Emergent reoperations in bariatric surgery

Emergent reoperations in bariatric surgery – experience in the first 100 cases in a private hospital in Oman.

Rajkumar Janavikula Sankaran, Dharmendra Kollapalayam Raman, Anant Shankar, Bader Aflah Salim Al Hadhrami

Department of General and Laparoscopic Surgery, Al Hayat International Hospital, Muscat, Sultanate of Oman

Abstract :

Laparoscopic bariatric surgery though growing rapidly in the past two decades has a high degree of immediate postoperative complications. We present three emergent complications in our series of first 100 cases in a private hospital in Oman which were tackled appropriately by our team of professionals. These complications were one staple line hemorrhage in laparoscopic sleeve gastrectomy, twist of gastric pouch in mini gastric bypass and leakage of gastrojejunal anastomosis in Roux‑en‑Y gastric bypass. In all the three cases, thorough postoperative vigil has been stressed upon as an important factor in postoperative bariatric surgical care. In the gastric bypass case, despite the absence of definite findings in the radiological investigations, patient was taken to the operating room on high degree of clinical suspicion as a part of diagnostic algorithm.

INTRODUCTION

Laparoscopic bariatric surgery, albeit growing by leaps and bounds across the world, is not to be taken lightly, because of higher rate of complications compared to nonbariatric surgery. This is because many of the patients have comorbid illnesses such as diabetes, hypertension,coronary artery disease, dyslipidemia, and because of excessively obese abdominal wall, adequate leverage of instrumentation is often difficult to obtain, making otherwise simple hemostasis, a difficult affair. Positioning of a bariatric surgical patient is another challenge for the entire operating team, and often times complications are related to prolonged operating time, in a given position, i.e., causing nerve injury. In our 36 months of experience in operative laparoscopic bariatric surgery in Oman, we report three emergent reoperations, for various indications (1. Staple line hemorrhage [laparoscopic sleeve gastrectomy (LSG)],

2. Twisted anastomosis [mini gastric bypass (MGB)], and 3. Leaked anastomosis [Roux‑en‑Y gastric bypass (RGB)]).

MATERIALS AND METHODS

Of all 100 patients in our center, are all operated by the senior author. The surgeries are:
1. Laparoscopic sleeve gastrectomy: 70
2. Laparoscopic MGB: 14
3. Laparoscopic RGB: 16.
In this group, we have had one major emergent reoperative complication in each of the groups. We would like to discuss these complications and how we had handled them.

Case no. 1: Staple line hemorrhage
A 38‑year‑old gentleman had undergone an uncomplicated LSG. He had two distal green (60 mm × 4.8 mm) staple cartridges fired and the remaining were blue ones (60 mm × 3.5 mm). There was a little bit of staple line bleed at the level of 2nd firing, but it seemed settled.The operation went off uneventfully. About 8 h of postoperatively, patient developed tachycardia, sweating, and hypotension. There was a sharp decline in urine output. O/E, patient was anxious, pale, and sweating. Pulse rate: 102 beats/min, blood pressure (BP): 90/60 mmHg, Hb‑7 gm%. Ultrasound was not contributory and we proceeded with the contrast‑enhanced computerized tomography (CECT) scan of abdomen which showed large amount of blood pooled in the perigastric region, Morrison’s pouch, and perisplenic area.

After rushing in 2 L of crystalloid fluid, we brought the BP up and we took the patient back to operating room (OR). Re‑laparoscopy revealed a small and steady spurter from the 2nd staple line firing. There was a definite spurter and the spurter was oversewn with continuous 2‑0 polypropylene.Perfect hemostasis was obtained. The patient underwent an uneventful postoperative period. About a year of postsurgery, he was down by 85% of his excess body weight and otherwise he was asymptomatic.

Case no. 2: Twist of gastric pouch
A 46‑year‑old gentleman of body mass index (BMI) 48 with Type II diabetes mellitus and hypertension underwent MGB. The standard 200 cm afferent limb was brought in and anastomosed to lesser curve based gastric sleeve. No Brolin suture to hitch up the anastomosis was inserted.Postoperatively, patient developed persistent vomiting on day 1, which did not settle with standard antiemesis regime.An urgent contrast study with the gastrografin revealed no passage of the dye beyond the stomach pouch. We opted for re‑laparoscopy and examined the MGB. It was found that afferent loop from the right side had come over to the left side with complete twist and shutting off the anastomosis. This was devolved and there was some doubt about the viability of the gastrojejunal anastomosis, so it was refashioned thus; the afferent and efferent loops were taken down from the stomach and the afferent loop was joined to the efferent loop 50 cm from the gastrojejunal,thus converting this into a Roux‑en‑Y loop. Postoperatively, patient was very well with no further  complications.

Case no. 3: Anastomotic leak
A 30‑year‑old man with a BMI of 52 with severe gastroesophageal reflux disease and hypertension aggressive with; possibly, an earlier re‑laparoscopy in the third case might have cut short a few days of ventilation and would have hastened his recovery.

