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Bariatric surgery for weight loss has become a common practice. The second most common bariatric procedure done today is the Roux-en-Y gastric bypass (RYGB). To be a practicing health professional in the modern era, one must recognize the more common chronic complications that may result from altering the gastrointestinal (GI) tract and how to manage these complications. To develop knowledge regarding the potential sequela of the operation, one must know the anatomy of the GI tract and the resulting physiologic effects of altering that anatomy. This activity reviews the common chronic complications following an RYGB concerning epidemiology, presentation, diagnosis, and treatment and highlights the role of the interprofessional team in evaluating and treating patients with this condition.
Bariatric surgery for weight loss has become a common practice in the United States, with about 179,000 operations performed in 2013. The second most common bariatric procedure done today is the Roux-en-Y gastric bypass (RYGB). To be a practicing health professional in the modern era, one must understand the more common chronic complications that may result from altering the gastrointestinal (GI) tract and how to manage these complications.
About one-third of patients will present within the first 3 months after surgery, and about one-half will present after 1 year. The most common presenting sign will be epigastric pain, and patients may less commonly present with nausea, vomiting, dysphagia, bleeding, or chronic anemia. Diagnosis is with upper endoscopy, and treatment is typically accomplished with proton pump inhibitors and repeat endoscopy to ensure healing. Medical treatment is successful in 85% to 95% of cases. Complications of marginal ulceration include perforation, stricture, and bleeding. Perforated ulcers typically require emergent surgery with a graham patch closure and distal feeding tube placement. Strictures and bleeding unresponsive to medical and endoscopic measures may need a surgical revision of the gastrojejunostomy.
Historically, the incidence of new gallstone formation following gastric bypass surgery ranges from 32% to 42%, and about one-third to one-half of those patients became symptomatic. Increased gallstone formation in RYGB patients is caused by supersaturation of bile with cholesterol secondary to a reduction in bile acid secretion because of the caloric restriction. Another reason is limited gallbladder contractility and emptying secondary to a reduction in the secretion of cholecystokinin (CCK) due to the bypassed duodenum. Most gallstones are formed within the first 6 months postoperatively.
This occurs within the first hour after ingesting a meal (usually within 10 to 30 minutes) and is attributed to the rapid introduction of nutrients into the small bowel, causing an osmotically driven fluid movement into the small bowel lumen. This will typically present with diarrhea, dizziness, flushing, and possibly hypotension. First-line treatment is with a low carbohydrate, high protein/fiber diet taken in small/frequent meals. If one has persistent symptoms, then octreotide can be used. This is typically a self-limiting disease and subsides in 12 to 18 months following surgery.
The incidence of low B12 one year postoperatively from an RYGB surgery is estimated to be around 30% to 35% but may be higher. Vitamin B12 is released from food by the action of stomach acid. An R binder protein then binds it. This bond is cleaved by pancreatic enzymes allowing B12 to complex with intrinsic factor(IF), a protein synthesized by parietal cells in the stomach. This complex is then absorbed in the terminal ileum. RYGB will alter all of the above processes leading to a vitamin B12 deficiency in the absence of supplementation. The liver can store a large amount of B12, which may defer the development of B12 deficiency syndrome for years. Patients are often asymptomatic but may present with megaloblastic anemia and neurological symptoms (paresthesias, unsteady gait, poor memory, agitation, confusion, depression.) Diagnosis is based on low serum vitamin B12 levels; if this is equivocal, it may be confirmed with methylmalonic acid and homocysteine levels. Treatment is primarily preventative as some of the sequelae are irreversible. Supplementation after surgery may be with daily orals or monthly injections.
Roux-en-Y gastric bypass is a commonly performed operation today in the United States. It has many advantages over other weight-loss surgeries but can present with early and late complications. Chronic complications include but are not limited to strictures, internal hernias, gastro-gastric fistulae, gallstones, marginal ulcers, dumping syndrome, and the nutritional deficiencies that accompany altering the GI tract. As increasingly more patients will have had this surgery, a healthcare practitioner must be aware of these sequelae and their management.
