMED - affiliated to the University of Buenos Aires, Buenos Aires, Argentine republic

Received 2014 Jun 15; Accustomed 2014 Nov 27.

Abstruse

Introduction

Gastric bypass is today the near often performed bariatric procedure, but, despite of information technology, several complications tin occur with varied morbimortality. Probably all bariatric surgeons know these complications, but, as bariatric surgery continues to spread, general surgeon must be familiarized to information technology and its direction. Gastric bypass complications can be divided into two groups: early on and belatedly complications, taking into account the 2 weeks period afterwards the surgery. This paper will focus the late ones.

Method

Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search linguistic communication was English language.

Results

There were selected 35 studies that matched the headings. Late complications were considered every bit: anastomotic strictures, marginal ulceration and gastrogastric fistula.

Decision

Knowledge on strategies on how to reduce the adventure and incidence of complications must be acquired, and every surgeon must exist familiar with these complications in order to achieve an earlier recognition and perform the best intervention.

Keywords: Postoperative complications, Follow-upwardly studies, Gastric bypass, Anastomosis, Roux-en-Y, Obesity

Abstract

Introdução

O bypass gástrico é hoje o procedimento bariátrico mais realizado, mas, apesar disso, várias complicações podem ocorrer com variada morbimortalidade. Provavelmente todos os cirurgiões bariátricos conhecem essas complicações, mas como a cirurgia bariátrica continua a se espalhar, o cirurgião geral deve estar familiarizado com essas complicações e seu manuseio. Every bit complicações do bypass gástrico podem ser divididas em dois grupos: equally precoces eastward tardias, tendo em conta o período de duas semanas após a operação. Este artigo irá focar as tardias.

Método

Foi realizada revisão da literatura utilizando as bases Medline/PubMed, Cochrane Library, SciELO, e informações adicionais sobre sites institucionais de interesse cruzando os descritores: bypass gástrico AND complicações; seguimento AND complicações; complicações pós-operatórias AND anastomose, Roux-en-Y; obesidade AND complicações pós-operatórias. A língua usada para a busca foi o inglês.

Resultados

Foram selecionados 35 estudos que combinavam com bone descritores. As complicações tardias foram consideradas como: estenose de anastomose, ulceração marginal e fístula gastrogástrica.

Conclusão

O conhecimento sobre every bit estratégias de como reduzir o risco e incidência das complicações deve ser adquirido ao longo do tempo, e cada cirurgião deve estar familiarizado com essas complicações, a fim de reconhecê-las precocemente e realizar a melhor intervenção.

INTRODUCTION

Among all the bariatric procedures, the gastric featherbed is the most frequently performed¹⁶. It belongs to the group of combined procedures considering it generates restriction and malabsorption.

The restriction is generated past cutting the proximal stomach, thereby reducing its volume and creating a pouch of approximately 10 to 25 ml, leaving the rest of the stomach excluded.

In the other paw, the malabsorption is generated past dividing the small-scale intestine into an alimentary limb (Roux limb) and a biliopancreatic limb. The alimentary limb of Roux-en-Y is created by dividing the jejunum 50 cm below the duodenojejunal ligament. And so the alimentary limb is measured and a side-to-side stapled jejunojejunostomy is created, typically 150 cm below the gastrojejunal anastomosis.

Despite of it well documented safe^{2, eight, 9, 27, 33, 38}, several complications can occur with varying degrees of morbidity and mortality risk. These complications includes: early - anastomotic or staple line leaks, gastrointestinal bleeding, abdominal obstruction⁴, and late complications - anastomotic strictures, marginal ulceration, gastro-gastric fistula and less common, incorrect Roux limb reconstruction.

Roux-en-Y gastric past pass (Laparoscopic Gastrointestinal Surgery. Palermo, Gimenez, Gagner. Cadiere and Dapri affiliate) AMOLCA 2014

METHOD

Literature review was carried out using Medline/PubMed, Cochrane Library, SciELO, and additional information on institutional sites of interest crossing the headings: gastric bypass AND complications; follow-up studies AND complications; postoperative complications AND anastomosis, Roux-en-Y; obesity AND postoperative complications. Search linguistic communication was English. There were selected 35 studies that matched the headings. Late complications included: anastomotic strictures, marginal ulceration and gastrogastric fistula.

