10.5 weeks out... Lots of stress in the home life
So far things have gone mostly well. I'll be 11 weeks out on Tuesday and I've lost 46 pounds which puts me well over the halfway point of what Nut thinks should be my "goal" weight... which will put me at a BMI of around 27... (I've been told I'm a "lightweight" since I only needed about a 75-77 pound loss).
I wish I could say it has been totally smooth sailing but there has been a rough patch or two. One hospital stay due to extremely low potassium. I have yet to ever throw up, but I fight nausea on a daily basis... which makes it hard for me to eat. My surgeon has prescribed pretty much every med possible to help the nausea.. I've been topping out at with only about 500 calories a day on a good day. It's causing a lot of "problems" with my hubby!! :( He's concerned that i'm doing nothing but "staving myself". My eatting has become a constant battle with him. Yeah I know I probably should eat more.. I really try.. but fighting the nausea all day just makes eatting and even the thought of food pretty much intolerable. He just doesn't get it!! :(
Probably related to the "lack of" food issue is my lack of energy to do anything.. ANother huge issue and cause of stress in the house. Sure 2 months ago I was 50 pounds heavier, but we were out every weekend hiking, geocaching, just doing something fun.. Now it's like I don't even want to leave the house except for work. :( I am getting to a point that I don't know how to handle things!! :(
I wish I could say it has been totally smooth sailing but there has been a rough patch or two. One hospital stay due to extremely low potassium. I have yet to ever throw up, but I fight nausea on a daily basis... which makes it hard for me to eat. My surgeon has prescribed pretty much every med possible to help the nausea.. I've been topping out at with only about 500 calories a day on a good day. It's causing a lot of "problems" with my hubby!! :( He's concerned that i'm doing nothing but "staving myself". My eatting has become a constant battle with him. Yeah I know I probably should eat more.. I really try.. but fighting the nausea all day just makes eatting and even the thought of food pretty much intolerable. He just doesn't get it!! :(
Probably related to the "lack of" food issue is my lack of energy to do anything.. ANother huge issue and cause of stress in the house. Sure 2 months ago I was 50 pounds heavier, but we were out every weekend hiking, geocaching, just doing something fun.. Now it's like I don't even want to leave the house except for work. :( I am getting to a point that I don't know how to handle things!! :(
Depression could be in the mix here and either exacerbate or be cause of somatic issues (nausea) as well. The push pull and control over your eating with hubby can certainly be an issue to exlore emotionally, sometimes our disordered eating either restricting or permitting is a way to try to numb/manage oour emotions (even subconsciously), I HIGHLY recommend if you are not already to seek professional assistance for yourself and as a couple! This smacks to me of this type of concern. similar to anorexia, not uncommon post RNY at all!
Depression after Bariatric Surgery: Triggers, Identification, Treatment, and Prevention
May 2008
by Cynthia L. Alexander, PsyD
http://bariatrictimes.com/2008/05/09/depression-after-bariatric-surgery-triggers-identification-treatment-and-prevention/
Can u do protein shakes to get needed protein to heal and keep metabolism up???
IF this iss ue is more psychosomatic than physically based antinausea meds won;t work, have to treat underlying issue.Now dehydration for sure can cause VICOUS cycle of dehydration are you gettign in AT LEAST 64 ounces of water daily? Until that happens you most likley may keep having severe nausea..has anyone checked your gallbaldder? (if you still have it), thought about the meds u r on? (Many vits and minerals can cause this as can medicatins) tellus what u take..iron for sure is a gut buster!
Are you diabetic? Gastroperesis si not uncomon.. again remeron may help
http://psy.psychiatryonline.org/cgi/content/full/47/5/440
Have you been ruled out for an ULCER or stomal stenosis???
One study I read used Mirtazapine (Remeron) for nausea post RNY...show this to surgeon may help mood and nausea!
http://www.springerlink.com/content/h21q680685401j1v/
http://www.springerlink.com/content/th170l4u5854w262/
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TBR-4JT3S8K-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort
&view=c&_version=1&_urlVersion=0&_userid=10&md5=efe010a72efab8b4e3c992e4fff70e14
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Lactose Intolerance
After bariatric surgery, lactase, the enzyme needed to digest milk and other dairy products, does not reach food in the usual fashion. Consequently, you may become lactose intolerant, leading to gas, cramping, and diarrhea. This can be resolved by avoiding dairy products and switching to alternatives like soy milk, rice milk, or a lactose-free milk like Lactaid.
Do you take multivit B12? B complex? Iron, Calcium citrate? IF so how oten/much if each?
When were all your vits mineral levels checked B1 for instance can cause this and lead to permanent nerve/brain damage?
http://news.bio-medicine.org/medicine-news-3/After-gastric-bypass-surgery--important-to-check-vitamin-B1-deficiency-6951-1/
http://www.medscape.com/viewarticle/471952_print
MedGenMed Gastroenterology
Gastrointestinal Complications of Obesity Surgery
John E. Pandolfino, MD; Brintha Krishnamoorthy, BS; Thomas J. Lee, MD
Medscape General Medicine 6(2), 2004. © 2004 Medscape
Posted 04/20/2004
Introduction
Obesity has achieved epidemic proportions and is currently a national health crisis in the United States. Twenty-seven percent of the American population is obese (body mass index [BMI] >/= 30 kg/m2), resulting in approximately 300,000 deaths annually and $100 billion per year in direct and indirect costs (17% of total healthcare costs).[1-3] Obese individuals are at increased risk for hypertension, diabetes, pulmonary disease, hyperlipidemia, cardiomyopathy, malignancy, arthritis, infertility, sleep apnea, and psychosocial impairments. Given the fact that intentional weight loss improves many of these comorbidities,[4] much effort has gone into the development of effective treatment modalities focused on sustained weight loss. Unfortunately, conservative medical treatment programs (dietary regimen, behavioral modification, and exercise) have been largely unsuccessful in achieving and maintaining long-term results in morbidly obese patients. Although initially promising, medical therapy has been limited by the side effects of the drugs and by their inability to maintain significant weight loss over long follow-up periods. Therefore, more aggressive treatment is typically required for obese subjects at risk for medical complications of obesity. Given these limitations, surgery has become an attractive alternative because it represents a long-term solution.
