Management of Post-Bariatric Complications

Marginal Ulcerations

Marginal ulceration at the site of the GJA is not uncommon, and has been reported in up to 16% of patients after gastric bypass surgery ( Fig. 44.2A ). The clinical presentation can range from being asymptomatic to having severe pain and obstructive symptoms or gastrointestinal bleeding, and, rarely, can present as perforation.

The mechanisms underlying the development of marginal ulceration have not been fully elucidated, and the etiology of this complication is likely multifactorial. There is substantial evidence that acidity plays a major role in the disease pathophysiology. Several potential inciting factors have been implicated including ischemia from the surgical creation of an anastomosis, foreign body materials (including staples or nonabsorbable sutures), gastrogastric fistula (GGF) which lead to excessive acid exposure from gastric remnant, nonsteroidal antiinflammatory drugs (NSAIDs), immunosuppressive agents, smoking, and gastric pouch orientation or size. The relationship between Helicobacter pylori (H. pylori) infection and the development of marginal ulceration is controversial; however, a 2017 nationwide analysis suggests a strong association.

During endoscopic evaluation, the gastric pouch should be closely inspected for a GGF. Endoscopic removal of foreign material, such as nonabsorbable suture or staples, should also be performed at the time of ulcer diagnosis ( Fig. 44.3 ). Pouch biopsies for H. pylori are less reliable, as most of the stomach where H. pylori resides is inaccessible.

The majority of patients with marginal ulcerations respond to medical therapy including high-dose proton pump inhibitor (PPI) therapy. PPI administration should be in soluble or open capsule form to enhance absorption, as recent evidence (2016) suggests it significantly decreases time to ulcer healing. The addition of liquid sucralfate has also been advocated, in addition to smoking cessation and indefinite discontinuation of NSAIDs.

Endoscopic suturing techniques to oversew the ulcer have been described, with small case series demonstrating technical feasibility and efficacy. Surgical revision of the gastrojejunostomy with truncal vagotomy has traditionally been performed in the small percentage of patients who do not improve. Reoperation, however, carries significant morbidity and a 7.7% recurrence rate.

Stomal Stenosis

Stricture of the GJA, also known as stomal stenosis , has been reported in up to one-fifth of patients undergoing RYGB, although the majority of studies report an incidence of less than 10% (see Fig. 44.2B ). Strictures can occur weeks to years after surgery. This complication is more common in patients undergoing laparoscopic RYGB, possibly due to the use of small-diameter circular staplers during the construction of the gastrojejunostomy. Tension or ischemia at the site of anastomosis, in addition to ulceration or anastomotic leak, may also contribute.

Stomal stenosis often leads to symptoms of progressive dysphagia, nausea, vomiting, and inability to tolerate oral intake. Endoscopic visualization is the first diagnostic tool. Although there is no clear definition for stomal stenosis, diagnosis is typically made when a patient is symptomatic and passage of a standard upper endoscope through the GJA is met with resistance.

Endoscopic balloon dilation of the stricture is used almost exclusively to treat this complication ( Fig. 44.4 ). Serial dilation using a through-the-scope balloon catheter should be performed with the goal of symptom resolution and target a stomal diameter of 8 to 12 mm, and rarely exceed 15 mm, as overzealous dilation may result in perforation or weight regain. The initial balloon size should be based on the estimated diameter of the anastomotic stricture, with effective dilation resulting in partial disruption of the GJA. A co-existent marginal ulceration may increase the risk of perforation, and dilation should be avoided or performed very carefully in this cohort of patients.

The majority of strictures can be effectively dilated in one or two sessions, with a 1- to 3-week interval between sessions. Other endoscopic interventions have also been reported with some success, including placement of a lumen-apposing metal stent (LAMS), needle-knife electroincision of the anastomosis, or steroid injection. Surgical revision is required in a small percentage of patients who are refractory to endoscopic management, or in whom coexistent marginal ulceration precludes optimal treatment.

Leaks

One of the most serious complications of bariatric surgery is postoperative leak, which occur at multiple points along any staple line, and typically within days to weeks following the operation. The incidence ranges from 0.1% to 5.6%, and revision surgery predisposes to increased risk of occurrence. The most common presenting findings are tachycardia, leukocytosis, and elevated inflammatory markers, but can also present as hemodynamic instability or sepsis.

Identification of the location of the leak is critical, as that will dictate appropriate management. Leaks occurring at the pouch or GJA can be managed with endoscopic placement of self-expandable metal stents. To prevent both incomplete closure as well as stent migration or mucosal hypertrophy leading to increased difficulty of stent extraction, it has been proposed that the optimal time for stent removal is between 6 to 8 weeks. Leaks at other sites may not be amenable to stenting, and other modalities have had variable results. Chronic leaks with a walled-off cavity should be treated like walled-off pancreatic necrosis. Surgical exploration is often required in patients who are unstable.

Gastrogastric Fistula

A GGF is an abnormal communication between the gastric pouch and the excluded stomach, or gastric remnant (see Fig. 44.2C ). In the era of nondivided gastric bypass, GGFs were one of the most common complications, occurring in upward of half of all patients. With the advent of the divided RYGB, in which the gastrointestinal stapler simultaneously places rows of staples and transects the tissue between the rows, the incidence of GGF has declined to less than 6%. Marginal ulceration, gastric leak, and foreign body erosion have all been additional postulated mechanisms for the development of this complication.

The most common presenting symptom is weight regain or inability to lose weight, although pain, nausea, reflux, and emesis are often reported. Endoscopy and upper gastrointestinal series should be performed to make the diagnosis, although GGFs can often be seen on abdominal computed tomography scan with oral contrast. On endoscopic evaluation, careful examination of the pouch should be performed, as GGF are often small and can be overlooked.

If present, maximum medical therapy should be instituted, with over one-third of patients experiencing symptom resolution. If the GGF is associated with a marginal ulcer, an initial conservative approach consisting of high-dose PPI therapy and liquid sucralfate may be sufficient to allow for fistula closure. NSAID use and smoking should be strictly avoided.

In a patient with persistent symptoms that are clearly attributable to the fistula, closure is indicated. Traditionally, procedural intervention has been accomplished via a surgical approach. However, endoscopic suturing symptoms should be considered, and these are especially effective when the fistula is less than 1 cm. Use of over-the-scope clips have been described in small case series, but should be used with caution, as these may interfere with subsequent surgical intervention if it is required.

Gastrointestinal Bleeding

Gastrointestinal bleeding following RYGB is often seen at the gastrojejunal anastomosis ( Fig. 44.5 ). Hematemesis is the most common clinical presentation in early postoperative bleeds. Endoscopic management can be challenging because of the higher risk of perforation at the newly created surgical anastomosis. Carbon dioxide should be utilized instead of air insufflation, and the use of nonthermal devices such as clips is preferred for hemostasis.

Beyond the early postoperative period, endoscopic therapy can be achieved by standard hemostatic interventions such as injection of vasoconstrictors, thermal therapy, or mechanical modalities. Discontinuation of NSAIDs and smoking are advised. Balloon-assisted enteroscopy is often required to access the jejunojejunal anastomosis and enable retrograde examination of the bypassed stomach and duodenum.