Chapter 38

Since its inception in the 1950s, bariatric surgery has evolved into a field that offers safe and effective operations, which result in meaningful and sustainable weight loss. However, even with successful weight loss, patients may still develop complications long after the surgical procedure was performed. With early recognition and appropriate management, these problems are generally nonlethal and minor. However, left untreated, they may result in devastating complications. It is therefore critical that all health care professionals responsible for bariatric patients recognize the signs and symptoms, know the proper diagnostic maneuvers, and institute the correct treatment in a timely fashion.

This chapter will cover three of the more commonly seen complications: ulcers, stenosis, and fistula. Since these issues are less commonly seen after laparoscopic adjustable gastric banding (LAGB) or vertical banded gastroplasty (VBG), the chapter will focus mainly on procedures that involve an anastomosis such as the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD), and the biliopancreatic diversion with duodenal switch (BPDDS).

### Ulcers

Generally speaking, ulcers after bariatric surgery will be either anastomotic (marginal ulcers) or peptic. Peptic ulcers occur in the distal gastric antrum or duodenum as they would occur in people who have not had bariatric surgery. After LAGB or VBG, the incidence of peptic ulcer disease is similar to that of nonbariatric patients. However, after GBP it is thought to be much lower in incidence. Printen et al. reported an incidence of 0.26% in over 3000 gastric bypasses.1

Marginal ulceration represents a mucosal erosion on the intestinal side of the anastomosis with the gastric pouch (Figure 38–1). In humans, the intestinal mucosa is normally not exposed to gastric acid, which gets neutralized by the alkaline biliopancreatic secretions. Unlike the stomach, which is resistant to acid, the intestinal mucosa has no natural barriers and easily ulcerates. Marginal ulceration has been reported to occur in 5–15% and 3–5% of patients who undergo undivided and divided RYGBP, respectively.2–5

###### Figure 38–1.

Endoscopic view of a marginal ulcer at the gastrojejunal anastomosis of a gastric bypass.

The majority of stomal ulcers that occur in the undivided RYGBP operation occur in conjunction with a disrupted vertical staple line (gastrogastric fistula).4 The incidence of stomal ulcers is higher when a gastrogastric fistula is present because the gastric acid from the excluded fundus is able to come in contact with the intestinal mucosa. Gastrogastric fistula can occur after both divided and undivided RYGBPs. However, it occurs more commonly in the undivided procedure where the staple line dehiscence rate is as high as 29%.6–8 In divided RYGBPs without gastrogastric fistula, the etiology of marginal ulceration remains unclear. Acid output by parietal cells in the standard 30-cc gastric pouch is minimal but not usually absent.2,9,10 Large pouches may likely contain more acid-producing ...

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