Bariatric surgery is a collective term for operations that involve reducing the size of the gastric reservoir with or without associated malabsorption. These operations have achieved impressive results, with approximately a 50% or more reduction in excess body weight by 18-24 months post operation.[5] Thus, it is not surprising that approximately 60,000-100,000 bariatric surgeries will be performed in the next year, and these numbers are rapidly escalating. Although most patients achieve successful outcomes, a significant proportion may develop postoperative gastrointestinal symptoms. Whether these symptoms represent "necessary evils" (adverse events related to dietary indiscretion) or "unnecessary evils" (postoperative complications) is difficult to interpret clinically, and frequently will require gastroenterology consultation. Thus, the aims of this review are (1) to familiarize the gastroenterologist with the various operations, (2) to describe the gastrointestinal complications associated with these operations, and (3) to discuss their management in a case-presentation format.
Bariatric Surgery
Bariatric surgery was first introduced in the 1950s and has evolved significantly since then Although there are multiple operative approaches, 2 main principles exist in combination, or alone, in the various procedures: restriction and malabsorption. The restrictive component limits the volume of solid food that can be ingested in a given period of time by mechanically decreasing the volume capacitance of the proximal stomach (eg, vertical banded gastroplasty and gastric banding). The malabsorptive component involves a diversionary operation in which part of the small intestine is bypassed, thereby establishing a partial, selective malabsorption (eg, gastric bypass and biliopancreatic diversion with or without duodenal switch).
Bariatric surgery is an appropriate treatment option with acceptable operative risks for well-informed, highly motivated patients who suffer from severe impairments secondary to their weight. Not all patients are candidates for these procedures, and optimal results are obtained with the involvement of a multidisciplinary team (including physician/surgeon, nutritionist, dietitian, psychologist, and/or psychiatrist).[5]
Current guidelines use the BMI classification scheme to identify patients at risk for developing adiposity-related complications. BMI represents the relationship between height and weight and is calculated as weight (kg) divided by height (m2). In 1991, a National Institutes of Health Consensus Conference proposed a risk-classification system based on BMI: Patients with a BMI of 25.0-29.9 are classified as overweight, and those with a BMI of 30 kg/ m2 or more are classified as obese. Obesity is further classified as high risk (class I, BMI 30-34.9 kg/m2), very high risk (class II, BMI 35-39.9 kg/m2), and extremely high risk (class III, BMI 40 kg/m2 or greater).[6] The National Institutes of Health concluded that patients with class III obesity (BMI 40 kg/m2 or greater) or those with class II obesity (BMI 35-39.9 kg/m2) and 1 or more severe, obesity-related medical problem(s) (eg, sleep apnea, hypertension, type 2 diabetes mellitus, and/or heart failure) are eligible for surgery.[6] Additionally, patients should have failed conventional weight-loss therapies, should have acceptable operative risks, and should be committed to comply with long-term treatment and follow-up.
Most bariatric surgeries have been performed laparoscopically with success. The laparoscopic approach is gaining favor because of shorter hospital stays, faster return to functional daily activities, improved cosmesis, decreased wound infections, lower incidence of incisional hernia, and less blood loss. In addition, the majority of studies have demonstrated that there is no difference in achieved weight loss after the open or laparoscopic procedure.[7-11] Laparoscopy, however, is not the preferred surgical approach for superobese patients (BMI >/= 50 kg/m2) because of limitations in the physical anatomy of these individuals.
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).[12-14]
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]
Comparison of the Procedures
Comparison studies have been performed to evaluate the various bariatric procedures. In general, RYGBP has been found to be the superior approach. One study[28] compared laparoscopic RYGBP and laparoscopic adjustable gastric banding; at 18 months post operation, patients who had RYGBP had an excess weight loss of 74.6% vs 40.4% excess weight loss after gastric banding. This difference was also maintained at 2-, 3-, and 4-year follow-up intervals,[28,29] demonstrating that gastric bypass was superior to the laparoscopic adjustable banding system. In addition, a study from Sweden[30] reported that within 7 years of their operation, 58% of 90 patients who underwent laparoscopic adjustable gastric banding were converted to RYGBP because of multiple complications (esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation).
Randomized trials comparing gastric bypass against VBG have reported greater weight loss in patients who underwent gastric bypass surgery.[12,16,31] In one trial,[12] average weight loss at postoperative year 1 was reported to be 42% after VBG and 68% after gastric bypass. At the 3-year, follow-up period, these differences in weight loss remained significant. In addition, long-term evaluations confirmed that weight loss was maintained for up to 14 years after gastric bypass surgery,[24] whereas patients who underwent VBG had poor sustained weight loss at 10 or more years post procedure.[13]
BPD procedures have had success in achieving excess weight loss greater than 75%,[2,32] slightly more than that reported with traditional gastric bypass operations. In a retrospective comparison[27] of 138 patients who underwent RYGBP and 105 patients who underwent distal gastric bypass/duodenal switch, similar excess weight loss was reported -- with excess weight-loss rates at 2 years post operation of 74% and 78%, respectively. These results coupled with the possibility of lower rates of protein deficiency and anastomotic complications make distal gastric bypass/duodenal switch an attractive surgical option. However, more long-term data are required before it is universally accepted.
