5 Things You Should Know about Early Complications of RYGBP

Mortality during the first year after bariatric surgery has decreased in recent years due to multiple factors, such as the laparoscopic approach, the specific training programs of the different scientific societies and the advances in the perioperative management of these patients.

In the short term, the complexity of bariatric techniques and the risk factors of morbidly obese patients cause postoperative emergencies that require early diagnosis and immediate treatment to avoid fatal consequences. In general, a high level of suspicion should be maintained to identify and diagnose these complications, as there is a great discordance between the scarce clinical symptomatology and the severity they usually entail.

There are multiple symptoms that can raise an alarm to the clinician: dyspnea and tachypnea, hiccups, fever, bladder spasms… The most important alarm sign when assessing morbidly obese patients after surgery is tachycardia (>100bpm).

Anastomotic/staple line leaks

– One of the most feared complications of bariatric surgeons: highest RR of multiorgan failure, admission to the intensive care unit, reoperation and readmission – Incidence: 0.1-8.3% after RYGBP; 0-7% after SG – Causes: mechanical or ischemic – Remember that most leaks occur after the patient is discharged from the hospital – Diagnostic test of choice: CT with oral contrast – Management: surgery (peritoneal cavity lavage, drainage placement, primary repair if possible) + allowing enteral nutrition (+ endoscopy in selected cases)

Hemorrhagic complications – More frequent in gastric bypass (0.6-4%) – Most cases management is conservative 🡪 diagnostic and/or therapeutic endoscopy – Obese patients are especially sensitive to hypovolemia and also have low baseline hemoglobin levels due to iron deficiency, so the therapeutic response must be rapid – Extraluminal vs endoluminal bleeding (easy vs difficult endoscopic access) – Management: first = resuscitative measures. Consider need of urgent surgical reintervention (alarm signs, drop in hematocrit, first 6h) or endoscopic treatment (late bleedings, persistent or rebleeding)

Complications of the abdominal wall – Laparoscopic approach on bariatric surgery has drastically reduced the incidence of incisional hernia (0,5%) – Herniation can be acute in the first hours after surgery as a consequence of abdominal hyperpressure (coughing, vomiting) or several years later – Port hernia, especially in cases debuting in the first postoperative hours, requires urgent surgical revision

Surgical site infection – Superficial vs deep infections – Favored by the excess of subcutaneous adipose tissue – Difficult to make an early diagnosis – Depends on surgical technique: ↑surgeries involving circular anastomosis and those that require implantable devices – Management: correct debridement and local cures (may require drainage, negative pressure devices or ATB)

Pulmonary thromboembolism – Prevalence: 0.3-2.4% of deep vein thrombosis (DVT); 0.15-0.3% of pulmonary thromboembolism (PTE) – PTE is the main cause of medical mortality after bariatric surgery – Currently insufficient scientific evidence of sufficient quality to establish clear guidelines with a high level of recommendation – Gold standard for the diagnosis of PTE: pulmonary angio-CT scan