Chapter 37

This chapter will cover the diagnosis and management of early complications after bariatric surgery. While certain problems are more generic and may occur after any operation, others are specific to the particular procedure performed. In this chapter, I will concentrate on the problems after Roux gastric bypass, although some of the generic complications may also be discussed in other chapters.

The morbidly obese are challenging surgical patients; the technical aspects of any intra-abdominal procedure are more difficult than with normal weight individuals. Intravenous access, airway management, monitoring of the vital signs, and general logistics of transport and ambulation are all more problematic. Diagnosis and management of complications is hampered by difficulty with physical examination and radiologic diagnostics.

It is difficult to compare complication rates between open and laparoscopic bariatric procedures, as the more current reports on laparoscopic series can be compared only to historical control groups. Experience, instrumentation, surgical techniques, diagnostic and therapeutic radiology, and critical care have evolved considerably in the last decade, no doubt improving outcomes in this group of patients. Concurrent groups cannot be compared, as open bariatric operations are now generally performed on the highest risk patients, either because of higher body mass index (BMI), past operations, or some other complicating factor. There is little doubt that abdominal wall complications, such as wound infections and incisional hernias, have declined significantly with the laparoscopic procedures. Mortality rate and length of hospitalization are also reduced from earlier experience, although the same is true of most major operative procedures.

Finally, the complication and mortality rates of many operations, ranging in complexity from laparoscopic inguinal hernia repair to Whipple pancreaticoduodenectomy and coronary artery bypass, have been shown to decrease with increased numbers of operations performed by individual surgeons and institutions. A similar association has been documented with Roux gastric bypass. Nguyen and others demonstrated significantly reduced hospital stay, overall complications, and cost in high-volume hospitals (≥100 cases/year) compared to that in low-volume hospitals (≤50 cases/year).1 The observed mortality, particularly in patients older than 55 years, was also lower in the high-volume centers. Courcoulas and colleagues have reported significantly reduced adverse outcomes and mortality with high-volume surgeons compared to low-volume (≤10 cases/year) surgeons.2

### Leaks

A leak is perhaps the most feared single complication after gastric bypass, occurring with a reported incidence of 0%–5.6%.3,4 Leaks are one of the most common causes of mortality and a source of serious morbidity. While most occur at the gastrojejunostomy, the staple-line closures of the gastric pouch or the distal stomach and the jejunojejunostomy anastomosis are other potential sites. Potential causes include technical factors, stapler malfunction, and tissue ischemia. Ischemia may occur from division of blood supply, dissection injury, or tension. However, the etiology of a leak cannot be defined frequently, even with reoperation.

### Diagnosis

Most leaks present in the first week after surgery, most ...

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