Gastrointestinal Complications of Bariatric Surgery
Complications of bariatric surgery can be separated into "true" complications associated with the operation and "side effects" associated with the alteration in the upper gastrointestinal anatomy (Table). The perioperative mortality of bariatric surgery is less than 1%[2,8] and is usually associated with anastomotic leaks with peritonitis (75%) or pulmonary embolism (25%).[2] Symptoms of an anastomotic leak can be overt with frank peritoneal signs or vague, with symptoms of mild abdominal pain, shoulder pain, back pain, unexplained tachycardia, or alteration in urination and bowel frequency. Given the devastating outcome of anastomotic leaks, there should be a low threshold for evaluation with water-soluble contrast agents and surgical exploration. Another early complication of gastric bypass surgery is acute gastric distention secondary to edema and obstruction at the enteroenterostomy. This complication may lead to staple line dehiscence or gastroenterostomic leaks. Acute gastric distention can be treated with radiographic-guided percutaneous gastrostomy or reoperation with tube gastrostomy.
Given the alteration in the upper gastrointestinal anatomy, certain side effects of bariatric surgery can be expected and ameliorated through patient education and postoperative treatment. In addition, patients with gastric bypass surgery should also be monitored for nutritional deficiencies and should take a multivitamin containing B-12 and folate, along with a calcium supplement.[2] Many patients experience symptoms of iron deficiency and anemia; these are potentially serious problems after gastric bypass, particularly in women who are menstruating. Combined with blood loss during menses, duodenal bypass and surgery-induced iron malabsorption make these women particularly susceptible to iron-deficiency anemia. Prophylactic oral iron supplementation is recommended for these patients.[33]
Nausea and Vomiting
Nausea and vomiting are the most common complaints after bariatric surgery, and they are typically associated with inappropriate diet and noncompliance with a gastroplasty diet (ie, eat undisturbed, chew meticulously, never drink with meals, and wait 2 hours before drinking after solid food is consumed). If these symptoms are associated with epigastric pain, significant dehydration, or not explained by dietary indiscretions, an alternative diagnosis must be explored. One of the most common complications causing nausea and vomiting in gastric bypass patients is anastomotic ulcers, with and without stomal stenosis. Ulceration or stenosis at the gastrojejunostomy of the gastric bypass has a reported incidence of 3% to 20% (Figure 5 A,B).[8,15,34] Although no unifying explanation for the etiology of anastomotic ulcers exists, most experts agree that the pathogenesis is likely multifactorial. These ulcers are thought to be due to a combination of preserved acid secretion in the pouch, tension from the Roux limb, ischemia from the operation, nonsteroidal anti-inflammatory drug (NSAID) use, and perhaps Helicobacter pylori infection.[35] Evidence suggests that little acid is secreted in the gastric bypass pouch; however, staple line dehiscence may lead to excessive acid bathing of the anastomosis. Treatment for both marginal ulcers and stomal ulcers should include avoidance of NSAIDs, antisecretory therapy with proton-pump inhibitors, and/or sucralfate. In addition, H pylori infection should be identified and treated, if present.
Figure 5. Anastomotic ulcers: (A) gastric and (B) jejunal or marginal ulcer.
Stomal stenosis after gastric bypass may respond to endoscopic dilation with through-the-scope balloon dilators and, thus, may obviate the need for surgical revision.[36] Patients with restrictive procedures, such as VBG, may also develop nausea and vomiting secondary to stomal stenosis, erosion of the restrictive band or ring, and increased gastroesophageal reflux. Treatment is dependent on the etiology, and it is unlikely that these patients will respond to balloon dilation secondary to the noncompliant ring or band. Severe gastroesophageal reflux disease may also be associated with VBG and, if present, may require proton-pump inhibitor therapy or conversion to a gastric bypass.
Another cause of mechanical obstruction in gastric bypass patients is internal hernia. This may occur where the Roux limb passes through the transverse mesocolon or at the mesenteric defect at the jejunojejunostomy. This problem is extremely difficult to diagnose because symptoms are nonspecific (cramping, periumbilical pain with or without nausea, and vomiting), and diagnostic radiographic studies can be normal.[37] If symptoms persist or become severe, surgical exploration is indicated to rule out internal hernia.
Dumping/Diarrhea
In addition to the obstructive complications, patients may also develop symptoms related to increased transit of ingested food directly into the small bowel ("dumping syndrome"). Symptoms related to dumping syndrome are increased with food containing a high sugar content and high osmotic activity. Patients may present with symptoms of nausea, bloating, abdominal pain, and lightheadedness. These symptoms generally improve with fasting and are a deterrent to overeating. Diarrhea is another component of dumping syndrome that will also improve with fasting. If a patient has greater than 3 watery stools per day despite fasting and dietary restriction, stool studies should be obtained. Because gastric bypass patients may be predisposed to bacterial overgrowth and the blind loop syndrome, empiric antibiotics should be considered in patients who show no improvement with fasting in the context of negative stool studies.
Gastrointestinal Bleeding
Gastrointestinal bleeding is an uncommon complication of bariatric surgery.[38,39] In general, gastrointestinal bleeding in patients with VBG or gastric bypass should be evaluated similarly to how one would evaluate patients without surgery. However, anatomic considerations pose both diagnostic and therapeutic dilemmas in patients with gastric bypass. Upper gastrointestinal bleeding in patients who have undergone gastric bypass surgery may occur in the esophagus, gastric pouch, and Roux limb just distal to the anastomosis. Fortunately, these areas are readily accessible to standard upper endoscopy and therapy. Although present in up to 20% of patients after gastric bypass, anastomotic ulceration is a rare cause of bleeding and is typically associated with concomitant NSAID use. Whether H pylori infection is an important risk factor for anastomotic ulceration is somewhat controversial. However, given the increased lifetime risk for peptic ulceration, it is not unreasonable to test patients preoperatively and institute treatment if they are H pylori-positive to avoid future complications.