Anastomotic strictures

In that location are two potential sites of strictures: the jejunojejunostomy and the gastrojejunostomy, being the latter the most common place of occurance^{24, 42}. It is reported in v-27% of cases, typically within ninety days later surgery. The symptoms usually consist on persistent or worsening postprandial vomiting with or without pain.

The cause of stricture formation is non complete clear, the possible mechanisms include ischemia causing scarring, not-ischemic excessive scar germination, recurrent marginal ulceration, tension or malposition of the anastomosis, and surgical technique. Among the technical factors that can contribute to increased stricture formation are type of stapler used (circular vs linear), stapler size, handsewing, and surgeon experience.

Round staplers offer surgeons a reproducible anastomosis, which eliminates any technique-dependent variability that might brand it difficult to scientifically assess the event of anastomotic size on incidence of stenosis and on the eventual weight loss resulting from gastric featherbed surgery. The incidence of gastrojejunostomy stenosis in laparoscopic RYGB (LRYGB) using a 21- versus 25-mm round stapler has been studied and it has been reported an increase of 29.6% in the lumen with the 25 mm stapler compared with the 21 mm stapler, reducing significantly the stenosis rates by half, and significantly delayed the onset of symptoms.

In contrast, other authors advocate for the use of a 21 mm stapler instead of the 25 mm. They argued that restrictive procedures fail when the stoma is too wide. And also the stapler of 21 mm is less hard to insert through the abdominal wall and pocket-size intestine, only, more importantly, because the small diameter of the anastomosis delays gastric pouch emptying and consequently increases weight loss in the long-termⁱ.

Another gene that has shown to reduce the incidence of strictures is the structure of the gastrojejunostomy by hand-sewn. Comparative studies of the circular mechanical anastomosis versus a hand-sewn anastomosis have shown a significant increase in stenosis rates in the circular stapler group (31% vs 3%)⁴¹.

This latter gene probably explain why it has been noted that strictures are substantially more frequent with the laparoscopic than the open approach^{18, 23}. It is for this very reason that robotic surgery could play a cardinal office in the future by combining minimally invasive approach of the laparoscopic surgery and the possibility to perform hand-sewn anastomosis.

Linear staplers are besides used for construction of the gastrojejunostomy. The reported stricture rate with this technique varies between iii.one% and 6.8%, seemingly lower than the rate quoted for circular staplers^{5, 27}.

Routine functioning of early on postoperative upper gastrointestinal serial would not seem to assist predict the occurrence or progression to strictures^half-dozen. Studies reported that a positive upper gastrointestinal series are 100% specific for the presence of stricture, whereas its sensitivity and negative predictive value is poor, making it unsatisfactory in definitively excluding the diagnosis. Marginal ulcerations can besides produce the same clinical symptoms of stenosis and tin even be the cause, therefore endoscopy is considered the preferred diagnostic procedure and has the added do good of existence therapeutic.

Several studies accept shown that endoscopic balloon dilation is the first footstep of treatment^{24, 37}. Findings accept shown that 17% to 67% of cases responded to the first dilation, whereas 3% to 8% of cases required 3 or more dilations. The dilation can be performed using pneumatic balloons or Savary-Gilliard bougies.

Late scarring and fibrosis at the anastomotic stricture would be a prohibitive factor and put the patient at increased adventure of perforation during dilatation.

A graded classification of anastomotic strictures divers past endoscopy and their related direction has been proposed past some authors every bit it is described as follows (Table 1)³⁹:

TABLE i

Postal service-LRYGB gastrojejunostomy strictures endoscopically graded

Course	Strictures characteristics
I	Mild stenosis, which will permit a x.five-mm endoscope to laissez passer
II	Moderate stenosis, which volition suit an viii.5-mm pediatric endoscope
III	Severe stenosis, through which a guide-wire tin exist passed
Iv	Consummate/near-complete obstacle, which is non traversable

• Form I: Mild stenosis tin can be managed past pneumatic dilation up to 16-18 mm and a second session for evaluation. The majority of patients do not require boosted dilations.

• Grade II: Moderate stenosis are usually managed by initial pneumatic dilation upwards to xv-mm. And a second session should exist scheduled 2 weeks afterward, in which Savary-Gilliard bougies are used (15-18 mm).

