Gastrointestinal Complications of Obesity Surgery

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

Disclosures
In This Article

Case I: Nausea and Vomiting

Case Presentation

The patient is a 46-year-old woman, status approximately 5 weeks post-RYGBP. She had been referred for RYGBP secondary to class III obesity (BMI ≥ 40 kg/m2) and obstructive sleep apnea. She had an uncomplicated postoperative course until her current presentation. She is now complaining of nausea, vomiting, and epigastric pain related to food intake for 5 days. The patient has been unable to tolerate both liquids and solids and notes significant pain with eating. She denies hematemesis, melena, and hematochezia. She also denies fever, chills, and diaphoresis. She has lost 20 lbs in 5 weeks.

On physical exam, she appears to be in mild distress and is afebrile. She is tachycardic with a pulse of 115 beats per minute and a blood pressure of 100/65; she exhibits orthostatic hypotension with a pulse elevation of 24 with standing. Her cardiopulmonary examination was normal, and her abdomen is soft and nontender with a healing incision scar from her gastric bypass. Her complete blood count is within the normal range, and her blood urea nitrogen is slightly elevated at 32 mg/dL, with a creatinine level of 0.9 mg/dL.

Management and Discussion

Because this patient's symptoms are severe and associated with dehydration and epigastric pain, she should be evaluated by upper endoscopy after resuscitation with intravenous fluids. Plain abdominal radiographs may be performed, but usually are unremarkable. Barium studies probably add little to the upper endoscopy in diagnosis and actually may impair endoscopic visualization if an obstruction is present at the anastomosis. Endoscopy in bariatric surgery patients may be complicated, and thus, it is prudent to observe some basic principles to ensure an efficient and safe exam. Recently, Stellato and colleagues[36] published guidelines for performing endoscopy in this patient population. These guidelines were modified from previous recommendations regarding endoscopy and endoscopic retrograde cholangiopancreatography (ERCP) in patients with upper gastrointestinal surgery.[47,48] The basic tenets of these guidelines are summarized below, along with some additional suggestions:

  1. Before proceeding with endoscopy, it is extremely important to discuss the case with the patient's surgeon and confirm the type of operation being performed so that the anatomy is clear. If direct dialogue is not possible, the endoscopist should review the patient's operative report, previous radiographic studies, and endoscopic reports.

  2. A bariatric surgeon should be consulted regarding the stability of the anastomosis, especially if dilation is contemplated. If an anastomotic leak is suspected, a water-soluble contrast study is indicated before endoscopy.

  3. Preprocedure preparation should include having the appropriate endoscopic equipment and accessories readily available. Access to fluoroscopy should be available if dilation therapy is contemplated.

After consultation with the bariatric surgeon, upper endoscopy was performed. Endoscopy revealed an anastomotic stricture, and dilation was performed with a through-the-scope balloon dilator (Figure 6 A-C).

Figure 6.

Anastomotic stricture: (A) Gastrografin swallow, (B) anastomotic stricture with a diameter of approximately 5 mm, and (C) dilation with a through-the-scope balloon dilator.

Currently, there is no absolute threshold diameter that defines critical obstruction of the anastomosis in gastric bypass patients. Most published experiences define obstruction on the basis of the inability to pass a 9-10-mm scope without resistance.[49] This appears logical because this is similar to the target surgical diameter during creation of the anastomosis. Therefore, small-caliber, 27-French (9 mm) endoscopes are preferred because symptomatic strictures or obstructions are typically < 12 mm. Both through-the-scope balloon dilators[36,38,49,50,51] and rigid dilators[52] have been used to dilate anastomotic strictures in gastric bypass patients. Most studies report using through-the-scope balloon dilators, and it is our opinion that balloon dilation is the preferred procedure. Dilation of an anastomotic stricture in gastric bypass patients presents different challenges as compared with esophageal strictures. In the setting of gastric bypass, the luminal area behind the anastomotic stricture is short and composed of the jejunum. In contrast, the luminal area beyond an esophageal stricture is large and composed of a thick-walled stomach, making it much more accommodating to distal movement during dilation. Theoretically, it is possible that the tip of the rigid guidewire could potentially become lodged behind the anastomosis in the blind pouch or Roux limb and cause a perforation.

Unlike esophageal dilation, there are no set guidelines regarding technique for anastomotic dilation.[53] Decisions regarding the size of balloon to use during the procedure and the number of dilations depend on the degree of narrowing, presence of ulceration, postoperative time period, and symptoms. Fluoroscopy should be used when visualization through the anastomosis is not adequate to ensure proper placement of the balloon dilator across the stricture safely into the Roux limb. The presence of ulceration may increase the risk of perforation, and dilation should generally not be performed in this circumstance. Similarly, a fresh anastomosis (less than 4 weeks) may also increase the risk of perforation. Careful assessment of the risk/benefits should be discussed with both the patient and the surgeon if endoscopy is performed within 4-6 weeks of the operation.

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