The distal stomach and proximal duodenum may not be accessible to endoscopy -- but bleeding from these areas is rare because of low-acid secretory states secondary to vagal interruption, lack of antral distention, and restricted contact with food. Patients are still susceptible to NSAID-related complications and should avoid these medications if at all possible. If bleeding from the distal stomach or proximal small bowel is suspected, a pediatric colonoscope or enteroscope may be used to evaluate the area. In addition, interventional angiography may be able to both locate and treat bleeding lesions in this area. Performance of colonoscopy is unchanged in patients who have undergone obesity surgery -- however, care should be given to the preparation because these individuals are unable to tolerate large volumes orally.[36]
Cholelithiasis
Obesity and rapid weight loss are known risk factors for gallstone formation, and thus, it is no surprise that approximately one third of patients may develop gallstones after bariatric surgery. Furthermore, 10% to 15% of all patients will require cholecystectomy for complaints related to gallstones.[40-44] Some centers routinely perform cholecystectomies with bariatric procedures to prevent complications of cholelithiasis, whereas other centers choose to administer ursodiol as prophylaxis for 6 months postoperatively. Two controlled trials[40,45] demonstrated the efficacy of 6 months of ursodiol therapy in decreasing the incidence of gallstone formation. Cholelithiasis was detected in 22% to 32% of controls vs in 2% to 3% of treated patients at 6-12 months.[40,45] Clinicians against prophylactic cholecystectomy suggest that the operation may increase the overall operative time and length of hospital stay and that a cholecystectomy may be easier to perform after weight loss has occurred.[46]
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[36,38,49-51] 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 cir****tance. 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.
Case II: Cholelithiasis and Choledocholithiasis
Case Presentation
The patient is a 58-year-old woman with a BMI of 70 kg/m2 who underwent a laparoscopic RYGBP without cholecystectomy at another institution 10 weeks before admission to a clinic. She had suddenly developed postprandial nausea and vomiting and appeared jaundiced. She had several gallbladder stones as well as a dilated common bile duct with a 1-cm stone in the distal common bile duct. The patient was transferred to our institution; her pain has since resolved.
On physical exam, she was in no acute distress. Her vital signs were as follows: temperature, 98.8°F; heart rate, 60 beats per minute; and blood pressure, 146/78. She was visibly jaundiced. Her abdomen had well-healed scars from her laparoscopic gastric bypass surgery. She had normal bowel sounds; her abdomen was soft; and she had moderate, right upper-quadrant tenderness to deep palpation. The patient had a gastrostomy tube, which had been placed in her gastric remnant during her gastric bypass operation. Results of laboratory studies revealed a white-blood-cell count of 5.9 x 103 cells/mm3; her electrolytes were normal. Her liver-function tests were elevated: alanine aminotransferase, 329 U/L; aspartate aminotransferase, 212 U/L; total bilirubin, 6.1 mg/dL; direct bilirubin, 4.5 mg/dL; and alkaline phosphatase, 280 U/L.
Management and Discussion
The patient was afebrile, and her symptoms had resolved over the previous day while given nothing by mouth; therefore, there was no immediate urgency to remove the stone or perform a cholecystectomy. Given her presenting symptoms, liver-function-test abnormalities, and results of ultrasound showing cholelithiasis and choledocholithiasis, no further diagnostic studies needed to be performed. Although cholecystitis is likely the most common complication of cholelithiasis in this patient population, choledocholithiasis presents a particularly unique problem in the gastric bypass patient. Removal or assessment of common bile duct stones with ERCP is virtually impossible by the normal endoscopic approach, given that the Roux limb is often 50-100 cm in length. However, ERCP can be performed in the operating room via a temporary gastrostomy to carry out the stone extraction, or in the case of this patient, even via her gastrostomy tube site after serial dilation. The latter was believed to be a poor option given the patient's superobesity, with difficulty in traversing her pannus with the duodenoscope, as well as in maintaining her stomach apposed to the peritoneum throughout the ERCP. Other options included percutaneous transhepatic cholangiography or an intraoperative cholangiogram for removal of the common bile duct stones.
Percutaneous transhepatic cholangiography was performed the next day and revealed a 1-cm common bile duct stone. After the papilla was dilated with a balloon, the stone was crushed, and the fragments were advanced through the papilla. The following day, the patient had a successful laparoscopic cholecystectomy without complications and was discharged on postoperative day 1 to a rehabilitation facility.
Conclusion
Obesity is one of the most striking public health problems in the United States today. Despite increased public awareness and aggressive education, the prevalence of obesity continues to increase. Because early data support the concept that bariatric surgery and its consequent weight loss can significantly relieve the comorbidities of obesity, surgery has become an essential part of our treatment armamentarium for morbid obesity, notwithstanding the potential problems that accompany it. The associated adverse events and true complications often necessitate a gastroenterology consultation, requiring the endoscopist to be well versed in the care of post-bariatric-surgery patients. For the gastroenterologist, successful management of these patients involves communication with the bariatric surgeon, knowledge of postoperative anatomy, an understanding of the potential complications, and implementation of appropriate treatment.
Tables
Table. Complications of Bariatric Surgery
Side Effects of Operation Complications of Operation
NauseaVomitingDiarrheaDumping syndromeNutrient deficiencyCholelithiasis Anastomotic leakAcute gastric distentionInternal herniaStomal ulcerationStomal stenosisStaple line disruption
References
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Funding Information
This work was supported by grant K23 DK62170-01 (JEP) from the Public Health Service.