• Class Three: Severe stenosis should exist managed by careful passage of a guide wire, over which a half-dozen-mm CRE balloon is advanced, inflated for sixty seconds, so withdrawn. Further dilation in the same sitting should not exceed a 10 mm sized balloon. The patient should be then scheduled for subsequent endoscopy in the fluoroscopy suite 1-2 weeks later. In that sitting, dilation is started with a 10-mm CRE airship. If, post-obit this pneumatic dilation, the stricture allows traversing with the endoscope (10.5 mm), further dilation with Savary-Gilliard bougies up to 15 mm may be attempted; otherwise, a tertiary session must be scheduled for that purpose.

• Form IV: Initial dilation should not be attempted in this grouping. These patients should be referred for surgical revision of their anastomosis.

In the rare instance of failure of the endoscopic technique, an operative approach may be justified. Laparoscopic revision of a strictured anastomosis is a technically challenging procedure because of adhesion formation and difficulties in anatomical identification. An antecolic antegastric road of the Roux limb may brand this attempt easier¹¹.

Gastrojejunostomy strictures following RYGB are a relatively common complexity, especially when stapled anastomosis are performed. The symptoms ordinarily consist on postprandial vomiting with or without hurting. The initial diagnostic and therapeutic attempt should be flexible endoscopy with concomitant pneumatic balloon dilation to the maximal diameter condom. A planned repeat session should be scheduled two weeks later with the intent of secondary dilation unless the anastomosis is viewed to be widely open.

Marginal ulceration

Information technology is known as marginal ulceration the appearance of a peptic ulcer at the jejunal mucosa about the site of the gastrojejunal anastomosis. Marginal ulceration has been reported to be the nearly unremarkably found abnormality on endoscopy in symptomatic patients who underwent LRYGB⁵⁰. It is diagnosed in one% to xvi% of patients^{6, xx, 32}.

Factors predisposing patients to marginal ulceration are unclear and take non been completely revealed²³, but the origin is probable multifactorial. Several factors, including pouch size and orientation, mucosal ischemia, staple-line disruption and gastrogastric fistula (which allows the retrograde reflux of acid through the fistula), strange body reaction and exogenous substances accept been all implicated every bit potential causes²⁶. Other intrinsic factors, such equally hormonal and metabolic, versus extrinsic factors, such as tobacco and non-steroidal anti-inflammatory drug use have too been suggested.

Recently, it has been shown that the presence of Helicobacter pylori infection preoperatively may correlate with the evolution of a marginal ulceration in the postoperative menstruum possibly suggesting a causative part for this organism²¹. Patients who present with upper gastrointestinal symptoms should undergo endoscopy before gastric bypass and should exist treated if Helicobacter pylori is diagnosed. Yet, some authors believe that the prevalence of it in patients undergoing RYGB is similar to that in the general population, and that preoperative Helicobacter pylori testing and treatment does not subtract the incidence of anastomotic ulcer or pouch gastritis.

Larger pouch size (>l mL) and orientation take been thought to predispose patients to marginal ulceration and reducing its size has been shown to subtract its incidence. Studies accept shown that creating a pouch limited to the cardia can result in a 0.6% marginal ulceration charge per unit at 3-twelvemonth follow-up. Thus, larger pouch size was postulated early to exist correlated with increased acid product, leading to increased incidence of marginal ulcers.

A machinery in which less acrid reaches the antrum, leading to excessive stimulation of antral gastrin-secreting cells and higher gastrin levels, has been proposed⁴². Later investigators showed that footling, if any, gastric acid is produced in the pouch³⁷. Yet, the significant subtract in acrid secretion after gastric bypass may not be universal and acid secretion could contribute in some patients with marginal ulceration (fifty-fifty though gastric acid secretion is nearly absent in most patients after gastric bypass, 43% of the patients can have a low pH within the pouch)¹⁰.

An interesting finding is that serum gastrin levels are found to be universally low afterward gastric bypass. It seems that gastric acid secretion is primarily stimulated by gastrin in near obese patients; but, in patients who proceed to have low gastric pH afterward surgery, vagal innervation may exist the primary stimulus for acid secretion, putting them at higher take chances for marginal ulceration. This role of acrid secretion in developing marginal ulceration is supported by evidence that acid suppression alone is constructive in healing about marginal ulcerations²⁰.