Except in extreme circumstances, there is no reason why a patient who has just had laparoscopic bariatric surgery cannot have another laparoscopy, especially if it might turn out to be a life‑saving one. Yet another learning point is CECT, when available, trumps all other investigations in the search for a leak. Although ultrasound is a helpful modality, especially if CECT scan is not available, in a set up where underwent laparoscopic RGB. Although in the immediate postoperative period, he passed flatus and motion and went home on 3rd postoperative day, he was back again within 48 h with fever, vomiting, abdominal pain, and breathlessness. He was admitted and investigated. Complete blood count showed leukocytosis with a shift to left. Ultrasound abdomen did not obviously show any fluid collection. CECT of abdomen was too inconclusive. Since he was tachycardic and hypotensive, peritonitis was suspected purely on clinical grounds. He was aggressively resuscitated and taken back to OR. Re‑laparoscopy showed the following findings:

1. An intact gastrojejunal anastomosis which showed no sign of leak with the methylene blue test. However, there was evidence of postoperative leak with purulent fluid in the perigastric area

2. A jejunal loop distal to the gastrojejunal anastomosis had entered the mesenteric defect, causing an obstruction – perforation syndrome (the increased intraluminal pressure of the proximal jejunum had caused a gastrojejunal leak that sealed spontaneously).

The loop of bowel was pulled out from the mesenteric defect and the defect was closed with 2‑0 vicryl. Thorough peritoneal lavage was done and the gastrojejunal anestomosis although with the sealed leak was resutured and reinforced with 2‑0 vicryl. Postoperatively, patient was hypotensive, acidotic, and oliguric. He had features of fully fledged septic shock. He was aggressively treated with broad spectrum antibiotics and was put on ventilator and underwent temporary renal filtration therapy. He made a steady recovery over the next 10 days and discharged after 2 weeks of re‑laparoscopy. On follow‑up after 1 year, he had lost 45 kg and got rid of all comorbid conditions and had no further problems.

DISCUSSION

The fact that all three patients were well managed and that we had no mortality in all 100 cases vindicates the advantages of paranoid postoperative vigilance in these patients. An increasing pulse rate was the common factor in all three cases. It has been repeatedly shown in literature as a harbinger of disaster in the postoperative bariatric patients.In the first case, it was due to hypovolemia and hypotension and in the second case, it was due to gastrointestinal obstruction and in the third case, the culprit was sepsis. We would like to reiterate the truth that tachycardia in the postoperative bariatric patient is to be taken very seriously. The second learning point for us and others is that in the postoperative period, it is better to look and see rather than wait and see. Indeed we believe that being even more CECT is readily available, it is still the gold standard for postoperative leak. However, still CECT misses 30% of leaks, and here aggressive re‑laparoscopy holds the key as seen in our third case where re‑laparoscopy was done on high degree of clinical suspicion. In the first case, CECT findings were contributory though it is noteworthy that ultrasound had shown the same findings.

Figure 1: Hemoperitoneum in laparoscopic sleeve gastrectomy

Figure 2: Staple line bleed in laparoscopic sleeve gastrectomy

Figure 3: Staple line bleed – suturing in progress

Figure 4: Twist of anastomosis in mini gastric bypass

Figure 5: Twist of anastomosis in mini gastric bypass  Figure 6: Inconclusive contrast-enhanced computerized tomography in leaked Roux-en-Y gastric bypass patient

Figure 7: Leaked Roux-en-Y gastric bypass patient

In an age, when patients’ perceptions are constantly bombarded even by a single complication in the bariatric arena, we are happy to report the first 100 laparoscopic bariatric surgeries done in our center with zero mortality and three emergent postoperative morbidities that were promptly tackled by re‑laparoscopy.
In terms of prevention of complications, one must conclude with the following points:

1. In the first case, perhaps if a pericardial buttress has been used along with the stapler, this bleed might not have occurred. However, increased cost engendered will rarely be justified and this is not a standard practice in most of the centers worldwide.Glaysher et al. conclude that current evidence suggests that staple‑line reinforcement reduces the incidence of leakage and postoperative complications than nonreinforcement but does not significantly reduce bleeding complications.[1‑4]

2. Perhaps the Brolin stitch taken to afferent and efferent loops might have helped to fix the loops to the stomach and might have prevented the twist that caused the acute gastrojejunal volvulus in a patient with MGB. We have subsequently made it a policy to take this stitch in all patients who undergo MGB. Noun et al. concludes in his series of 1000 cases that MGB is an effective, relatively low‑risk, and low‑failure bariatric procedure. In addition, it can be easily revised, converted, or reversed.[5,6]

3. Gastrointestinal leak after gastric bypass surgery is an infrequent complication which can happen at some
point in every bariatric surgeon’s experience. Early detection and treatment of a gastrointestinal leak after
gastric bypass could be pivotal in reducing morbidity and mortality. CECT might be useful to detect postoperative leaks in some patients, but important limitations exist in its accuracy, in part because of issues inherent to the bariatric patient population that could make CECT imaging impractical or impossible. Surgical reexploration is an acceptable and important strategy to diagnose and treat patients who are highly suspected of having a postoperative leak after gastric bypass. Surgical reexploration that reveals no explanation for a postoperative patient’s adverse clinical findings or deterioration after gastric bypass should be considered an appropriate and indicated intervention and not a complication and should indeed be included in the diagnostic algorithm.[7‑9]

4. More effective closure of mesenteric defects (we now close mesenteric as well as Petersen’s defects) might
have prevented the loops from herniating within, creating the higher pressure in the gastrojejunal anastomosis (obstruction – perforation syndrome). However, Cho et al. reports in his series of 1400 cases of RGB that antecolic antegastric laparoscopic RGB without division of the small bowel mesentery or closure of mesenteric defects does not result in an increased incidence of internal hernias. The laparoscopic approach for reexploration appears to be an effective and safe option.[10‑12]

We would like to pass on these few learning points to the medical and surgical fraternity. To conclude, an intensive and careful postoperative vigil always pays rich dividends in terms of successful patient outcome, a generalization that is even more relevant for the postoperative bariatric surgical patient.

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