John E. Pandolfino, MD, Assistant Professor of Medicine, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Brintha Krishnamoorthy, BS, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Thomas J. Lee, MD, Gastroenterology Fellow, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Disclosure: John E. Pandolfino, MD, has disclosed that he has received grants for clinical research from AstraZeneca and Medtronic.
Disclosure: Brintha Krishnamoorthy, BS, has no significant financial interests to disclose.
Disclosure: Thomas J. Lee, MD, has no significant financial interests to disclose.
Depression after Bariatric Surgery: Triggers, Identification, Treatment, and Prevention
May 2008
by Cynthia L. Alexander, PsyD
http://bariatrictimes.com/2008/05/09/depression-after-bariatric-surgery-triggers-identification-treatment-and-prevention/
Can u do protein shakes to get needed protein to heal and keep metabolism up???
IF this iss ue is more psychosomatic than physically based antinausea meds won;t work, have to treat underlying issue.Now dehydration for sure can cause VICOUS cycle of dehydration are you gettign in AT LEAST 64 ounces of water daily? Until that happens you most likley may keep having severe nausea..has anyone checked your gallbaldder? (if you still have it), thought about the meds u r on? (Many vits and minerals can cause this as can medicatins) tellus what u take..iron for sure is a gut buster!
Are you diabetic? Gastroperesis si not uncomon.. again remeron may help
http://psy.psychiatryonline.org/cgi/content/full/47/5/440
Have you been ruled out for an ULCER or stomal stenosis???
One study I read used Mirtazapine (Remeron) for nausea post RNY...show this to surgeon may help mood and nausea!
http://www.springerlink.com/content/h21q680685401j1v/
http://www.springerlink.com/content/th170l4u5854w262/
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6TBR-4JT3S8K-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort
&view=c&_version=1&_urlVersion=0&_userid=10&md5=efe010a72efab8b4e3c992e4fff70e14~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Lactose Intolerance
After bariatric surgery, lactase, the enzyme needed to digest milk and other dairy products, does not reach food in the usual fashion. Consequently, you may become lactose intolerant, leading to gas, cramping, and diarrhea. This can be resolved by avoiding dairy products and switching to alternatives like soy milk, rice milk, or a lactose-free milk like Lactaid.
Do you take multivit B12? B complex? Iron, Calcium citrate? IF so how oten/much if each?
When were all your vits mineral levels checked B1 for instance can cause this and lead to permanent nerve/brain damage?
http://news.bio-medicine.org/medicine-news-3/After-gastric-bypass-surgery--important-to-check-vitamin-B1-deficiency-6951-1/
http://www.medscape.com/viewarticle/471952_print
MedGenMed Gastroenterology
Gastrointestinal Complications of Obesity Surgery
John E. Pandolfino, MD; Brintha Krishnamoorthy, BS; Thomas J. Lee, MD
Medscape General Medicine 6(2), 2004. © 2004 Medscape
Posted 04/20/2004
Introduction
Obesity has achieved epidemic proportions and is currently a national health crisis in the United States. Twenty-seven percent of the American population is obese (body mass index [BMI] >/= 30 kg/m2), resulting in approximately 300,000 deaths annually and $100 billion per year in direct and indirect costs (17% of total healthcare costs).[1-3] Obese individuals are at increased risk for hypertension, diabetes, pulmonary disease, hyperlipidemia, cardiomyopathy, malignancy, arthritis, infertility, sleep apnea, and psychosocial impairments. Given the fact that intentional weight loss improves many of these comorbidities,[4] much effort has gone into the development of effective treatment modalities focused on sustained weight loss. Unfortunately, conservative medical treatment programs (dietary regimen, behavioral modification, and exercise) have been largely unsuccessful in achieving and maintaining long-term results in morbidly obese patients. Although initially promising, medical therapy has been limited by the side effects of the drugs and by their inability to maintain significant weight loss over long follow-up periods. Therefore, more aggressive treatment is typically required for obese subjects at risk for medical complications of obesity. Given these limitations, surgery has become an attractive alternative because it represents a long-term solution.
Bariatric surgery is a collective term for operations that involve reducing the size of the gastric reservoir with or without associated malabsorption. These operations have achieved impressive results, with approximately a 50% or more reduction in excess body weight by 18-24 months post operation.[5] Thus, it is not surprising that approximately 60,000-100,000 bariatric surgeries will be performed in the next year, and these numbers are rapidly escalating. Although most patients achieve successful outcomes, a significant proportion may develop postoperative gastrointestinal symptoms. Whether these symptoms represent "necessary evils" (adverse events related to dietary indiscretion) or "unnecessary evils" (postoperative complications) is difficult to interpret clinically, and frequently will require gastroenterology consultation. Thus, the aims of this review are (1) to familiarize the gastroenterologist with the various operations, (2) to describe the gastrointestinal complications associated with these operations, and (3) to discuss their management in a case-presentation format.
Bariatric Surgery
Bariatric surgery was first introduced in the 1950s and has evolved significantly since then Although there are multiple operative approaches, 2 main principles exist in combination, or alone, in the various procedures: restriction and malabsorption. The restrictive component limits the volume of solid food that can be ingested in a given period of time by mechanically decreasing the volume capacitance of the proximal stomach (eg, vertical banded gastroplasty and gastric banding). The malabsorptive component involves a diversionary operation in which part of the small intestine is bypassed, thereby establishing a partial, selective malabsorption (eg, gastric bypass and biliopancreatic diversion with or without duodenal switch).