Another precipitating factor for marginal ulceration after LRYGB may be the prolonged irritation by foreign material, such as not-absorbable sutures at the gastrojejunostomy. Studies have been published comparison the incidence of marginal ulceration associated with the utilise of not-absorbable sutures versus absorbable ones and they found a significant decrease in incidence from 2.6% to i.3%, respectively^five. Local ischemia has also been suggested as a cause of marginal ulceration, although it might more than unremarkably lead to the development of stricture formation.Tobacco apply is also an of import factor in the development of ulcer disease. Studies have shown significant compromise of the gastric mucosal barrier and impaired wound healing associated with smoking⁴¹. Decreased tissue oxygenation has been proposed equally the gene responsible for the impaired wound healing. It is of import to remember that the jejunum, unlike the native duodenum, does not possess an innate acrid buffer, and this is probably the most important contributor to the development of marginal ulceration at the gastrojejunostomy.

Timing and presentation of marginal ulceration after LRYGB vary widely. The diagnosis tin can occur inside three months of surgery in 30 % of the cases, between iv and 12 months in 23 %, and after 12 months in 47 % of the patients²³.

In patients with a marginal ulcer, epigastric pain is the about mutual presenting symptom and is oft the merely symptom. However, patients may present with nausea and vomiting, dysphagia or haemorrhage from their ulcers which tin lead to fatigue due to chronic anemia. Often, symptoms of marginal ulcer are confused with common postoperative complaints related to overeating.

In the presence of these symptoms in a patient who has gone under RYGB, the endoscopy should exist performed to achieve the diagnosis³⁰. In addition to marginal ulceration, postoperative endoscopy for symptoms subsequently LRYGB may also reveal stenosis of the gastrojejunostomy or a gastrogastric fistula (although many physicians treat the symptomatic patients empirically with acrid-blocking agents and exercise non perform diagnostic endoscopy). Late presentation of gastrointestinal haemorrhage at the gastrojejunostomy is nearly commonly associated with marginal ulceration⁶.

Regarding to the treatment, this is primarily medical consisting of anti-secretory therapy with proton pump inhibitors and sucralfate. In example of presence of a gastrogastric fistula surgery must be performed.

Most cases of marginal ulceration respond to proton pump inhibitors, H2-occludent or sucralfate therapy. If non treated promptly, marginal ulceration may pb to stricture formation and gastric pouch outlet obstruction, which will require endoscopic dilation. Different the more than common peptic ulcers, these lesions tend to crave prolonged therapy, usually for iii to 4 months, and echo endoscopy is recommended to confirm ulcer resolution.

An effort should be made to place the causative factor if present, such as NSAID use, smoking, or a remnant suture, which should then be managed appropriately. Occasionally, revision of the gastrojejunostomy anastomosis will be required for patients with persistent symptoms and ulceration despite aggressive medical therapy

In case of acute presentation with perforation, surgery must not exist delayed. The incidence of this event is estimated in 0.85%. Also the traditional treatment with wash out of the intestinal cavity and suturing of the perforation, techniques with endoscopic suturing devices and omental patch repairs have been described²⁵.

In conclusion, patients with upper gastrointestinal symptoms after RYGB warrant endoscopy regardless of time elapsed since the original performance. Abnormalities are found often in this population, and future therapy can be tailored based on endoscopic findings. The etiology of marginal ulceration remains an area of considerable debate. Although medical therapy is successful in most patients who develop a marginal ulcer after RYGB, a small-scale number of patients volition require operative revision for intractable ulcers.

Gastro-gastric fistula

A gastro-gastric fistula (GGF) is an aberrant communication betwixt the gastric pouch and the excluded tummy. It is an uncommon only potentially of import complication later divided LRYGB, with an incidence ranging between one.v% and six.0%²².

Historically, the early on open RYGB procedures involved the creation of a non-divided or partially divided gastric pouch^{15, 21}. GGF rates of 49% were reported after primary RYGB when the pouch and tummy were stapled in continuity or partially divided. Following complete transection of the gastric segments meaning reduction in the incidence of GGF to 2.6% were reported, with further reduction with the employ of jejunal limb interposition proton pump inhibitors³⁶. These surgical techniques minimize the incidence of GGF formation, but do not eliminate it.

The most common symptom of GGF is inadequate weight loss or weight gain. However, intractable marginal ulceration, recurrent upper gastrointestinal hemorrhage, pain and stricture formation can all herald the presence of GGF¹¹. In that location are many factors responsible for it after LRYGB (Table 2). Non-divided RYGB procedures, equally said, take been associated with an unacceptably high incidence of GGF considering of breakdown of the staple line with reestablishment of continuity between the gastric segments. Technical variations with reinforcement of divided RYGB procedures with bands or rings to increase restriction and preclude stomal and pouch dilation are also related with a high incidence of GGF³⁹. Intragastric migration of the ring or ring with erosion of the staple line was implicated in the evolution of GGF in these procedures^{24, 26}.