Roux-en-Y gastric bypass is a commonly performed operation today in the United States. It has many advantages over other weight-loss surgeries but can present with early and late complications. Chronic complications include but are not limited to strictures, internal hernias, gastro-gastric fistulae, gallstones, marginal ulcers, dumping syndrome, and the nutritional deficiencies that accompany altering the GI tract. As increasingly more patients will have had this surgery, a healthcare practitioner must be aware of these sequelae and their management. Patients need to be made aware that surgery does not cure obesity- it is just a temporary method of inducing weight loss, and if the patient does not partake in exercise or a change in diet, the weight will soon be regained.
Procedure-related risk factors include the formation of a hematoma, the use of foreign material such as drains, leaving dead space, prior infection, duration of surgical scrub, preoperative shaving, poor skin preparation, long surgery, poor surgical technique, hypothermia, contamination from the operating room, and prolonged perioperative stay in hospital.
When looking at the theatre environment, appropriate planning, maintenance, and training are essential to minimize the rates of SSI. An appropriate theatre block should allow optimal patient flow and the separation of clean and contaminated areas. Furthermore, the operating room layout and item materials should be arranged in a way to maintain a clean and sterile environment. When considering ventilation, positive pressurization, filtering, laminar airflow systems, and the number of air exchanges are important factors. Appropriate reduction of patient flora in the form of chlorhexidine shower is widely used in some specialties the day before surgery. Hair removal should only be done when necessary, and with clippers just before surgery. Using iodine or chlorhexidine based agents for preparation of surgical area is a controversial topic, and certain subspecialties have their protocols. For the surgeon, appropriate scrubbing technique and double gloving have been shown to reduce rates of infection. The WHO surgical checklist has been designed to improve communication, prevent complications, and to improve safety overall, which includes surgical site infections as well.
Also, identifying wound infections is more challenging due to increased prevalence of day case surgery, and shortened hospital stays.CDC data from 2018 is to be read with the above precautions. The morbidity for 2018 in the US was 157,500 for surgical site infections (SSI), with an estimated mortality of 8,205. 11% of all deaths in intensive care units were associated with SSI. It is a burden for the patient with an additional 11 days of hospitalization for each SSI and a burden to the system with an overall cost of $3.2 billion per year. SSI rates also depend on what type of surgery is performed:
The typical timeframe for the appearance of SSI symptoms is 3-7 days post-procedure, and as per definition, they have to occur within 30 days post-surgery (or one year in cases with implant). Patients with metabolic syndrome, especially diabetics, smokers, elderly, and immunosuppressed people, are at higher risk. People with difficult/long or contaminated surgery are at higher risk as well. Most patients complain of a gradual onset of pain and discharge, and they may feel generally unwell.
For preoperative risk assessment for SSI, various tools can predict the likelihood of developing an infection based on the risk factors. There are traditional systems such as the national nosocomial infection surveillance system, the Australian Clinical Risk Index, and the European System for Cardiac Operative Risk Evaluation, which are all internationally recognized. However, their value is somewhat limited because many risk factors are missing from their calculations. Some have weak discriminatory abilities or do not risk-stratify for specific surgeries. Due to the need for individualized treatment, more specialty and even operation-specific scoring systems are emerging, such as the Infection Risk Index in cardiac surgery or Surgical Site Infection Risk Score.
For prophylaxis considerations, a safe, narrow-spectrum agent should be used with coverage for the expected microorganisms and should be prescribed for the shortest effective period. The antibiotic should be given 30 to 60 minutes before knife to skin time to allow tissue concentrations to reach therapeutic levels at the time of operation. For clean procedures, the antibiotics need to cover Staphylococci. For clean-contaminated procedures, similar coverage for Staphylococci is required, with additional coverage as required depending on the surgery and geography. This is usually cefazolin 2g (weight-adjusted) or vancomycin 15mg/kg plus metronidazole, cefoxitin, or ertapenem. For contaminated and dirty procedures, prophylaxis is generally not indicated, because therapeutic antibiotic management is required.
Often early surgical debridement is the preferred option to resolve infection successfully. However, in complex surgery, re-opening the surgical site can cause significant morbidity. If there is sufficient information that the infection is superficial, a decision can be made to treat conservatively. 2b1af7f3a8