Bariatric surgery is an appropriate treatment option with acceptable operative risks for well-informed, highly motivated patients who suffer from severe impairments secondary to their weight. Not all patients are candidates for these procedures, and optimal results are obtained with the involvement of a multidisciplinary team (including physician/surgeon, nutritionist, dietitian, psychologist, and/or psychiatrist).[5]
Current guidelines use the BMI classification scheme to identify patients at risk for developing adiposity-related complications. BMI represents the relationship between height and weight and is calculated as weight (kg) divided by height (m2). In 1991, a National Institutes of Health Consensus Conference proposed a risk-classification system based on BMI: Patients with a BMI of 25.0-29.9 are classified as overweight, and those with a BMI of 30 kg/ m2 or more are classified as obese. Obesity is further classified as high risk (class I, BMI 30-34.9 kg/m2), very high risk (class II, BMI 35-39.9 kg/m2), and extremely high risk (class III, BMI 40 kg/m2 or greater).[6] The National Institutes of Health concluded that patients with class III obesity (BMI 40 kg/m2 or greater) or those with class II obesity (BMI 35-39.9 kg/m2) and 1 or more severe, obesity-related medical problem(s) (eg, sleep apnea, hypertension, type 2 diabetes mellitus, and/or heart failure) are eligible for surgery.[6] Additionally, patients should have failed conventional weight-loss therapies, should have acceptable operative risks, and should be committed to comply with long-term treatment and follow-up.
Most bariatric surgeries have been performed laparoscopically with success. The laparoscopic approach is gaining favor because of shorter hospital stays, faster return to functional daily activities, improved cosmesis, decreased wound infections, lower incidence of incisional hernia, and less blood loss. In addition, the majority of studies have demonstrated that there is no difference in achieved weight loss after the open or laparoscopic procedure.[7-11] Laparoscopy, however, is not the preferred surgical approach for superobese patients (BMI >/= 50 kg/m2) because of limitations in the physical anatomy of these individuals.
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).[12-14]
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]
Comparison of the Procedures
Comparison studies have been performed to evaluate the various bariatric procedures. In general, RYGBP has been found to be the superior approach. One study[28] compared laparoscopic RYGBP and laparoscopic adjustable gastric banding; at 18 months post operation, patients who had RYGBP had an excess weight loss of 74.6% vs 40.4% excess weight loss after gastric banding. This difference was also maintained at 2-, 3-, and 4-year follow-up intervals,[28,29] demonstrating that gastric bypass was superior to the laparoscopic adjustable banding system. In addition, a study from Sweden[30] reported that within 7 years of their operation, 58% of 90 patients who underwent laparoscopic adjustable gastric banding were converted to RYGBP because of multiple complications (esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation).
Randomized trials comparing gastric bypass against VBG have reported greater weight loss in patients who underwent gastric bypass surgery.[12,16,31] In one trial,[12] average weight loss at postoperative year 1 was reported to be 42% after VBG and 68% after gastric bypass. At the 3-year, follow-up period, these differences in weight loss remained significant. In addition, long-term evaluations confirmed that weight loss was maintained for up to 14 years after gastric bypass surgery,[24] whereas patients who underwent VBG had poor sustained weight loss at 10 or more years post procedure.[13]
BPD procedures have had success in achieving excess weight loss greater than 75%,[2,32] slightly more than that reported with traditional gastric bypass operations. In a retrospective comparison[27] of 138 patients who underwent RYGBP and 105 patients who underwent distal gastric bypass/duodenal switch, similar excess weight loss was reported -- with excess weight-loss rates at 2 years post operation of 74% and 78%, respectively. These results coupled with the possibility of lower rates of protein deficiency and anastomotic complications make distal gastric bypass/duodenal switch an attractive surgical option. However, more long-term data are required before it is universally accepted.
Gastrointestinal Complications of Bariatric Surgery
Complications of bariatric surgery can be separated into "true" complications associated with the operation and "side effects" associated with the alteration in the upper gastrointestinal anatomy (Table). The perioperative mortality of bariatric surgery is less than 1%[2,8] and is usually associated with anastomotic leaks with peritonitis (75%) or pulmonary embolism (25%).[2] Symptoms of an anastomotic leak can be overt with frank peritoneal signs or vague, with symptoms of mild abdominal pain, shoulder pain, back pain, unexplained tachycardia, or alteration in urination and bowel frequency. Given the devastating outcome of anastomotic leaks, there should be a low threshold for evaluation with water-soluble contrast agents and surgical exploration. Another early complication of gastric bypass surgery is acute gastric distention secondary to edema and obstruction at the enteroenterostomy. This complication may lead to staple line dehiscence or gastroenterostomic leaks. Acute gastric distention can be treated with radiographic-guided percutaneous gastrostomy or reoperation with tube gastrostomy.