TABLE ii

Pathogenesis of gastro-gastric fistula later on laparoscopic Roux-en-Y gastric featherbed

Crusade	Description
Iatrogenic	Poor surgical technique
	Incomplete gastric transection
Anastomotic leak	Pouch staple line disruption
	Gastrojejunal anastomotic disruption
	Coagulation injury
	Ischemic necrosis due to strange body: VBG, LAGB
	Incomplete gastric transection
Operation blazon	Non-divided gastric bypass
Marginal ulcer, perforation	Tissue ischemia
	Staple migration
Foreign body erosion	Use of non-absorbable suture material
	Preanastomotic rings in banded gastric featherbed
	Bovine pericardial strips
Natural tendency	Natural gastric migration to reattach to the remnant

In the current era of divided RYGB, the majority of GGF are acquired by poor surgical technique with failure to completely divide the stomach during pouch creation with maintenance of continuity betwixt the pouch and remnant. In society to reduce the incidence of GGF some authors recommend a meticulous oversewing of staple lines, careful anastomotic technique with expert bites of healthy tissue, avoidance of alimentary limb obstacle, and intraoperative confirmation of anastomosis integrity using methylene bluish³⁴.

Another common crusade of GGF is an acute leak from the gastrojejunal anastomosis or the pouch staple-line disruption, which is reported in up to 4.3% of patients after LRYGB^xxx.

Malfunctioning of linear staplers tin can besides occur, although this complexity has go uncommon with the advent of more sophisticated devices²⁵.

Diverse techniques have been used to reduce the occurrence of pouch staple-line leak and GGF, including jejunal and/or omental interposition, suture reinforcement of the staple line, vapor-heated fibrin sealant, and more recently, bovine pericardial strips^{5, 7, 11, 20}.

All patients with a GGF should be treated with a proton pump medication regardless of symptoms, with the improver of sucralfate for concomitant marginal ulceration and/or stricture. The surgery must be considered when medical direction failed in a symptomatic patient, when there is weight regain with non-resolution of comorbidity, recurrent or non-healing gastrojejunal ulceration with persistent abdominal pain and/or hemorrhage, and recurrent gastrojejunal anastomosis stricture.

Currently, at that place is no accepted surgical technique to manage symptomatic GGF. I possible arroyo is to perform a remnant gastrectomy with trimming of the gastric pouch and excision or exclusion of the fistulous tract. This approach has the reward that does non interfere with the gastrojejunal anastomosis.

The pouch size determines the need for fistula excision or exclusion. In the presence of an adequately sized small pouch, the tract tin be excluded by vertical transection of the gastric remnant lateral to the fistula. Information technology is of import to excise as much of the antrum as possible to avert the creation of a retained antrum and the theoretical risk of hypergastrinemia. Therefore, the distal stomach is transected just proximal to the pylorus. Remnant gastrectomy can be performed successfully by a laparoscopic approach in the bulk of patients.

Excision of the gastrojejunal anastomosis with re-anastomosis is required in the presence of significant marginal ulceration with stomal stenosis or prior RYGB, where complete pouch revision is required.

In other cases the identification, isolation and transection of the fistulous tract with an Endo GIA stapler could be enough to solve information technology^xx. And besides, recent reports of transgastric and endoscopic approaches using a through-the-scope endoclip repair accept attracted some interest. However, in that location are express data on the long-term durability or overall efficacy of these repairs.

In summary, GGF formation can complicate divided LRYGB. Symptoms may include: weight loss or weight gain, intractable marginal ulceration, recurrent upper gastrointestinal hemorrhage and abdominal pain. Asymptomatic GGF tin be managed conservatively. There is no standardized surgical treatment approach for symptomatic GGF. The range of therapeutic options includes from remnant gastrectomy to isolation and transection of the fistulous tract.

CONCLUSIONS

Knowledge on strategies on how to reduce the adventure and incidence of complications must be acquired, and every surgeon must be familiar with these complications in guild to accomplish an early recognition and better intervention.

Footnotes

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737339/

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