The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most common bariatric (weight reduction) procedure, but also the gold standard to which all others are compared, and it accounts for about 70% of all bariatric surgeries performed worldwide (Griffith, Birch, Sharma, & Karmali, 2012).
Postoperative complications following LRYGB can be broadly grouped into early and late complications. By definition, early complications occur within the immediate perioperative period — the first two weeks post-LRYGB. Late complications arise after the second postoperative week (Griffith, Birch, Sharma, & Karmali, 2012). Early complications that are specific to the surgical procedure are as follows:
Anastomotic or Staple Line Leaks
Anastomotic or staple line leaks are the most dreaded and potentially devastating complication of this surgical procedure (Griffith, Birch, Sharma, & Karmali, 2012). Gonzalez et al. found a 2.1% incidence of anastomotic leak in 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers (Gonzalez et al., 2007). Anastomotic leaks occur most frequently at the gastrojejunal anastomosis (the site of joining the stomach and the jejunum) (Griffith, Birch, Sharma, & Karmali, 2012).
The site where the stomach is joined with the small intestine (jejunum) is secured by staples or sutures. The holes created around this junction by staples/sutures are expected to be sealed off by the natural healing process. However, if this failed, the gastric content leaks into the abdominal cavity and leads to a condition known as peritonitis. Most of the leakage occurs within three days post-op (0-28days) (Gonzalez et al., 2007).
This can either be bleeding into the abdominal cavity (intra-abdominal) or bleeding into the lumen (intraluminal). Intra-abdominal bleeding may be from staple lines at the gastrojejunostomy, jejunojejunostomy, gastric pouch or the excluded stomach. Patient with intraluminal bleeding will present with any of melena stool (passage of black shining stool), hematemesis (vomiting of blood) or hematochezia (passage of frank blood in the stool). In patients with substantial postoperative hemorrhage, abdominal re-exploration using either a laparoscopic or open approach must be performed (Griffith, Birch, Sharma, & Karmali, 2012).
Small Intestinal Obstruction
The most common causes of small bowel obstruction following LRYGB are related to internal hernias (Griffith, Birch, Sharma, & Karmali, 2012). The maneuvers during surgery create many potential mesenteric defects into which small intestine may herniate. An incidence of 3.1% was found in a retrospective study of 2000 patients (Higa, Ho, & Boone, 2003). Internal hernias can pose a life-threatening risk to patients who have undergone gastric bypass owing to the possibility of strangulation and perforation of bowel loops trapped within a hernia. Inadequate closure of mesenteric defects has also been incriminated as a causative factor, with various groups advocating the meticulous closure of all possible defects with running, nonabsorbable suture as a means of reducing the rate of this complication (Griffith, Birch, Sharma, & Karmali, 2012).
The late complications are those that occur after 2weeks of surgery.
Abnormal narrowing of the point where the stomach is joined with the jejunum is one of the long term complications of laparoscopic Roux-en-Y gastric bypass (LRYGB). The incidence can be as high as 23% at the time of diagnosis ranging from 25–309(mean of 52) days after the surgery (Alasfar, Sabnis, Liu, & Chand, 2009). The development of structure has been associated with too much tension while suturing and reduced healing capacity. The incidence of gastrojejunostomy anastomotic stricture may be higher when a 21 mm versus a 25 mm circular stapler is used in the construction of the gastrojejunostomy (Griffith, Birch, Sharma, & Karmali, 2012).
This is an ulcer that develops in the mucosa of the jejunum near the gastrojejunal anastomosis. The incidence varies between 1-16%. Factors associated with the development of MU include pouch size, pouch orientation, staple line integrity, and mucosal ischemia. Nonsteroidal anti-inflammatory drugs (NSAIDs) and Helicobacter pylori may also contribute to MU, but their mechanism of action in the RYGB patient has not been studied (Sapala, Wood, Sapala, & Flake, 1998). Patient presents with epigastric pain with or without nausea, vomiting, or bleeding from the ulcer site.
Gastrogastric Fistula (GGF)
This is an abnormal communication between the gastric pouch and the excluded stomach. It occurs in about 1.5-6% of patients. This usually leads to inadequate weight loss or weight gain after surgery (Griffith, Birch, Sharma, & Karmali, 2012). The commonest cause is incomplete gastric transaction during surgery. (Christou, Look, & Maclean, 2006).
Weight gain after bariatric surgery occurs in about 10% of patients after five years and in about 20% of patients after ten years (Christou, Look, & Maclean, 2006). Pouch dilatation and GGF are part of the causative factors.
Nutritional deficiency is another complication you can encounter following the laparoscopic Roux-en-Y gastric bypass (LRYGB). The presentation may be anemia due to deficiencies of vitamin B12, folate, and iron. Significant deficits were also noted in magnesium, calcium, zinc, 25-hydroxyvitamin D, thiamine and β-carotene (Griffith, Birch, Sharma, & Karmali, 2012).