Given the alteration in the upper gastrointestinal anatomy, certain side effects of bariatric surgery can be expected and ameliorated through patient education and postoperative treatment. In addition, patients with gastric bypass surgery should also be monitored for nutritional deficiencies and should take a multivitamin containing B-12 and folate, along with a calcium supplement.[2] Many patients experience symptoms of iron deficiency and anemia; these are potentially serious problems after gastric bypass, particularly in women who are menstruating. Combined with blood loss during menses, duodenal bypass and surgery-induced iron malabsorption make these women particularly susceptible to iron-deficiency anemia. Prophylactic oral iron supplementation is recommended for these patients.[33]
Nausea and Vomiting
Nausea and vomiting are the most common complaints after bariatric surgery, and they are typically associated with inappropriate diet and noncompliance with a gastroplasty diet (ie, eat undisturbed, chew meticulously, never drink with meals, and wait 2 hours before drinking after solid food is consumed). If these symptoms are associated with epigastric pain, significant dehydration, or not explained by dietary indiscretions, an alternative diagnosis must be explored. One of the most common complications causing nausea and vomiting in gastric bypass patients is anastomotic ulcers, with and without stomal stenosis. Ulceration or stenosis at the gastrojejunostomy of the gastric bypass has a reported incidence of 3% to 20% (Figure 5 A,B).[8,15,34] Although no unifying explanation for the etiology of anastomotic ulcers exists, most experts agree that the pathogenesis is likely multifactorial. These ulcers are thought to be due to a combination of preserved acid secretion in the pouch, tension from the Roux limb, ischemia from the operation, nonsteroidal anti-inflammatory drug (NSAID) use, and perhaps Helicobacter pylori infection.[35] Evidence suggests that little acid is secreted in the gastric bypass pouch; however, staple line dehiscence may lead to excessive acid bathing of the anastomosis. Treatment for both marginal ulcers and stomal ulcers should include avoidance of NSAIDs, antisecretory therapy with proton-pump inhibitors, and/or sucralfate. In addition, H pylori infection should be identified and treated, if present.
Figure 5. Anastomotic ulcers: (A) gastric and (B) jejunal or marginal ulcer.
Stomal stenosis after gastric bypass may respond to endoscopic dilation with through-the-scope balloon dilators and, thus, may obviate the need for surgical revision.[36] Patients with restrictive procedures, such as VBG, may also develop nausea and vomiting secondary to stomal stenosis, erosion of the restrictive band or ring, and increased gastroesophageal reflux. Treatment is dependent on the etiology, and it is unlikely that these patients will respond to balloon dilation secondary to the noncompliant ring or band. Severe gastroesophageal reflux disease may also be associated with VBG and, if present, may require proton-pump inhibitor therapy or conversion to a gastric bypass.
Another cause of mechanical obstruction in gastric bypass patients is internal hernia. This may occur where the Roux limb passes through the transverse mesocolon or at the mesenteric defect at the jejunojejunostomy. This problem is extremely difficult to diagnose because symptoms are nonspecific (cramping, periumbilical pain with or without nausea, and vomiting), and diagnostic radiographic studies can be normal.[37] If symptoms persist or become severe, surgical exploration is indicated to rule out internal hernia.
Dumping/Diarrhea
In addition to the obstructive complications, patients may also develop symptoms related to increased transit of ingested food directly into the small bowel ("dumping syndrome"). Symptoms related to dumping syndrome are increased with food containing a high sugar content and high osmotic activity. Patients may present with symptoms of nausea, bloating, abdominal pain, and lightheadedness. These symptoms generally improve with fasting and are a deterrent to overeating. Diarrhea is another component of dumping syndrome that will also improve with fasting. If a patient has greater than 3 watery stools per day despite fasting and dietary restriction, stool studies should be obtained. Because gastric bypass patients may be predisposed to bacterial overgrowth and the blind loop syndrome, empiric antibiotics should be considered in patients who show no improvement with fasting in the context of negative stool studies.
Gastrointestinal Bleeding
Gastrointestinal bleeding is an uncommon complication of bariatric surgery.[38,39] In general, gastrointestinal bleeding in patients with VBG or gastric bypass should be evaluated similarly to how one would evaluate patients without surgery. However, anatomic considerations pose both diagnostic and therapeutic dilemmas in patients with gastric bypass. Upper gastrointestinal bleeding in patients who have undergone gastric bypass surgery may occur in the esophagus, gastric pouch, and Roux limb just distal to the anastomosis. Fortunately, these areas are readily accessible to standard upper endoscopy and therapy. Although present in up to 20% of patients after gastric bypass, anastomotic ulceration is a rare cause of bleeding and is typically associated with concomitant NSAID use. Whether H pylori infection is an important risk factor for anastomotic ulceration is somewhat controversial. However, given the increased lifetime risk for peptic ulceration, it is not unreasonable to test patients preoperatively and institute treatment if they are H pylori-positive to avoid future complications.
The distal stomach and proximal duodenum may not be accessible to endoscopy -- but bleeding from these areas is rare because of low-acid secretory states secondary to vagal interruption, lack of antral distention, and restricted contact with food. Patients are still susceptible to NSAID-related complications and should avoid these medications if at all possible. If bleeding from the distal stomach or proximal small bowel is suspected, a pediatric colonoscope or enteroscope may be used to evaluate the area. In addition, interventional angiography may be able to both locate and treat bleeding lesions in this area. Performance of colonoscopy is unchanged in patients who have undergone obesity surgery -- however, care should be given to the preparation because these individuals are unable to tolerate large volumes orally.[36]
Cholelithiasis
Obesity and rapid weight loss are known risk factors for gallstone formation, and thus, it is no surprise that approximately one third of patients may develop gallstones after bariatric surgery. Furthermore, 10% to 15% of all patients will require cholecystectomy for complaints related to gallstones.[40-44] Some centers routinely perform cholecystectomies with bariatric procedures to prevent complications of cholelithiasis, whereas other centers choose to administer ursodiol as prophylaxis for 6 months postoperatively. Two controlled trials[40,45] demonstrated the efficacy of 6 months of ursodiol therapy in decreasing the incidence of gallstone formation. Cholelithiasis was detected in 22% to 32% of controls vs in 2% to 3% of treated patients at 6-12 months.[40,45] Clinicians against prophylactic cholecystectomy suggest that the operation may increase the overall operative time and length of hospital stay and that a cholecystectomy may be easier to perform after weight loss has occurred.[46]
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[36,38,49-51] 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 cir****tance. 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.
