Gastrointestinal Complications of Obesity Surgery

John E. Pandolfino, MD; Brintha Krishnamoorthy, BS; Thomas J. Lee, MD

Disclosures
In This Article

Bariatric Surgery Procedures

Vertical Banded Gastroplasty

Vertical banded gastroplasty (VBG) involves creating a vertical pouch by stapling the front to the back wall of the stomach below the esophagogastric junction. The end of the newly created gastric pouch is constricted with either a 1-cm diameter polypropylene band (VBG) or a 1-cm silastic ring (vertical ring-banded gastroplasty; Figure 1). Although these procedures are simple and relatively safe, they are not as effective as other bariatric operations in achieving long-term reduction in excess weight (approximately 25% to 45% of patients maintain their weight loss).[12,13,14]

Figure 1.

Vertical banded gastroplasty (VBG). A vertical pouch is created by stapling the front of the stomach to the back wall, below the esophagogastric junction. The end of the newly created gastric pouch is constricted with either a 1-cm diameter polypropylene band (VBG) or a 1-cm silastic ring (vertical ring-banded gastroplasty).

Complications that are associated with VBG include stomal stenosis, staple line disruption, pouch dilation, erosion of the band, and gastroesophageal reflux. Some complications, such as gastroesophageal reflux and stenosis, have become so severe that they have warranted conversion of VBG to other bariatric surgeries, most commonly, gastric bypass.[15] Moreover, staple line disruption, found in up to 35% of patients, can lead to rapid weight gain.[16]

Gastric Banding

Gastric banding involves placing a silastic band below the esophagogastric junction to restrict oral intake, thereby creating an hourglass effect (Figure 2). This is a purely restrictive operation. However, because gastric banding does not involve surgically entering the gastrointestinal tract, it helps to reduce operative risk and complication rates.[17]

Figure 2.

Adjustable laparoscopic banding. A band is laparoscopically placed around the upper stomach to create a restrictive pouch. The balloon in the band is connected to a port that is placed subcutaneously and can be accessed to inflate or deflate the balloon, consequently changing the size of the band circumference.

An adjustable band that is laparoscopically placed around the upper stomach has been developed. The balloon in the band is connected to a port that is placed subcutaneously and can be accessed to inflate or deflate the balloon, consequently changing the size of the band circumference. This laparoscopic banding system was approved for clinical use by the US Food and Drug Administration in June 2001 and is currently the most popular bariatric surgery performed outside the United States.[18] Although long-term results have been favorable in Europe,[19,20] they have not been as promising in the United States.[21] Complications reported have included band stenosis, band erosion, band slippage or migration, gastric pouch dilation, and esophageal dilation.[22]

Gastric Bypass (Roux-en-Y Gastric Bypass)

Roux-en-Y gastric bypass (RYGBP) is primarily a gastric-restrictive procedure, but it's the diversionary component of the Roux limb (which bypasses the distal stomach, duodenum, and upper jejunum) that contributes to weight loss by causing malabsorption of calories and inducing a dumping syndrome. Similar to VBG, a small pouch is constructed by stapling or transecting the proximal stomach (Figure 3). No randomized clinical trials have been performed evaluating the optimal pouch size; most surgeons believe that the pouch should be as small as possible and that the stomal outlet should be approximately 1 cm in diameter. However, the length of the limb can be varied depending on the size of the patient.[23] Currently, most limbs are 50-100 cm in length.

Figure 3.

Roux-en-Y gastric bypass (RYGBP) surgery. A small pouch is created by either stapling or transecting the stomach. The pouch is then connected to and empties into the Roux limb of the jejunum, which is approximately 50-100 cm in length.

Gastric bypass procedures have largely been very effective in achieving sustained weight loss. Pories and colleagues[24] reported up to a 68% reduction in excess weight, with weight loss being maintained for up to 14 years. Given these results, RYGBP is quickly becoming the procedure of choice for bariatric surgeons.[14] Associated complications include anastomotic ulceration and stenosis, hemorrhage, and anastomotic leak leading to peritonitis, internal hernias, staple line disruption, and acute gastric distention.

Biliopancreatic Diversion

Biliopancreatic diversion (BPD) has 2 components: a limited gastrectomy and the creation of a long-limb Roux-en-Y anastomosis with a short, 50-cm alimentary channel. The latter is accomplished by transecting the small intestine approximately 250 cm from the ileocecal valve and attaching the distal end to the gastric pouch. The proximal end is then joined near the ileocecal valve (Figure 4 A). This procedure is different from jejunoileal bypass in that there is no defunctionalized small intestine. This is an important distinction because it is believed that the defunctionalized small intestine was responsible for many of the liver abnormalities associated with jejunoileal bypass.

Figure 4.

(A) Biliopancreatic diversion (BPD) A limited gastrectomy is created, and the transected ileum is anastomosed to the gastric pouch. (B) BPD with duodenal switch. A sleeve gastrectomy is created to maintain the pylorus and avoid anastomotic complications. Similar to classic BPD, the transected, distal small bowel is connected to the stomach via a small part of the first potion of the duodenum.

This procedure may result in significant weight loss, especially in the first postoperative year, through a decrease in oral intake and induction of a significant amount of malabsorption (diversion of bile and pancreatic secretions to induce fat malabsorption), which acts to maintain weight reduction in the long term. This procedure has been successful, achieving a 65% to 75% loss of excess body weight.[14,25] However, critics have thwarted acceptance of this procedure because of concerns that the malabsorptive component may result in serious nutritional complications. To avoid these problems, BPD patients must take lifelong supplemental calcium and vitamins. The most serious potential complication is protein malnutrition, which is associated with hypoalbuminemia, anemia, edema, ascites, alopecia, and generally requires 2-3 weeks of hyperalimentation and hospitalization.

BPD with duodenal switch appears to be an extremely promising alternative to BPD. Initial data suggest that this procedure can achieve comparable weight loss but with fewer side effects vs traditional BPD. The procedure involves a 70% to 80% greater curve gastrectomy (referred to as a sleeve gastrectomy), maintenance of the pylorus and a small part of the duodenum, and the construction of Roux-en-Y duodenoenterostomy (the efferent limb acts to decrease caloric absorption, and the biliopancreatic limb acts to divert bile from the contents of the alimentary canal; Figure 4 B).[26] Unlike the unmodified BPD, the maintenance of the pylorus and duodenal system reduces the possibility of stomal ulcers and dumping syndrome and preserves nutrient absorption. Proponents of this technique purport that it almost entirely eliminates these complications.[26,27]

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