Case II: Cholelithiasis and Choledocholithiasis
Case Presentation
The patient is a 58-year-old woman with a BMI of 70 kg/m2 who underwent a laparoscopic RYGBP without cholecystectomy at another institution 10 weeks before admission to a clinic. She had suddenly developed postprandial nausea and vomiting and appeared jaundiced. She had several gallbladder stones as well as a dilated common bile duct with a 1-cm stone in the distal common bile duct. The patient was transferred to our institution; her pain has since resolved.
On physical exam, she was in no acute distress. Her vital signs were as follows: temperature, 98.8°F; heart rate, 60 beats per minute; and blood pressure, 146/78. She was visibly jaundiced. Her abdomen had well-healed scars from her laparoscopic gastric bypass surgery. She had normal bowel sounds; her abdomen was soft; and she had moderate, right upper-quadrant tenderness to deep palpation. The patient had a gastrostomy tube, which had been placed in her gastric remnant during her gastric bypass operation. Results of laboratory studies revealed a white-blood-cell count of 5.9 x 103 cells/mm3; her electrolytes were normal. Her liver-function tests were elevated: alanine aminotransferase, 329 U/L; aspartate aminotransferase, 212 U/L; total bilirubin, 6.1 mg/dL; direct bilirubin, 4.5 mg/dL; and alkaline phosphatase, 280 U/L.
Management and Discussion
The patient was afebrile, and her symptoms had resolved over the previous day while given nothing by mouth; therefore, there was no immediate urgency to remove the stone or perform a cholecystectomy. Given her presenting symptoms, liver-function-test abnormalities, and results of ultrasound showing cholelithiasis and choledocholithiasis, no further diagnostic studies needed to be performed. Although cholecystitis is likely the most common complication of cholelithiasis in this patient population, choledocholithiasis presents a particularly unique problem in the gastric bypass patient. Removal or assessment of common bile duct stones with ERCP is virtually impossible by the normal endoscopic approach, given that the Roux limb is often 50-100 cm in length. However, ERCP can be performed in the operating room via a temporary gastrostomy to carry out the stone extraction, or in the case of this patient, even via her gastrostomy tube site after serial dilation. The latter was believed to be a poor option given the patient's superobesity, with difficulty in traversing her pannus with the duodenoscope, as well as in maintaining her stomach apposed to the peritoneum throughout the ERCP. Other options included percutaneous transhepatic cholangiography or an intraoperative cholangiogram for removal of the common bile duct stones.
Percutaneous transhepatic cholangiography was performed the next day and revealed a 1-cm common bile duct stone. After the papilla was dilated with a balloon, the stone was crushed, and the fragments were advanced through the papilla. The following day, the patient had a successful laparoscopic cholecystectomy without complications and was discharged on postoperative day 1 to a rehabilitation facility.
Conclusion
Obesity is one of the most striking public health problems in the United States today. Despite increased public awareness and aggressive education, the prevalence of obesity continues to increase. Because early data support the concept that bariatric surgery and its consequent weight loss can significantly relieve the comorbidities of obesity, surgery has become an essential part of our treatment armamentarium for morbid obesity, notwithstanding the potential problems that accompany it. The associated adverse events and true complications often necessitate a gastroenterology consultation, requiring the endoscopist to be well versed in the care of post-bariatric-surgery patients. For the gastroenterologist, successful management of these patients involves communication with the bariatric surgeon, knowledge of postoperative anatomy, an understanding of the potential complications, and implementation of appropriate treatment.
Tables
Table. Complications of Bariatric Surgery
Side Effects of Operation Complications of Operation
NauseaVomitingDiarrheaDumping syndromeNutrient deficiencyCholelithiasis Anastomotic leakAcute gastric distentionInternal herniaStomal ulcerationStomal stenosisStaple line disruption
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Funding Information
This work was supported by grant K23 DK62170-01 (JEP) from the Public Health Service.
John E. Pandolfino, MD, Assistant Professor of Medicine, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Brintha Krishnamoorthy, BS, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Thomas J. Lee, MD, Gastroenterology Fellow, Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
Disclosure: John E. Pandolfino, MD, has disclosed that he has received grants for clinical research from AstraZeneca and Medtronic.
Disclosure: Brintha Krishnamoorthy, BS, has no significant financial interests to disclose.
Disclosure: Thomas J. Lee, MD, has no significant financial interests to disclose.
Take Care, 
Jamie Ellis RN MS NPP
100cm proximal Lap RNY 10/9/02 Dr. Singh Albany, NY
320(preop)/163(lowest)/185(current) 5'9'' (lost 45# before surgery)
Plastics 6/9/04 & 11/11/2005 Dr. King www.albanyplasticsurgeons.com
http://www.obesityhelp.com/member/jamiecatlady5/
"Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"
Jamie Ellis RN MS NPP
100cm proximal Lap RNY 10/9/02 Dr. Singh Albany, NY
320(preop)/163(lowest)/185(current) 5'9'' (lost 45# before surgery)
Plastics 6/9/04 & 11/11/2005 Dr. King www.albanyplasticsurgeons.com
http://www.obesityhelp.com/member/jamiecatlady5/
"Being happy doesn't mean everything's perfect, it just means you've decided to see beyond the imperfections!"
Hi - So sorry to hear you are having problems - I was just wondering if you are getting all of your fluids in daily? At least 64 oz. a day? The reason I ask is because I too, suffered with the nausea though not daily and the extremem fatigue. The fatigue would hit me like a rock. I finally figured it out that I was not getting all of my fluids in daily. Also, my vitamins! Duh!! Anyway, try increasing your fluids as my nut told me it could also stave off the nausea I was feeling and I found she was right. Sometimes it is very hard to get that amount in but I come as close as I can and find that everything works better, my plumbing, digestive systems, etc. Hope this helps you, good luck Molly P.
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